At a glance
Most people who wonder whether they need therapy have been managing something difficult for a long time, and managing is not the same as being well. Deciding turns less on how bad the difficulty is than on how much of your attention it has begun to take. This article helps you weigh that honestly.
Clinical insights from 22 years in psychotherapy
I’m Mark Colclough, MA, psychotherapist in Copenhagen. Qualified at the Psychosynthesis Education Trust and the University of East London. 22 years of full-time, face-to-face clinical practice.
- The question carries the answer. Clients who ask me whether their difficulty is serious enough have usually been asking themselves that for months before they ask me.
- Size is not the measure. Most of my clients come when a difficulty has taken up more room inside them than its size from outside would suggest.
- The late arrival. Many of my clients tell me in a first session that they could have come two years earlier, and that what held them back was doubt about their own need rather than doubt about therapy.
Clinical notes: My observations are anonymised and compounded from my session notes since 2004.
Is this bad enough to be worth a session?
There is no threshold you have to cross first. People arrive expecting me to hold up a line and tell them which side they are on, and no such line exists. What I listen for instead is whether the difficulty has stopped being an event and become a fixture: something you now arrange your week around, something you check on when you wake.
You can test that without me. Think of the thing you have been carrying and ask how long it has been there, and whether it has moved in any direction in that time. A difficulty that keeps shifting, that is worse in one month and lighter in the next, usually still has your own resources working on it. One that has been exactly the same weight for six months has settled, and settled things rarely move on their own.
Living abroad raises the bar in a particular way. When everything is new, the language, the winter, the colleagues, the way people stand in a queue, you expect to feel unsteady and you give yourself permission to be unhappy for a while. That permission is sensible for the first year and it quietly outlives its usefulness. Some of the people I see in Copenhagen have been granting themselves that allowance for four years.
Why can I manage everything else, but not this?
Capability is never spread evenly across a life. The people who find their way to me are often extremely good at the parts of living that respond to effort and organisation. They move countries, hold difficult jobs, keep a household running in a second language. Then one area refuses to answer to any of that, and because everything else answers, the failure feels personal.
It is usually the area with the least practice behind it. Emotional life is learned the way a language is learned, from the people who were around early on, and most of us were taught some parts of it and not others. You may have learned to be reliable and not to be disappointed. You may have learned to look after other people’s feelings and never to locate your own. The gap shows up decades later, in a relationship or a flat in a city where no one knows you, and it looks like a character flaw rather than a part of the curriculum nobody taught you.
That is also why advice slides off. Advice reaches the thinking part, and the difficulty is sitting somewhere older than thinking. You can know precisely why you should speak up with your partner and find that your throat closes anyway. The feeling comes first, the body follows it, and the explanation arrives last and usually too late to be of use.
What am I protecting by handling it alone?
Wanting to manage it yourself is a form of self-respect long before it becomes a problem. It has usually worked. It got you through something once, possibly something nobody helped you with, and it is reasonable to trust a method that has a record.
It is also the most common place people stop. Household surveys across 24 countries found that among those who did recognise they needed help and still did not start treatment, wanting to handle the problem on their own was the reason given most often, by 63.8% of them.1 The same work found that attitudes mattered more than practical obstacles for people whose difficulties were mild or moderate. What stands between most people and a first session is rarely the money or the diary.
When I ask what handling it alone is protecting, the answers tend to fall into a few shapes.
- The picture other people have of you. The competent one, the one who copes, the one the family rings when something goes wrong.
- The fear of finding out it is worse than you thought. As long as nobody looks properly, the size of it stays unknown, and unknown feels safer than large.
- An old loyalty. In some families, asking for help was treated as a complaint about the people raising you, and the prohibition outlasts the household.
None of those is foolish. Each of them deserves to be taken seriously rather than argued out of you, which is part of what a first session is actually for.
What if my circumstances are the problem, and not me?
Circumstances often account for a great deal, and there is usually still something left that belongs to you. I meet people who have decided the whole difficulty is Copenhagen: the dark from November, a workplace that goes quiet at four, a partner’s family who are pleasant and never quite let you in. Often they are right about a large part of it. A life can be genuinely hard to live without anyone being ill.
The useful question is what would remain if the circumstances changed tomorrow. If the light came back and the job improved and you spoke the language fluently, what would still be sitting there? Sometimes the honest answer is very little, and then the work is practical rather than therapeutic. Sometimes the answer is a feeling that has followed you across two or three countries, and that is worth your attention wherever you happen to be standing.
Hold both. Your situation is real and it is pressing on you, and your part in it is also real, and neither cancels the other out.
What can I try first, and when is trying on my own not enough?
Start by making the difficulty specific, because a vague difficulty cannot be worked on by anyone, including a therapist. Four things are worth doing before you decide anything.
- Put it in one sentence. Not a diagnosis and not a story, just what happens and when: I go flat on Sunday evenings, I cannot say no at work, I feel nothing when he touches me.
- Watch it for two weeks. Note when it is heavier and when it lifts. Patterns that are invisible day to day become obvious across a fortnight.
- Tell one person the whole of it. Most people have told several people a quarter of it each, which keeps the thing in pieces and leaves them feeling unmet.
- Change one condition and watch what happens. Sleep, daylight, how much you are drinking, how often you are alone. If a fortnight of that shifts it, you have learned something useful and cheaply.
Those steps have limits, and it is worth knowing where they run out. They are not enough when the difficulty has been the same weight for months and nothing you have altered has touched it. They are not enough when sleep or appetite changed and then stayed changed. They are not enough when you are keeping things steady by making your life smaller, turning down invitations, dropping what you used to enjoy, keeping conversations shallow so that nothing opens up.
Working on your own responses is also the wrong instrument when the trouble is coming from someone else’s behaviour towards you, and you find yourself frightened, managed or diminished by it. Self-management will not reach that, and trying harder at it tends to make it worse. That situation needs to be looked at directly, with someone, and named for what it is.
If you want to talk any of this through before deciding, a session or a free 30-minute call is enough to find out whether the difficulty is one that therapy can reach.
Questions people ask
Do I need a diagnosis before I can start therapy?
No. You can begin with a difficulty you can only describe loosely, and much of the early work is giving it a clearer shape. A diagnosis answers a different question from the one most people bring.
How do I know whether to come on my own or with my partner?
If the difficulty is mostly in what happens between you, couples work reaches it faster, and if it follows you out of the relationship, individual work is the better fit. It is a reasonable thing to decide in a first conversation rather than before one.
What if I come once and decide therapy is not for me?
That is a legitimate outcome of a first session, and you are not committed to anything beyond it. Knowing it is not what you want now is more useful than continuing to wonder.
Is it worth coming if I cannot explain what is wrong?
Yes, and that is how a good proportion of first sessions begin. Not being able to name it is information about the difficulty rather than a reason to stay away.
How soon would I know whether it is helping?
Most people have a sense within the first few sessions of whether they are being understood, which is the thing to judge early on. Change in the difficulty itself usually takes longer and arrives less evenly than people expect.
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Sources
How this article was written: I choose the subject and the angle. An AI assistant researches and drafts. I read the draft, correct and improve it and stand behind every clinical statement. The professional and clinical judgement is mine.
