Published on August 12, 2011 by Anne Rettenberg, LCSW in Beyond Don JuanWe've all known people who seemed badly to need psychological help yet refused to go. Numerous times, I have given referrals to patients for their friends or family members, and only occasionally do these people follow through. Why don't more people seek help? There are many possible reasons, some more valid than others:
Fear. Some people have traumatic memories that are mostly repressed. They know if they start talking, more will surface. The prospect of dealing with the resulting emotions can be terrifying. It's not necessarily an irrational fear; an inexperienced or poorly trained therapist can mismanage treatment with severely traumatized individuals, causing re-traumatization. A typical example is a person who has been a victim of terrible wartime trauma. These individuals are often overwhelmed with emotions such as anxiety, grief or guilt when they think about their experiences. Some individuals who are deeply traumatized may only be able to participate in very simple therapy based on increasing coping skills, or may need medication before they start therapy. There is a misconception among the general public (and some therapists) that talking about traumas is the way to resolve them. Eventually, people may need to deal with unresolved feelings from trauma-especially guilt feelings. But emotional flooding early in therapy is a bad idea.
Hopelessness--"I am how I am." There are others who are convinced they can't change--that their life is their destiny. When I was a counselor in a substance abuse treatment program, a client once told me that when she was using heroin, she thought she was just a junkie and that was how things were. Eventually she gave herself a chance, but many people do not. Such individuals may have a sense of helplessness from a traumatic past, or they may have internalized a damaged self-image to protect a neglectful figure from childhood on whom they were dependent and therefore unable to hate. They turned the hatred inward and developed a sense of worthlessness-"I don't deserve better." Hopeless and worthlessness frequently go together.
Denial: There are others who are convinced that everything that goes wrong is someone else's fault, so why should they go to therapy to learn what's "wrong" with them? It doesn't occur to them that if they keep repeating unsatisfying patterns in life, they must have some role in what's going on. This awareness would disturb their grandiose self-image, so they distort reality. This type of narcissism represents a malformation of the personality. It probably stems from a combination of genetics and negative early childhood experiences.
Envy: A couple of decades ago, the psychoanalyst and psychiatrist Otto Kernberg, who extensively studied psychotherapy and personality disorders, noted that there are some patients who don't progress in therapy because to do so would mean that the therapist helped them-an idea they cannot tolerate because of their pathological envy and competitiveness. It's occurred to me that there are probably also people who never go to therapy in the first place because of this type of envy. Why would some people-usually people with narcissistic personality disorder--envy someone who helps others? Helping someone else demonstrates compassion, a trait narcissists often lack. Secondly, if you have to go to someone for help, it implies that the other person knows something you don't-an intolerable possibility for persons with severenarcissistic personality disorder.
"Nobody Can Understand Me." This can be a symptom of grandiosity or a cover for fear or shame. Sometimes these people do best in 12-step programs or other topic-related groups, where they are surrounded by people who have the same problem. It's hard, when you're surrounded by people who are just like you, to claim "they can't understand me."
Can't Find a Decent Therapist: I can relate to this one. I first went to therapy as a teenager, to sort out some issues. I was lucky to have a good therapist. When I sought further help in graduate school, I wasn't so lucky. I tried out a dozen different therapists before I found one who could help me. Some people have a bad experience with a therapist and never return. But persistence pays.
Why are so many therapists so bad? Graduate programs need to enroll students to make money. They aren't going to turn away people who aren't suited to the profession if it would mean not filling their slots. My graduate program, which was considered one of the best in the country, didn't even require a personal interview for admission. This failure to adequately screen applicants has created a pool of therapists who just shouldn't be working with people. But a good therapist can be found if you look hard enough.
Can't Afford Therapy: This common excuse is one I don't buy. If you live in or near a major city, not only can you find therapists who have sliding scale fees, but you can probably find a public or non-profit or charitable clinic with very low fees. I've worked part-time in clinics that charged people as little as $40 a session. I know of a hospital outpatient clinic in New York that charges as little as $15 a session for some patients-- not too many people can't afford that, and if you are one of them, you probably qualify for Medicaid. It can be hard to find a therapist when you live in a rural area, but today there is the option of online therapy (which tends to be cheaper than in-person therapy, though it may not be as effective).
The sad paradox of psychotherapy is that those who need it the most often don't go.
Fear. Some people have traumatic memories that are mostly repressed. They know if they start talking, more will surface. The prospect of dealing with the resulting emotions can be terrifying. It's not necessarily an irrational fear; an inexperienced or poorly trained therapist can mismanage treatment with severely traumatized individuals, causing re-traumatization. A typical example is a person who has been a victim of terrible wartime trauma. These individuals are often overwhelmed with emotions such as anxiety, grief or guilt when they think about their experiences. Some individuals who are deeply traumatized may only be able to participate in very simple therapy based on increasing coping skills, or may need medication before they start therapy. There is a misconception among the general public (and some therapists) that talking about traumas is the way to resolve them. Eventually, people may need to deal with unresolved feelings from trauma-especially guilt feelings. But emotional flooding early in therapy is a bad idea.
Hopelessness--"I am how I am." There are others who are convinced they can't change--that their life is their destiny. When I was a counselor in a substance abuse treatment program, a client once told me that when she was using heroin, she thought she was just a junkie and that was how things were. Eventually she gave herself a chance, but many people do not. Such individuals may have a sense of helplessness from a traumatic past, or they may have internalized a damaged self-image to protect a neglectful figure from childhood on whom they were dependent and therefore unable to hate. They turned the hatred inward and developed a sense of worthlessness-"I don't deserve better." Hopeless and worthlessness frequently go together.
Denial: There are others who are convinced that everything that goes wrong is someone else's fault, so why should they go to therapy to learn what's "wrong" with them? It doesn't occur to them that if they keep repeating unsatisfying patterns in life, they must have some role in what's going on. This awareness would disturb their grandiose self-image, so they distort reality. This type of narcissism represents a malformation of the personality. It probably stems from a combination of genetics and negative early childhood experiences.
Envy: A couple of decades ago, the psychoanalyst and psychiatrist Otto Kernberg, who extensively studied psychotherapy and personality disorders, noted that there are some patients who don't progress in therapy because to do so would mean that the therapist helped them-an idea they cannot tolerate because of their pathological envy and competitiveness. It's occurred to me that there are probably also people who never go to therapy in the first place because of this type of envy. Why would some people-usually people with narcissistic personality disorder--envy someone who helps others? Helping someone else demonstrates compassion, a trait narcissists often lack. Secondly, if you have to go to someone for help, it implies that the other person knows something you don't-an intolerable possibility for persons with severenarcissistic personality disorder.
"Nobody Can Understand Me." This can be a symptom of grandiosity or a cover for fear or shame. Sometimes these people do best in 12-step programs or other topic-related groups, where they are surrounded by people who have the same problem. It's hard, when you're surrounded by people who are just like you, to claim "they can't understand me."
Can't Find a Decent Therapist: I can relate to this one. I first went to therapy as a teenager, to sort out some issues. I was lucky to have a good therapist. When I sought further help in graduate school, I wasn't so lucky. I tried out a dozen different therapists before I found one who could help me. Some people have a bad experience with a therapist and never return. But persistence pays.
Why are so many therapists so bad? Graduate programs need to enroll students to make money. They aren't going to turn away people who aren't suited to the profession if it would mean not filling their slots. My graduate program, which was considered one of the best in the country, didn't even require a personal interview for admission. This failure to adequately screen applicants has created a pool of therapists who just shouldn't be working with people. But a good therapist can be found if you look hard enough.
Can't Afford Therapy: This common excuse is one I don't buy. If you live in or near a major city, not only can you find therapists who have sliding scale fees, but you can probably find a public or non-profit or charitable clinic with very low fees. I've worked part-time in clinics that charged people as little as $40 a session. I know of a hospital outpatient clinic in New York that charges as little as $15 a session for some patients-- not too many people can't afford that, and if you are one of them, you probably qualify for Medicaid. It can be hard to find a therapist when you live in a rural area, but today there is the option of online therapy (which tends to be cheaper than in-person therapy, though it may not be as effective).
The sad paradox of psychotherapy is that those who need it the most often don't go.
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