Worsening After a Session Has Been Measured, and the Numbers Are Reassuring
Temporary symptom worsening during trauma-focused therapy affects a minority of patients. In a 2016 analysis of three trauma-focused protocols, worsening occurred in 28.6% of patients receiving cognitive processing therapy, 20.0% of those receiving prolonged exposure, and 14.7% of those receiving a cognitive-only variant (Larsen and colleagues, Behaviour Research and Therapy, 2016). An earlier trial found that after the first imaginal exposure session, 15.4% of patients showed increased PTSD symptoms, 28.2% increased general anxiety, and 12.8% increased depression (Foa and colleagues, Journal of Consulting and Clinical Psychology, 2002).
In both studies the increases were time-limited, and in both they were unrelated to whether patients finished treatment.
This page covers the interval between sessions. For what EMDR is, the eight phases, and what the trials show, see the EMDR clinical guide. For how it compares with the other guideline-recommended trauma therapies, see EMDR versus CBT.
Patients who go looking for those numbers rarely find them. They find forums, where the aftermath has acquired a name and very little else. The name is useful because it describes something real. What's missing around it is any sense of scale, duration, or meaning.
The Days After a Processing Session
The common pattern involves fatigue that arrives several hours after the session and not during it, tearfulness that shows up without an obvious trigger, and irritability that the patient notices mostly through other people's reactions. Sleep is frequently disrupted for one to three nights, often with unusually vivid dreams. Headache, nausea, and general physical heaviness are reported often enough that they're worth anticipating out loud before the first processing session.
Patients describe it the same way in the office. One version, close to verbatim across many people: "I felt fine walking out. Two days later I couldn't get off the couch, and I had no idea whether that meant it was working or that I'd broken something."
That uncertainty is the actual problem. The physical experience is tolerable for most people. The interpretive vacuum around it is what drives the 2 a.m. searching, and it's what leads people to quit a treatment that was working.
Processing Continues Between Sessions
EMDR assigns no homework. Treatment is completed within sessions, which distinguishes it from prolonged exposure and cognitive processing therapy, both of which assign structured between-session work. That difference is one of the practical reasons patients choose it.
The absence of homework doesn't mean the absence of activity. Material that was opened during a session continues to settle for some days afterward, which is the likely source of the dreams, the intrusive fragments, and the emotional volatility that patients report in the interval. Accordingly, the between-session task is to let that settle.
The Intensity of the Reaction Does Not Measure the Progress
A belief circulates widely among patients that a harder crash indicates deeper processing. The available data point the other way.
In the 2016 analysis, patients who experienced symptom exacerbation still achieved clinically significant improvement by the end of treatment. However, they finished with higher symptom scores and were more likely to still meet criteria for PTSD than patients who had not exacerbated. Worsening, in other words, is survivable and common, and it carries no bonus.
Critically, this cuts in both directions. A patient who feels steady after sessions has no reason to conclude that treatment isn't reaching anything. A patient who feels wrecked has no reason to conclude that it's reaching more.
What Helps in the First 72 Hours
Three things account for most of the benefit: protected sleep, reduced demand, and a lowered bar for the day.
Scheduling matters more than any specific technique. A processing session placed the night before a performance review, a custody exchange, or a long drive is a scheduling error. Patients who front-load their week and leave the day after a session comparatively empty describe a markedly easier interval, and this is worth planning at the outset rather than discovering in week four.
Alcohol deserves specific mention. It's the most common self-treatment for the post-session interval, it works acutely, and it degrades exactly the sleep architecture the recovery depends on. Cannabis carries the same problem with a longer tail.
Movement, hydration, and ordinary food help more than their simplicity suggests. Further, contact with one person who knows you're in treatment shortens the interval reliably. Patients who go through this alone report the longest and most frightening versions of it.
When Worsening Is a Reason to Make Contact
Five patterns warrant a call before the next scheduled session rather than a report at it.
First, worsening that fails to lift between sessions and deepens week over week. The expected shape is a difficult interval that resolves. A stepwise decline across three sessions is a different phenomenon and calls for a change in pacing.
Second, new or increasing thoughts of suicide. This one carries a specific hazard: patients frequently withhold it because they're afraid the EMDR will be stopped. The clinical response to emerging suicidal thinking during trauma work is to adjust the sequencing, not to abandon the treatment, and knowing that in advance makes disclosure likelier.
Third, new dissociative episodes, losing time, or waking in places you don't remember getting to.
Fourth, an inability to work or to care for dependents that extends beyond a day or two.
Fifth, restarting a substance you had stopped, in order to manage the interval.
The most common way trauma treatment goes wrong is processing that starts before the patient can tolerate it, and the failure in those cases lies in the sequencing rather than in the treatment. Notably, when patients drop out of trauma-focused therapy, it most often happens before exposure work begins (van Minnen and colleagues, European Journal of Psychotraumatology, 2012). The risk window is early, which is precisely when patients are least likely to have been told what to expect.
Dropout Rates Put the Aftermath in Proportion
Across 116 randomized trials, the pooled dropout rate from psychological therapies for PTSD was 16% (95% CI 14 to 18). For EMDR specifically the rate was 18% (95% CI 12 to 24) across 21 trials, and for prolonged exposure 22% (95% CI 16 to 28) across 22 trials (Lewis and colleagues, European Journal of Psychotraumatology, 2020). Those intervals overlap substantially, and the difference between the two treatments should be read as small.
Trauma-focused therapies were associated with significantly greater dropout than therapies without a trauma focus. That finding is unsurprising and worth stating plainly to patients: the treatments that work on the memory directly are harder to stay in, and staying in them is the part that requires support.
What Isn't Known
Three limitations apply to everything above. First, the exacerbation rates come from prolonged exposure and cognitive processing therapy. EMDR trials have not reported exacerbation separately, and while the pattern likely extends, that extension is an inference. Second, no study has measured how long the post-session interval lasts, which is the single question patients ask most often. Third, the trial populations skew toward single-incident trauma, and patients with developmental trauma report longer and less predictable intervals than the data describe.
Nevertheless, the direction of the evidence is consistent across protocols and across two decades. Temporary worsening is common, it resolves, it doesn't predict dropping out, and it doesn't prevent recovery.
Frequently Asked Questions
How long does the post-EMDR interval last?
Most patients describe one to three days, with sleep normalizing first and emotional volatility resolving last. No trial has measured this directly, so the range comes from clinical report and not from published data. Intervals that consistently run longer than a week are worth raising with your clinician, since they usually indicate that the pacing needs adjustment.
Does feeling worse mean EMDR is working?
No. Patients who experienced symptom worsening in trauma-focused trials still improved, and they finished with somewhat higher symptom scores than patients who did not worsen. The intensity of the reaction carries no information about the quality of the processing.
Should I stop EMDR if I feel worse after sessions?
Usually not. Temporary worsening affected 14.7% to 28.6% of patients in measured protocols and was unrelated to treatment completion. Worsening that deepens across weeks, or that brings new suicidal thinking, new dissociation, or a return to substance use, is a reason to contact your clinician and adjust the pacing.
Is it normal to cry for days after an EMDR session?
Tearfulness without an identifiable trigger is among the most commonly reported features of the interval. It typically resolves within several days. Persistent crying accompanied by hopelessness, rather than by the sense of something moving, is worth reporting.
Can I work the day after an EMDR session?
Most patients can, and many prefer the structure. Scheduling high-stakes obligations for the following day is the more common error. Patients who protect the day after a processing session describe a substantially easier interval.
Why didn't my therapist warn me about this?
Preparation for the between-session interval is inconsistently delivered, and patients frequently learn about it from other patients before they hear it from a clinician. Anticipating it out loud before the first processing session is straightforward, and it changes how the interval is experienced.
What This Means for Treatment
The aftermath of a processing session is a known, bounded, and manageable feature of trauma-focused work. Patients who are told what to expect, who plan the day after, and who have an agreed threshold for making contact tolerate it well and stay in treatment. Patients who encounter it without preparation interpret it as damage, and a proportion of them stop.
Related: EMDR with a psychiatrist in NYC and PTSD and complex PTSD treatment.
Accordingly, the interval between sessions deserves the same clinical attention as the session itself. For patients managed with medication alongside EMDR, that interval is also where sleep, substance use, and emerging suicidality are most usefully monitored, which is one practical argument for keeping the psychiatric and psychotherapeutic sides of the treatment in the same hands.