• Therapist Donna Marie Bottomley explores four common reasons that people might delay getting the mental health support that they need

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I am often a last resort for my clients. Someone they’d rather not see, in a place they don’t really wish to be. Sometimes they mention it, sometimes not, but it’s in the words they use and the way they position themselves: the assumption that they should know how to sort things out on their own rather than be here with me. ‘Why can’t I stop it?’ ‘Why does it upset me so much?’ ‘Why can’t I just forget about it?’

They tell me how they’ve been distracting themselves from their ‘it’ by running, dieting, drinking, smoking or generally keeping so busy that the ‘it’ cannot take over. The ‘it’ has become their shadow ghoul, and the fear of it is very real. They may have tried self-help books, or mindfulness apps, which may or may not have helped (when you’re trying to avoid your ‘it’ you don’t really want to give it space by doing mindfulness!). But I am usually one of the options at the end of the list. The reason I am a last resort is sometimes thrown into the air in frustration during our initial meeting – ‘I feel stupid: why can’t I sort this out myself?’ – or is whispered as a question – ‘Does this mean I’m going mad?’

I want to explore this fear of therapy and of getting upset. Why do we delay getting help, and why are we so afraid of getting upset? What do we think it means about us if we see a therapist? I use the word ‘we’ because from my practice I know that therapists and doctors, along with other people in responsible positions, are not immune to this difficulty in seeing a therapist. We can often feel that we should be able to sort things out for ourselves without needing help, and we worry about being considered unfit to practise if we do seek help.

Why do we delay getting help?

1. Procrastination

We all put things off sometimes, especially when there is uncertainty. But we can often procrastinate without realising that we are doing so. I will book an appointment with my GP when it becomes apparent that I need to. But if I need to call the local garage to book my car in, I will rarely do it straight away. I don’t want to be without my car, and I feel hesitant and awkward when I’m with mechanics, like I’m out of my depth, and could be judged as foolish or silly. So I delay. This delaying behaviour is procrastination. 

Whenever we are unsure, uncertain or uneasy about something, we will usually distract ourselves, either knowingly or unknowingly (Lauderdale, 2017). We can then get stuck in a cycle of avoidance where the need to procrastinate will be rein-forced (Gautam et al., 2019). There has been some research showing that the brain gets a hit of dopamine (the reward chemical) when we put something off. This would indicate that trying to stop procrastinating is like trying to stop a bad habit and can be just as difficult.

2. Fear of judgement 

I know that underneath my reticence to speak to a mechanic is a fear of looking stupid or being laughed at. When I’m at the garage I hide this by deliberately making silly jokes at my own expense, in an effort to try to control the outcome and the laughs. It’s a situation in which I know I’m more vigilant for signs that tell me I might be sounding silly. This is the self-fulfilling prophecy of anxiety. We become hyper-vigilant for what might go wrong, but this means we are more likely to see signs of our worst-case scenarios. When we are in this mode our brains are predicting what might happen and as a result we are more likely to see these things. If you look out for what might go wrong, you will likely find it.

When we put off or try to suppress our struggles with our own body and mind then there can be consequences. Yousaf et al.’s 2015 systematic review found that men were more likely to delay seeking help until their symptoms became serious. One of the reasons that came out in the study was the fear of talking to health professionals. The participants reported that this made them feel out of control. This fear ties in with research that sadly shows higher statistics for male suicide (Office for National Statistics, 2015) and how things can become very bad before help is sought, if it is sought at all. The gender difference is quite pronounced in the research literature and is often spoken about as a difference in terms of whether a person prefers to talk about emotions or instead focuses on solving a problem (Liddon, Kingerlee & Barry, 2018). Although this finding does seem to be well documented, it is important to consider there may be many reasons for this difference. For example, there could be a bias in the way that participants are categorised in such studies. Also, society’s expectations of gender can be a reason why we might make certain judgements. The expectations on men to be stoic and not show emotions are still widespread, although several recent campaigns have tried to chip away at this mindset. See for example the recent efforts within rugby union, Prince William’s mental health initiatives and the ongoing work of CALM (the Campaign Against Living Miserably).

Another systematic review (Clement et al., 2015) found that there wasn’t a clear male-female split, and that other groups were affected disproportionally as well. It demonstrated how the fear of judgement when it comes to mental health affected people from ethnic minorities, as well as certain professions such as the military and health workers. There is also a growing awareness from the neuro-divergent community of how mental health systems have incorrectly judged and misdiagnosed them for many years.

Difficulty talking to professionals showed up as one of the barriers to people seeking help in Clement et al.’s study. But other fears were also present. The fears that were found to be most associated with delays in seeking help were thoughts about oneself being in some way ‘weak’ or ‘crazy’ (judgements about the self), and social judgements about seeking help for mental health (judgements from others). Fears about disclosure and confidentiality and the impact on employment were also present in this study. This is another key area of importance, because people have reported in previous studies that they have lost their jobs due to mental health (Nelson & Kim, 2011). The judgements of others matter to us as much as the judgements we place upon ourselves. In a bio-psychosocial sense the two are closely linked and one informs the other. Our brains rush to judge because the brain needs to quickly categorise. It does this based on our shared social norms and our personal past experience. If you want to see this in action, aim to ‘notice’ the quick thoughts that you have in response to items in the news or on social media.

It is clear that fear – either of the judgements people are making of themselves or of what they fear others are making about them – is a barrier to people seeking help, and in my practice I see that this fear can affect a great many of us. I see mothers with young babies who are terrified of being judged if they admit to feeling anxious or low. I see police officers, GPs and teachers, both male and female, who are in positions of responsibility. They keep their feelings to themselves out of fear of being judged not fit to practise, or of being considered ‘weak’, by themselves just as much as by others.

There have been damning statistics showing that black men are judged much more harshly by the psychiatric system, and as a result are logically going to find it very difficult to seek help. Sadly, this can mean that their difficulties will be much more severe by the time they do get help.

The fear of judgement keeps people silent and struggling, until they find a way out of their difficulties one way or the other. The high rates of addictive behaviours and suicide amongst doctors is a particularly shocking commentary on this unseen struggle to cope (Gerada, 2018a).

There are some other factors to take into account here, such as cost, availability and not being aware that therapy could be helpful. All of these play a role. The cost of private therapy can be outside many people’s budgets, and as a result there are many who are on agonizingly long NHS waiting lists. However, there does still remain a great deal of fear when it comes to seeking help, particularly a fear of judgement (Topkaya, 2015), and what this judgement could ultimately lead to.

Some of my clients only decided to come to me once they started thinking of taking their own lives. There is no clearer indication of just how hard it can be for people to seek help.

3. Powerlessness

In many of the studies on delays seeking help, there is mention of feeling out of control when talking to health professionals as well as the fear of being judged. In my practice I hear this too. I’d like to show you an example:

Therapist (T): How do you feel about being here and seeing me?
Client (C): Like I must be really crazy or something.

T: If you were crazy, what would that mean about you?

C: That I’ve lost it, got no control, can’t be trusted any more. T: And if you can’t be trusted and have lost control, what would that mean?

C: I wouldn’t be able to do anything, I’d have no choices, other people would tell me what to do.

T: And if that happened, what would that mean?

C: I’d be powerless.

In this example I have used a technique called the ‘downward arrow’ to get to the belief that was underneath this client’s worry about seeing me. This form of questioning was developed by the founder of cognitive therapy, Dr Aaron Beck, as a way of getting to a ‘core belief’ of what something means to that person (Beck et al., 1979).

For the client above, we followed a chain of meaning that led us to her core belief that seeing a therapist could mean she would be made powerless. As a result, it was incredibly difficult for her to come and see me, and she had put it off many times. It is important to note that she would not necessarily have been aware that this was the reason why she was delaying seeking help. We are not always conscious of how our core beliefs filter our perceptions and interpretations.

Being rendered powerless is something that is potentially dangerous from a survival point of view, so it makes sense that we would be motivated to avoid anything that could trigger this feeling. However, not all of us will have this fear triggered to the same degree when it comes to seeing a therapist. Our past experiences shape the strength of our beliefs as well as what we believe, and some of us may have been surrounded by positive messages about what it means to see a therapist. Nevertheless, anxieties about having our power and control taken from us are a core human fear (Millings & Carnelley, 2015), and different things can trigger this in us.

4. Helplessness

Here’s another example from my practice, and sadly quite a common one:

T: What does it mean to you to be seeing a therapist?

C: It means I need help.

T: What does it mean to you if you need help?

C: If I need help it means I’m weak.

T: Needing help means you are weak?

C: Yes.

T: What does it mean about you if you are weak?

C: That I’m helpless.

In this example the client believed that needing help was something that made him feel he was weak. When we looked at what being ‘weak’ meant, we got to the fear that this could leave him helpless and at the mercy of others. This is a potentially dangerous state for us humans: to be rendered helpless. Our instinct will be to avoid anything that might make us feel powerless or helpless.

If we have had experiences where we have been rendered powerless or helpless and have feared for our lives and sense of agency, then this feeling will be remembered and laid down as a fear memory. We learn through our experiences in the world and with those around us. This teaches us what could be dangerous or problematic. 

Cognitive behavioural researchers, led by Aaron Beck, state that we develop core beliefs as a result of our early and significant experiences (Osmo et al., 2018). These core beliefs help us to categorise and filter the way we see the world. Barrett (2017) calls them our ‘concepts’ and states they are the brain’s way of making sense of the large amount of input and activity within and around us. Beck and fellow researchers have found that these beliefs (or ‘Schemas’ as Jeffrey Young calls them) can be the filter through which we then come to view certain situations. Sometimes this can cause us problems if we hold a particular negative, rigid belief about something we fear is happening but that isn’t actually happening.

For example, imagine growing up in an environment where high achievement is the norm and is expected. You are praised when you achieve and are expected to win. You strive for the top position or grade and feel ignored or punished if you don’t achieve. If this is what is expected of you, you will want to achieve and not ‘fail’. You might also feel unloved if not achieving. In this sense you could develop a belief that to be ‘good enough’ you have to be the best, be perfect, pass every exam, get an A grade. Anything other than achieving success can trigger feelings of failure and not being good enough, or feelings of worthlessness. I have painted an extreme example here, but this belief about needing to achieve to feel good enough can be something that isn’t verbalised, or maybe even noticed, until something happens to trigger it. 

A failure on an exam can be a time when a belief like this can be seen. Instead of seeing the many different reasons why they didn’t pass that exam, a person might go straight to the negative label of ‘I’m a failure’. This is where the beliefs can become unhelpful, because the person’s sense of self is tied up with needing to be ‘good enough’. If they don’t meet their standards or expectations, then they judge themselves and feel even worse. Sadly, the way that the brain then retrieves memories where we have had the same feeling, means that we are likely to have other thoughts and images and feelings which we may label as ‘failure’ and then this can colour the way we see the present. We can then become stuck in low mood and feeling like everything we do is a failure.

If you are feeling upset about a particular event or situation, sometimes this can be because you hold a particular belief about what that event means to you. It takes time to develop the newer beliefs though so go easy on yourself if you are going to try this. This is a good example of where therapy can help you to release the power of these core beliefs or schemas.

We can develop beliefs in many different ways, but for things that are potentially dangerous for us, it is clear that we very quickly learn to fear those things. Our brain has a survival circuit that is able to come online swiftly to alert us to anything that might be dangerous for us. Anything that could potentially render us vulnerable to attack, powerless or helpless will not be overlooked by the brain.

Unfortunately, psychiatry and our approach to mental health have historically not helped with these fears, and it could be argued they are the origin of some of them. As a result, the way that we perceive mental health and therapy can be through a particularly negative lens, unless we have had experiences that have enabled us to develop more accepting beliefs. The history of how people have been treated in asylums and psychiatric institutions has understandably helped to reinforce a fear of being rendered powerless. We not only have our individual beliefs here but also shared social norms for psychiatry, therapy and mental health.

Donna Marie Bottomley is a therapist and the author of Do I Need to See a Therapist?

Further reading

Therapy helped me see there is strength in asking for help

Are more men seeing therapists?

The differences between face-to-face and online therapy

Can you convince someone with depression to get help?

Why it's so important to ask for help when you need it