Therapy Session Anxiety: A Therapist's Guide to Surface and Underlying Blocks
Introduction
As a licensed therapist in Detroit, I’ve heard “I don’t know what to talk about” many times throughout my career as a therapist. I’ve heard it in initial consult calls, individual sessions, and group therapy. I’ve heard it enough to know it’s worth thinking and writing about.
If this has happened to you, you might feel awkward, stuck, or unsure if you’re doing it “right.” This fear might feel big enough to stop you from starting or continuing therapy. This blog post will be a space to think through some of the reasons why this is so common and offer some ways to think about these feelings and how they can be a part of your therapy.
My practice grows and changes as I grow and learn. I first wrote about this topic five years ago, and at that point my approach was more goal-oriented. I wrote about ways that you can help yourself get organized around your goals for therapy.
My approach has expanded to include more psychodynamic theory, which offers ways to think about this anxiety beyond goal-setting. In this blog, I’ll share some of my thoughts on both conscious and unconscious reasons why you might not know what to talk about in therapy, ways to overcome the initial fear enough to get in the door, and some ways to think about your anxiety with your therapist. Keep in mind that every therapist works and thinks differently, and this blog is intended to be more of a starting point than an all-encompassing guide.
Why It Happens
On the Surface
You might feel like you already know why you’re unsure of what to talk about in therapy. Your conscious reasons might sound something like:
“I’m not in a crisis so there’s nothing that important to talk about.”
“My therapist is probably sick of hearing the same thing over and over again.”
“Other people have real problems that are more serious than anything I have to say.”
“I don’t want to waste my time or misuse my time in therapy. It’s hard to know what’s most important."
“I know what I need to talk about but I don’t want to go there.”
There’s no trick here; I call these types of thoughts conscious thoughts because just as the word conscious implies, you have conscious awareness of these thoughts and the accompanying anxiety. These are the types of thoughts you can use reasoning to make sense of.
You might even find yourself going back and forth between a few conflicting thoughts like:
“My therapist is sick of hearing these small issues but isn’t this what I’m paying for?”
“Other people’s problems might be more important than mine, but I still care about my friends’ problems even if they seem small.”
“Maybe I’m not in a crisis, but I still have goals for my treatment that are important to me.”
The first part of these thoughts name a fear, and the second parts include a way that you’re trying to reframe your own thought. It can be useful to offer yourself these types of reframes and to take the time to think through your initial hesitation. If these thoughts come up in between sessions, maybe you and your therapist develop some of these reframes together. This might be a good enough way of working with these thoughts for you to feel a sense of resolve.
But what if these thoughts persist, no matter how good of a reframe you develop? That’s a good clue that there is more happening outside of your awareness, or unconsciously.
Going Deeper
Therapy is a place to make sense of what’s happening deeper than what you are already aware of. Psychodynamic therapy understands this part of your mind as your unconscious. Something that is happening outside of your awareness, or unconsciously, might initially sound wrong. Of course, some of these possibilities might be completely wrong for you. It’s important to work with a therapist you trust to collaborate in understanding your unconscious mind together.
Some possibilities for what’s making it feel so difficult to know what to talk about in therapy are:
Terror of what you’ll discover if you keep talking.
It’s one thing to feel a bit nervous, but much more powerful to have a deep fear of what you will learn about yourself. The deep fear of learning something you don’t want to know about yourself can show up in defensive thoughts like, “I’m doing ok, I don’t have anything that important to talk about.” There are important reasons why your mind is protecting you from knowing everything about yourself all at once, and it can take time in treatment to feel safe enough to tolerate gradually knowing more and more of yourself.
A deep sense of devaluing yourself.
If you are chronically worried that what you have to say isn’t important enough to be worth listening to, it’s possible that you are used to trying not to need or want “too much.” There may be developmental and cultural reasons why this might be true for you, and it is a key theme to work through in therapy.
Something happening in the relationship with the therapist.
Sometimes when a patient is feeling something towards their therapist that they don’t want to feel, it remains outside of their awareness but blocks them from sharing as openly as maybe they once did. For example, they might be feeling angry, fear relying on the therapist too much, or could be experiencing erotic transference (having romantic or sexual feelings towards the therapist). It takes time in therapy to trust that these types of feelings can be talked through and are actually really helpful to understanding the patient.
How we deal with this in the room
Every piece mentioned in this blog – both the conscious and unconscious reasons why you might be feeling unsure of what to say in therapy – can be talked about in treatment. It isn’t an aside or afternote to the therapy, but is actually a key part of understanding how you relate to yourself and others.
The difference between these feelings in relationships with friends, partners, co-workers, or family members, is that in therapy you can talk about your feelings about the relationship and use those feelings to better understand yourself. The therapeutic relationship uses boundaries around time, money, and (the therapist’s) personal disclosures to foster a space that is different from other relationships. The focus of your feelings about the therapist and the therapy is to use them to understand yourself, not to protect the therapist’s feelings. The ongoing focus on how your thoughts and feelings help you understand yourself is a big part of what sets therapy and your relationship to your therapist apart from your other relationships. That doesn’t mean it’s easy to speak completely openly, but it does mean that whatever it is that you’re thinking and feeling can be talked about.
Role of Silence
This blog has shared a lot about talking in therapy, but if you really truly can’t think of anything to say or where to start? What if you just sit there in silence?
Silence is okay, and can eventually be understood. Silence can be a sign of aggression, hostility, anger, confusion, fear, acceptance, or a way to communicate that you’re not ready to talk about what you need to talk about. Silence can be “resistance,” which is another way of saying it can be protective or can feel protective. No two silences are the same, and sitting in silence doesn’t mean you are wasting your time. Over time, you and your therapist can work together to understand what the silence means for you.
A Note on Goal-Setting
When I wrote about this topic in 2020, I had the idea that refocusing on goals would be a useful way to handle the uncertainty. Five years later, I agree that remembering one’s own goals for therapy can be useful to maintain commitment to the therapeutic process and find motivation to keep showing up. But I actually disagree with the idea that it’s a useful way to handle not knowing what to talk about while in session.
I would generally not ask a current patient to think about their goals in session with me when they don’t know what to talk about. Firstly, goals can change quite profoundly throughout a treatment. Sometimes, an outcome that provides relief is the opposite of what the original goal was, like if someone were to quit a job rather than try to find a way to be okay with an abusive environment. Secondly and more importantly, goals can only tell us about conscious thoughts and behaviors.
Many people come to therapy because they want to feel better, but they don’t know what they need to do to feel better. They can have a goal like “I want to be kinder to myself,” but consciously telling themselves that they need to be kinder to themself is absolutely not helpful. The therapy is about trying to understand what fantasies, wishes, conflicts, and experiences are impacting how they view themselves. The attempt to focus on one goal isn’t as useful as sharing whatever comes to mind in session to form a more well-rounded conceptualization of how their mind is organized. In fact, sometimes the desire to focus on a goal can be part of a mental defense against knowing more about one’s own mind.
Ways to Get in the Door
We’ve talked about some ideas of why you might not know what to talk about and how I work with this issue in session, but how can we help support you to get you into the room?
When you know that you want to seek therapy but feel anxious about what to talk about, the most important step is to help yourself get in the door, knowing that once you are in session you can talk through your anxieties and ambivalence with your therapist.
Trust that your mind will feel differently when you’re there – physically or virtually.
You might not know what to talk about and that’s okay. Once you are in session, eventually something will come to mind. It doesn’t have to be a well thought out agenda or a fully formed thought. But something will come to mind, and if you can trust yourself to say it out loud, it will have value. It could be as simple as, “I have no idea what to talk about today and that made me so nervous to show up.”
The power of the unconscious mind is that what comes to mind when you are in therapy has significance, even if it’s not obvious what that significance is. For example, have you ever heard of a “doorknob confession” when someone says something really important in the last minutes or moments of a conversation? They might say that they “just” remembered something. This is the unconscious mind “just now thinking of it” and there are reasons why you do or do not “remember” something in session. The process will unfold as it’s meant to.
Remind yourself of what motivated you to start therapy.
As mentioned earlier, the focus on goals can be limiting or even be used defensively. But there must have been good, strong reasons why you were motivated to begin therapy. Those reasons might have changed, but can be helpful to remember when you’re not easily accessing anything concrete to talk about in session.
Don’t take this as a sign that you shouldn’t keep showing up
It’s common and expected that there will be times when you don’t know what to talk about in therapy. It doesn’t mean you’re doing it wrong or even that you’re off track. It means there’s an opportunity to explore what’s happening in the treatment, ultimately to help you understand your own mind.
Conclusion
Not knowing what to talk about in therapy can be a doorway to deeper understanding of your mind, your relationships, and the therapy. These moments of "not knowing" can be valuable parts of your therapeutic journey.
Remember that therapy isn't about performing or doing it "right." It's about creating space to understand your mind, including the parts that feel stuck or silent. Trust that by showing up you're already doing important therapeutic work. The process of therapy, like the workings of your mind, isn't always linear or immediately clear, but it unfolds in its own meaningful way.
The approach I've described reflects both my psychodynamic orientation and personal style. Other therapists may work differently with these moments of uncertainty. Some might offer more structured guidance, while others might have a completely different way of conceptualizing these moments.
If you're in the Detroit area and interested in exploring therapy from this perspective, I welcome you to contact me here. Together, we can work through these moments of uncertainty.