Finding a Therapist: Part II

Do I really need a therapist?

Asking yourself if you really need a therapist is somewhat akin to asking yourself if you are really in love.  There are a few exceptions to this, which I will discuss presently, however in general,  knowing when to seek professional mental help is a question without a simple answer.

There are times in life when professional intervention is clearly advisable.  These times are the exception to the rule of subjectivity.  If you are actively experiencing suicidal thoughts, it is important to seek help.  If you feel you might hurt yourself, it is important to call a friend you trust, call a help line (1-800-SUICIDE here in BC), go to the hospital, and/or call 9-1-1.  If you are experiencing symptoms of psychosis, it is also important to seek immediate help.  In both the aforementioned cases, a therapist is unlikely to be the first line of treatment, although they will probably be an important adjunct.  In both cases, and particularly in the case of psychosis, pharmacological intervention and thus a psychiatrist may be necessary.

So what about the rest of the time?  In a perfect world, it would be easy to advise you to err on the side of caution.  I would like to say that you have nothing to lose by making an appointment with a therapist, however saying this would be dismissive of the realities of many people’s lives, and the reality of people’s lives often dictates what is and what is not possible.  Seeking professional help for mental health might be easy for some, but it comes at a steep cost for others.  Those who work 40+ hours a week at minimum wage jobs are often unable to earn a living wage, live without benefits, and are unable to take time off work.  For those who take public transportation, seeing a therapist means taking an hour for the session and often an additional one or two hours in transit.  Minimum wage jobs, in the service industry in particular, often give employees schedules and schedule-changes at the last minute, which hardly allows for planning appointments with therapists.  For those who have never lived below the poverty line or who haven’t lived pay check to pay check since their early twenties, it might be hard to imagine how prohibitive scheduling and transportation concerns can be.  This is not to mention the impossibility of covering therapist fees without extended health.  So, for many people, the cost benefit analysis of seeing a therapist needs to be given careful consideration.

This is not to mention the emotional toll that therapy, and in particular that beginning therapy, can take.  Finding the right therapist is a process.  It often means exposing yourself to multiple strangers and feeling misunderstood, judged, alienated, disappointed, hopeful, and then let down again.  It can be an emotional roller coaster, and it is one many people get off before finding the help they need.

So knowing how important it is to know whether or not therapy is actually needed before investing time, money, and precious emotional energy, I have devised a list of questions a person might ask.  Many of these questions come from official criteria from the Diagnostic and Statistic Manual of Mental Disorders (DSM), while others come from personal and professional experience

  1.  Is the way I am feeling affecting my functioning in some way?  For example, am I having trouble concentrating at work, falling asleep, staying asleep?  Is the way I am feeling affecting my energy, such that I am either too tired to get things done or constantly on edge and unable to relax?  This is fundamentally a question of impact.  Although you may not be able to identify exactly what you are feeling or why, you may be able to determine its’ impact.  What is not working in your life and how badly is it not working?
  2. Is the way I am feeling affecting my relationships?  This is a big one in the DSM, but it has also been born out in my personal and professional experience.  Do you feel yourself becoming easily irritated by people in your life?  Has there been increased conflict in your relationships?  Decreased intimacy?  Do you find yourself withdrawing from social relationships?  No longer enjoying relationships you once enjoyed?
  3. Are you engaging in self-harming/compulsive behaviours? Self-harming/compulsive behaviours include cutting yourself, burning yourself, starving yourself, binge eating, purging, pulling out your hair, picking scabs, misusing or abusing alcohol or drugs, compulsive gambling, compulsive gaming, compulsive spending, risky sexual behaviours, excessive online activity.  Self-harming/compulsive behaviours are survival behaviours aimed at coping with past trauma, anxiety, depression, and as such they act as landmarks.  They are indicators of underlying pain and emotion dysregulation that should be addressed.
  4. Are you feeling nothing at all? Numbing, anhedonia, lack of pleasure, emotional flatting.  Each of these is a symptom as worthy of attention as any bought of crying, panic attack, or fit of insomnia.
  5. Are you experiencing unexplained physical symptoms?  Many people ‘somaticize’ psychological pain, trauma, and discomfort.  This means that instead of crying or feeling sad or feeling nervous, a person might experience stomach aches, head aches, skin problems etc.  There may not be a clear connection between the physical symptom and its underlying psychological cause, however unexplained body sensations and pains are often found to have psychological explanations.  It is important to see a physician in order to rule out physical causes.
  6. Has there been a discernible change or decline in everyday functioning, relationships, and/or subjective sense of well-being?  Change is another landmark.  Perhaps you are a self-described introvert.   You recharge through reading, spending time with books.  You have always avoided large social gatherings and have modest social needs.  This is not a problem in and of itself.  Pay attention to any change that runs counter to your temperament or established MO.
  7. Have you experienced a trauma in the recent or distant past? Resilience is built into our nervous systems and it is a normal component of psychological functioning, however many people experience post traumatic stress following a trauma.  For some people these symptoms can persist for many years after the initial trauma and need professional intervention in order to be resolved.  If you are wondering what post traumatic stress looks like, check out the the PTSD-Checklist -Civilian version (PCL-C).  This is an empirically validated screening tool for PTSD.
  8. Are you experiencing a major life transition or stressful life event? Major life transitions such as death, career change, moving, divorce, marriage, or children (this list is not exhaustive) may require additional emotional support.  This may be particularly true if your social network is small or not particularly strong.
  9. What does your gut tell you?  If you knew this you wouldn’t be reading this post right?  You may read the above criteria and find you don’t relate to any of them.  You may feel none of them really apply.  And yet, something feels ‘off’, something feels ‘wrong’, somehow there is subjective sense of dissatisfaction or unease.  Pay attention to these feelings.  If they persist longer than a couple weeks, consider seeking therapy.  It is not necessary to have a fully baked understanding of one’s concerns in order to start therapy.  In fact, many people do not.  This makes me think of something I once read about addiction.  How do you know if you have a problem?  If you are asking yourself this question, you have a problem.  While this edict has to be taken with a grain of salt, I think there is some fundamental wisdom here.

It is my impression that many people wait too long to seek therapy.  That is to say, people often wait until a problem is severe or extreme before seeking therapy.  While it is not true that ‘everyone could use a therapist’, it is probably true that ‘most people will need a therapist at some point in their life’.  When in doubt, err on the side of seeking and not eschewing help.