This study investigated if and how physical health is discussed in open-ended psychotherapy in a naturalistic setting, including identifying frequency and content of reported physical health issues, in-session responses to these reports, decisions not to report a physical health issue, and relationships with other session variables. Participants were 54 clients and 11 doctoral therapists-in-training engaged in open-ended treatment at a low-fee, community psychotherapy clinic. Data about physical health was collected for each client at intake, and data on report of a physical health issue, characteristics of the report, therapists’ response during the session, decision not to report, working alliance, real relationship, and session evaluation were collected after each session. Data were analyzed using descriptive statistics, mean comparison, and linear regression. Results indicate that while talking about a physical health issue was relatively infrequent, clients had physical health issues that they found distressing. The most common physical health issues discussed were sleep, weight, and pain. Clients were more likely to share issues in session that they rate as more distressing and related to their mental health than those they chose not to share. Clients were three times more likely than therapists to initiate discussion about physical health in session, and issues that were discussed usually came up in the early phase of long-term, open-ended treatment, and were discussed in more than one session. In sessions when a physical health issue was discussed, depth of the discussion varied greatly, but when clients’ understanding of their physical health issue was evolving or unclear, they more consistently talked about the issue in depth. When talking about physical health, therapists reported helping clients draw connections with their mental health through insight, while clients felt therapists focused more on exploration of the issue. Qualities of the discussion about physical health in session related to client-rated working alliance, real relationship, and session evaluation. Implications for training, research and practice are discussed.