Yeah, hate that question. Never worked for me either.

My last therapist started a bit differently with me. The first few minutes he asked about my depression level, anxiety level, sleep patterns, etc. This was helpful because I went through years of severe depression that resulted in repeated hospitalizations, so starting with this check in gave him an idea of where I was in comparison to my baseline. (We had spent some time figuring out what baseline looked like for me and coming up with a common rating system for all of the above categories so we were always on the same page.)

In the process of that check in, he would ask me questions (or I would offer up information) about what was going on that might be affecting those levels. As we talked about those levels, inevitably the topic to start with would arise in that discussion, and from there we continued.

I found the check in routine helped me settle in, and the topics for the session seemed to so naturally and effectively develop from that check in. I honestly almost never went into a session knowing what I wanted to discuss, but somehow we always landed in exactly the right place. My therapist was good that way; he had quite a knack at getting me to come up with the focus even when I didn't know it when I walked in. (I had other good therapists, but he was definitely the best at getting things rolling.)