What do I say in therapy if I have no idea?

Do I have to arrive with a problem?

You need a starting point, and a starting point is a much smaller thing than a problem. People sit down and apologise for not having organised their difficulty into a presentable shape. I have never needed that, and the people who bring it often spend the first 20 minutes reading out a summary while the thing they actually came about waits behind it.

A starting point is anything specific and recent. The moment on Tuesday when your chest tightened and you could not say why. The conversation with your partner that ended the way it always ends. The feeling you had walking home that you have been having for a year and have never described to anyone. Any of those will open the hour.

What I am listening for while you talk is not the content so much as where the temperature changes. Something you mention in passing and then move away from quickly is usually more interesting than the subject you prepared, and I will come back to it. That is most of what my training is for, and it is why you do not have to do that work in advance.

What if what I bring sounds trivial?

Almost everyone measures their difficulty against someone whose life is harder, and almost everyone loses. I hear it constantly, and from people living away from where they are from more than anyone: they chose this, nothing terrible has happened, other people have real troubles.

That comparison does 2 unhelpful things at once. It disqualifies your experience before it has been looked at, and it keeps you explaining the context instead of saying what you feel. By the time you have justified why the thing is allowed to bother you, the session is half gone and the feeling has cooled.

The small material is usually the most useful material anyway. A pattern is easier to see in an ordinary Tuesday than in a crisis, because in a crisis everyone behaves unusually. If you tell me that you went quiet when your partner praised you, there is something precise to work with. A general statement that your relationship is difficult gives nothing to hold.

What happens when I run out of things to say?

Silence in a session is not empty, and it is one of the more useful things that can happen. People dread it because in ordinary conversation a pause is a failure that someone has to repair. Here nobody has to repair it.

When a client goes quiet, a few different things are usually happening, and they feel much the same from the inside.

• Something arrived and was turned away. A thought came and was judged too petty, too disloyal or too strange to say aloud, and the judging happened faster than the noticing.
• The feeling got ahead of the words. You are in something that has not been put into language before, and language takes a while to catch up with it.
• The talking had become a performance. Running out can be the moment the account you usually give of yourself stops working, which is often when the session gets real.

My job at that point is to stay with you rather than fill the gap. Often I will ask what is happening in your body, because the body tends to know first and says it plainly: the throat tightening, the heat in the face, the sudden tiredness. Starting there is more reliable than hunting for the right sentence.

Will talking actually change anything?

Talking on its own changes very little, which is why therapy is not only talking. You have probably already described your difficulty to friends several times and found that it helped for an evening. The difference here is that someone is tracking what happens while you speak, and will stop you at the places you pass over.

Change tends to arrive in a particular order. A feeling you have been keeping at arm’s length gets felt in the room rather than reported from a distance. Your body registers it. Only afterwards does the understanding come, and it comes as recognition rather than as a conclusion you worked out. That order matters, because insight arrived at the other way round has a habit of staying theoretical.

How you expect it to go seems to matter too. In 6 randomised trials of therapist-guided treatment, covering 491 people in total, how credible and promising people found the treatment at the start was related to how they were doing when it finished, and that held whether the work was done in person or at a distance.¹ Six trials covering different difficulties is a small body of evidence, so take it as a reasonable signal rather than a settled fact. It fits what I see: doubt is workable, but open contempt for the whole idea tends to stall the work until it is itself talked about.

How do I use a first session, and when is talking not the right tool?

Treat the first session as a conversation to find out what the difficulty actually is, not an examination you can fail. Four things make it more useful.

• Bring one recent moment. Not your history. One occasion, with a day attached to it, that still has some charge in it when you think of it.
• Say the thing you nearly left out. Most people arrive with one item they have privately decided to mention later. Later rarely comes on its own.
• Report the feeling before the explanation. I would rather hear that you felt cold towards him than hear your theory about why.
• Notice how the hour leaves you. Relieved, exposed, irritated, lighter. That reaction tells you more about the fit than anything said in the hour.

Talking is not always the right instrument, and it is worth saying where it stops. It will not resolve a difficulty that is mainly practical and has a practical answer: a contract, a visa, a flat, a decision somebody else has to make. It is also limited while you are so stretched that you cannot think, when sleep has gone and the days have no shape, because there is nothing steady enough to work with. Putting some ground back under you comes first, and the exploring comes after.

And when the difficulty is mainly what passes between 2 people, your account of it on your own will only reach so far. That work belongs in a session with both of you, where I can watch it happen rather than hear it described.

If you would rather test all this than read about it, online psychotherapy is where the work happens, and the free 30-minute call is the quickest way to find out what you have to say. Sessions run by video wherever you live.

Questions people ask

Should I prepare something before a session?

One recent moment that still has some feeling in it is plenty, and a written summary of your life is usually less useful. Preparation tends to produce the version you have told before.

What happens if I cry, or cannot speak at all?

Both are ordinary in a session and neither needs managing by you. What is happening instead of the words can be worked with just as well.

Can I talk about something that happened years ago?

Yes, and old material usually earns its place by still being active in how you live now. What matters is the part of it that is still running.

Is it a problem if I bring a different subject every week?

No, because the thread usually runs underneath the subjects rather than through them. Part of my work is noticing what the different weeks have in common.

How much do I have to tell you about my past?

Only as much as the present difficulty turns out to need, and you decide the pace of that. Nothing has to be told before you are ready to tell it.

Sources

1. Association between expectations and clinical outcomes in online v. face-to-face therapy: an individual participant data meta-analysis. Psychological Medicine, 2024.

How this article was written: I choose the subject and the angle. An AI assistant researches and drafts. I read the draft, correct and improve it and stand behind every clinical statement. The professional and clinical judgement is mine.