What I have been noticing recently — and something many trauma therapists will likely recognise — is the experience of a client appearing calmer and more regulated within the therapy room, only to return the following session describing feeling better initially before becoming overwhelmed, disconnected, or unable to access the strategies discussed in session.
Clients can feel they have failed, often apologising for not practising calming strategies. Therapists may question whether they explained things clearly enough (my concern often!).
It is worth remembering this is a very normal trauma response pattern. Often what has happened is that the client felt motivated, connected, and co-regulated within the therapy space. But as attention gradually returned to everyday stressors, old nervous system patterns and coping responses re-emerged.
Why Regulation Difficulties Are So Common in Trauma Work
There are many reasons regulation difficulties can emerge between therapy sessions:
- the nervous system activates quickly and on a ‘just in case’ basis
- relational environments may be difficult to navigate
- clients may have little emotional support between sessions
- life stress, responsibilities, parenting, work pressures, and exhaustion all continue outside the therapy room
- long-established coping patterns often return automatically under stress
Sometimes clients do not yet have an emotionally safe person they can turn to between sessions. Sometimes they have spent years surviving rather than learning how to regulate emotion safely and consistently.
Therapy may be the first place they have ever experienced co-regulation, emotional validation, or space to slow down enough to notice themselves.
Why Insight Alone Often Isn’t Enough
Once the nervous system becomes activated, the body is already moving through a cascade of stress responses involving hormones, neurochemicals, attention shifts, emotional memory, and survival-based coping patterns.
Insight alone rarely creates lasting change — for any of us.
Most of us know things that would probably help our wellbeing that we still struggle to practise consistently. Clients are no different.
Lasting regulation often requires:
- repetition
- predictability
- practice
- state-dependent learning
- nervous system familiarity
- habits developed gradually over time
Understanding why something is important and being able to access it when distressed are often two very different things.
What Can Happen Between Sessions
Clients will often say things like:
“I know what I should do but I don’t do it.”
Or they may describe returning to familiar coping patterns such as:
- Netflix
- vaping or smoking
- alcohol
- overworking
- excessive exercise
- reassurance seeking
- isolating from others
- listening to sad playlists to “get the sadness out”
- listening to upbeat playlists in an attempt to make difficult feelings disappear
These are just some of the examples clients have shared with me over the years.
Clients may also experience:
- emotional exhaustion
- difficulty embedding new routines
- shame about “not doing therapy properly”
- intellectual understanding without practical integration
Sometimes therapy can begin to live mostly in the intellectual part of the self while the nervous system continues responding in old familiar ways.
Why Clients May Struggle to Use Regulation Strategies Independently
Thoughts – A client who has never been shown how to regulate emotions may place enormous hope in the therapist having the one piece of information that finally changes how they feel. Psychoeducation can absolutely help clients make sense of their experiences, but understanding something intellectually does not automatically create nervous system change.
Clients may also hold thoughts such as:
- “I should be able to cope by now.”
- “If this was going to help it would already be working.”
- “I’m failing therapy.”
These thoughts can themselves increase shame and dysregulation.
Feelings – Many clients experience deep feelings of low self-worth, hopelessness, exhaustion, or emotional overwhelm. Devoting time and energy towards their wellbeing may feel unfamiliar, uncomfortable, or even undeserved.
Some clients also describe feeling frustrated when calming strategies help temporarily but difficult emotions later return. This can lead them to conclude that the strategies “don’t work,” rather than recognising that regulation is something built gradually through repetition and practice.
Behaviours – Clients often live very busy lives filled with responsibility, caregiving, work pressures, relationship difficulties, and chronic stress. Introducing new regulation practices into an already overwhelmed system can feel like an additional burden rather than a support.
As a result, clients may understandably return to coping strategies that are immediate, familiar, and require less effort in the short term, even if they do not provide lasting stabilisation.
Slowing the Conversation Down: An Integrative Model I Return To
Something I have found myself struggling with lately is how to communicate regulation and stabilisation with clients in a way that truly lands beyond an intellectual level.
I often turn to the research and find myself talking about the nervous system, the vagus nerve, the phrenic nerve, window of tolerance, and the physiology of activation. Clients are usually very “onboard” in the session and the explanations make sense to them.
But over time I noticed that although clients often understood the psychoeducation intellectually, many still struggled to integrate regulation practices into everyday life.
I also noticed that even when we practised calming exercises together in session, clients could leave feeling significantly more settled and still find themselves dysregulated again several days later.
For a while I found myself questioning my ability to socialise clients into trauma-informed therapy and the importance of stabilisation work.
Then I realised there is no single perfect way to do this.
It is nuanced and complex.
We all live our lives not consistently doing things we know would probably help us. Why would trauma survivors be any different?
Over time I found myself moving away from trying to “convince” clients using neuroscience explanations alone, and returning instead to a simpler, more collaborative and integrative conversation.
A Simple Visual Model for Exploring Coping and Regulation
Here is an integrative formulation model I developed years ago based on what clients repeatedly shared with me in therapy. Please feel free to use it, adapt it, or change it in whatever way feels most helpful for your clients.
Download the Free Stabilisation Formulation Template here.
This is generally the structure I use:
- I start by asking:
“What does happy, content, calm, relaxed, or settled feel like?”
To get a clearer picture of how it feels you could ask what has or what they believe would make them feel that way. I write it in the centre and draw a small circle around it.
2. I then ask what feelings they notice day to day — perhaps what brought them to therapy, or the feelings they wish they did not experience so intensely.
I write these around the outside and draw a larger circle around them and draw an arrow from the inner to the outer circle.
3. I ask what helps them cope day to day that involves a particular person, place or thing. I draw an arrow from the outer circle to a heading called ‘coping’. Importantly, there is no judgement here. If cigarettes, alcohol, vaping, scrolling, or avoidance are on the list that is completely fine. The aim is to understand what the nervous system has learned to reach for.
If clients struggle to identify coping strategies, I may ask:
“What people, places, or things help you feel even slightly less overwhelmed, sad, anxious, or distressed?”
4 & 5. We then explore which of these coping behaviours, strategies and tools help them. Specifically – when they no longer have that person, place or thing do they return to the inner circle (calm, content) or the outer circle (back to feeling dysregulated)?
6. I move to asking about things they can access internally without relying entirely on another person, place, or external coping tool.
For example:
- breathing practices
- sighing
- grounding
- mindfulness
- compassionate self-talk
- shifting attention
- perspective taking
- remembering positive memories
- relaxation
- visualisation
- daydreaming positive outcomes
Although this list is often shorter initially, most clients usually identify something.
- Clients will often say:
“But I don’t stay there.”
And of course, none of us do.
The goal is not to remain calm all the time. The goal is gradually developing more ways to help ourselves return there and be able to do so more often and on purpose.
What the Model Often Reveals
I learn a great deal from this formulation process about my clients and where stabilisation work may need to focus.
It frequently reveals:
- forgotten coping strategies that were once helpful
- dependence on external regulation
- exhaustion and overwhelm
- survival adaptations
- patterns of emotional avoidance
- low self-worth
- lack of compassionate self-care
Clients often remember things that genuinely helped in the past but were gradually lost under stress or life pressures.
For example, someone may remember that yoga previously helped them regulate but they stopped attending classes because of finances, exhaustion, parenting, or time pressures. Exploring this can open discussions around whether elements of those practices are still accessible in smaller ways.
The formulation can also help clients recognise how much of their energy has gone into avoiding or escaping distress rather than building stabilisation skills that increase nervous system flexibility over time.
Importantly, all coping makes sense in context. Even strategies that later become problematic often began as understandable attempts to manage overwhelming emotion.
Supporting Regulation Without Encouraging Avoidance
Stabilisation is not about avoiding emotion or “staying positive.”
It is about helping clients develop enough nervous system flexibility and safety to remain present more often.
The aim is not emotional suppression. Nor is it forcing clients into calm states they are not ready for. It is more about gently expanding the client’s capacity to stay connected to themselves for slightly longer periods of time.
How Between-Session Audio Resources May Help
One thing I have increasingly come to appreciate is that clients often need support that is easy to access when dysregulated. In highly activated states, strategies that require a great deal of thinking, remembering, or effort can become difficult to access.
Predictable, repetitive regulation practices can sometimes help bridge the gap between therapy sessions by reducing cognitive demand and supporting familiarity through repetition.
Some clients find that listening to grounding or stabilisation audio between sessions helps them reconnect more quickly with practices explored collaboratively within therapy. Others may not engage with audio resources at all, and that is important information too.
As always, therapist judgement, pacing, and individual formulation remain central.
Important Clinical Considerations and Boundaries
Stabilisation approaches are not one-size-fits-all and are not intended to replace therapy or relational support.
Regulation work can initially feel unfamiliar, frustrating, or even unsafe for some clients, particularly when heightened activation has been present for many years.
Pacing matters enormously. Some clients may need very small, collaborative steps before independent regulation practices feel accessible or tolerable.
Therapist judgement, attunement, flexibility, and collaborative adaptation remain essential throughout this process.
Final Reflections
Clients struggling between sessions is often not a sign that therapy is failing.
Many clients are transitioning from never having been taught how to regulate their nervous system to gradually learning how to do so with increasing confidence and flexibility.
Change can be slow. Nervous systems learn through repetition.
Stabilisation is rarely something we focus on briefly at the beginning of therapy before moving on. More often, it becomes something we return to repeatedly throughout therapy and encourage beyond the therapy room itself.
Initially, much of trauma therapy regulation is co-regulation. Over time, through repetition, modelling, safety, and practice, some of this gradually becomes internalised.
Sometimes the work is not helping clients understand more. But more helping clients practise returning to themselves repeatedly and gently enough that eventually the nervous system begins to believe something different is possible.
To support this phase of therapy, I’ve developed clinician-designed bilateral audio resources for stabilisation and nervous system regulation between sessions.
• Explore the full audio library → Willow Tree Wellbeing Audio Library
• Or try a short stabilisation audio → Access free stabilisation audio
About the Author
Donna Dickinson is a BABCP-accredited CBT therapist and EMDR-trained psychotherapist with over 19 years of NHS experience in trauma-focused work. Her clinical interests include nervous system regulation and stabilisation in therapy. She develops clinically informed audio resources to support stabilisation and regulation within trauma-informed practice.