Anxiety is one of the most common emotional experiences encountered in psychotherapy. Most people associate anxiety with everyday worries such as work, relationships, finances or health. However, anxiety also develops within the therapeutic relationship itself. It appears at different stages of treatment and often tells us something important about what the patient is experiencing emotionally.
For the psychotherapist, understanding where that anxiety comes from is just as important as understanding the problems that first brought the patient into therapy. Rather than being something to eliminate immediately, anxiety often becomes an important source of information about the patient’s inner world, their past experiences and the way they relate to other people.
One of the first occasions when anxiety appears is at the very beginning of psychotherapy.
For people who have previously been in therapy, whether recently or many years ago, starting treatment with a new psychotherapist often brings considerable uncertainty. Even though they may already understand what psychotherapy involves, beginning again with someone new is rarely a neutral experience.
Many questions naturally arise.
What will this psychotherapist be like?
Will they understand me?
Do they have enough knowledge and experience to help with my particular difficulties?
Will they really listen to what I have to say?
Will therapy help me, or will it make me feel even worse?
Will I change?
If I do change, will those changes be helpful, or will they be frightening?
These questions are perfectly understandable. Entering psychotherapy means placing one’s emotional life into the hands of another person. That requires a considerable amount of trust, particularly when previous experiences of relationships may have involved disappointment, neglect, criticism or emotional pain.
For some patients, these worries settle relatively quickly as the therapeutic relationship begins to develop. For others, particularly those who are naturally more anxious or who have experienced significant trauma, the uncertainty may remain for much longer.
This is why it is so important for the psychotherapist to recognise these anxieties from the very beginning rather than waiting for the patient to raise them. Simply acknowledging that it is natural to feel uncertain can itself reduce a great deal of anxiety. It helps the patient recognise that their reactions are understood and expected rather than seen as unusual or problematic.
One of the most important foundations of psychotherapy at this stage is what we call containment.
Although the word may sound technical, the idea itself is actually very straightforward.
Imagine placing something hot into a glass jar and then putting the lid on securely. The contents remain safely inside. They do not spill out or spread beyond the container.
Psychological containment works in a similar way.
The therapy session becomes a place where painful thoughts, overwhelming feelings, fears and anxieties can be safely held. Rather than escaping into every part of the person’s daily life, they are brought into a space where they can be thought about together with the psychotherapist.
Whether the therapy takes place in a consulting room or online, the principle remains exactly the same.
The therapeutic setting itself becomes the container.
The room.
The regular appointment.
The reliable presence of the psychotherapist.
The knowledge that what is discussed remains confidential.
Together, these provide a sense of safety that allows even the most distressing experiences to be explored gradually rather than becoming emotionally overwhelming.
For many patients, this experience of containment is unlike anything they have previously known.
Perhaps they have spent years keeping everything to themselves.
Perhaps they have felt that no one was willing to listen.
Perhaps they feared that once painful feelings emerged, they would become impossible to control.
Psychotherapy offers a different experience. Difficult emotions do not have to be faced alone, nor do they have to be pushed away. Instead, they can be held within a safe, professional and confidential therapeutic relationship until they become easier to understand.
For many people, this is the first step in reducing the anxiety that accompanied them into therapy. It is not simply the discussions themselves that provide reassurance, but the experience of knowing that whatever is brought into therapy can be contained, thought about and understood without becoming overwhelming.
This sense of containment forms one of the foundations upon which the rest of psychotherapy is built.
Another significant source of anxiety in psychotherapy often emerges towards the end of treatment.
For patients who have been in long-term psychotherapy, particularly those who have attended regularly over several years, the therapeutic relationship frequently becomes one of the most important relationships in their lives. It is built gradually through trust, consistency, confidentiality and the shared experience of working through some of life’s most painful difficulties.
For many people, there is simply no other relationship quite like it.
Many years ago, I remember discussing this with a colleague who was both a psychotherapist and a priest. We spoke about the difference between what people brought to confession and what they brought into psychotherapy. Although there are similarities, there was also an important difference. During psychotherapy, many patients gradually reach a point where they begin talking about experiences that they have never shared with another person. They may have carried these thoughts, memories and feelings for decades without ever finding a place where they felt sufficiently safe to speak about them.
This makes the therapeutic relationship unique.
As trust develops, patients often begin discussing experiences of trauma, bereavement, abuse, violence, profound loss or deeply personal events that have remained hidden throughout much of their lives. They are not simply telling another person about these experiences. They are allowing another person into parts of their emotional world that have often remained inaccessible to everyone else.
It is therefore understandable that the thought of bringing psychotherapy to an end can create considerable anxiety.
Many questions naturally arise.
What will happen when therapy finishes?
Will I cope without these sessions?
Will I lose the progress I have made?
Who will I talk to if something difficult happens again?
Will I miss my psychotherapist?
Will I feel alone again?
These concerns are entirely understandable because endings frequently awaken much older emotional experiences.
For some patients, the end of psychotherapy brings back earlier experiences of separation, bereavement, loss or abandonment. The emotions connected with previous endings in life often become intertwined with the ending of therapy itself.
For this reason, ending psychotherapy should never be viewed simply as the final appointment.
It is a therapeutic process in its own right.
One of the most important tasks during this stage is helping the patient develop what many psychotherapists refer to as an internal therapist.
Over months or years of working together, patients gradually begin developing an internal way of thinking that reflects the conversations they have shared with their psychotherapist. They begin asking themselves the kinds of questions that previously would have been asked during therapy. They begin reflecting rather than reacting immediately. They become more able to understand their own emotional responses before acting upon them.
In time, the therapeutic dialogue becomes something the patient can continue within their own mind.
This does not replace the psychotherapist.
Nor does it remove the emotional experience of saying goodbye.
The loss remains real because the relationship itself has been real.
The psychotherapist will no longer be sitting in the consulting room or appearing on the computer screen at the agreed time each week. That absence is naturally felt, particularly when the relationship has become an important source of stability, understanding and emotional support.
However, although the therapist is no longer physically present, something important remains.
The understanding developed together.
The ability to reflect.
The capacity to think before reacting.
The experience of feeling understood.
These gradually become part of the patient’s own psychological resources.
Many patients discover that, after therapy has ended, they find themselves remembering conversations they once had with their psychotherapist. They begin approaching difficult situations differently because they have internalised a new way of thinking about themselves and their relationships.
This is one of the lasting benefits of successful psychotherapy.
The relationship comes to an end, but much of what was developed within that relationship continues to live on within the patient.
Although the anxiety surrounding the ending of psychotherapy can be considerable, it often reflects the importance of the relationship itself. Rather than avoiding these feelings, psychotherapy encourages them to be spoken about openly. In doing so, the ending becomes another valuable part of the therapeutic work rather than simply the point at which treatment stops.
Another important form of anxiety often emerges only after a strong therapeutic relationship has developed.
As trust grows between the psychotherapist and the patient, people gradually begin speaking about experiences that they have never disclosed to anyone before. Some have lived with these memories for decades. Others have spent years trying to forget them or convincing themselves that they should never be spoken about.
These may include experiences of trauma, violence, abuse, profound bereavement or other deeply painful events that have remained hidden throughout much of their lives.
For many patients, speaking about these experiences for the first time can feel both relieving and frightening at exactly the same time.
The relief comes from no longer carrying the burden alone.
The anxiety comes from allowing another person to know something that has never previously been shared.
Many patients begin worrying about confidentiality.
Who will know about this?
Will anyone else have access to my information?
What happens to therapy notes?
Are recordings made?
Who can read the records?
Will this ever become public?
These questions are entirely understandable. They often become particularly important when patients disclose experiences that may have legal implications or involve serious criminal acts committed against them.
Some patients worry that simply talking about these events will automatically result in legal proceedings or public disclosure. Others fear that once the information has been spoken aloud, they will somehow lose control over what happens to it.
This is why it is so important for the psychotherapist to explain confidentiality carefully from the very beginning of treatment and to revisit these discussions whenever necessary.
Patients need to understand that psychotherapy provides a professional, confidential and carefully contained space in which they can speak openly about even the most painful experiences.
There are, of course, rare situations where confidentiality cannot be maintained completely, such as when there is an immediate risk to life or serious harm to another person. Whenever these situations arise, they should be discussed openly and sensitively with the patient so that there are no unexpected surprises.
For the overwhelming majority of therapeutic work, however, confidentiality remains one of the cornerstones of psychotherapy.
Knowing that their experiences will be treated with respect, sensitivity and discretion allows many patients to speak about events that they have carried alone for years.
Containment and confidentiality work together.
The patient gradually discovers that painful experiences can be spoken about without becoming emotionally overwhelming and without losing control over their own story.
Another source of anxiety sometimes develops when patients begin wondering whether the psychotherapist can truly understand them.
This may centre on differences in age, ethnicity, nationality, religion, language or cultural background.
Patients sometimes wonder whether someone from a different background could possibly understand what they have experienced.
These concerns should never be dismissed or criticised.
Instead, they deserve thoughtful exploration.
Sometimes these worries genuinely reflect questions about culture or life experience.
At other times they tell us much more about the patient’s own concerns than they do about the psychotherapist.
Over the years, I have often noticed that when patients became particularly interested in my own background, education or my personal experiences, the questions were rarely about me alone.
More often, they reflected something the patient was trying to understand about themselves.
The issues they raised were frequently difficulties that they themselves had been struggling with for many years.
Their curiosity was understandable, but it often pointed towards something much deeper within their own emotional life.
This can be seen in many different situations.
Someone who has experienced war may feel immediately understood if their psychotherapist has lived through similar experiences.
Another patient may feel anxious precisely because they imagine that the therapist comes from a background associated with people who caused them suffering.
These reactions are understandable, but they arise from the patient’s own experiences, memories and emotional world.
What ultimately matters in psychotherapy is not the psychotherapist’s ethnicity, religion, nationality or country of origin.
What matters is the therapist’s knowledge, experience, ability to understand, capacity to contain difficult emotions and willingness to engage thoughtfully with whatever the patient brings into therapy.
Very often, the anxieties that patients experience about these differences gradually become important subjects for therapeutic exploration rather than obstacles to treatment.
There is another group of patients whose anxiety centres upon the effect that psychotherapy itself may have on their daily lives.
This is particularly common among people living with long-term depression, chronic physical illness or conditions that affect not only themselves but also their partners, children and families.
These patients often worry about what will happen after the session has finished.
Will I be able to cope?
Will talking about these issues make me feel worse?
Will I continue thinking about today’s session all evening?
How will this affect my family?
Will I still be able to manage my responsibilities?
These concerns are entirely understandable because psychotherapy often brings people into closer contact with feelings that have been avoided for a long time.
The aim, however, is never to overwhelm the patient.
The purpose is to help them understand these experiences gradually within a safe and supportive therapeutic relationship.
For many people, one of the greatest sources of comfort is simply knowing that they no longer have to carry these difficulties alone.
There is another mind thinking with them.
Another person helping them to make sense of experiences that may previously have felt confusing, frightening or impossible to manage.
That experience alone often reduces anxiety significantly.
It reminds the patient that support is available and that even the most difficult experiences can become more manageable when they are shared within a professional therapeutic relationship.
The anxieties described throughout this article are among the most common encountered in private psychotherapy practice, where patients enter treatment voluntarily because they want help in understanding themselves and improving their lives.
The picture can be quite different in statutory mental health settings, where treatment may sometimes be compulsory or provided within hospitals or other services. The anxieties that emerge in those settings are often influenced by very different circumstances and deserve separate discussion.
Ultimately, anxiety should not simply be viewed as another symptom to eliminate.
Within psychotherapy, anxiety often tells us something important about what matters most to the patient.
Whether it appears at the beginning of treatment, during the development of the therapeutic relationship, when deeply personal experiences are disclosed, or as patients begin thinking about the impact of therapy on their lives, anxiety points us towards the areas that require the greatest understanding and care.
When approached with patience, containment and thoughtful exploration, anxiety gradually becomes not an obstacle to psychotherapy, but one of its most valuable guides.
Discussion Points
- Have you ever felt more anxious about starting psychotherapy than about the problems that brought you to therapy in the first place? What were your biggest concerns?
- Do you think feeling safe, understood and emotionally contained is one of the most important foundations of successful psychotherapy? Why or why not?
- Have you ever found yourself worrying that a psychotherapist could not fully understand you because of differences in age, culture, nationality or life experience? How did those concerns develop over time?
- For those who have experienced long-term psychotherapy, what was it like thinking about the ending of treatment? Did you notice feelings of loss, uncertainty or separation?
- Do you think anxiety in psychotherapy should always be reduced as quickly as possible, or can it sometimes become an important source of understanding and psychological growth?
- Looking back on your own experiences, has there ever been a time when sharing something you had never told another person reduced your anxiety more than you expected? What made it possible to speak about it?
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