Therapy hangover: why you can feel worse after a session

What is a therapy hangover?

Research does recognise that sessions affect how you feel afterwards. A standard research questionnaire asks clients how they feel “right now” at the end of a session, on scales such as “happy–sad”, “calm–excited”, “confident–afraid” and “wakeful–sleepy”^[3]. A review of side effects in therapy notes that “crying in psychotherapy may be unavoidable or even necessary”^[4].

What we could not find is any reliable figure for how common a therapy hangover is, or how long it lasts. Time spans you may see quoted online are not backed by any research we found. This article is about the hours and days after any session. If you are just starting, our guide to your first therapy session covers what to expect.

Why you can feel worse after a therapy session

You went somewhere painful

Researchers who study sessions rate them on two separate scales. One is depth: how powerful and valuable the session felt. The other is smoothness: how comfortable and safe it felt^[5]. Research supports treating these as separate^[3], so a session can be one of the most useful you have had and still leave you rattled.

Early sessions can be rougher. In a study of 117 people with depression who rated every session, sessions felt more positive as therapy went on. Early on, sessions in one of the therapies were “less smooth (i.e., more tense and uncomfortable)”^[6].

Feeling things is part of the work, in the right dose

Across 66 studies, clients who expressed more emotion in therapy tended to have better results. That is a link, not proof of cause^[7]. But more is not always better. In a small study of 38 clients, “Too much or too little emotion was found to be not as helpful as a moderate amount”^[8]. Pace matters, and it is something you can talk about with your therapist.

The session itself is tiring

An hour of talking about hard things, while paying close attention, takes effort. If you have a session by video and go straight back to work, there is no journey home to let it settle. There is more on video sessions below.

Does feeling worse mean therapy is working?

Not necessarily. You may have read that feeling worse after a session shows you are “really processing” things. The research does not back that up.

• In one study of CBT and another talking therapy, the change in clients’ mood from the start to the end of a session was “unrelated to outcome” in both^[1].
• In an older study of 40 clients, their own ratings of their sessions “did not show the expected correlations with improvement”^[5].
• Researchers reviewing negative effects in therapy list the belief that patients need “to feel worse before feeling better” as something that is not well understood, not as a rule^[9].

So one rough evening does not prove therapy is working, and it does not prove it is failing. It is also normal for progress to be uneven. “Psychotherapy does not always follow a linear path”: in a study of 1,500 outpatients, about 3 in 10 had a sudden shift, up or down^[10]. Sudden improvements are common, and across 50 studies they were linked with better results at the end of therapy^[11]. That does not mean a bad session is a sign a breakthrough is coming. It is more useful to look at how things go over several weeks, and to talk about it.

Feeling worse during trauma therapy

Trauma-focused therapies for PTSD, such as prolonged exposure (PE), cognitive processing therapy (CPT) and EMDR, ask you to face painful memories. Here, feeling worse for a while is common and usually passes:

• In a study of 183 people having CPT in community services, 67.3% had at least one temporary rise in symptoms. Only 1.6% still had higher symptoms at the end, and the rises did not predict who finished therapy or how well they did. The authors suggest these rises “may be a normal, transient part of treatment”^[12].
• In two trials with 192 women, symptoms got worse for a while in 28.6% of people having CPT and 20.0% having PE. Those people ended with slightly higher symptom scores on average, but they still improved clearly, and they were no more likely to stop^[13].
• In an earlier study of exposure therapy, only a minority had a reliable rise in symptoms, and those who did “benefited comparably from treatment”^[14].

The US National Center for PTSD says the discomfort in CPT is “usually brief and people tend to feel better as they keep doing CPT”, and that “Most people who complete CPT find that the benefits outweigh any initial discomfort”^[15]. It says much the same about EMDR^[16] and PE^[17].

Good trauma therapy should also help you cope between sessions. UK guidance says EMDR should “include the teaching of self-calming techniques and techniques for managing flashbacks, for use within and between sessions”, and trauma-focused CBT should include “strategies for managing arousal and flashbacks, and safety planning”^[18]. One caveat for EMDR: of 51 trials, only nine mentioned side effects. Where they were reported, they were typically mild and temporary, but the evidence is thin^[19]. These figures are about trauma therapy, not all therapy. Our page on trauma explains more.

What helps after a hard session

There is very little research on what helps after a hard session specifically. Below, each step says where the idea comes from.

Things like a warm shower or a weighted blanket may feel comforting, and that is fine. We found no research testing them for this.

Tell your therapist, and how to raise it

If a session left you feeling worse, say so. That includes feeling hurt or misunderstood by something your therapist said. An NHS talking therapies service puts it simply: “We understand that therapy can be hard and sometimes it can make you feel worse before you start to feel better. If you have any concerns around your therapy or aren’t sure if it feels right, please speak to your therapist”^[2]. The BACP says you should feel able to give “honest feedback on how you feel about your therapy and how you’re working together”^[23].

Do not assume your therapist already knows. One study found that “clinicians rarely accurately predict who will not benefit from psychotherapy”^[24], and a review notes they “are often poor at recognising if a patient has worsened”^[9]. When therapists get regular feedback on how clients are doing, fewer of the clients at risk of doing poorly get worse^[25]. Talking about a strain in the relationship can help too. Across 11 studies, when a strain between client and therapist was repaired, results tended to be better. That is a moderate link, not proof^[26].

You can ask your therapist to slow the pace, to leave time at the end of a session to settle, or to teach you ways to calm down between sessions. If you are not sure how to start, you could say (these are our suggestions, not a script):

• “Last session stayed with me for days.”
• “Can we slow down a bit?”
• “Could we leave some time at the end to settle?”
• “Something you said last time has been on my mind.”

If it keeps happening, it is fair to ask whether this is the right approach or the right therapist. NIMH says: “If you have been in therapy for what feels like a reasonable amount of time and are not getting better, talk to your therapist”^[27]. The BACP adds that “if you’re unsure about your therapist or their approach, you can look for another one”^[23]. Our first-session guide has questions to help you judge the fit.

On Bliss Therapy

On Bliss Therapy you choose a therapist yourself, who speaks your language, by video, with no waitlist. If it is not the right fit, you can choose someone else. 52 psychologists and counsellors list anxiety and stress, with sessions from €30 (about £25). Between them they speak 23 languages. See how it works.

Our therapists are based outside the UK and the US, so they are unlikely to be on UK registers or covered by US health insurance. Ask any therapist about their training and their registration in the country where they practise.

Feeling drained after online therapy

Bliss Therapy sessions are by video, so this matters to us too. Research on video meetings, not therapy, found that people who used video calls more often, for longer and “with fewer breaks” reported more tiredness. So did people who felt anxious seeing their own face on screen or felt physically trapped in front of the camera^[28]. We found no study of clients’ tiredness after video therapy, so treat this as a hint, not a finding.

Video therapy works about as well as in person for common problems. A review found therapy “is no less efficacious when delivered via videoconferencing than in-person”^[29]. A few low-risk ideas, which are common practical advice: hide your own video if you can, step away from the screen when the call ends, and take a short walk to stand in for the journey home.

When feeling worse is a warning sign

Feeling low for an evening after a hard session is different from getting steadily worse. Therapy does not help everyone, and a small share of people get worse. In depression trials, 5% of people in therapy got worse, compared with 12% to 13% in the comparison groups^[30]. In a survey of 14,587 people treated in England and Wales, 5.2% said therapy had lasting bad effects. The authors say therapists “should discuss the potential for both the positive and negative effects of therapy before it starts”^[31]. As one review puts it, “psychotherapy is not free of side effects”^[4].

Talk to your therapist soon if:

• the low or shaky feeling after sessions does not pass
• it gets more intense week after week
• you feel worse overall, not just after sessions
• it is affecting your sleep, eating or work
• you have started to dread or avoid your sessions
• you have new or stronger thoughts of harming yourself

If you are getting worse overall, a doctor can help too. The NHS says: “Speak to a GP if you’re still having problems after your CBT has finished”^[32].

You can tell your therapist about dark thoughts. In one small study, clients who hid suicidal thoughts often feared what would happen, such as being sent to hospital, and may have had “exaggerated or inaccurate ideas about the consequences of disclosure”^[33]. If you are worried, ask your therapist what would happen if you told them.

Therapy is not an emergency service. “If you’re feeling like you want to end your life, it’s important to tell someone”^[34]. “A mental health emergency should be taken as seriously as a physical one”^[35]. In the US, the 988 Lifeline “is available 24/7/365. Your conversations are free and confidential”^[36].