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The relationship between a patient and a therapist is a delicate one, one that requires careful nurturance and the gradual building of trust, as there are deeply personal, fundamental issues being explored and revealed to someone who is otherwise a stranger. It is more than understandable why many people are afraid to even seek out a therapist initially, given this huge leap of faith involved.
But a therapist’s creed is to provide a truly safe space, to become a private and confidential listener and adviser. They have dedicated their lives to directly addressing and guiding people through the struggles of life, oftentimes the darkest and most painful ones, such as trauma, abuse, and illness. They are crucial outside support, a neutral party, and sounding board for difficult family, relationship, and workplace stressors.
There are some common themes in therapy that can be sensitive to broach or discuss, but not unlike tension points in one’s muscles, those are often the areas that require the most help and targeted intervention. But because of their sensitivity, it may sometimes take a longer period of time, even months or years, for someone to open up or acknowledge some of these crucial concerns.
I am hoping to highlight these important topics so that readers can consider more direct attention and focus on them, whether they are in therapy and still haven’t discussed them, or whether they are considering beginning therapy.
1. Traumas and Tragedies
Tragic and painful life events are often the underlying basis or trigger for other presenting symptoms that initially manifest to a therapist’s office. For example, it’s not uncommon for someone to come in saying they are having trouble sleeping and have a lot on their mind, that they are feeling sad or irritable or stressed out. But shortly after, they will then note that their loved one recently passed away, or that they were raped when younger and never told anyone, and other serious, devastating events.
Even when openly admitted to, the process of uncovering the ripples and layers that radiate from a traumatic event often defines the process of therapy itself moving forward. Trauma becomes the elephant in the room that must never be ignored, although the process of addressing it must be individualized and occur at a safe, agreed-upon pace for the patient.
2. Obsessive Thoughts and Anxiety
Anxiety spans a wide range of causes and themes, everything from seemingly unprovoked panic attacks to obsessive-compulsive disorder to isolated phobias (like flying). It is another one of the most common reasons for people to visit therapists. Anxiety is a complex condition that is linked to both neurobiological loading, where people have physiological and/or genetic priming to develop hyperreactive responses to fear-provoking phenomena and complex emotional and psychological defense mechanisms from past life memories or relationship dynamics that can manifest as anxiety.
What is important for patients to open up about is the thought content linked to any anxiety, even anything that seems incredibly trivial, absurd, irrational, or frightening and disturbing. All of these “automatic thoughts” (as cognitive-behavioral therapy calls them) cropping up with anxiety are important data pointing towards an underlying cause that needs to be addressed.
3. Sexual Concerns
One of the most embarrassing and difficult topics for people to open up about is sexual problems. Given our still relatively conservative societal taboos about sexuality, and also past histories of people who have abused appropriate boundaries, many people don’t feel comfortable talking about these issues with strangers.
However, although many of Sigmund Freud’s overtly specific theories about sexuality are considered outlandish today, he wasn’t wrong necessarily about the importance of sexuality itself on human development and how it manifests in relationships and anxiety. A therapist is a professional who understands this context and maintains a non-judgmental, open-minded space to address this crucial part of human existence; their goal is to be pragmatic and supportive of sexual concerns.
4. Emotions Underlying Physical Pain
Due to ongoing stigmas, particularly in certain cultures or gender norms, about emotional vulnerability, and worries about having emotional concerns dismissed, sometimes serious mental conditions like depression and anxiety manifest initially as physical or somatic issues, in order to get more direct attention.
Any true medical issue should absolutely be fully worked up to its full extent first and taken at face value, but if there is ample evidence that the underlying cause may be psychological, it is important to create an atmosphere of safety and acceptance, so these patients can express those underlying emotional concerns and not feel dismissed or ignored (which may have led to those initial presentations).
5. How Bad Things Really Get
The hardest thing to discuss for some is the feeling or frank intent of ending one’s life. While some patients manage to open up about these thoughts (a crucial point for intervention, since they are clearly a cry for help), many suicides still occur without warning.
Most therapists will directly ask you about these suicidal thoughts as part of a screening interview; unfortunately, many people will not reveal the full extent of those thoughts due to fear that they will be hospitalized or misunderstood, or because they do not trust a new person. (Of course, others are determined to go through with it and won’t tell anyone.) If you are unsure, and your thoughts are imminent or severe, it may be your best chance to receive the full extent of help available and learn what options are out there; you deserve that chance.
Ultimately the goal in partnering with a therapist is to confront the troubles in your life in a safe and professional manner. It may be the one space and setting where you can discuss difficult and taboo topics with an expectation of privacy and with the goal of understanding and growth. In a future blog post, we will discuss certain defense-related untruths that one should avoid telling one's therapist.
Note: A version of this article was originally commissioned for psycom.net.
