Why therapy sometimes hurts before it helps

You’ve come home from your third session and instead of relief you feel — weight. The conversation opened something you hadn’t touched in years, and now it’s standing in the middle of the room. You find it harder to fall asleep, thoughts that weren’t there before catch you during the day, maybe you’re more irritable, more tender, closer to tears. And in your head a question you don’t dare say out loud: if therapy is helping me — why do I feel worse?

That question deserves an honest answer, not reassurance. So in this piece I’ll explain why therapy often hurts first before it relieves: what happens when something long closed is opened, why feeling stirred up after a session isn’t a sign that something isn’t working, where the line runs between pain that heals and being overwhelmed, which doesn’t — and what you can do for yourself after a hard session.

Let one thing be clear in advance: “worse before better” isn’t a rule that has to apply to you. But it’s a common enough experience that no one should meet it unprepared.

What happens when you open what’s been closed a long time

Picture a room that’s been locked for a decade. When you open it, the first thing that rises is dust. That isn’t a sign that opening it was a mistake — it’s the physics of closed spaces.

It’s much the same with feelings. Most of us learned to tidy painful experiences away: not to think about them, to minimise them (“it wasn’t that bad”), to drown them out with work, caring for others, humour. That tidying has a price — psychologists call it experiential avoidance, and research consistently links it with poorer mental health in the long run — but in the short term it works: you don’t feel the pain. Therapy does exactly the opposite: it invites you to look where you haven’t looked in years. And the first result of looking at what’s been pushed aside isn’t peace. It’s contact with pain that was there all along — you just weren’t feeling it.

The classic evidence for this mechanism comes from research on writing about difficult experiences. In his well-known experiments, James Pennebaker found that people who write for several days in a row about the hardest events of their lives feel worse immediately afterwards than a control group — sadder, more agitated. Yet in the weeks and months that follow, their wellbeing and even their physical health improve more than in those who wrote about neutral topics. Short-term pain and long-term benefit aren’t opposites — often they’re the same road.

Why feeling stirred up after a session isn’t a sign that therapy isn’t working

A therapy session lasts fifty minutes; processing doesn’t. What opens in the room goes on being worked through by body and brain for hours and days afterwards — in thoughts that return, in dreams, in emotions that arrive at unexpected moments. I’ve written about how important that in-between time is in the piece on what happens between sessions — here let me just sum up the essence: the session sows, and the week is where it grows. And growth sometimes feels like unrest.

Research on the psychotherapy process also shows that change is almost never linear. In a review of patterns of change in therapy, Adele Hayes and colleagues showed that fluctuations — periods of worsening followed by a leap forward — are a common and often even favourable pattern: the temporary destabilisation of the old system makes room for a new organisation. Similarly, Tony Tang and Robert DeRubeis described “sudden gains”: large improvements that often occur in a single step — as a rule after sessions in which something important, and often uncomfortable, happened.

The same holds in trauma treatment: research on exposure therapies (Larsen and colleagues, 2016) shows that a temporary increase in symptoms during treatment is not unusual — and, crucially, doesn’t predict a worse final outcome. Translated from statistics into life: the fact that a session shook you doesn’t mean you’re on the wrong road. Often it means you’ve touched, for the first time, the very thing you came for.

The grief that comes with insight

There’s another kind of pain in therapy that gets talked about too little — the pain of insight. As you start to see your patterns, your story and your relationships more clearly, sadness often arrives alongside the understanding. And with good reason, because insight almost always means loss as well:

• Grieving for time. “How many years did I live like that?” Realising that much could have been different if you’d understood sooner or sought help sooner can hurt deeply. (If it’s any comfort: you came when you were able to. There was no sooner.)
• Grieving for relationships. When you look at your childhood or your marriage with open eyes, you may see what wasn’t in them — warmth, protection, being seen. Grieving for something you never had is one of the quietest and most real forms of grief.
• Grieving for illusions. Sometimes the hardest thing to lose is the story that protected you: “if I try hard enough, they’ll love me”, “my family was perfectly fine”, “I can manage everything alone”. Illusions were a support — and even a support that limited you hurts to say goodbye to.

This sadness isn’t a side effect to be got rid of. It’s part of the processing — I’ve written in more detail about why sadness is a process of change and not a system failure in the piece on sadness. In therapy it gets space, a pace and someone to speak to; that’s precisely what distinguishes it from sadness a person carries alone.

“Worse before better” — common, but not obligatory

Let me be precise, because there’s a lot of mythology here: therapy is not supposed to hurt continuously, and pain is no proof of quality. Many people feel relief very early on — research shows that a considerable proportion of people notice improvement within the first few sessions, because for the first time in their lives someone is genuinely listening. Others go through periods when it’s harder. Both are normal.

When is an interim worsening more likely? As a rule when the work reaches deeper: when a traumatic history opens, when an old defensive system starts to come down, when insights shake important relationships. Life can also “get worse” outwardly for a while: you start setting boundaries and the people around you grumble; you stop playing the role that suited everyone; in your relationship you say what has gone unsaid for a decade. That isn’t therapy ruining your life — that’s your life adjusting to who you actually are.

To this I’d add an observation from practice that almost everyone who has been through a longer process confirms: looking back, it’s often precisely the hardest periods that people describe as the turning points. “At the time I thought I was falling apart — today I know that what came down was what had to.” In the moment itself this is of course impossible to see; which is why it matters so much to walk through the valley accompanied, rather than alone with the conclusion that you’ve lost the way.

The time frame matters, though: the valleys along the way are periods, not a permanent state. If week after week you only feel worse, with no bright shifts, no sense that you understand more, and it goes on for a long time — that isn’t “a normal part of the process”, that’s information that belongs in therapy. More on this in the next section.

Productive pain or being overwhelmed? The key difference

Not all pain in therapy is useful. So you need a measure — and the field has one. It’s called the window of tolerance: the range of arousal within which the nervous system can feel, think and process all at once. I’ve described psychiatrist Daniel Siegel’s concept in more detail in the piece on the myth of “what doesn’t kill you makes you stronger”; here let’s use it practically.

Productive pain happens inside the window: it hurts, but you stay present. You cry and at the same time you know where you are. After a session you’re tired, loosened, perhaps sad — but a day or two later you notice you understand more, that something has shifted, that breathing is easier. That’s the pain of processing: the emotion was felt and worked through.

Being overwhelmed is something else: the emotion throws you over the edge of the window. The signs can be: regularly falling apart for days after sessions; being unable to work, sleep or look after yourself; a sense of being “disconnected”, numb, as if in fog; panic that doesn’t subside. In that state the brain isn’t processing — it’s surviving. And pain without processing isn’t therapy, it’s repetition.

And now the most important sentence in this piece: if any of this is happening to you, tell your therapist. Not because there’s anything wrong with you, but because regulating the pace is the therapist’s job — and they can only do it if they know what’s happening to you between sessions. A good therapist will take that feedback seriously and adjust the work: slow down, add stabilisation, give more space to your sources of strength. If they brush it off with “you have to push through”, that’s a serious reason to reconsider working together.

Brakes are part of driving, not a failure of it

In therapy you have the right to your own pace throughout. You’re allowed to say: “I can’t open that today.” You’re allowed to say: “The last session was too much — I need a lighter week.” You’re allowed to ask for a break from a particular subject. That isn’t avoidance and it isn’t self-indulgence; it’s precisely the skill of sensing and expressing your own limits that you’re learning in therapy for life outside it too.

More than that: in my work with people I notice that the moment a client first dares to say “no” or “slower” is often one of the most important in the whole process. The therapeutic relationship is a space where you can safely test whether your boundary makes someone angry, disappointed or pushes them away — and find that it not only holds it but respects it. Why that experience is so healing I’ve described in the piece on why the therapeutic relationship heals.

Well-designed therapeutic work is also never only opening. It alternates opening and consolidating: hard sessions are followed by calmer ones, work with pain is interwoven with work on resources — with what carries you, what you’re good at, what gives you strength. If you have the sense that your therapy only digs and never builds, that too is worth saying out loud.

Self-care after a hard session

Finally, something entirely practical — what you can do for yourself after a session that has shaken you loose:

• Don’t plan demanding things straight after therapy. If you can, leave half an hour of transition after a session: a walk, a coffee, a drive home without phone calls. Give your body time to level out.
• Name what’s happening. “An old story has opened and I’m working through it” is more settling than “I’m falling apart”. Same experience, different frame.
• Use your body. Processing isn’t only mental: movement, a warm bath, a lengthened out-breath, a few minutes at the window looking into the distance — all of it tells the nervous system that the danger has passed.
• Write it down. A few sentences about what opened up and what you feel unburdens your thoughts and saves them for the next session.
• Be with someone you don’t have to perform for. You don’t need to recount what happened in therapy — closeness without demands is enough.
• Lower your standards for that day. You don’t run a marathon after the dentist. After a deep therapy session you don’t need to be the best version of yourself.

And one thing that’s easily forgotten: self-care after a hard session isn’t indulgence, it’s part of the therapeutic work. Processing needs conditions — sleep, food, movement, quiet. If you give your body none of that after opening an old wound, you’re asking it to heal with nothing to work with. So you can talk about your self-care in therapy too; together with your therapist you can put together a very concrete plan for the days after more demanding sessions.

And if the balance between pain and benefit in your therapy stays off for a long time, talk about it — first with your own therapist, and if that doesn’t get anywhere, it’s entirely legitimate to seek a second opinion. If you’re only just considering therapy and this piece has perhaps frightened you, let me reassure you: a good therapist adjusts the pace to you, not the other way round. How I work and what you can come to me with you’ll find on the Services page — and a first conversation can be perfectly light. Only what we’re ready to open together hurts, and only when you’re ready.