Many patients leave their first analytic sessions feeling worse and think about stopping. Freud and André Green help explain why this pain is often a sign that the work has begun — and how to tell the pain of working through from the pain of a technical problem.
A scene repeats itself with regularity in the first weeks of any serious analysis. The patient begins psychotherapy with a reasonable expectation of relief: they sought help because they were suffering, they imagine the process will slowly make the suffering more manageable, and they expect to leave each session a little lighter than they came in. At some point between the third and the eighth session, that expectation is frustrated. They leave the session worse. They feel anxious at night. They have a strange dream. They cry for no apparent reason on Monday morning. They feel irritated with people close to them who didn’t bother them before. And they arrive at the next session with a doubt they often don’t voice: am I getting worse because of this? Should I stop?
This is one of the most important questions at the start of an analysis, and the clinical answer needs to be given with precision — because both “yes, this is bad, stop” and “no, hang in there, it will pass” can be wrong, depending on what is happening. This text deals with that distinction. And it begins with a thesis that psychoanalysis has held for more than a century: an important part of what hurts in analysis hurts because the work is beginning to function, not because it is failing.
What emerges when the silence loosens
The starting point is to understand what psychotherapy mobilizes, technically. Before any analysis, the patient lives with a certain psychic organization that has served — well or poorly — to keep life running. That organization includes defenses, avoidances, ways of not feeling what would be costly to feel, ways of not thinking what would be costly to think. What analysis does, when done well, is create a space in which those defenses loosen. Not because the analyst attacks them — they don’t — but because the setting, the regularity, the attentive listening and the guarantee of confidentiality produce a psychic temperature in which what was held back can begin to move.
When that begins to happen, material that had been kept out of consciousness begins to present itself. Not necessarily as organized thought — it often comes as anxiety without an object, as sadness that appears without explanation, as irritation with specific people in one’s close circle, as dreams that bring back old scenes. It is the unconscious delivering material. Freud called this the return of the repressed. André Green described it, among other things, as the work of the negative — what had been kept in absence begins to present itself.
This material doesn’t arrive comfortably. It arrives whole, with its own weight, and it arrives before the patient has the resources to work it through. That is why it hurts. Not because the process is wrong — because the process is beginning to do what it set out to do.
Resistance has a recognizable shape
There is a clinical sign that usually accompanies this moment, and it is useful to be able to recognize it: resistance to continuing appears precisely when the work begins to reach something important. It is as if the psychic structure, sensing that valuable material is about to emerge, mobilized defenses to postpone the encounter. This can present itself in several forms. A sudden urge to cancel sessions. Doubt about the analyst’s competence. The impression that “I’m not making progress.” A sudden conviction that “I’ve already resolved what I needed to resolve.” A specific tiredness before sessions that doesn’t appear before other commitments.
Freud devoted an important part of his work to describing this dynamic, especially in texts such as “Remembering, Repeating and Working-Through.” The clinical reading he proposed — and that experience with patients continues to confirm — is that the intensity of the resistance tends to be proportional to the importance of the material that is about to emerge. In other words: when the patient feels a strong urge to stop, it is often because the work is about to reach something decisive.
Not always. And that is where the reading needs to be done with care — because not all pain in analysis is the pain of working through.
When the pain is a sign that something is wrong
There are situations in which post-session discomfort doesn’t signal progress in the work, but a problem in the setting or in the analytic relationship. These situations are worth naming, because confusing one with the other has real consequences.
If the patient feels that the analyst intrudes, over-interprets, makes remarks that sound aggressive or disqualifying, that is not working through — it’s a technical failure. A well-trained analyst knows that premature or ill-timed interpretation produces pain without corresponding clinical yield. If the discomfort has that quality — of intrusion, humiliation, lack of understanding — it’s worth bringing the subject into the session itself. A good analyst receives this without defensiveness and adjusts the technique.
If the patient leaves the session feeling they weren’t heard, that the analyst was distracted, that there was no continuity with the previous session, that isn’t working through either — it’s a sign that the therapeutic alliance is fragile. A fragile alliance can be worked on, but it can’t be ignored. It’s worth talking about.
If the post-session pain is accompanied by progressive worsening of symptoms over months — not transient turbulence, but sustained worsening — it’s worth reassessing. An analysis that keeps getting worse without responding to the work for many months in a row calls for reassessment, whether to adjust the method, to include pharmacological treatment if it is indicated, or, in specific cases, to recognize that the analyst-patient pairing isn’t working and that it’s worth considering another partnership.
The criterion for separating the pain of working through from the pain of a problem is, deep down, this: the pain of working through produces movement — even if painful, something moves, a dream appears, a memory appears, a new reading appears, the overall picture fluctuates but moves forward. The pain of a technical problem is stagnation with suffering: nothing emerges, nothing takes shape, the patient leaves worse and stays in the same position session after session without progress.
What to do in the middle of this
The clinical recommendation I hold with my patients when this moment arrives is a single one: don’t decide whether to continue or interrupt analysis under the immediate effect of a difficult session. The time to decide that is later — when the psychic temperature drops — and, ideally, within the next session itself, talking with the analyst about the experience.
What well-trained analysts expect from this moment is not that the patient suffer stoically and say nothing. It’s that they bring the experience into the consulting room: “I left the last session feeling very bad, I had dream X, I thought about stopping.” That is precisely the clinical material with which the work moves forward. By bringing it, the patient allows the analyst to work with it — and this often unblocks the material that was emerging, allowing it to be worked through.
Staying silent out of politeness, or out of fear of offending the analyst, or out of doubt about “whether it’s normal to feel this,” is what usually leads patients to give up at stages in which a direct conversation would unblock weeks of work.
The goal of the process
It’s worth ending where psychotherapy stands as a real possibility: the goal of the work is not to make the patient suffer. It’s for the suffering that already existed — in other places in life, in diffuse form — to begin to present itself within the setting, where it can be worked on, so that it stops running everything else.
What hurts in analysis, when it hurts for the right reason, is precisely what had already been hurting underneath, now with a name, a form, an outline. And what gains a name can be worked through. That is the clinical wager that sustains the method. Not that the pain will end — no serious analysis promises that — but that the pain stops being unnamable, and therefore stops running life in the same way.
If you have been in analysis for a short time and the process is hurting, it’s worth opening this subject with your analyst. It is not a sign that you should stop. Often it’s a sign that the work is beginning exactly where it needed to begin.
Related reading
- Psychotherapy once, twice, or three times a week: why higher frequency does not mean greater severity
- I leave the session worse than I came in: when this is work, when it is a warning sign
- When the psychiatrist is your own psychotherapist: the advantages of combined treatment with the same professional
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Dr. Leonardo Sodré is a psychiatrist and psychotherapist in Brasília, Brazil (CRM-DF 14.206 · RQE 14.761). He holds a PhD in Psychiatry from UFRGS and teaches at the University of Brasília School of Medicine. This content is informational and educational, and does not replace individual clinical evaluation, diagnosis, or treatment.