Do I Need Therapy?

“Do I need therapy” is a common contemplation before calling or attending a session. This is a question more people are confronting since the COVID pandemic and a strong emphasis on mental health. Not only is there a shortage of providers but wait lists are long for therapy services. How do you know that you picked the right provider for your specific needs? What about coaching? What are the differences? What about Psychometric testing to diagnose? I see a lot of referrals for adults and children who want therapy, but have no idea what they want to work on or why they are going. Since the pandemic we have been isolated, lost family, and changed how we view the world and interact with it. Social Media has taken over in person connection and how we perceive events. Parents, young adults, and teens are using location tracking services leading to feelings of FOMO (Fear of Missing Out) and FOBLO (Fear of Being Left Out) and Helicoptering. The experiences pre-2009 of being able to interact with our environment without fear of images and videos without our consent to go viral are gone. Video screens have replaced real in person interactions and have influenced our ability to connect with others and experience community. Connection is no longer an emotional one, it is a technological one that has created a significant increase in anxiety, depression, suicide rates, domestic violence, and abuse in homes. We have lost our autonomy and ability to have boundaries and privacy to the impulse of someones 15 seconds fame. No wonder we feel like we need some relief.

The intention of therapy is to work through current and past events in a person’s life to reduce the emotional and somatic intensity of symptoms they experience and to process thoughts, beliefs, and relationship dynamics to gain insight and perspective. This insight and perspective is intended to aid in resolving internal conflicts a person may have to making major life decisions that the person feels stuck. Therapy can also resolve embodied trauma responses that are stored in our limbic system and trigger the fight, flight, freeze, fawn response. The limbic system according to the Oxford Dictionary: [is] a complex system of nerves and networks in the brain, involving several areas near the edge of the cortex concerned with instinct and mood. It controls the basic emotions (fear, pleasure, anger) and drives (hunger, sex, dominance, care of offspring). Therapy will never erase a memory or experience but it can make it less distressing and overwhelming when those memories happen. Therapy also is meant to be objective and to challenge a person’s perception to learn new ways of understanding themselves and relationships, as well as build skills to remain grounded and set boundaries.

Memories are more than just a visual movie or picture in our heads. Memories are stored throughout our body in our nervous systems. This is why certain events can trigger a feeling, sensation, or reaction and we have no idea why. In some cases we might refer to this as “pre-verbal” trauma with children and adults when there is a looming feeling or issue and a known history of trauma before language developed. In other situations it is the imprint on the body and limbic system that has been trained to react in a specific way. An example of this is when a veteran who has been trained to perform certain duties comes back from a conflict and reacts severely to loud noises without thinking, but other situations don’t even phase them. These are also the memories we have when we smell fresh baked bread or cookies. Not all triggers in our limbic system are negative. Many are there for a reason to protect us and serve a purpose.

But how do we know when to go to therapy? This is dependent on the person and the stage of life they are in. Some people have a lot of emotional and physiologic responses to things and from the outside it would be easy to determine “that person really needs therapy…” but, the catch is that person who appears to be so out of sync and reactive has to be ready and willing to embrace the changes and realities therapy will confront and bring up for them. Court ordering or requiring someone to enter therapy can backfire if that person is overly defensive or in denial about their need. If someone is not ready to do this, therapy will be ineffective. This doesn’t mean there aren’t other things that person can work on outside of the big issues to build to a point of engagement. But this will appear much different than may be expected. We see this most commonly with individuals who struggle with addiction and substance misuse. This is also very common in teenagers struggling and adults with undiagnosed and untreated personality disorders. They have to be ready.

This is the same for children. It is well assumed that a child who has experienced what adults believe is a traumatic event, or several, “needs” therapy or to be “fixed”. But here’s the interesting part, maybe they don’t? Maybe they are not in a place to process the events they have experienced. Or, maybe they didn’t internalize those experiences to make them traumatic. Trauma and abuse are two separate things. Abuse is an action or situation that could cause harm in some form to a person. Trauma in the internalization of an event that impacts a persons perception and functioning in a negative way. Abuse can happen, be acknowledged, but does not mean it was trauma for that person. Just because one person experienced an event at traumatic, does not mean the next person will. Children are amazingly resilient. And there definitely are situations when they are displaying behavior and emotional responses. Therapy can be needed to process feelings to lessen the triggers and reactions but is not always the case. But this may not mean they need mental health focused therapy, they may need occupational therapy services to address this from a sensory or developmental perspective first.

So the question is more than “Do I Need Therapy?”. The question is what are you wanting to work on and are you ready to do the work? Therapy can be a grueling process for some. It means talking about situations that a person hoped to leave behind or now suddenly starts remembering. Our brains are amazing machines and unpredictable. It also means being ready to sit with an emotion or experience that was distressing and actually feeling it again, but in a safe place with support. To work through our issues, we have to be willing and open to accept it is going to suck. This is often where people quit. Sometimes therapy can be a trigger and emotions and behavior may intensify outside of therapy before it gets better. Therapy also means we sometimes have to admit to and take accountability for things we don’t want to, or admit we may have been wrong. This is why it is so important to have a family systems approach to help those around the person in therapy understand what is going on and how to support them.

Sometimes we think we need therapy when really what we are looking for is advice and coaching. This is not a service that is considered medical, it is not a deep dive in to history and processing emotions and experiences. Coaching is neutral advice giving from a trained professional. Actually anyone can provide a coaching service. There are no licenses or requirements to be a “life coach” or “divorce coach” although many training programs to give structure to these practices exist. I see it a lot that a person comes in to therapy, meets for two to four sessions and has resolution to an issue they simply were seeking advice and validation on. They did not want to dig deep in to history and processing. That is perfectly acceptable, however this is not therapy.

It is also more common in today’s post COVID world after spending almost two years isolated to video shorts and inaccurate PSA’s on mental health that everyone believes they have a diagnosis and need to be tested to confirm this. Self Diagnosis off a 20 second video meme is the most current trend, and in some cases might be accurate. Social Media has helped in raising awareness and challenging outdated criteria. The DSM has even become less specific and adapted criteria to make diagnosing serious brain health conditions easier, which may not be a good thing. Requests for in depth psychometric testing is increasing. I think first before we request psychometric testing, we need to understand the role it plays in diagnosis and why we are asking for these highly complex tests. Psychometric testing alone is not an accurate tool for diagnosis. It is meant to measure thought processes, beliefs, and consistency in reporting of symptoms and emotions. It really depends on the test that is given and what we want to measure. A person in a highly stressful situation and going through a highly contentious divorce is going to present differently than when they are in a calm state in their life with typical daily stressors. So we have to be careful how we use these tests and what conditions to understand why we get the results we do. I have also experienced significant bias in evaluating testing based on that professionals personal beliefs and training. I have test results less than two years apart from two highly respected clinicians who trained in the same internships for their license that have almost identical test scores, but two very different outcomes and suggested diagnoses. Psychometric testing is important to assess for serious personality disorders, PTSD, and things like ADHD and Autism. It can help guide a diagnosis for Schizophrenia and Bi-Polar disorder. However the relationship with the clinician is a huge piece of these tests, along with training in observed symptoms. And as much as we have a long history of fine tuning these tests, they do have error rates and some can even be tricked if you know what you are doing. The other piece is, can we diagnose without the invasive and extensive testing and still be accurate? The answer in most situations is yes. Testing is a great way to narrow down issues or understand symptoms, areas to target in therapy services, and gives us a picture of how a person perceives the world and their relationship to it, but it is not required to diagnose most brain health conditions. In fact, the question of why we even need a diagnosis is common. What will having that diagnosis help since there is no “one size fits all” treatment or cure for brain health issues. Symptom management with treatment is typically the focus of therapy services. Diagnosis is honestly a tool for insurance reimbursement and when used inappropriately or inaccurately can be highly stigmatizing creating barriers to treatment and support. In a positive light diagnosis also helps a person describe their experience and those living with someone to understand better what is going on. We have to be cautious that we are not “living in” versus “with” a diagnosis without proper symptom management. Living In a diagnosis can lead to self-victimization and a resistance to treatment for some. Our society is currently obsessed with labels and how many brain health disorders we can acquire as a status symbol.