Mental Health
What Really Happens in a Therapy Session

What Really Happens in a Therapy Session

10 min read


Caitlin Harper

Have you ever wondered what goes on in a real therapy session? Because of the confidential nature of therapeutic relationships and the stigma that still exists around seeking mental health treatment, we don’t always have a good idea of what happens behind closed doors.

Whether you’re new to therapy or you just wonder if your current experience is “normal” (spoiler: there is no “normal,” and the only thing that matters is that whatever care you receive is working for you!), we’ve collected some anonymized examples from actual sessions with our community of therapists so you can see the range of topics covered in-session.

It’s important to remember that if you don’t see something that resonates with you here, that your experience and needs are still totally valid. It’s impossible to have examples of everything we might experience, and your therapist will honor your unique life and its ups and downs and tailor your treatment and care to you. So here are just a few examples of what really happens in a therapy session.

When you first start therapy, you might not know what to expect

There can be a lot of anxiety around starting therapy, and that makes total sense. You’re embarking on a new journey, sharing your innermost thoughts and feelings with a total stranger, and, if this is your first time working with the therapist, it might all be new to you.

“I worked with a client who decided to come into therapy for the first time because they were experiencing panic attacks,” said Madison McCullough. “These panic attacks were often unpredictable and overwhelming. Through our work together, we identified that the primary source of the client’s stress was their living situation. Our work focused on equipping the client with the tools they needed to cope with panic attacks when they came up, as well as helping the client build up their assertiveness to confront their inconsiderate roommate and ultimately find a new (and much more supportive) living situation.”

Setting boundaries is an extremely common theme in therapy, and your therapist can help you identify where boundaries might be helpful and how to put them in place

Similar to “self-care,” the term “boundaries” has been popping up all over social media feeds. But, what do boundaries actually mean? Personal boundaries can be thought of like rules you set to manage stress, anxiety, and other emotions, and/or your physical space.

“One client was having difficulties managing an overbearing mother-in-law, who often used emotional manipulation such as guilt trips, crying, and other things to get her way,” said Andrea Yuen-Sing Chan. “While the client’s husband was understanding and intended to stand up to the mother, he seldom was able to, and the entire family eventually caved to the mother-in-law’s demands. This caused the client considerable resentment towards her husband, and they found themselves fighting and bickering more than ever. On top of all of that, they just had a baby and this had heightened the stakes.”  

“In this case, I worked with my client on a two part strategy,” Andrea said. “One way was to help her consider what her boundaries were with both her husband and her mother-in-law. My feeling was that her resentment came from her inability to effect change on her husband’s behavior, but meanwhile she was also failing to enforce her own boundaries with him. The expectation that the husband should stand up to his mother on my client’s behalf forced her husband to ‘choose’ who he loves more, which can escalate tensions for him no matter what he does. He was in a double bind.”

“It was better to find a way for my client to live with the real situation and effect change through managing her own resentment. One way of doing this was to set boundaries with her husband so he could set his own boundaries with his mother in order to maintain equilibrium for himself and his family. So I might say ‘when your mother-in-law makes requests or pursues a manipulative tone that is outside what you feel is reasonable, how can you best set boundaries with your husband that will mitigate your resentment?’”

“Of course, setting boundaries is very difficult because they are counterintuitive; at first they don’t feel good, they feel restrictive. This is often because people believe that more open, fluid boundaries indicate that we have been designated as special, as this person will do anything for us. On the contrary, boundaries are one thing that allows us to feel safe, and are absolutely essential in healthy intimacy, so establishing firm boundaries is really an act of love! Of course, too strict boundaries can also be a defense from getting close to someone, so one must walk the tightrope between the two (which a therapist does every day!).”

“For my client, the answer was in simple strategies such as saying things like, ‘I’d love to be a part of the family activity with my mother-in-law, but I don’t want to do this particular thing because I am afraid it will make me angry and resentful, and I want to feel good about our relationship. So I think I will sit this one out, unless we can find something that we all agree on.’ With time, this strategy really works!”

Social stigma, cultural differences, and our own ideas about mental health mean that talking about mental health can be difficult—especially with your parents. But kids and teens can go to therapy too!

Whether you’re a child, a teen, or in college, it’s never too early to seek the support of a therapist.

“A young woman came in to see me after graduating from college,” said Ariella Soffer. “She was feeling lost, depressed, and highly anxious as she didn’t know what career she wanted to pursue. She was also struggling with the relationship with her parents, as she was living back at home with them after having been away during college. During therapy we worked on identifying ways that she could label and express her feelings more effectively to reduce her panic and anxiety.”

“We identified areas of interest that could translate into prospective jobs/career paths, and worked on building her confidence so that she could interview more effectively. Over the course of the work together, this young woman began to assert herself more freely with her parents and started to feel more independent again, like she had in college. She started to feel more confident as she developed competencies and strengths as a working woman. Our work focused both on generating insight into the ways that she would internalize things her parents said that made her feel terribly about herself, and also on specific tools to help her navigate the life stressors she was facing (i.e. interviewing, dating).”

No matter your age, your therapist will take your individual needs and desires into account.

“Over the course of four months, I collaborated with an adolescent female in her senior year of high school; this healer was diagnosed with bipolar disorder and presented with difficulty navigating depressive states, social anxiety, low self-esteem, severe school avoidance, and strained relationships with her family members,” said Laquanique Lake. “Sessions focused on amplifying and affirming her reality by providing the space for her to uninhibitedly share her experiences and develop her own vision for her wellbeing.”

“This vision became the center point around which sessions were designed, focusing primarily on amplifying the empowering internal (heart’s) voice that she was already attuned to and using the truths spoken by that voice to identify, question, and challenge the unbalancing lies perpetuated by the mind. The healer was introduced to heart-led, narrative rewriting techniques and perspective-expanding communication strategies. She was also made aware of the ways in which she could use her spiritual and creative processes to take ownership of her choices and exert authority over emotion.”

“At the conclusion of our collaboration, the healer demonstrated increased school attendance, increased engagement with a positive peer group, improved emotional awareness, an increased ability to express feelings and emotions in a nonthreatening manner, the ability to collaboratively develop an emotion regulation plan that included parental support, and maintenance of her goal of remaining medication-free.”

Stress is a physical or mental response to an external cause, whereas anxiety is your body's reaction to stress and can occur even if there is no current threat—therapists can help with either

Experiencing occasional anxiety is a normal part of life. However, people with anxiety disorders frequently have intense, excessive and persistent worry and fear about everyday situations. Often, anxiety disorders involve repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes (panic attacks). Whether you have an anxiety disorder or are suffering from stress, your therapist will help you develop tools to cope.

“With one client who suffered from anxiety, we first talked about anxiety triggers—what makes him anxious?” said Jenna Sackman. “Then we explored if his anxiety (the effect) was proportionate to the trigger (the cause). We discussed that while we often cannot control the things that make us anxious, we can control our reaction to them which, in turn, reduces the intensity and power that our anxiety has over us. However, doing so requires a level of awareness and consciousness that we often don’t utilize.”

“In order to increase his awareness, we broke down the many ways that anxiety manifests itself physically (how does anxiety show itself in your body?), emotionally (how do you feel when you’re anxious?), and behaviorally (what do you do when you’re anxious?). From there, we discussed and practiced uniquely tailored techniques to mitigate and reduce his reaction to and manifestation of anxiety. For him, we discovered that mindfulness, particularly doing a quick body scan when experiencing physical symptoms of anxiety, and daily meditation were helpful in reducing his anxiety." 

With anxiety, there are often patterns in thought, behavior, and action that feed our symptoms. If we do not address those patterns at their core, our symptoms will likely return. Therapy will help you get to the root of what you are experiencing. Over time, you will release narratives that no longer serve you, increase your distress tolerance, and break the pattern of distressing symptoms moving forward.

“A client presented with work stress and our initial focus was on her giving examples of what she likes about her job and what issues she is facing, such as conflict with her supervisor, poor work/life balance, and not feeling in tune with the overall company mission,” said Jay Sandys. “It soon became clear that alignment with mission was an important variable for this client to feel work satisfaction. We continued to explore career goals, and along with this exploration, other underlying issues became apparent, such as the client’s conflictual relationship with her parents and how this colored how she viewed other relationships."

There are many ways to treat addiction and substance use and abuse, and your therapist can work with you to tailor a treatment that suits you the best

“With one client, we explored their active substance use,” said Sohaula DePeyster. “They had reached a point of low self-esteem, unemployment, and feelings of hopelessness. We started sessions by discussing what life was like before the addiction to understand a baseline. We then discussed triggers and how the drugs both aided and harmed the client. He became aware of his triggers and how the drug aided in building self-confidence.” 

“The client and I found four ways to replace the need of the substance through exercise, new employment opportunities, creating a supportive network, and building self-esteem. The client went from abusing substances daily to achieving recovery, gaining employment, and having purpose.”

Because substances are often used as a coping mechanism, your therapist will work with you to treat the underlying issues also.

“One of my clients came to therapy seeking help for his alcohol problem,” said Laura DeInnocentiis. “His progressive drinking had contributed to the end of a marriage and to the recent loss of a job. As a result, he temporarily moved in with his mother, the same person who disowned him for nearly 10 years when she learned of his homosexuality. While she eventually accepted him back into her home, she continued to control him and shame him about his sexuality.”

“He and I explored his chronic depression and anxiety he had been trying to alleviate with alcohol. We also revisited a specific traumatic event that occurred at a pivotal time in his development, which left behind a deep ‘mother wound.’ He continued to seek his mother’s love, acceptance, and approval but was consistently disappointed.”

“Our work focused on breaking down his protective defense mechanisms and allowed him to experience the intense feelings he had been suppressing for so many years. He learned to express his pain and anger instead of turning it inward. He developed healthy substitutions to cope with his feelings in place of drinking, which boosted his self-esteem and decreased his feelings of depression and anxiety. Gradually, he set appropriate boundaries with his mother and began accomplishing his own goals.”

Topics like self-esteem and self-doubt are common in people seeking therapy and can show up in all sorts of experiences—regardless of how they show up, your therapist will work through it with you

“One client who was experiencing a lot of self-doubt and feeling like the world was out to get her,” said Nicole Barman. “We explored her family dynamics, her move from Bangladesh to the United States, trauma she has endured, and the narrative she has created for herself. By exploring her past, we were able to investigate how it plays into the present. Together we discovered her desire to be taken care of, but in fact she always was taking care of others, which left her neglecting her own needs. A lot of the work included narrative therapy and CBT, and by the time we terminated, the client had made immense progress. When the client first came to me, she was unable to set boundaries; we worked on how she could express her needs to the people she loved without feeling guilty.”

“With another client, we did a lot of work on his self-esteem, how he perceived himself, and the internal dialogue he had with himself that would prevent him from doing things such as hanging out with friends,” said Nicole. “Together, we were able to discuss toxic masculinity and how this has affected the way he views himself. The client was able to be his most authentic self in the room, which crossed over in the real world as time went on. This client came to realize that people are not always staring at him and talking about him; he was able to go out into the world without his headphones in and his hood up, and he was able to express himself without as much fear about what others thought.”

Even when the surface topic is similar, such as with domestic violence and abuse, the individual needs of clients are different—and so is their care

“I’ve done a lot of work with survivors of violence, and even when people came in for what seemed to be similar issues, the work played out in different ways,” said Jill May. “One client, who was attempting to leave a domestic violence situation after 24 years, focused on what life could look like once she got out. She had a hard time believing it was possible.”

"We spent several sessions safely planning and talking about what was holding her back. Eventually, she came to the realization that she was afraid of what would happen or who she would be once she was free. We were able to move forward by recognizing that what happened to her was an integral part of her experience, but that it wasn’t something that defined her entire being.”

“Another client had already left a similar situation and had the same feeling of being stuck,” said Jill. “After sessions of discussing what happened to them and what they wanted for their life, I helped them prepare court documents. This was during COVID, so the work was virtual, but sometimes you just need someone that you trust to sit on the phone with you while you organize and scan police reports in preparation for court. Once the weight was lifted from that previous stress, this same client worked on other areas (sexual orientation exploration and past traumas).”

Chronic illnesses such as cancer, heart disease, or diabetes may make you more likely to have or develop a mental health condition, and there are therapists who specialize in chronic illness

It is common to feel sad or discouraged after having a heart attack, receiving a cancer diagnosis, or when trying to manage a chronic condition such as pain, and while temporary feelings of sadness are expected, if these and other symptoms last longer than a couple of weeks, it might be depression.

“One of my clients is struggling with a debilitating disease that leaves him bed-bound and at the mercy of others for basic needs,” said Christina Viera. “As a result, he is depressed and longing for a more active lifestyle. The client is contemplating assisted suicide and would like the assistance from his therapist to find resources that would help him make this happen. The client has full autonomy to make decisions that would benefit him, however, my role as the therapist is to process the client’s thoughts, feelings, and beliefs that led him to decide assisted suicide is an option.”

“Each session was approached with a person-centered therapeutic style to allow the client to feel a sense of control over his destiny, as I—as the therapist—believe the client has the power and tools to make the best decision. As the therapist, I allow the client to guide the session, while providing empathy, unconditional positive regard, and genuineness. To address the client's depressive symptoms, I perform CBT reframing techniques to address the negative self-talk the client experienced as a result of his condition.”

Even if you’ve recovered from an illness, the mental health impacts can linger. The good news is, a therapist can help you process your thoughts, feelings, and experiences no matter where you are in your health journey.

“During an eight-month period, I collaborated with a woman who, after recovering from cancer, experienced symptoms of depression and severe anxiety,” said Laquanique Lake. “We explored her vision of her healing, the details of her current challenges, what she discovered to be nurturing and hindering her healing journey, and the internal and external strengths that she could leverage in order to support her healing process.”

“When the healer was ready to take a more active role in creating the life experiences that she desired to have, our shared time became focused on using what she discovered about herself to develop tools, skills, and strategies that would help her achieve her goals. With guidance, encouragement, and persistent practice, the healer began to bring about the changes that she envisioned. Her experience shifted from one characterized by excessive sleeping, frequent panic attacks, isolation, and familial conflict to one wherein she created and effectively implemented an anxiety-reduction routine of her own; she began to actively pursue employment; she began adorning herself in ways that made her feel confident; she began to travel locally; and she began to experience less conflict with her children and spouse.”

It can be intimidating to start therapy without knowing exactly what might happen

But that’s part of the process—your treatment is going to depend on your unique experience and needs. Above all, your therapist is there to support you every step of the way. 

Whether you’re still not sure if you might benefit from therapy, you’re ready to find a therapist, or you’re already on your therapy journey and are looking to go deeper, we’re here to support you as well.

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About the author

Caitlin is an organizational change strategist, advisor, writer, and the founder of Commcoterie, a change management communication consultancy. She helps leaders and the consultants who work with them communicate change for long-lasting impact. Caitlin is a frequent speaker, workshop facilitator, panelist, and podcast guest on topics such as organizational change, internal communication strategy, DEIBA, leadership and learning, management and coaching, women in the workplace, mental health and wellness at work, and company culture. Find out more, including how to work with her, at

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