Do I Need Therapy? Answers From a Psychotherapist

Distress is the biggest signal it’s time to seriously consider psychotherapy.

Photo by Priscilla Du Preez on Unsplash

Are you distressed?

The question “Do I need a therapist?” is a serious one.

It is heartbreaking and measurably costly that people don’t get the help they deserve. The consequences can be monumental.

Each day, 123 people take their own lives, making it a top-ten cause of death in the United States. Seven in ten of those are white men. The aggregate global economic cost of untreated anxiety and depression is an astounding $1 trillion per year. And, 5% of adults with ADHD are 2–4 times more likely to be fired and earn lower wages.

high-functioning women are particularly vulnerable to years or decades of misdiagnosis and shame

There’s one thing every disorder on this list has in common. Distress.

That’s a leading indicator in whether psychotherapy is appropriate and, consequently, will inform what your psychotherapist recommends for treatment.

Assuming distress is a given, the selected disorders give are a glimpse into what your psychotherapist will be thinking about — and asking you about — when you meet.

Defining distress

Symptoms cause distress to the individual to such a degree they disrupt functioning in one or more life domains, such as relationships or work.

This is a fundamental requirement for most mental health diagnoses, serving as a critical point of differentiation between everyday stressors and one — or more — robust disorders.

The aim of this article is to point you toward reliable, science-based resources and organizations and seek out psychological testing, if appropriate, as part of a strategy for working with a therapist.

The resources in this article are trustworthy authorities on ADHD, depression, anxiety, PTSD, OCD, and personality disorders, though many other organizations offer science-based information about testing, diagnosis, and treatment.

Adult Attention-Deficit/Hyperactivity Disorder (ADHD)

ADHD is surrounded by a swirl of myths and misconceptions.

Losing your car keys might be a sign you have adult ADHD, but so are a lot of other quirky behaviors you might not realize are connected with inattention, hyperactivity, and impulsivity.

The very image of ADHD that pops into your head likely involves a scenario in which a young boy is running around a classroom tormenting teachers to exhaustion while incessantly inquiring about any and everything, or forever forgetful about his homework.

There are four myths about ADHD embedded in this stereotype:

1. ADHD is a male issue.
2. ADHD is an issue for kids.
3. ADHD has obvious symptoms.
4. ADHD is a problem with discipline or intelligence.

In reality, symptoms differ for several reasons.

However, intelligence is not strongly related to ADHD. Another factor that is particularly misunderstood is why some people have more inattention symptoms than hyperactivity symptoms. This disorder also isn’t a problem with discipline or willpower.

Because of these discrepancies and myths, high-functioning women — with successful careers and college education, for example — are particularly vulnerable to years or decades of misdiagnosis and shame. Many women are not diagnosed with ADHD until/if their child is diagnosed.

Tweet credit: Annette Miller

As the Attention Deficit Disorder Association points out, “adult ADHD is real!”

The problem is we haven’t done a good job in the clinical psychology community of transposing the symptoms we associate with ADHD in children to adult symptoms checklists. Treatment approaches for ADHD vary, but adaptations to CBT in recent years are worth investigating along with stimulant and non-stimulant medication options.

Resources

• Attention Deficit Disorder Association
• National Institute of Mental Health
• CDC List of Resources by State

Major Depressive Disorder (MDD)

Depression — also called Unipolar Depression — is a leading cause of disability worldwide.

A 2018 report from the World Health Organization (WHO) found that 300 million people across the world suffer from depression. That’s roughly how many people live in the United States! The WHO added, “depression is a major contributor to the overall global burden of disease.”

Thankfully, it is also one of the most treatable and best understood mental health conditions on earth. Furthermore, investments in treatment are promising — every $1 invested in treatment accessibility for depression and anxiety in the US may result in $4 of increased workability and health improvements.

Pharmaceutical treatment such as selective serotonin reuptake inhibitors (SSRIs) is a particularly helpful adjunctive to evidence-based psychotherapies, including several types of cognitive-behavioral therapy (CBT), like acceptance and commitment therapy (ACT) and functional analytic psychotherapy (FAP).

What we most commonly think of when we hear the term depression is formally known as Major Depressive Disorder (MDD).

A psychotherapist — such as a clinical psychologist, counseling psychologist, marriage and family therapist, or licensed professional counselor — would ask you how you’ve been feeling the majority of the time over the last two weeks using a standardized set of questions.

The Beck Depression Index, Second Edition (BDI-II), is among the most trusted resources for gathering and analyzing specific information about your symptoms to inform your treatment plan. Like other tools in this list, it is respected within the scientific community and can only be ethically administered by a licensed professional in your state.

Do you identify strongly or very with over ⅓ of these symptoms, commonly associated with depression?

1. Sadness
2. Guilty feelings
3. Pessimism
4. Punishment Feelings (“I feel I am being punished”)
5. Past failure
6. Self-dislike
7. Loss of pleasure
8. Self-criticalness
9. Suicidal thoughts or wishes
10. Worthlessness
11. Crying
12. Loss of energy
13. Agitation
14. Changes in sleeping patterns
15. Loss of interest
16. Irritability
17. Indecisiveness
18. Change in appetite
19. Difficulty concentration
20. Loss of interest in sex
21. Tiredness or fatigue

Persistent Depressive Disorder (PDD)

This condition may be unfamiliar to you. It has been known by several names — chronic depression, low-grade depression, and dysthymia.

The name was changed in the most recent edition of the Diagnostic and Statistical Manual (DSM-VI) in 2013.

As its names suggest, PDD is characterized by symptoms that persist over a long period of time. In fact, this period of time is defined as two years. Although that may seem like a long time, a heartbreaking reality is that many people may suffer from this condition but not even know it, going years without hope for change.

Symptoms to watch for include:

• Poor appetite or overeating
• Insomnia
• Low energy
• Low self-esteem
• Poor concentration or difficulty making decisions
• Feelings of hopelessness

Bipolar Depressive Disorder (BDD)

There are other types of depression as well. One is Bipolar Depression Disorder (BDD) — often colloquially referred to as manic-depressiveness.

There are two levels of Bipolar Depression diagnoses. They are differentiated by the severity of client symptoms.

Unlike MDD, this type of depression can swing like a pendulum between extremely depressed and extremely energetic. This surge of energy can appear without warning, wreaking havoc on the individual’s life as they’re driven to make decisions they normally wouldn’t.

Author’s Note: Bipolar Depression Disorder and Major Depressive Disorder are treated with fundamentally different types of medications (e.g., lithium versus SSRIs) and therapies. It cannot be overemphasized that a proper diagnosis is critical to getting appropriate treatment. Lithium can cause harmful effects in patients who do not, in fact, have BDD.

Resources

• Mental Health America — Depression
• Mental Health America — Bipolar
• Anxiety and Depression Association of America

Anxiety Disorders

Anxiety disorders are an entire category of their own and also a leading cause of disability. Like depression, anxiety disorders take many forms.

These anxiety disorders can occur concurrently. In other words, people can have multiple types of anxiety disorders at once. Commonly, Panic Disorder is bedfellows with Generalized Anxiety Disorder.

The Beck Anxiety Inventory (BAI) was specifically designed to reduce the overlap between depression and anxiety scales by measuring anxiety symptoms shared minimally with those of depression. It is known to be scientifically valid and has high reliability for adults.

If you relate strongly or very strongly to ¼ or more of the symptoms below, a psychological assessment from a licensed therapist should clarify if you would benefit from psychotherapy to treat anxiety.

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is identifiable by excessive and uncontrollable worry, occurring more days than not for the last 6 months about a range of events or activities. Roughly 3% of US citizens suffer from anxiety, but less than half seek help for it. While Generalized anxiety disorder (GAD) is characterized by free-floating anxiety, other common anxiety disorders, including Phobias, have identifiable triggers.

Symptoms associated with anxiety frequently include:

1. Muscle tension; sweating, nausea, diarrhea
2. Irritability; accelerated heart rate, dizziness
3. Restlessness or feeling on edge; trembling, twitching, feeling shaky; soreness
4. Being easily fatigued
5. Difficulty concentrating or mind going blank
6. Difficulty sleeping

Resources

• Substance Abuse and Mental Health Services Administration (SAMHSA)
• American Psychological Association
• National Association of Mental Illness
• American Psychological Association — Panic Disorder

Obsessive-Compulsive Disorder (OCD)

Until recently, OCD was characterized as a type of anxiety disorder. Why?

It is common for people suffering from OCD to have concurrent conditions, including major depressive disorder or generalized anxiety disorder.

The common link between anxiety disorders and OCD is that obsessions and compulsions are driven by a cycle of anxiety:

1. Anxiety due to an intrusive thought → “The germs on this cafeteria salad bar could kill me”
2. Temporary relief from anxiety → “I washed my hands so I feel clean now”
3. Anxiety returns → “I feel clammy and nervous imagining the salad bar at lunch tomorrow”

Put another way, OCD is a brain’s dysfunctional attempt to cope with anxiety in the absence of other emotional resources to do so. OCD treatment approaches sometimes resemble those for anxiety disorders because of that.

In particular, prolonged exposure and ritual prevention (EXRP) is highly effective in treating the condition.

It addresses cognitive, behavioral, and emotional triggers and maladaptive responses to anxiety to help clients reduce sensitivity to anxiety by activating their anxiety in a controlled manner, gradually increasing it over time. They also cut out the second step in the cycle — temporary relief.

Ironically, that step — although it provides very temporary relief — strengthens the brain’s associations with anxiety in response to specific fears.

OCD can be particularly disruptive to a marriage. Recent research supports previous findings that the partner without OCD consistently experiences lower relationship satisfaction. Consequently, you may benefit from psychotherapy treatment for OCD in multiple ways, including benefits to your romantic relationship.

Resources

• International OCD Foundation
• National Institute of Mental Health
• IntrusiveThoughts.org

Post-Traumatic Stress Disorder (PTSD)

Author’s note — Racial trauma is a subtype deserving of its own future story. The very existence of racial trauma remains absurdly controversial within the field as a result — despite ample empirical evidence — of white supremacy’s legacy in American society. Psychotherapy research and practice remain plagued by microaggressions toward clients, inequities in mental health access, and disproportionately low representation of ethnoracial minority professionals in the field.

Combat trauma is the most obvious example of PTSD; veterans are plagued at alarming rates. The range of events that can result in trauma is vast, however.

Traumatic events can include unimaginable tragedies such as rape, witnessing a death, chronic workplace bullying, domestic abuse, and racism. It is also possible to experience trauma as a proxy event. The newest revisions to diagnostic criteria for PTSD include threats to life as experienced by another person, such as a child.

In my experience, what the general population is often surprised to learn is that post-traumatic stress is not the standard neurobehavioral response to trauma. In fact, humans are surprisingly resilient to trauma. Rather, in a minority of cases, after someone experiences a traumatic event, there are recovery complications.

Here’s an analogy I have seen within the clinical psychology community.

Normally, our brains use memory to store and retrieve information as we need it, as it is relevant to what’s happening in our lives at present. However, PTSD is like a jam in the filing cabinets causing it to pop open at inappropriate times and spill the contents of the file, with horrifically textured detail (e.g., smell, sounds, visuals), all over the floor.

Common symptoms associated with PTSD include:

1. Recurrent, involuntary, and intrusive distressing memories of the event
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the event
3. Flashbacks or loss of awareness of present surroundings
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the event
5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the event

Therapists trained in quality, accredited programs are trained in the use of trauma-informed care. This means they have been taught to consider the role PTSD may have on treatment for other mental health issues, such as depression or anxiety, and provides a framework for planning your therapy goals and activities.

Resources

• Mental Health America
• Substance Abuse and Mental Health Services Administration (SAMHSA)
• National Center for PTSD
• American Psychological Association

Interpersonal Trauma

While this is not technically a diagnostic category, it’s important to touch on the critical ways our interpersonal relationships shape our identities and connections as adults.

I’m not a huge fan of the phrase “Personality Disorder,” but that’s what we’re exploring in this section.

If you’ve found it difficult to form or maintain close relationships with people your entire life — or if that’s putting it nicely because it’s a real roller coaster with your spouse sometimes — there are several possibilities a licensed therapist might consider during the course of the assessment.

One of them is the role of childhood, interpersonal trauma on your personality.

Brief screening assessments a therapist might use include the Inventory of Interpersonal Problems or the Temperament and Character Inventory. A more comprehensive approach might include the Personality Diagnostic Questionnaire, 4th Edition (PDQ-4).

Symptoms from a range of personality disorders include:

1. Distrust or suspiciousness that others’ motives are suspicious
2. Detachment or acute discomfort in social relationships
3. Emotional expression is limited
4. Emotional instability; excessive emotional displays or attention-seeking
5. Unstable self-image; feelings of inadequacy
6. Impulsivity
7. The constant need for admiration
8. Lack of empathy or disregard for the rights of others
9. Extreme social inhibition
10. Hypersensitivity to negative evaluation
11. Clingy behavior or excessive need to be taken care of
12. Preoccupation with control, perfection, orderliness

Although most of Sigmund Freud’s theories have been disproven, one idea he pioneered has borne fruit — adult functioning is linked to child-parent relationships. We’ve learned since the cigar-loving psychologist was at the helm of the discipline that the Oedipus complex is not really a thing.

However, it turns out the consistent use of boundaries signals to children their parents are engaged and care about our safety. Similarly, the reliability of our parents’ affection demonstrates a fundamentally unconditional bond. That stuff shapes our personality development — including how neurotic we are, how easily we trust, even how extroverted we are.

If you’ve ever taken a Psych 101 class, you’ve probably seen a version of the graph that shows parenting with high warmth (e.g., affection, empathy) and high control (e.g., structure or boundaries) lead to the most well-adjusted children.

Consider the opposite.

If a parent does not provide any ground rules, attention, or consequences to their child, nor shows them, unconditional love, the child would rightly question what they need to do in order to elicit engagement and love. These wounds don’t magically heal on their own in most cases, leading to a carry-over in interpersonal skills from childhood.

In other words, the behavior patterns you learned would get your parents’ attention and comfort as a child are the same patterns you use to get or keep the attention and affection of people you want to be closer with as an adult. That might sound nuts on its face, but we begin learning social skills when we are very young.

Change does require a commitment, but there’s hope. A brilliant psychologist, Dr. Marhsa Linehan, Ph.D., developed a type of therapy with great promise (and empirical support) for helping people suffering from personality disorders to make those changes.

Resources

• American Psychological Association
• The Linehan Institute
• National Alliance on Mental Illness — Borderline Personality Disorder

In some ways, the only way to answer such a subjective question as “Do I need a therapist?” is to ask yourself another. If mental health disorders are defined by causing clinically significant distress, the question is simpler.

Are you distressed?

If so, the answer you came looking to confirm is probably yes.