One of the most common concerns people have when considering psychotherapy is the possibility of feeling worse before they feel better.

Many have heard this idea repeated by therapists, friends, family members, or people who have previously attended therapy. It has become almost an accepted belief that psychotherapy must involve a period of increased distress before meaningful improvement can occur.

However, the reality is more complex.

Some people do experience periods of increased emotional discomfort during therapy. Others do not. Some experience gradual and steady improvement from the beginning, while others move through periods of progress, difficulty, reflection, and emotional adjustment before significant change takes place.

For this reason, it is important to understand that feeling worse before feeling better is not a requirement of psychotherapy. It is not something that must happen, nor should it be actively pursued as a goal. Instead, it is one possible experience that may emerge for some patients as part of the therapeutic process.

To understand why this sometimes occurs, it is helpful to consider what psychotherapy is actually trying to achieve.

Most people enter therapy because they are struggling with something that has become difficult to manage alone. These difficulties may involve anxiety, depression, trauma, relationship problems, grief, emotional distress, low self-esteem, long-standing patterns of behaviour, or experiences that have never been fully understood or processed.

In the early stages of psychotherapy, much of the work focuses on building a therapeutic relationship.

The patient and the psychotherapist gradually get to know one another. Trust develops. The patient begins to feel safer discussing personal experiences. Questions are asked, information is gathered, and the difficulties that led the person to seek help become clearer.

At this stage, many patients feel relief simply because they are finally talking about issues they have carried alone for a long time.

As therapy progresses, however, something deeper may begin to happen.

The patient is no longer simply talking about difficult experiences.

They begin to reconnect with them emotionally.

Memories that have been kept at a distance may start to feel more immediate. Feelings that have been avoided for years may become more accessible. Experiences that have been discussed intellectually may begin to be experienced emotionally.

This is where the idea of emotional reawakening becomes important.

Many people have spent years protecting themselves from painful feelings through various coping mechanisms. Some minimise difficult experiences. Others intellectualise them. Some avoid thinking about them altogether. Others keep themselves constantly busy so that they never have to fully engage with what they are feeling.

These strategies often develop for good reasons.

At one point in life they may have been necessary for survival.

The problem is that what protects us from pain can also prevent us from processing it.

When psychotherapy creates sufficient safety and trust, these protective barriers sometimes begin to soften. The patient starts to experience emotions that may have been hidden, suppressed, avoided, or defended against for many years.

This can feel unsettling.

A person who has spent years avoiding grief may suddenly begin to experience profound sadness.

Someone who has protected themselves from anger may become aware of longstanding resentment.

A patient who has kept traumatic experiences emotionally distant may begin to reconnect with the fear, helplessness, or vulnerability that originally accompanied those experiences.

In psychodynamic psychotherapy, these moments are often understood as important parts of the therapeutic process.

The goal is not simply to discuss experiences but to understand them emotionally, psychologically, and relationally.

For some patients, this can lead to what is sometimes described as a cathartic experience.

The patient not only remembers what happened but re-experiences aspects of the emotional reality connected to it.

The feelings become alive again.

This can create the impression that things are becoming worse.

In reality, something different may be occurring.

Feelings that were previously hidden are becoming conscious.

Experiences that were previously avoided are being acknowledged.

Emotional pain that has been carried privately is finally being brought into a relationship where it can be understood, thought about, and contained.

Containment is particularly important during these periods.

A skilled psychotherapist does not simply encourage emotional expression and then leave the patient alone with overwhelming feelings.

The role of the therapist is to help the patient understand what is happening in the here and the now.

The emotional experience needs to be thought about, understood, and placed within a meaningful context.

When this happens effectively, the patient does not simply become overwhelmed by distress. Instead, they gradually develop a greater capacity to understand and manage difficult emotional experiences.

This is one reason why the strength of the therapeutic relationship is so important.

Patients who trust their therapist are often better able to tolerate difficult feelings because they no longer feel alone with them.

The relationship itself becomes part of the containment process.

However, it is equally important to challenge the belief that everybody must experience significant emotional deterioration before improvement can occur.

Many patients do not.

Some people enter therapy with a good level of psychological awareness. They understand their difficulties reasonably well and are motivated to work on them. They are able to reflect, think about emotional experiences, and engage actively with the therapeutic process.

For these individuals, progress may be relatively steady.

They may experience difficult moments, but they do not necessarily undergo dramatic periods of emotional worsening.

Other patients arrive with substantial resistance.

Resistance is not simply opposition to therapy. More often, it reflects understandable fears about change, vulnerability, dependency, emotional pain, or what might happen if long-avoided issues are finally confronted.

As these resistances begin to decrease, stronger emotional reactions sometimes emerge.

The patient becomes more open both to the therapist and to themselves.

This increased openness can temporarily make emotional difficulties feel more intense because the individual is no longer avoiding them in the same way.

Yet even in these situations, the purpose of therapy is not to make the patient suffer.

The purpose is to help the patient understand what is happening and develop the capacity to work through it.

This requires sensitivity, patience, and good clinical judgement.

Particularly when dealing with trauma, abuse, violence, loss, or other deeply distressing experiences, psychotherapists must be careful not to move too quickly.

Some patients understandably want rapid solutions.

They may request brief therapy for problems that have existed for decades.

They may hope that a few sessions will resolve difficulties that have developed over a lifetime.

While the wish for relief is understandable, some issues require time, patience, and careful exploration.

Attempting to force emotional breakthroughs before sufficient trust and stability have been established can be counterproductive and, in some cases, potentially harmful.

Good psychotherapy therefore balances exploration with containment.

It allows difficult material to emerge while ensuring that the patient remains emotionally supported throughout the process.

Ultimately, whether someone feels worse before they feel better depends on many factors. The personality of the patient, the nature of the difficulties being addressed, the strength of the therapeutic relationship, the degree of trust that develops, the presence of resistance, and the skill and experience of the psychotherapist all play important roles.

In clinical practice, meaningful change rarely comes from overwhelming patients with emotion. Rather, it emerges through a gradual process of understanding, reflection, emotional growth, and the development of a therapeutic relationship strong enough to contain difficult experiences when they arise. Some patients may experience temporary increases in emotional discomfort as previously avoided feelings become accessible, while others progress more steadily. What matters most is not whether a person feels worse before they feel better, but whether the therapeutic process is helping them develop a deeper understanding of themselves and a greater capacity to manage the difficulties that brought them into therapy in the first place.

DISCUSSION POINTS:

1. Do you think it is inevitable that people will feel worse before they feel better in psychotherapy?
2. Why might discussing long-avoided experiences sometimes increase emotional distress temporarily?
3. What role do you think trust plays in helping patients explore difficult feelings?
4. How important is the therapeutic relationship when working through painful experiences?
5. Do you think emotional pain that has been avoided for many years can be processed without being re-experienced to some degree?
6. What is the difference between feeling overwhelmed by emotions and understanding them?
7. Why might some patients improve steadily while others experience periods of increased emotional difficulty?
8. How should psychotherapists balance emotional exploration with emotional containment?
9. Do you think brief therapy is suitable for long-standing psychological difficulties?
10. In your view, what helps people remain engaged with therapy when difficult emotions begin to emerge?

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