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This question actually leads many folks to terminate therapy, reduce the frequency of psychotherapy, or never begin in the first place. People worry that they won’t know what to talk about in sessions, or that they won’t have enough material for weekly psychotherapy. What they don’t know is that a good psychotherapist can help them figure out what to talk about in sessions, or rather how to use their sessions.

The Topic of the Week

The false premise is that what we talk about in therapy are the events of the week. Certainly the events of the week may be a regular topic in sessions. The concrete, external events of our lives may be a source of crises, or confusion, or distress, and routinely benefit from grabbling with in sessions with a therapist, particularly if there was a life event that lead to seeking out therapy, like a divorce, or job loss, conflict with a family member, or illness.

But when we are helping our clients deal with the external events in their lives, our work is more characterized by counseling, as opposed to psychotherapy. When helping our clients deal with external events in their lives, we are likely to do things like validate, support, encourage, explore options, make suggestions, and offer resources and counsel. All of those are great things but do not characterize psychotherapy proper.

Our Central Themes

Another way to use sessions, that allow the therapist to bring more of their skills to bear, is to track internal psychological events. All of us live with a story we tell ourselves about who we are, who others are, what our life means, and what the world has to offer us. This narrative frames how we see ourselves and others, how we experience the world and our interactions, and ultimately directs our behaviors and choices. This is the realm of psychotherapy.

In psychotherapy we are trying to help our clients understand their role in their suffering. We are not trying to blame our clients for their suffering, at all. But we are trying to help our clients see themselves, others, life and their relationships to self, others and life, with clarity. We are trying to help people track the way they think and react and behave and see if they can tie all that to early injuries/experiences, and to belief systems that hurt them.

An Example of Low Self-Esteem

An example is someone who has low self-esteem. Whatever clients come in to therapy to talk about, for instance a recent break-up, while we want to help them deal with that situation, we can not set aside the larger issue: Why do they have low self-esteem? Where did they come to view themselves negatively? How do they reenforce that in their self-talk? How does it impact their behaviors and choices?

If a friend wants to help someone with their low self-esteem, they will tell them about all their great qualities, validate and support them, and dispute their negative self-appraisal. A therapist will help them find the roots of their poor self-esteem. A therapist will help identify the many beliefs and behaviors they engage to reinforce their negative opinion of themselves. The therapist will have as their goal to help the client ultimately understand all the hooks that keep that self perception in place so that they can remove them one by one.

What to Talk About in Therapy Today

If the goal of therapy is to address internal issues, then we will always have topics readily available to talk about in therapy; the issue will be choosing between them! If for instance self-esteem is one of our issues, we will talk about the language we heard ourselves use against ourselves the other day when we tripped. We will talk about this little memory we had during the week about this thing our brother once said to us when we lost a competition. We will share the words we almost said to our kid the other day when they were frustrated and suddenly realized that it was a set-up for low self esteem. We will tie in a Netflix show we were watching with a character that we could relate to who had an epiphany. Basically, we will take one of our central themes, and share the internal and external events that gave us new clues to cracking the code of how to free ourselves from that perspective.

We all have multiple central themes…ways we approach life and living that hurt and limit us. We all have doubts and worries and angers that keep us up at night and trip us up during the day. We have old injuries and thoughts we don’t ever want to share with anyone because they seem so whiny, or self-indulgent, or petty, or shameful. If they could safely be kept secret without impacting our self-view, sure, keep it to ourselves. The problem is that these secrets effect everything about our perspective.

When someone is in high crises in their lives, a good therapist will help their client get through those events. But if the goal is to improve our overall way of living, helping us stop repeating patterns that hurt us, then what we talk about in therapy requires us to look inside more than just outside ourselves, but to explore thoughts and dreams and associations as much as concrete actions and behaviors.

If you are on your way to therapy, and you don’t know what to talk about, try to remember what your central themes are, what ails you at night, what you fear, what you do over and over that drives you crazy. It doesn’t matter if it is a totally new topic that you have never brought up in therapy. It doesn’t matter if you think there is no context at all for why you are thinking about the topic. Your own free association will often help the therapist collect clues related to your central themes and current struggles. You don’t need to understand anything about why the topic is important before you bring it in to a session. Let the therapist do their job and help you figure that out.


Smith is an analytically oriented psychotherapist with 25 years in practice. She is additionally the  Founder/Director of Full Living: A Psychotherapy Practice, which specializes in matching clients with seasoned clinicians in the Greater Philadelphia Area.

If you are interested in therapy and live in Philadelphia or the Greater Philadelphia Area, please let Full Living: A Psychotherapy Practicematch you with a skilled, experienced psychotherapist based on needs and issues as well as personality and style. Request an Appointment Today.

For more or related topics in blog and video blog, follow the links below:

It is Not the Glass that is Half Empty; It is the Breast

Up-Selling Psychotherapy:Are Therapists Even Allowed to Do That?

Why Would I Do Something SO Stupid? 3 Tools for Answers


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Author Karen L. Smith MSS LCSW Karen is the founder and director of Full Living: A Psychotherapy Practice, which provides thoughtful matches for clients seeking therapists in the Philadelphia Area. She provides analytically oriented psychotherapy, and offers education for other therapists seeking to deepen and enriching their work with object relation concepts.

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