What To Talk About In Therapy: Topics & How To Start The Conversation

You show up for therapy, ready to talk, but then nothing. You have things on your mind, but you’re not sure how to say them. Or maybe you do talk, but you leave sessions wondering, “Was that helpful? Am I doing this right?”

Research shows that people who engage in psychotherapy generally have better outcomes than those who don’t. But the key to getting the most out of your sessions comes down to knowing how to navigate the conversation. This guide offers suggestions on what to say, how to approach the trickier topics, and how your therapist might respond.

What to talk about in therapy

Therapy is a space for anything that affects your mental health or quality of life. You can explore your relationships—family, friends, coworkers—including conflicts, struggles, or feelings of loneliness and disconnection. Feelings like anxiety, sadness, fear, guilt, anger, shame, numbness, or burnout are all valid to bring up, even when you’re not entirely sure what you’re feeling.

Identity and background are important topics. You might discuss race, ethnicity, gender, sexuality, religion, ability, or culture, and how these aspects affect how you move throughout the world.

“People often feel more at ease with therapists who mirror aspects of their identity, culture, or life story,” says Johana Jimenez, licensed professional counselor. “For bilingual clients, especially, it can be healing to process trauma in the language where it was first experienced. Even if we don’t share the exact same culture, there is often a shared understanding of what it means to navigate between worlds (whatever those worlds are). The main factor is for clients to feel comfortable with their therapist.”

You can also talk about current pressures such as work stress, uncertainty about life direction (hello quarter-life crisis), or major transitions like moving, career changes, or parenthood. Past experiences can also shape how you feel: challenging memories, loss or grief, trauma, chronic illness, or even events like abuse, bullying, or accidents.

Therapy is a place to build coping skills, work through patterns like people-pleasing or self-doubt, and reflect on personal growth. You can discuss the therapy process itself, including your relationship with your therapist. If you feel nervous about therapy itself (anxiety about being there, worries about opening up, or uncertainty about the process), that’s worth bringing up too.

Because mind and body are connected, topics like sleep, energy, physical health, and daily habits, and how they impact your mental well-being, are all fair game. Struggles with eating, body image, or your relationship with food are also important to address.

Beginning therapy sessions

Asking about your therapy type

Your therapist’s website said “CBT” (cognitive behavioral therapy) or maybe they mentioned “DBT (dialectical behavioral therapy) techniques,” and you nodded along, but you have no idea what that means. It’s okay if you don’t understand these therapy types—many people don’t! Your therapist is there to help you understand and navigate these terms.

Understanding your therapist’s approach can help you get more from your sessions. You could ask: “I don’t really understand what this type of talk therapy involves. Can you explain your approach, and how it might help with what I’m dealing with?” A good therapist will explain their approach in simple language and give examples. 

Learning from previous therapy experiences

Maybe your last therapist was dismissive, pushed too hard, too fast, or made you feel judged. Those experiences can make it hard to trust the process again.

“Many therapists will ask about prior experiences in therapy and want to know about the disappointing ones and the rewarding ones,” says Harouni Lurie. “This helps us understand what doesn’t work for you and what might be helpful for you specifically. If your new therapist doesn't ask, bring it up early.”

Consider saying:

• “I’ve had therapy before, and it didn’t go well. I’m worried about that happening again.”

• “My last therapist [specific issue — made assumptions about my culture, never gave me tools, etc.], and I want to make sure we avoid that.”

Your therapist should take that seriously and work with you to create a different relationship. They might say something like, “This sounds really frustrating. Here’s how I typically handle [that situation]. If you notice me doing something that doesn’t work for you, tell me right away.” 

When you’re not sure what to work on

Work stress, family tension, relationship issues, money worries, old regrets, climate anxiety—where do you even start?

Here’s a suggestion on how to work through it:

1. Write down everything that’s bothering you. No filter, just dump it all out.

2. Notice what feels heaviest. Not what should feel most important, but what actually keeps you up at night.

3. Rate each problem from 1-10. How much does it mess with your daily life? How ready are you to work on it?

4. Look for patterns. Maybe your work stress, family pressure, and relationship anxiety all come from the same people-pleasing habit.

5. Pick one or two things to focus on first. If you’re stuck, tell your therapist: “I have about 20 things I want to work on, but I don’t know where to start.”

“When everything feels urgent, I often invite clients to notice what is creating the most emotional weight right now,” notes Christina P. Kantzavelos, a licensed clinical social worker. “Sometimes that’s the loudest crisis, but often it’s a quieter underlying pattern that’s draining their energy. Therapy works best when you give yourself permission to focus on one thread, trusting that addressing it can help other parts of life.”

Saba Harouni Lurie, a licensed marriage and family therapist, adds: “Sometimes it makes sense to start with the issue that's been on the back burner forever, which is often the one they've always assumed couldn't be changed. Working on that can actually give both the therapist and the client a lot of information and help discover connections between different issues.”

Your therapist can help explore what matters most right now, ask clarifying questions on how different issues affect your daily life, and collaborate on a starting point. Often, we come to therapy for one thing but end up figuring out there is an underlying issue that needs to be discussed as well.

“Many times, clients begin therapy with a presenting concern like anxiety or insomnia,” explains Jimenez. “As the therapeutic relationship grows, they may start to uncover and share the deeper experiences fueling those struggles. I once worked with a client for several years. In the first year, we made meaningful strides in areas such as anxiety, insomnia, and self-esteem. About a year into our therapeutic relationship, the client finally shared that they had been sexually abused at a younger age. Once this came to light, we adjusted the treatment plan and began addressing the abuse directly.”

Having difficult conversations

Talking about family and relationships

Maybe you worry your loved one would be upset if they knew you were discussing them in therapy. Perhaps you’re from a culture where mental health support carries heavy stigma, or you’re not sure a therapist from a different background will understand your experience.

“It's really not unusual for people to struggle with discussing conflict around family or partners,” Harouni Lurie explains. “They may feel protective of these relationships, or it might feel uncomfortable to air their dirty laundry with someone they just met. I’d encourage people to communicate this struggle directly. A skilled therapist should be able to normalize that discomfort and make space to explore the relationships and the impacts they are having on you.”

You could open with:

• “My family would be really upset if they knew I was talking about this, and that makes it hard for me to be open.”

• “In my culture, we don’t really discuss mental health openly. I need to help with this, but it feels like I’m betraying something important.”

• “I’m not sure if you’ll understand what it’s like being [your identity] in [your situation].”

If you’re looking for a therapist who shares or deeply understands specific aspects of your identity, resources like our guide to finding LGBTQIA+ affirming therapy or adjusting the filters in the Project Healthy Minds directory can help you find culturally responsive care.

When emotions feel out of reach

Some people come to therapy because they feel everything. Others feel nothing at all—they know something is wrong, but they can’t access how they feel about it. This disconnect often develops as protection—from a chaotic home, from depression that numbs everything, because you’re neurodivergent and process emotions differently. Whatever the reason, it’s information, not a failure.

“For people who haven't had much practice talking about their feelings, becoming familiar with different emotional states is a helpful first step,” suggests Harouni Lurie. “This means slowing down and looking inward, while also building a new vocabulary for what you're experiencing. It can feel awkward at first, but a skilled therapist can really help guide that process and meet you where you are.”

You might try saying:

• “I know something is wrong, but I can’t really feel anything about it.”

• “Everyone says I should be angry about what happened, but I just feel blank.”

• “I can describe the events, but I'm unsure how I felt about them.”

Your therapist can help you build emotional awareness gradually, without pressing you. This might start with simple questions like “How does your body feel right now?” rather than “What emotion are you experiencing?” They might help you focus on physical sensations (such as tension, tiredness, or restlessness) or help you notice subtle differences between emotional states. Feelings wheels or other resources to help expand your emotional vocabulary are available online, or you can ask your therapist for recommendations.

Bringing up trauma and shame

Trauma, abuse, addiction or substance use, aspects of your sexual identity, family secrets, things you are ashamed of—sometimes you know what you need to talk about, but it feels impossible to say out loud.

Kantzavelos explains: “It’s normal to need time before sharing something that feels too big or too vulnerable. Start by naming your hesitation. You might say, ‘There is something I want to talk about, but I am not ready yet.’ That statement itself is a bridge. You can work together to create enough safety so that when you do bring it up, you don’t feel alone.”

Consider phrases like:

• “Something happened that I’ve never talked about, but I’m not ready to go into details yet.”

• “There is something I’m ashamed about, and I don’t know how to bring it up.”

• “I have some memories that might be relevant, but they’re hard to discuss.”

Your therapist should respect your timeline completely. They might say something like: “Thank you for telling me that. We can work on building safety and trust, and you can share more when you’re ready. There’s no pressure.” If you feel pushed to share before you’re comfortable, that’s worth addressing directly.

Taking an active role in your sessions

Setting your therapy session agenda

Research consistently shows that the therapeutic relationship—the connection between you and your therapist—is one of the most important factors for positive outcomes. You’re not just showing up to be fixed; you’re an active participant shaping the work.

Between sessions, try texting yourself things that came up during the week, noticing patterns in your thoughts or behaviors, or writing down situations where you tried something new.

At the start of sessions, take the lead and say something such as “I would like to spend some time today on [specific topic]” or “something happened this week that connects to what we’ve been working on.” During sessions, speak up about your feelings regarding progress and pacing. “This is overwhelming. Can we slow down?” or “This was helpful because [reason].”

Your therapist should welcome your input and work it into the session. They might sometimes suggest something else if they see an important connection with reasoning, but should ultimately respect what feels most urgent to you. Keep in mind that each therapy approach works differently—some therapists explain their thinking more openly than others. This back-and-forth helps your therapist understand what’s working so they can adjust.

“As therapists, we often sense when something deeper may be hidden, based on a client’s patterns, fears, or the way they carry themselves,” observes Jimenez. “Still, I always remind my clients that they are in charge of their therapeutic journey. We go only as fast as they feel ready to go. They are setting the route, and they are holding the steering wheel; I am simply a co-pilot.”

Understanding the relationship with your therapist

How you interact with your therapist is valuable information in itself. Maybe you’re trying to be the "perfect client,” who never complains or you hold back when conversations get uncomfortable. Maybe you worry about disappointing them or taking up too much space.

These patterns often mirror how you relate to others in life—people-pleasing with your therapist might connect to people-pleasing everywhere else. Recognizing and discussing these patterns is powerful therapeutic work. For example, if you notice you’re constantly apologizing in sessions or downplaying your struggles (‘I know other people have it worse’), bringing this up can help you explore where else this pattern affects your relationships and daily life.

Try opening with:

• “I notice I hold back when we talk about my family. I think I’m worried about your reaction.”

• “I feel like I’m trying to be a good client instead of just being honest.”

• “I’m worried about disappointing you, and I realize I feel that way with a lot of people.”

Your therapist should explore these observations with curiosity and without judgment. They might ask questions about where this pattern shows up, help you understand where it originated, and work with you to practice within the safety of the therapeutic relationship. For example, they might say, “I’m really glad you noticed that and brought it up. That takes courage. Let’s explore this pattern together, what else do you notice yourself holding back because you’re worried about someone’s reaction?”

Requesting practical tools

Not everyone needs to spend months exploring their past. Some people need concrete strategies right now for managing anxiety, handling conflict, navigating ADHD, or dealing with specific situations.

You could say:

• “Can you give me some specific strategies for [situation]?”

• “I’d like homework or exercises to work on between sessions.”

• “Talking helps, but I also need practical tools I can use this week.”

Your therapist can provide techniques tailored to your situation and explain how to use them. For instance, if you’re struggling with panic attacks, your therapist might teach you a specific grounding technique like the 5-4-3-2-1 method, where you identify five things you can see, four you can touch, three things you can hear, two things you can smell, and one thing you can taste. Depending on your needs, this could range from breathing exercises, communication tips, cognitive strategies, and emotional regulation techniques.

Harouni Lurie notes, “If you want homework or want to stay engaged in the work between sessions, that's excellent! Just let your therapist know. And it's also totally okay to do the work while you're in therapy and to allow yourself to integrate over time. Therapy can be a lot, so take it at a pace that works for you.” 

Knowing when therapy is working

You’ve been going for months, spending hundreds of dollars, and you’re not sure if therapy is working. That’s not a sign you’re failing—it means you’re paying attention. 

Try phrases like:

• “I’m not sure if this is working. How do we know if I’m making progress?”

• “What should progress actually look like for my situation?”

A good therapist will welcome this conversation. They should help you identify markers of progress relevant to your goals. Progress isn’t always linear, and setbacks don't mean failure. They might review your initial goals or discuss what’s changed since you’ve started.

If you’ve given it several months and still feel stuck despite raising your concerns, it might be worth considering if this person is the right therapist for you. Our guide on when and how to end the therapist relationship can help you think through your options.

Your next steps

Therapy works best when you’re honest about what’s actually happening. You don’t need to be the perfect client. You need to be real.

Trust yourself to know when something is or isn’t working. The conversations about the therapy process itself are just as valuable as talking about your problems. Speaking up in therapy teaches you to speak up everywhere else.

Ready to find a therapist who gets you? Check out the Project Healthy Minds directory to connect with services that understand your background. If cost has been a barrier, read our guide on finding affordable therapy options. 

The conversations that make therapy work aren’t always the ones you planned—they're often the ones about why conversations feel hard in the first place.