Therapist Insights / Therapy Process
Saying I don't know in therapy.
The phrase turns up in almost every course of therapy, usually in answer to a question that sounded simple when it was asked. Most people hear themselves say it and assume they have failed the exercise. A clinician hears something narrower and more useful: an event with a cause, arriving at a particular moment, in answer to a particular question, and worth slowing down for.
THE QUICK TAKEAWAY
Adults in therapy say I don't know for reasons that look identical from the outside and are not. Sometimes no word for the feeling has arrived yet, which is what the research on alexithymia describes. Sometimes the word is available and saying it out loud costs more than the moment can carry. Sometimes the phrase is a request for the therapist to come closer and take more of the weight. CEREVITY clinicians read it as information about the moment rather than as a failed answer, and what happens in the thirty seconds after it is said matters more than the three words themselves.
§01 / 09 / Definition
What the phrase is actually doing.
Three separate things can produce the same three words in a therapy session: no available label for the feeling, a protective stop, or a bid for the therapist to take more of the weight. CEREVITY clinicians work with the version in front of them instead of treating every instance as avoidance.
Most people who said it three times in one hour leave the session convinced they wasted it. The reading is understandable and it is usually wrong. In a conversation analytic study of psychodynamic psychotherapy published in Frontiers in Psychology in 2024, a researcher worked through roughly 29 hours of video from 32 recorded sessions and isolated every silence of three seconds or longer that followed a patient finishing a piece of narrative. Twenty-one moments met the criteria, spread across eleven sessions. They ran from 3.0 to 13.7 seconds and averaged 5.5. What the transcripts showed is that the patients were not simply stopping. They had signaled through syntax, intonation and gaze that a turn was complete, and then left the next move to the therapist. The author is explicit that although silence in some contexts might indeed be construed as defense or even resistance, there are other contexts in which it is certainly not, and describes it as produced jointly by both people rather than unilaterally by the one who went quiet. The same holds for the sentence people use to fill that silence. Not knowing is an event in the room, it has a shape, and the shape is readable by anyone paying attention to what came immediately before it.
Five things the phrase can be protecting
A word that has not arrived
Some people genuinely cannot find the label. Alexithymia is the clinical term for persistent difficulty identifying and describing feelings, and it is a measured trait rather than a moral position. When the word is missing, more questions do not produce it any faster, and the honest answer is the accurate one.
A cost that has already been priced
The answer exists and is expensive. Saying a thing out loud in front of another person makes it real in a way that thinking it does not, and some answers commit you to a decision you are not ready to make. Not knowing buys time, and time is sometimes exactly what is needed.
A question that landed at the wrong altitude
How did that make you feel is a reasonable question and an unanswerable one for many people in the first months of therapy. Abstraction fails where description works. A question about what happened in the twenty minutes before the argument tends to get a full answer from the same person.
A relationship being quietly tested
Sometimes the phrase is aimed at the therapist rather than the topic. Systematic review work on alliance ruptures describes withdrawal, where one party moves away and disengages, as one of the two main rupture types. A vague answer can be the first visible sign of it, and it is repairable when it is noticed.
An answer you have already graded as wrong
High achievers often treat a session as an examination with a marking scheme. The fear is not of the feeling but of producing the wrong feeling and being quietly marked down for it. Not knowing is safer than a wrong answer, and it is the only response that cannot be graded.
▶ Research
The strongest single finding relevant to this whole question is not about the phrase at all. A 2024 study in Frontiers in Psychology surveyed 700 adults in individual psychotherapy about their most recent session and found the working alliance had the strongest relationship with how the patient rated that session, at a correlation of 0.74. In a simultaneous regression the alliance still held the strongest association after the other components of the therapeutic relationship were accounted for, and the four components together explained 30 percent of the variance in session outcome. The practical reading for someone who keeps saying they do not know: the strength of the working relationship is doing more for the hour than the fluency of any single answer inside it.1
What the research separates
Not knowing and not saying are different problems
One is a vocabulary problem and one is a safety problem, and the interventions diverge immediately. A missing word responds to description, to slowing down, to questions about events rather than about meaning. A withheld word responds to safety and to having the cost of saying it named out loud. Guessing which is in play wastes sessions; asking takes about ninety seconds.
A withdrawal is not a verdict on the work
A 2024 systematic review in Frontiers in Psychology, covering seventeen studies of interpersonal coordination in rupture and repair, describes ruptures as disagreements about the goals of treatment, an inability to work collaboratively on its tasks, or strains in the relational bond, and notes they are believed to be inevitable in treatment. Inevitable is the word that matters. A stall is a normal feature of the process rather than evidence that the match is wrong.
What the therapist does next is the actual variable
Across the recorded sessions, the therapist's choice after the pause is what moved the hour: a question, an interpretation, a challenge, or a reformulation of what was already said. None of those options require the client to have produced a better answer first. Adults in therapy tend to think the pause is theirs to solve. Half of it belongs to the other chair.
Three things happening at once
One sentence, three simultaneous events. Pulling them apart is most of the clinical work, because the response that helps a missing word is not the response that helps a withheld one, and using the wrong one costs weeks. Every instance of the phrase carries all three of these layers, in different proportions.
The question that preceded it
Every instance is a response to something. The most informative detail is usually the question, not the answer: how abstract it was, how much it asked you to commit to, and whether it asked for a fact, an interpretation or a verdict on yourself. Questions that ask for a verdict get the fewest answers.
The answer, present or absent
Behind the phrase there is either something or nothing, and the two require opposite responses. Where the answer is absent, pressure produces guesses that mislead everyone. Where it is present and held back, pressure produces compliance rather than disclosure. Naming which one is in play is a question a clinician can simply ask.
The pair in the room
Neither person produces this moment alone. The 2024 conversation analytic work found the patient signaling turn completion and the therapist choosing whether to fill the space, with the resulting silence produced jointly. Adults in therapy tend to blame themselves for a stall that both people are actually building.
§02 / 09 / Telehealth
Where not knowing comes from.
Alexithymia, the clinical term for persistent difficulty identifying and describing feelings, has been estimated across various studies at 10 to 19 percent of the general population. Not every instance of the phrase is alexithymia, and separating the trait from a defense from a badly aimed question is the clinical work.
Difficulty naming feelings is a described trait, not a character flaw
A 2019 overview in Frontiers in Psychiatry sets out five features of alexithymia: difficulty identifying one's emotions, difficulty describing feelings verbally, a reduced or absent capacity to experience emotions, an externally oriented cognitive style, and poor capacity for fantasy or symbolic thought. The same paper reports that various studies have estimated prevalence at between 10 and 19 percent, while noting that precise figures are hard to fix because clear diagnostic criteria do not exist. It also records that people experiencing alexithymia may find it difficult to engage with and benefit from psychological therapy, which is a reason to name the trait early rather than a reason to give up on the work.
Avoidance is a documented defense with a long clinical literature
The StatPearls clinical reference on defense mechanisms, updated in 2023, describes them in Anna Freud's terms as unconscious resources the ego uses to reduce internal stress. Avoidance and denial sit among the primitive or immature defenses it lists, alongside projection, regression and splitting. The reference also draws the line between repression, which happens below awareness, and suppression, which is a conscious decision to push a thought away. That distinction maps directly onto the two very different sentences that come out sounding the same, and the reference notes that psychodynamic work helps people recognize their own defenses and improve self-awareness.
The silence around the phrase is jointly produced
In the 2024 Frontiers in Psychology analysis, therapists responded to those twenty-one silences in four ways: eleven questions, six interpretations, two challenges and two formulations that rephrased what the patient had already said. Every one of those interventions kept the discussion on the same topic while asking for further engagement. Nobody changed the subject to rescue anyone. That is a small dataset and it is a real one, and it describes a specific clinical habit: stay on the topic, hand the turn back, do not treat the pause as a verdict.
§03 / 09 / Mechanism
How much it matters in session.
Frequency and timing change the clinical meaning of the phrase. Adults in therapy who say it once in answer to a hard question are doing something different from those who say it to every question in every session, and the second pattern is worth naming out loud rather than working around quietly.
Said once, in answer to a question that reached further than the last one, the phrase is close to meaningless as a signal and entirely ordinary as an event. Nobody has same-day access to every internal state. Said in answer to the fourth question in a row, it stops being about any one question and starts being about the session. Said in answer to every question for six weeks, it is the material, and the useful move is to stop asking about the topics and start asking about the pattern. That shift is not a confrontation. It is a change of subject that moves toward the person rather than away from them, and most people find it a relief, because the thing they were dreading being asked about turns out not to be the thing.
There is a second reason not to treat the phrase as a failure, and it is structural. A course of therapy is not an interview and the hour is not an audit. The person asking the questions already expects a proportion of them to land badly, because a question calibrated to be always answerable is a question that never reaches anything new. CEREVITY runs assessment before matching for exactly this reason: what a person can and cannot yet describe is part of what a match is made on, which is how the clinical model is structured rather than an afterthought. A clinician who has been told in the first session that direct questions about feeling tend to produce a blank will ask differently in the fourth.
Where the phrase does carry weight is when it maps onto something with a name. Sustained low mood that never interrupts performance often shows up first as a flatness in session, an inability to report much of anything about the week, and the work there is closer to depression that does not look like depression than to any communication problem. Exhaustion that has stopped responding to time off produces a similar blankness for a different reason. Both are treatable, both are commonly missed by the person carrying them, and neither is diagnosable from a single vague answer, which is why the assessment exists and why a first session asks about sleep, appetite and function rather than only about feelings.
► Standard advice vs. CEREVITY's approach
Standard therapy
"Treat every I don't know as avoidance"
CEREVITY
"Ask whether the word is missing or the word is expensive"
Standard therapy
"Fill the pause quickly to spare everyone the discomfort"
CEREVITY
"Let the silence run its five or six seconds and see what arrives"
Standard therapy
"Apologize for not having an answer prepared"
CEREVITY
"Describe what happens in your body when the question is asked"
| Standard insurance-based therapy | CEREVITY's specialized approach |
|---|---|
| "Treat every I don't know as avoidance" | "Ask whether the word is missing or the word is expensive" |
| "Fill the pause quickly to spare everyone the discomfort" | "Let the silence run its five or six seconds and see what arrives" |
| "Apologize for not having an answer prepared" | "Describe what happens in your body when the question is asked" |
A break from the page
Not knowing is a starting point, not a disqualification.
A first inquiry is confidential and commits you to nothing. CEREVITY is a nationwide network of independent licensed clinicians working private-pay, with no insurance claim submitted and no diagnosis on a payer record. If the honest answer to most questions about how you feel is that you are not sure, start with a private inquiry and say exactly that.
§04 / 09 / Cases
Common challenges we address.
The executive who answers every other question instantly
The patternSomeone who briefs a board without notes, handles hostile questions from investors, and then produces nothing at all when asked what the last quarter cost them personally. The fluency is real everywhere except here, which makes the blank feel like a defect rather than a boundary.
What we addressThe gap between those two performances is the material, not an obstacle to it. Where the flatness turns out to be exhaustion that no longer lifts on holiday, the work moves toward the difference between tiredness and clinical burnout, which is a clinical distinction rather than a matter of degree, and one that a person inside it almost never makes for themselves.
The client who reads the blank as proof that therapy is failing
The patternA person four sessions in who has decided they are bad at this, usually the same person who is good at everything else and has never sat in a room where fluency was not the measure. The private conclusion is that they are wasting the money and someone else would be getting more out of it.
What we addressThat conclusion is a familiar one and it belongs to a pattern with a name, close to the fear of being found out as the one person who cannot do this. Naming it in session usually produces more material in ten minutes than the preceding four sessions of careful questions, because the fear of failing at therapy is itself an answerable question.
§05 / 09 / Methods
Evidence-based treatment approaches.
Five recognisable versions of the phrase account for most of what happens in session: the genuine blank, the protective stop, the bid for help, the signal about the relationship, and the fear of the wrong answer. Each one asks for a different response from the clinician, and CEREVITY clinicians are trained to tell them apart rather than to push through all five the same way.
The genuine blank
No label is available, and no amount of asking will produce one in the next thirty seconds. This is the version the alexithymia literature describes: difficulty identifying one's own emotions and difficulty describing them verbally, present at an estimated 10 to 19 percent of the general population depending on the study. The tell is that questions about events get full, precise answers while questions about feeling get nothing. The response that works is description before interpretation: what happened, in what order, what your body did, who was in the room. Feeling words tend to arrive later, attached to a scene rather than produced on demand.
The protective stop
The answer is there and it is not coming out yet. Defense mechanisms are described in the StatPearls clinical reference as unconscious resources the ego uses to reduce internal stress, with avoidance and denial among the primitive ones and intellectualization and rationalization among the more mature. The same reference separates repression, which happens below awareness, from suppression, which is a conscious choice. Both come out of the mouth identically. The response is not confrontation but arithmetic: what would it cost to say this here, today, to this person. Once the cost is named, it usually drops.
The bid for help
Sometimes the phrase hands the turn back deliberately. In the 2024 conversation analytic study, patient silence often functioned as an action directed at the therapist, a request for their participation, rather than as withdrawal from the work. The person is not refusing; they are asking to be met halfway because they have gone as far as they can alone. The tell is that they stay physically engaged, holding gaze, waiting. A clinician who fills that space with a question, an interpretation or a reformulation is doing exactly what the recorded therapists did.
The signal about the relationship
Occasionally the phrase is about the person asking. Rupture research divides these moments into confrontation, where one party moves against the other, and withdrawal, where one party moves away and disengages. A sudden run of vague answers after weeks of detailed ones is a withdrawal marker worth taking seriously, and the systematic review literature treats ruptures as inevitable in treatment rather than as evidence of a bad match. Repair is a normal part of the process. Saying that something in the last session did not sit right is the whole intervention.
The fear of the wrong answer
The last version is a performance problem and it is the most common one among people who are excellent at their jobs. The private belief is that feelings have correct answers, that the clinician has a rubric, and that a wrong answer will be recorded. Not knowing is the only response that cannot be marked down. The response is to say the rubric does not exist, and then to prove it by asking for something unfalsifiable: not what you feel, but what you noticed, or what you would have said if you were not worried about getting it right.
§06 / 09 / Investment
Understanding the investment in private-pay care.
Private-pay, nationwide, and paced to the work
At CEREVITY, our online individual therapy sessions are structured as a direct investment in your mental agility and overall well-being. The investment includes:
- Licensed mental health professional specializing in private-pay individual therapy for high-responsibility adults
- Evidence-based, one-on-one approaches proven effective for anxiety, depression, burnout, and difficulty naming what you feel
- Flexible online scheduling including evenings and weekends
- Complete privacy with no insurance involvement or red tape
- Adults in therapy expertise and understanding
- Outcome tracking and progress measurement
The cost of saying I don't know in therapy going unaddressed
Consider what is at stake when saying I don't know in therapy goes unaddressed:
What private-pay changes about a slow start
Working outside insurance means no claim submitted, no diagnosis on a payer record, and nobody outside the room deciding how many sessions a person is allowed before the material arrives. That matters more than usual here, because a course of therapy that begins with several weeks of not knowing is a normal course of therapy, not an inefficient one, and it should not have to justify itself to a benefits reviewer. View our current rates here: cerevity.com/our-pricing-for-therapy/.
Session formats that give the work room
Care is delivered by secure telehealth nationwide across all 50 states. Most of this work sits comfortably in what fits inside a standard 50-minute session, where the rhythm of weekly contact does more than any single hour does. Where a person needs longer to get past the opening layer, and where the useful material has a habit of arriving at minute forty-two, extended sessions give room for work an hour keeps interrupting. Formats, pacing and everything else available through the network are set out in the full range of services.
§07 / 09 / Evidence
What the research shows.
The honest summary is that this is a well-observed clinical phenomenon with a modest and specific evidence base, and that the evidence points away from the interpretation most people reach for. Alexithymia gives a name and a rough size to the version where the word genuinely is not there, at an estimated 10 to 19 percent of the general population across various studies, with the 2019 Frontiers in Psychiatry overview also recording that clear diagnostic criteria for it do not exist and that it can make psychological therapy harder to use. The defense mechanism literature, summarized in the StatPearls clinical reference, gives a name to the version where the word is there and is being held, and draws the line between the unconscious and the deliberate forms of that holding.
► Three numbers behind the phrase
estimated prevalence of alexithymia in the general population across various studies.
Frontiers in Psychiatry, 2019
seconds was the average length of the recorded in-session silences, which ranged from 3.0 to 13.7.
Frontiers in Psychology, 2024
correlation between the working alliance and patient-rated session quality across 700 adults in individual therapy.
Frontiers in Psychology, 2024
The process research is smaller and more direct. Twenty-one silences of three seconds or more in 29 hours of recorded psychodynamic sessions is not an epidemiological dataset, and it was never meant to be; what it offers is a close reading of what actually happens, which is that the pause is built by both people and that the therapist's next move keeps the topic open rather than rescuing anyone from it. Alongside that, 700 adults rating their own most recent session put the working alliance at the center of how good that session felt, with a correlation of 0.74. Ruptures in that alliance are treated as inevitable in the review literature rather than as failures. Taken together, none of this supports the idea that a person who cannot answer is doing therapy badly.
§§ / 09 / Recap
Key takeaways.
Five things to remember
- The phrase is data, not a dead end Three words with at least five distinct causes behind them, each asking for a different response. The clinical question is never whether you should have known, it is which version of not knowing is in the room today.
- Missing words and withheld words need opposite handling Pressure on a missing word produces guesses that mislead everyone for weeks. Safety around a withheld word produces the answer on its own schedule. A clinician can simply ask which one it is, and most people know.
- Silence is shorter than it feels The recorded pauses in the 2024 study averaged five and a half seconds and reached under fourteen at their longest. What feels like a collapse of the session is usually the length of a deep breath, and the material often arrives on the other side of it.
- The working relationship carries more than the answers do Across 700 patients rating their own sessions, the alliance was the strongest correlate of a session that felt worthwhile. Fluency was not measured because fluency is not the product. More of the practical detail sits in common questions about working with CEREVITY.
- CEREVITY provides this through online individual therapy nationwide, with full privacy through its private-pay concierge network and no insurance involvement.
§08 / 09 / FAQ
Frequently asked questions.
Why do I say I don't know to everything?
Repeated I don't know answers usually mean the phrase has become a default rather than a report. Adults in therapy land there for three main reasons: the feeling has no available label yet, which is what the alexithymia literature describes; the label exists but naming it out loud carries a cost that has not been agreed to; or the questions keep arriving in a form that cannot be answered directly, usually because they ask for a verdict rather than a description. A pattern that consistent is worth saying out loud in session. CEREVITY clinicians will often stop asking the question and start asking about the answer, which moves faster than another attempt at the same prompt and usually produces more in ten minutes than the previous month of careful questions did.
Is it normal to not know what to say in therapy?
Not knowing what to say is ordinary, and it happens to people three years into therapy as often as it happens in a first session. Adults in therapy frequently arrive with the assumption that they should turn up prepared, as though the hour were a meeting with an agenda and a blank page were a wasted slot. Sessions do not work that way. What the mind does when nothing has been prepared is itself usable material, and a CEREVITY clinician can work with it directly rather than waiting for something better. The blank page is a starting position, not a failure to have done the reading.
Why can't I identify my emotions?
Alexithymia is the clinical term for persistent difficulty identifying and describing feelings, and a 2019 overview in Frontiers in Psychiatry reports that various studies have estimated its prevalence at between 10 and 19 percent of the general population. The same paper lists an externally oriented cognitive style and a reduced capacity to experience emotion among its features, and notes that clear diagnostic criteria for it do not exist, which is why it is measured as a trait rather than diagnosed as a disorder. It also records that people with high alexithymia may find it harder to engage with and benefit from psychological therapy. CEREVITY clinicians treat that as a starting condition to work around rather than as a disqualification, which usually means beginning with events and physical sensation instead of with feeling words.
What should I talk about in therapy when I don't know what to talk about?
Nothing has to be prepared in advance for a session to be useful. Four openings work reliably when adults in therapy arrive empty: say plainly that you have nothing, which is itself a subject; report the week as facts rather than as feelings, including sleep, appetite and what you cancelled; describe the last moment you noticed anything physical, such as a tight chest in a meeting; or name the thing you decided not to mention on the way in. The fourth one is usually the fastest. A CEREVITY clinician will normally take the blank itself as the first subject rather than filling it with a topic of their own.
Does my therapist think I'm lying when I say I don't know?
Clinicians do not read the phrase as a lie by default, because the clinical literature gives them at least two honest explanations before dishonesty is reached. The StatPearls reference on defense mechanisms separates repression, which operates below awareness, from suppression, which is a conscious decision to push a thought away, so both a genuine blank and a deliberate hold are recognized categories rather than accusations. The 2024 conversation analytic study makes the same point about silence, stating explicitly that although it can sometimes be construed as defense or resistance, there are other contexts in which it certainly is not. In practice, a CEREVITY clinician is far more interested in what made the question hard than in whether the answer was complete.
What happens during an awkward silence in therapy?
Silence in a session is shorter than it feels and more structured than it looks. In the 2024 Frontiers in Psychology analysis of psychodynamic sessions, the pauses that met the study criteria ran from 3.0 to 13.7 seconds and averaged 5.5, and the therapists responded to those twenty-one moments with eleven questions, six interpretations, two challenges and two reformulations of what the patient had already said. Every one of those responses kept the discussion on the same topic instead of changing the subject. Adults in therapy who dread the pause are usually dreading something that lasts about as long as a deep breath, and that the person opposite is trained to use.
Does saying I don't know mean therapy is not working?
Progress in therapy is not measured by how fluently the questions get answered. A 2024 study of 700 adults rating their most recent individual session found the working alliance had the strongest relationship with how good that session was judged to be, at a correlation of 0.74, with the four measured components of the therapeutic relationship together explaining 30 percent of the variance in session outcome. Review work on alliance ruptures treats strains and withdrawals as inevitable features of treatment rather than as signs of failure. What would genuinely warrant a review is months of the same pattern with nobody naming it, which is a reason to raise it with the clinician rather than a reason to stop.
How does your private-pay pricing structure work?
As a private-pay concierge network, we offer structured investments in your mental health without the restrictions or privacy risks of insurance. You can review our full fee schedule and specific session lengths directly on our website. While this costs more than insurance copays, it provides the flexibility, total privacy, and highly specialized care that standard options cannot offer. View our current rates here.
How do you protect my privacy?
Privacy is foundational to our network. As a private-pay network, your sessions never appear on insurance records or EOBs that could be seen by employers, boards, or family members. We use HIPAA-compliant nationwide telehealth platforms, and you can attend sessions from anywhere with a private internet connection.
§09 / 09 / Begin
You do not have to know before you start.
If the honest answer to how are you is that you genuinely could not say, that is a workable place to begin rather than a reason to wait. CEREVITY is a nationwide network of independent licensed clinicians providing confidential, private-pay care across all 50 states. Call (562) 295-6650 or send a private inquiry.
Available by appointment 7 days a week, 8 AM to 8 PM (PST)§§ / Author
About Emily Carter, PhD.
Emily Carter, PhD
Dr. Carter is a Licensed Psychologist specializing in therapy for executives, entrepreneurs, and high-achieving professionals. Her work integrates cognitive behavioral therapy, acceptance and commitment therapy, and attachment-informed approaches calibrated to the demands of high-responsibility careers. She sees clients via CEREVITY's nationwide telehealth network. View full bio →
§§ / Sources
References.
- Frontiers in Psychology. Silence after narratives by patients in psychodynamic psychotherapy: a conversation analytic study. 2024. frontiersin.org
- Frontiers in Psychiatry. Alexithymia and Its Associations With Depression, Suicidality, and Aggression: An Overview of the Literature. 2019. frontiersin.org
- StatPearls Publishing. Defense Mechanisms. 2023. ncbi.nlm.nih.gov
- Frontiers in Psychology. Patients' perspective on the therapeutic relationship and session quality: the central role of alliance. 2024. frontiersin.org
- Frontiers in Psychology. The role of interpersonal coordination dynamics in alliance rupture and repair processes in psychotherapy: A systematic review. 2024. frontiersin.org
- CEREVITY. High-functioning anxiety and depression therapy. cerevity.com/anxiety-and-depression-therapy
- CEREVITY. Executive burnout therapy. cerevity.com/executive-burnout-therapy
- CEREVITY. Our services. cerevity.com/services
⚠ Crisis resources
If you are experiencing a mental health crisis or having thoughts of suicide, please reach out immediately. 988 Suicide & Crisis Lifeline · Call or text 988 Crisis Text Line · Text HOME to 741741 National Alliance on Mental Illness · 1-800-950-NAMI (6264)
