Meta-analyses show a positive relationship between depth of patients’ emotional experiencing and positive outcomes from psychotherapy. A therapist’s focus on affective experience has also been associated with greater change over the course of therapy. Most treatment approaches agree that crying in therapy provides a unique opportunity for patients to engage in affective experiences. The key is for patients to grow in their ability to experience and express vulnerability in their everyday lives. Crying may also be a key moment that can strengthen the therapeutic relationship. Interventions that precede crying are affect-focused, such as encouraging patients to express their emotions and exploring uncomfortable feelings in session. In this study, Voicu and colleagues examined the relationship between patient crying events (their intensity and duration) and the therapeutic alliance and outcomes. Patients were 58 adults with a mean age of 28.8 (SD=12) seeking treatment at an outpatient clinic. Most had a mood or anxiety disorder (67%). The mean number of therapy sessions they attended was 23 (SD=17). Therapists were 21 advanced doctoral-level students with at least 1 year of supervised psychotherapy experience, practicing psychodynamic-interpersonal therapy. Independent judges rated video recordings of 3 early sessions to assess crying intensity and duration, and therapists’ interventions prior to crying events. Patients filled out pre- and post-symptoms measures to assess outcomes. Patients and therapists also rated session quality and the alliance. 45% of patients cried in at least one session, 25% in two sessions, and 9% in three sessions. Crying tended to last an average of 3 minutes with varying intensity. Both patients and therapists reported sessions with crying to be more difficult than non-crying sessions. The number of crying events was not significantly associated with outcomes, but greater emotional intensity related to crying and longer crying duration were significantly associated with better patient symptom outcomes and therapeutic alliance. Therapists’ affect-focused techniques (helping the patient remain with the emotion) and providing an interpretation (helping the patient understand the meaning of emotions) preceded most of the crying events.
Practice Implications
Patients’ crying is relatively common in psychotherapy and leads to more difficult but potentially rewarding sessions. Crying communicates distress and invites solace and care from others. Helping the patient remain with the emotion and understand the crying, if done appropriately, allows for exposure to intense emotions that may be corrective and generalizable to their daily lives. Therapists need to develop a sensitivity to nonverbal emotional expression to facilitate these interventions. Rather than moving too quickly to intervene, therapists may find it useful to pause, allow the patient to express and experience their feelings, and then invite exploration of what the tears mean to the patient. Patients may also find it useful to process what it was like to share these tears with the therapist.
Voicu, A., Hilsenroth, M., Umphlet, K.C., & Mullin, A. (2026). Relationship between patient early treatment crying experiences with psychotherapy process and outcome. Clinical Psychology & Psychotherapy 33, (3), e70267. https://doi.org/10.1002/cpp.70267