Holding back in therapy is common, and a doubt said out loud can be worked on together

Many people hold things back in therapy. Some of what goes unsaid is personal. Some of it is about the therapy itself, such as a comment that did not sit right, or a sense that the sessions are not helping. If you are in therapy, you may wonder whether it is all right to say so. If you are a therapist, you may wonder what your clients are not telling you. Both people have a stake in the answer, because what goes unsaid is often where the work can change.

I want to be clear that this is not a post about blame. Holding back is common, and in the research the reasons clients give are mostly kind ones: wanting to be polite, not wanting to upset the therapist, or finding a topic uncomfortable (Blanchard & Farber, 2016). None of this makes someone a bad client. What the research does suggest is that a doubt said out loud is something a client and therapist can work on together.

The first post in this series looked at what therapists may miss. This one looks at what clients may not say.

What clients hold back, and why

In an online survey of 547 adult psychotherapy clients, 93% said they had lied to their therapist at least once, and 72.6% said they had lied about at least one topic related to therapy itself (Blanchard & Farber, 2016). It is not a figure for all clients: it comes from one self-selected online sample, it relies on memory, and "ever lied" includes small, polite untruths.

Common therapy-related lies included pretending to like the therapist's comments, giving false reasons for being late or missing sessions, and pretending to find therapy effective (Blanchard & Farber, 2016). Not admitting to wanting to end therapy was among the lies clients rated most extreme (Blanchard & Farber, 2016). Together, these describe doubts about therapy, kept quiet.

The reasons matter as much as the lies. Typical reasons for therapy-related lies were "I wanted to be polite", "I wanted to avoid upsetting my therapist" and "this topic was uncomfortable for me" (Blanchard & Farber, 2016). One reading, which is an inference rather than a finding, is that holding back is often a way of protecting the relationship, not a lack of commitment to therapy.

A review of the disclosure research concluded that most clients disclose deeply personal experiences in therapy, while a significant proportion conceal some significant information (Farber, 2003). Clients tend to keep negative reactions in the moment, in session, to themselves (Farber, 2003).

How common holding back looks depends on the question asked. Of 115 people in therapy, about half were keeping a secret from their therapist (Baumann & Hill, 2016). In a survey of 83 outpatient clients at a mental health hospital, 27.7% of clients said they were keeping a relevant secret from their therapist (Kelly & Yuan, 2009). These figures differ because the studies asked different questions of different people, so they should not be merged into one number.

Secrets and shame: what clinicians can expect

This section is mainly for clinicians, so that therapists can expect the topics clients find hardest to raise.

In the same study of 115 people, most had revealed a secret to their therapist, even as about half were keeping one (Baumann & Hill, 2016). Concealed secrets were most often sexual in nature, and were kept because of shame or embarrassment (Baumann & Hill, 2016). A review of the disclosure research points the same way: shame inhibits the disclosure of negative feelings, and sex, aggression and personal failure were among the least discussed topics in therapy (Farber, 2003). In the survey of therapy-related lies, the lies clients rated most extreme included romantic or sexual feelings toward the therapist (Blanchard & Farber, 2016). Clinicians can expect some material to arrive late, if at all, and can make room for it.

Two small studies from the early 1990s asked clients straight after a session what they had left unsaid (Hill et al., 1993; Regan & Hill, 1992). Most of what went unsaid was negative, often reactions to the therapy itself, and therapists usually could not tell what it was. As summarised in later reviews, counsellors in the brief-therapy study correctly identified what their client had held back 17% of the time, and in the long-term study, 17 of 26 clients said they had left reactions unsaid, while 27% of therapists correctly identified the kind of reaction (Balmforth, 2012; Marks, 2017). These are small, older studies with trainee counsellors in one and self-selected pairs in the other, and the original papers could not be read.

There is also a hopeful side. Disclosed secrets were most often about relationships, and clients shared them because they trusted their therapist and thought sharing would help (Baumann & Hill, 2016). Clients said they would share a concealed secret if keeping it stopped them making progress, and about half of those keeping a secret thought they would eventually disclose it (Baumann & Hill, 2016). Looking back, clients recalled equal negative and positive feelings when they first disclosed a secret, but felt more positive and less negative about it now (Baumann & Hill, 2016).

In interviews with 21 clients, most in long-term psychodynamic therapy, disclosing at first brought shame and anxiety, but in time brought feelings of safety, pride and authenticity (Farber et al., 2004). Clients felt that keeping secrets held back the work, and said that therapists should actively pursue material that is hard to disclose (Farber et al., 2004). I like to call this a meta-level conversation: a conversation about the conversation. For example: "How is this going?", "How are you feeling talking about this?" or "I'm noticing that when I say X, you respond with Y." This places part of the work of disclosure with the therapist. It is a small sample from mostly one kind of therapy.

Why it matters: a strain has to be spoken to be repaired

Holding back matters most when what goes unsaid is about the relationship itself. Researchers call this rupture and repair: a strain in the working relationship between client and therapist, and the work of noticing it and working it through together. Eubanks et al. (2018) define a strain of this kind as a deterioration in the therapeutic alliance, such as disagreement on the goals of therapy, a lack of collaboration on its tasks, or a strain in the emotional bond.

Strains themselves go with somewhat poorer outcomes. A recent meta-analysis included only studies that measured strains directly (Babl et al., 2026). Four publications met its criteria, giving 18 effect sizes from 301 clients, and strains were associated with poorer therapy outcomes, r = -0.21, which the authors describe as a small but consistent negative association (Babl et al., 2026). This is a small, correlational evidence base, and the authors call for a larger analysis that also looks at repair (Babl et al., 2026). It does not show that strains cause poorer outcomes.

Repair, on the other hand, goes with better ones. Across 11 studies with 1,314 patients, repair was linked to better outcomes, r = .29 (d = .62, p = .003), a moderate relation (Eubanks et al., 2018). This too is an association, not proof of cause. Together, the two findings suggest that what happens after a strain may matter.

This is where holding back comes in. Clients keeping a relevant secret rated the working alliance significantly lower, and their therapists also reported a weaker alliance, even though the therapists typically did not know about the secret (Kelly & Yuan, 2009). Keeping a secret was also negatively related to the "real relationship" with the therapist (Baumann & Hill, 2016). Both studies are cross-sectional, so the direction is unknown: secret keeping may weaken the relationship, or it may happen more when the relationship is already weak (Kelly & Yuan, 2009).

The next step is an inference, not a finding. A strain a client keeps to themselves is hard to repair, because neither person can work on what has not been named. A doubt said out loud gives both people something to work with.

What the evidence does not show

• How often strains go unrepaired is not known. None of the studies here measured it.
• It does not show that holding back causes worse outcomes. Keeping a relevant secret was not related to symptom change (Kelly & Yuan, 2009), and the links with the relationship are cross-sectional.
• It does not show that repair causes better outcomes. The meta-analysis found a moderate association (Eubanks et al., 2018).
• It does not show that training therapists in repair is useless, or that it works. Across 6 studies with 276 trainees or supervisees, training or supervision in resolving strains did not show a significant pooled link to patient outcome (r = .11, d = .22, p = .28). The link was stronger in brief treatment, in training closer to cognitive behavioural than psychodynamic therapy, and in samples with fewer patients with personality disorders (Eubanks et al., 2018).
• No source here tested a single question, prompt or script that makes clients say more.
• None of it says that every secret must be shared. Some holding back may be a reasonable choice about timing (a cautious reading, not a finding).

If you are in therapy

For clients, the main message is a permission. Holding back is common, and you are not a bad client for doing it.

You can tell your therapist that something is not working. A good therapist will want to hear it. If a session did not help, or something your therapist said did not sit right, saying so gives you both something to work on. Telling your therapist that you are thinking of stopping is useful information, not rudeness. In my view, what you tell your therapist about how therapy is going is usually one of the only tools a clinician has for assessing your progress. Therapy is also work. It asks for a mental, physical, emotional and spiritual investment, and an investment where problems cannot be named and repaired is a wasted one.

You do not have to share everything at once. In one study, about half of clients keeping a secret thought they would share it eventually (Baumann & Hill, 2016). If saying something out loud feels too hard, try a smaller step: "There is something I am finding hard to bring up."

If your therapist asks you to fill in a short questionnaire, answer it honestly. It is there to help both of you see what is changing.

Questions you can take to your therapist

• "How will we know if this is working, and what should I do if I am holding something back?"
• "If I say something about therapy itself is not sitting right, how will we handle that together?"

These questions are not a test. They make doubts something you plan for together.

If you are a therapist

For clinicians, a few things to consider. This is general information, not advice about any particular client or setting.

• Assume some things are unsaid. In this research, holding back is the norm, not a sign of a difficult client (Blanchard & Farber, 2016; Baumann & Hill, 2016).
• Ask about the therapy, not only the problem. For example: "Is there anything about how we are working that is not sitting right?" or "What would you be reluctant to tell me?" Clients in one small study said therapists should actively pursue material that is hard to disclose (Farber et al., 2004). I like to call this a meta-level conversation: a conversation about the conversation. For example: "How is this going?", "How are you feeling talking about this?" or "I'm noticing that when I say X, you respond with Y."
• Make it easy to disagree. Thank the client when they raise a doubt, so that a strain becomes something you can repair together. In my experience, coming in with humility, and presenting as someone who is fallible, often allows this to happen naturally.
• Expect some material to come late. A strong alliance and more time in therapy were linked to more disclosure (Farber, 2003).
• Check progress from more than one angle. A fuller picture can come from a quick scaling question (for example, 0 to 10), a standard questionnaire such as the PHQ-9 or GAD-7, the client's own account in their own words, and, only with the client's explicit consent, observations from people in the client's life outside therapy. The PHQ-9 and GAD-7 are screening and tracking tools; they do not diagnose. This is general information: no source here shows that this combination improves outcomes.
• Training alone may not be enough. Repair training did not show a significant pooled link to outcome (Eubanks et al., 2018), so it may help to pair it with routine checking in (an inference, not a tested step).

Consent and ethics

Clients have a right to raise doubts about therapy and to say when something is not working. Saying so is useful information, not a failure. Observations from family or friends outside therapy need the client's explicit consent and careful handling of privacy. This post is general information only, not individual clinical advice, and it contains no client stories or client data.

Limitations

Each source has limits worth stating plainly.

• Blanchard and Farber (2016): a self-selected online sample, retrospective self-report and no therapist data. It may over-represent people with strong views about therapy.
• Baumann and Hill (2016): a modest sample of 115, self-report, and a cross-sectional design, so concealment cannot be shown to cause a weaker relationship.
• Eubanks et al. (2018): few studies (11 for repair, 6 for training). A published commentary on the review notes that the included studies were naturalistic and correlational, with no study randomly assigning patients to repaired or unrepaired strains, so repair is linked to better outcomes but is not shown to cause them, and that the strength of the link varied between studies more than chance would predict (Drug and Alcohol Findings, 2018). The training result depended on moderators.
• Babl et al. (2026): a small evidence base of 4 publications and 301 clients, and correlational.
• Kelly and Yuan (2009): one hospital site, 83 clients and 22 therapists, and one survey after a session.
• Farber (2003): a narrative review. The abstract gives no numbers and does not say how studies were chosen.
• Farber et al. (2004): 21 clients, mostly in long-term psychodynamic therapy, so the findings may not apply to brief or other therapies.
• Across all of them, nearly all the evidence is client self-report, most designs are cross-sectional, and studies define "lying" and "secret" differently, so the rates cannot be pooled.
• Most findings here come from the published abstracts, not the full texts. The two early 1990s studies (Hill et al., 1993; Regan & Hill, 1992) are described second-hand from later reviews, and the limitations of Eubanks et al. (2018) come from a published commentary on the review.
• The suggestions for clients and therapists are general information, not tested steps.
• Lines marked "In my view", "In my experience" or "I like to call this" are my own professional opinion, not research findings.

Saying it out loud

Taken together, the research suggests that holding back in therapy is common, that the reasons are mostly kind ones, and that repairing strains is linked to better outcomes. None of this asks clients to share everything at once. It asks both people to make room for doubts, so that a doubt said out loud becomes something a client and therapist can work on together.

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General information, not clinical advice.

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