Are symptom increases during treatment something to worry about?

Larsen and colleagues (2020) examined this question in a community sample of participants receiving CPT. Previous investigations had been primarily in randomized clinical trials. The concern with these trials has been that the participants and therapists are in some way different to the “average” community-based clinic. For example, therapists may be receiving more specialised training and participants may receive more frequents sessions.

Larsen et al (2020) community sample were receiving weekly treatment and attending in community settings such as private practice or government funded agencies. Therapists had attended a standardized 2-day CPT workshop and were participating in consultation.

Larsen’s group (2020)  found that in their sample most participants experienced at least one symptom exacerbation during treatment (67.3%), and 26.9% experienced more than one exacerbation. They highlighted a few important points.

1. Symptom increases did NOT predict:

  • Treatment noncompletion
  • Posttreatment PTSD symptom levels
  • Loss of probable PTSD diagnosis.
  • The trajectory of PTSD symptoms over the course of treatment.

2. Those with symptom exacerbations showed no less change in PTSD symptoms over the course of treatment (than those without symptom exacerbation).

3. Demographic variables examined were NOT associated with exacerbations:

  • Age
  • Gender
  • Years of education
  • Employment status
  • Military enrolment
  • Veteran status

4. Diagnostic variables examined were NOT associated with exacerbations:

  • Depression
  • Anxiety
  • Substance use
  • Personality disorder

5. Strategies used to train clinicians did NOT predict exacerbations.


Larsen and colleagues provided an important Clinical Impact Statement that can be a useful guide.

“It is relatively common to experience temporary symptom increases during participation in cognitive processing therapy and other trauma-focused therapies. Our results indicate that these symptom increases may be common but are not problematic for overall treatment prognosis. Clinicians can be encouraged that clients can benefit from trauma-focused treatment even if they experience symptom exacerbations during therapy.”


And of course, it may be prudent for the clinician to examine such self-statements as “I have made my client worse.”



Larsen, S. E., Mackintosh, M.-A., La Bash, H., Evans, W. R., Suvak, M. K., Shields, N., Lane, J. E. M., Sijercic, I., Monson, C. M., & Wiltsey Stirman, S. (2020, January 23). Temporary PTSD Symptom Increases Among Individuals Receiving CPT in a Hybrid Effectiveness-Implementation Trial: Potential Predictors and Association With Overall Symptom Change Trajectory. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication.