Trauma is a threat to the psyche and the body: In-person therapy for trauma offers more to manage physical symptoms and responses

Trauma therapy takes a lot of work. In the larger picture, the task is to “work through,” meaning find ways of talking about what happened as a part of integrating the traumatic experience so that its effects are no longer overwhelming. Like recovering from a physical trauma, there are ways this recovery itself can be a struggle to endure. People who seek therapy for trauma often need help being in the world, being in their bodies, and tolerating the difficult work to get better.

In particular, trauma represents a level of threat to both the psyche and the body, often expressing itself in both places. Fear lives in the muscles and bones, not just the brain. Regardless of the approach to treatment, there is frequently a need to help with the embodied manifestations of trauma, such as panic attacks and other forms of anxiety, stomach aches, startle responses, headaches, avoidance, and struggling with breathing. Because the body can respond to trauma, even unconsciously, being present in the room for in-person therapy offers more opportunities to manage these symptoms, whether breathing together, going for a walk, or using somatic interventions.

The therapy office can be both a place of protection and a space where hard feelings and memories live

The therapy office can be, at times, both a safe space that offers comfort and a sense of protection through the therapist’s support and a scary place where hard feelings and memories live. It can’t be overstated how important the “both-ness” of this is for trauma therapy. In fact, it’s one of the lines that separates good therapy for trauma from mediocre therapy. Therapy that seeks to simply help someone feel better in an hour, whether intentional or not, avoids dealing with precisely the trauma it seeks to help. While there is a lot we can do to help someone feel better at a given moment and even more we can do to help someone avoid feeling bad at all, healing from trauma involves, in part, the very work of moving towards that which feels terrible.

This, of course, requires great care and consideration of timing and conditions. Plenty of people experience traumatic events and work through them on their own. The kind of serious trauma and impact that brings people to therapy requires great skill on the part of the therapist in order to help an individual talk about what happened. In therapy, we need to build conditions to do so. It requires a relationship of trust in which there is an ability to notice and decide together what is too much. We need to know when to stop and let the work settle. We need to know when an unrelated event, like starting a new job or relationship, or dealing with a recent loss, indicates a need for a pause in revisiting trauma. We also need to be prepared with tools and techniques to help, like with a panic attack that feels overwhelming. While these conditions can be built remotely, it’s nearly always better face-to-face

Trauma makes it harder to trust: The embodiment of in-person therapy goes a long way to build a relationship with a therapist

Trauma therapy makes use of the vital relationship between the therapist and patient, especially through the scarier work. This trusting relationship can be healing in and of itself. It also provides a secure context from which hard things can be faced. However, one horrible fact of trauma is that it makes it harder for people to build and sustain the very trust that, for many, is essential to working through that trauma. A therapist and patient must build trust together, and this work cannot simply be substituted by offering credentials, a CV, or other tokens of validating safety. Trust has to be built, sometimes little by little.

This is a careful process that benefits from all the help it can get. In-person therapy for trauma offers more opportunities to share in each other’s humanity. Being in the office, a space that represents who a therapist is, seeing other patients come and go, experiencing body language, and witnessing subtleties in tone that may not be conveyed remotely can all go a long way to build the necessary trust.

It's natural to want to avoid the discomfort of working through trauma: In-person therapy offers fewer distractions

Trauma is an experience of pain—psychic pain and embodied pain—as well as fear. By its very nature, trauma compels the very reasonable desire to avoid: to not feel, not think about, distract, and change the subject. It’s similar to going to the dentist—it doesn’t feel good and it’s reasonable to want to avoid it, and yet it’s important to do so. A skilled trauma therapist, then, has a balance to maintain: When is it too much? When does there need to be an invitation to move toward discomfort? While effective, remote work makes this effort harder. There are so many distractions on the screen, in the room, in the house, or at work that can be identified, consciously or not, as a way out of feeling something scary.

In contrast, a therapist has a great deal of control over their office. Both the patient and the therapist generally stay off their phones in order to fully be with one another. The office itself is designed to minimize distractions, both real (noises, beeps, screens, and other disruptions) and psychic (Does that bathroom switch need to be fixed? Did I file that expense report? Did I respond to that email?). These distractions can so easily collude with a patient’s wish to avoid the pain of remembering and talking about difficult things in trauma therapy. This can be overridden online when one is determined, but for many who have experienced serious trauma, they’re already overriding so much just by showing up to therapy.

Meet our founder and clinical director, Matt Lundquist, LCSW, MSEd

A Columbia University-trained psychotherapist with more than two decades of clinical experience, I've built a practice where my team and I help individuals, couples, and families get help to work through difficult experiences and create their lives.