Sometimes it strikes you when you start your counselling session, sometimes you start thinking about it a day or two or more before: What to talk about in your counselling session?

This dilemma is actually more common than is sometimes realized. Often the thinking around this topic goes like this:
1. I have a problem(s)
2. Book an initial or a follow-up session with a counsellor
3.Talk about the problem(s)

Simple? Not always. Sometimes we just don’t know what to bring up with our therapist in our counselling session(s) and there are a number of reasons for this.

Before we get into how not knowing what to talk about can show up in or before your counselling session, I think it’s useful to look at counselling structure and how it affects what gets brought up (or not) in a counselling session.

The Counselling Frame

I’ve said many times that therapists are as diverse as the clients they serve, which also means that the “frame”—or structure—of the counselling session can vary, depending on the therapist. Therapists’ methods of counselling can influence how much onus is placed on the client to come up with what they want to talk about, and some frames are better for some clients and other frames are better for other clients. There is no one right way for everybody.

At one end is a therapy frame that is highly regimented: such counselling sessions might follow a very specific format such as identifying, leading or continuing with predetermined topics; standard therapy questions that are covered every session; specific in-session exercises and perhaps routine questionnaires, with may involve measuring outcomes. Warning: there may be whiteboards involved! Homework is most likely included and the therapist may be using one very specific method—in fact the client may have specifically sought the therapist out for this reason. In some situations, the client may be working through a workbook, chapter by chapter with their therapist.

On the other end of the continuum, the therapist may wait to speak until well after the client starts talking, may only ask sparse questions and provide no feedback. This mode of therapy exists but is not particularly common in Vancouver.

Most therapy sessions fall somewhere in-between with both therapist and client dialoguing in a way that allows for space about what to talk about: the client may be clear about this or the therapist may assist by asking questions to help the client identify what is important to discuss.

But, even with the support of a counselling session and therapist, it can still be difficult to determine what to talk about.

Scenarios

Let’s look at some scenarios where it may be difficult to know what to talk about as well as some possible solutions.

Scenario 1 – Mind Goes Blank

This is typically a manifestation of intense anxiety, similar to what is sometimes observed in test-related anxiety. This experience can be intensified when a client has never met the therapist that they have hired, have mixed feelings about counselling, have had a previous negative experience in counselling, or are very new to the process.

This type of situation can also occur when clients are very shut down or dissociative and it can take time for a client to access what they want to talk about and/or feel safe enough to want to talk about it.

Possible Solutions:

• Practice relaxation techniques such as box breathing or anxiety management strategies prior to attending the appointment; let your therapist know if this anxiety is still present and whether or not they can assist with an in-session relaxation or grounding exercise.
• Understandably, clients sometimes need time to develop a comfortable rapport with their therapist, in order know what they want to discuss and for the nervous system to recognize that the therapist is a safe person to open up to. This has to be done on the client’s schedule; readiness can’t be rushed.

Scenario 2 – Too Many Problems: How to Choose?

I’m stating the obvious here but some weeks are just very intense. Whether it’s life events, things that have triggered us or what we are going through internally, it can be hard to know where to start.

Possible Solutions:

• Give your therapist the heads up that you have a lot on your mind and are struggling to prioritize. Ask for their help, keeping in mind that it is typically not possible to cover all of your concerns in a typical therapy hour.
• Book an extended counselling session, if available.
• Do some journalling before your session, to help organize your thoughts. Are there themes that keep repeating themselves? Even writing a list can help orient you towards priorities.
• View counselling sessions as a series of chapters rather than a one-time blowout. Work with the therapist on pacing your concerns.

Scenario 3 – What I Want To Talk About Keeps Changing

It’s common to think repeatedly about an upcoming session, leading up to your appointment: something bothers you during the week and the thought arises “maybe I should bring this up in counselling.” Then something else happens and you may think “or maybe I should talk about this instead.” And sometimes the topic just keeps changing, particularly if crises or upsetting incidents pile up or conversely, get resolved, but then it’s on to a different problem.

Sometimes what is at play here is what therapists refer to as “over-activation” of the nervous system: one’s nervous system reacting to a sense of perceived threat, even when no actual threat to our personal survival exists: this can including rapid heart rate, racing thoughts, dry mouth, tightness in the chest. Symptoms may be particularly intense, as in a panic attack or something less acute such as muscle tension or irritability.

Possible Solutions:

• Let your therapist in on the fact that you are experiencing a frequently-shifting sense of urgency. While problem-solving or prioritizing may be needed, sometimes the place to start is actually finding strategies for calming your nervous system, sometimes known as “down-regulation.”
• There are situations where we are under threat and need help. Here a crisis response service may be needed, not therapy.

Scenario 4 – I’m Not Vibing With My Therapist

You are working with a therapist who is not on your wavelength. It happens. They may have had radically different experiences in life, have different life philosophies, or there my be significant racial/cultural/class or other systemic differences. When we’re feeling it’s not a good fit, it’s hard to open up and be vulnerable, or even truthful, which then means that you’re not getting full value from a counselling session.

Possible Solutions:

• If the fit seemed good previously, but there has been a therapeutic rupture, I recommend talking it through with your therapist, if you feel emotionally safe doing so, to see if your relationship with your therapist improves.
• If you think you are just two very different people, or you feel chronically misunderstood, disempowered or disrespected by your therapist, look for a new counsellor.

Scenario 5 – I Know What I Need To Talk About, But I Just Can’t

When we turn our attention inwards, sometimes we actually know what we need to talk about in our counselling session, but we’re too afraid to bring it up. Sometimes this is due to a fear of judgment, the worry that once something is voiced it becomes more real and we have to face it or deal with it, or bringing it up just feels too painful and we’re not ready. In some situations for for some folks, counselling is just not the right vehicle for change.

Possible Solutions:

Let your (trusted) counsellor know that you have something very sensitive to discuss but you’re not sure you’re ready. A counsellor with good boundaries will not pressure you in such a situation. If they do, express your concerns and find a new counsellor if they become defensive or dismissive.

Scenario 6 – Nothing Much is Happening

This is sometimes related to a crisis-mindset where we think that something has to “have happened” or be wrong in our lives to bring to counselling, but this may also mean that urgent matters have been dealt with to the extent where you are finally at a place do some deeper work in counselling.

Alternatively, you may have met your goals in counselling and your work is done! Congratulations!

Possible Solutions:

• Bring up this topic with your therapist to get their take on things.
• Review the goals that you had originally set out in counselling and see if they are still relevant today.
• Reflect on your progress and determine whether you still are in need of ongoing counselling support. If you think you are good to fly solo, I recommend going for a closing session with your therapist so you can review your gains and discuss a plan for moving forward independently.