Ep. 39 - Why People Want Therapy But Still Avoid It

Sometimes the hardest part of getting help isn’t finding a therapist. It’s actually walking through the door.

Dr. Andrew Rosen and Dr. David Gross talk honestly about the many reasons people struggle to follow through with mental health care. Someone may call a clinic asking about therapy, even schedule an appointment, and still never show up. That gap between wanting help and accepting it is something clinicians see every day.

A lot of it comes down to what psychologists call resistance. Shame, embarrassment, fear of being judged, and the simple discomfort of sharing personal struggles with a stranger can make people hesitate or hold back. Family upbringing, cultural expectations, and the idea that asking for help means something is “wrong” with you all play a role.

They also talk about what happens once someone does make it to therapy. Trust takes time. Painful experiences may not surface until many sessions later. Sometimes people apologize for crying. Sometimes they worry that medication means they are weak or defective. Other times they hope for a quick fix without addressing the deeper issues that led them there.

What most people don’t realize is that resistance doesn’t disappear. It’s part of being human. Therapy often means working through that resistance slowly, building trust, and recognizing that emotional pain is just as real as physical pain.

For many people, simply showing up is already half the battle.

Contact the Docs:

Email: twoshrinksandamic@gmail.com

Transcript

SPEAKER_00 0:04

Hi, I'm Dr. Andrew Rose, and I'm a psychologist.

SPEAKER_01 0:08

And I am Dr. David Gross, psychiatrist, and we are Two Shrinks and a Mike. For today's podcast, we're going to continue a discussion on mental health issues. As those of you have listened to previous podcasts, you know that we've talked about various diagnoses, treatment approaches, and to a small extent, some of the challenges that are present in obtaining mental health care. But today we thought we would talk about the obstacles to obtaining mental health care. One of the core ones is a concept in psychology entitled Resistance, issues inside of an individual that get in the way of being able to proceed with uh with care. And so we'll be talking about a number of these topics today.

SPEAKER_00 0:49

Yeah, the term resistance is originally uh discussed in traditional psychoanalytic uh theory, and it was based on the premise that people uh have a hard time in many different ways opening up and actually getting in touch with the reasons for their problems, and even in some cases, have a hard time uh appreciating the need to change and to deal with their problems. So there's many forms of resistance. Uh it it really becomes very obvious when you look at some statistics. Uh, a number of decades ago, actually, they did some pretty good uh evaluations and studies of what happens when people decide to uh go for therapy. And they they used um mental health clinics to get data. And amazingly, the percentage of people who actually m called for information to a center about getting treatment and then actually made an appointment. The ones that actually came to the first appointment, the percentage was very low. And the whole point of that was to demonstrate that people can have a desire for help and to receive treatment, but somewhere along the line after that initial decision to get help, things drop off. And the reasons for that are many. It comes from shame, embarrassment, fear, and the uh unknown. The fear of the unknown. What happens when I go for help? And who am I going to open up to? How can I trust that I'm gonna talk to somebody that I don't know? And it's embarrassing to talk about things that are very private. We're traditionally trained not to share dirty laundry. So there's a lot of reasons why there are uh resistances to getting help, and amongst other reasons, you know, practical ones, financial ones, et cetera. But psychological resistance is a very powerful issue, and we as mental health professionals are uh facing that every day, and we try to help people overcome resistance.

SPEAKER_01 2:53

You know, our species is known to be uh socially interactive and outgoing. I mean, everybody talks about the importance of social contact, social interactions. But if you think about it, we're all sort of private in terms of uh uh self-self-thinking, self-talk, and the thoughts that we that we have in our heads oftentimes get in the way. And for example, if a person's experiences uh worry, anxiety, there's a lot of self-talk that will be involved in um I must be unique in having these experiences. How can I share it with anybody? They're going to look down upon me. And oftentimes it's the self-talk that gets in the way in the ability to acknowledge the need for a problem. Um in addition to that, there's uh issues related to family, depending upon how you've been raised by your family. Um, a lot of families will want to uh uh minimize emotional difficulties. You know, I'll often hear people say that, you know, I came from a family where emotions were not allowed and um you had to behave and be proper and um and and and be respectful. But if you if you show emotions, uh that's a no-no. Then there's the difference between uh uh uh uh sexes. You know, the men are from Mars, women from Venus concept, where men tend to be uh a bit more non-emotional and and uh put things into categories and women tend to uh show feelings more openly, uh, which may be one of the reasons why I think uh women may be more in touch with uh problems with anxiety and depression and come for help more than that. And if you look at the data, uh the data suggests that the incidence may be greater in females, but a lot of it may be because they go for help and ask for help. Uh there's a certain amount of I've got to be macho, I've gotta be in charge, and take care of myself in the male ego that gets in the way. Um but this resistance is uh a problem. Um, and and it oftentimes um the mental health professionals will approach it by saying if if somebody does come into our waiting room and in our consultation room, uh the initial sessions will be just uh plain talk and not put too much pressure on the individual to open up because clearly what has to happen in the beginning of any kind of therapeutic interaction is the development of some trust, the belief that the individual who you're working with, the mental health professional, is going to have some unconditional regard and not judge you, and and it's a good listener. And so a lot of this is what the initial stages of therapy need to be all about, and uh um it helps promote the ability to talk about problems.

SPEAKER_00 5:28

I'm kind of reminded of one of my favorite comedians, Sebastian Menascalco. He has this routine where he says, you know, people, young people today, they're very often uh either in college or after college, they say they're going to take a year off and find themselves. And he said, if I told my father that I was going to go find myself, he'd say, Find yourself. I see you. There you are, you're right in front of me. So some cultures and and definitely historically, men in particular, were not supposed to find themselves. That wasn't something that uh was encouraged and it was actually made uh fun of. So there's a lot of different reasons for resistance, and uh some of it relates to the concept we've talked about a bunch of times already, and that is if you go see a men all professional, what does that really mean? Does that mean there's something wrong with me? Does that mean I'm defective? And I can't begin to tell you how often people will say to me, even if they're well into the therapy sessions, they'll say to me, I have something to tell you, but I think you're gonna think I'm crazy. So, you know, even if they're saying it in jest or sort of funny, it's an underlying issue that uh there are certain things that we all carry around with us that probably we will think somebody would think we're crazy to be thinking or to believe or to uh to behave like. So who wants to admit to another human being our our faults, our defects, our problems, our our behaviors if we think that they're either deviant or crazy or or weak or in some way uh embarrassing? So resistance is always there. It's not something as uh as people who treat people, it's not something we get rid of. It's not like after X amount of sessions a person doesn't have this resistance. The resistance stays. It's just a matter of how much of an obstacle it is to getting to what we might call the truth of a person.

SPEAKER_01 7:28

You know, previously we we spoke about the concept of psychological trauma, and uh that's a good example of what you're talking about because individuals may be talking about their marriage or problems with their job or anxiety or issues with mood. Um, but it may not be until the 10th or the 12th or the 13th session that they may open up and tell you about the trauma that he experienced because of how painful it is uh to even talk about or how well protected it is in the brain. You know, that the concept of of of uh self-protection and and repression is uh related to resistance. And uh you often will not hear about uh traumatic episodes until a person is comfortable enough so that their brain almost releases some of the memories that were held onto so tightly. It also reminds me of of what I see commonly in in the office, which is if somebody's talking about a painful life experience and they start to become tearful, they frequently will say, Well, I'm sorry. They'll apologize. And, you know, I look at them a little bit uh dumbfounded and say, you know, you're allowed to be human. And people forget about, you know, the the natural human qualities that we all have. And uh getting weepy and tearful over painful emotions is not unusual and not abnormal. Um individuals uh who come in to see us, um I I compliment them on the fact that the fact that they've come into the office, uh so half the battle is already won in that they've recognized that there are issues they want to address. And that's 50% of the the the goal of recovery. It's the old uh saying, you know, how many psychiatrists or psychologists does it take to change a light bulb? Well, the light bulb has to want to change. Um it's not how many psychiatrists are psychologists or how good they are, but the individual has to be motivated. And sometimes, and I'm sure you've had the same experience as I have, as we see adolescents who are whose arms are twisted to come into our office by their parents, they're certainly not happy to be there. And so our challenge is to establish a rapport so that they can't trust us and see that we're not there to judge them or to give them a hard time or to be or to represent their parents. We're there really to be their advocates. And once they begin to have that belief, uh they can begin to utilize the sessions for themselves.

SPEAKER_00 9:39

Yeah, no matter what, there's shame, there's embarrassment, there's a feeling of uh subjugation to the to this authority figure, there's all kinds of things that are automatic and not even all conscious on the part of the person who's coming in. Um but you know, we all know that if you cry, you're you're being weak and you're a baby. I mean, we're all we know that. So if we're told that over and over again in childhood and and even in adulthood, why are you crying? Oh, come on, toughen up, be a man, get strong. You know, these are all things that people have built into their psyche, and they affect the person's ability when they do come for treatment to just really, really open up and and get to the core of who they are. And in many cases, a person doesn't know really the core of who they are because they've tried to repress it for so long. So it's a process. I learned in my actually in my psychoanalytic treatment uh training that therapy is like peeling an onion. You know, you sort of have to go one layer at a time. And if you go if you don't go at all through the different layers, well, you've pretty much had what we have called in the past just kind of chit-chat therapy. And if you go too fast, you can really do some damage because people get scared and they feel embarrassed or they feel ashamed or they feel uh frightened and then they flee treatment, and that's a kind of a different form of resistance. But uh by and large, people want to get better, they want to get healthier, they want to have their problems reduced, they want to enjoy life more, but the process of doing it is scary. Similar, the parallel would be going to the doctor for a medical problem. People want to be healthy, they don't want to be sick, they don't want to have disease, but it's scary to go to the doctor. So, how many times do we hear about somebody goes to the to the family physician and they don't tell the doctor all the symptoms? You know, they keep some to themselves, they hide some of them because they're afraid to deal with them. Well, it's the same thing in in mental health treatment. Patients come in, but they don't tell you everything because they're afraid to deal with it or they're embarrassed about it. So we as clinicians have to be very respectful of that and aware of it as we work with the people.

SPEAKER_01 12:02

You know, one of the things I learned a long time ago um in working with people who are suffering and and and and and experiencing depression, anxiety, or life difficulties, et cetera, is that you can't recover from illness until you give yourself permission to be sick in the first place. And even though it sounds like a silly concept, um think about it for a second. If if you have uh a strep throat, uh go to the doctor, your throat kills you, you have some fever, you feel terrible, uh do a test and clear enough it's strep throat, you have no difficulty giving yourself permission to be sick. But if you have anxiety or depression, that's another story. Um, because w remember we talked about a number of podcasts ago about uh some of our Judeo-Christian belief systems in modern society based upon the the the thinking of John Locke, which is the concept of free will. And much of our modern thinking, even though we've been to the moon, we have computers and artificial intelligence and all this fancy stuff, is that uh we have free will to do anything we want. Well, I couldn't hit a home run if I tried. And that's not because of not trying hard enough, it's just that my brain is not uh the kind of brain that allows me to develop a good enough swing to hit a home run. I'm perhaps if I'd practiced for several years with a trainer, I could, but you should have told me. I would have built you. But that's not the case. So the the reality is that we have some degree of of willpower, but we also have limitations. The same way that, you know, when when both of us see individuals who have had psychological testing and IQ testing, and you know, they see the individual gets their results and they see that there are areas where there are deficiencies, but it also means that there are areas where there are strengths. And part of our job as mental health professionals is to take a look not just at the weaknesses, but the strengths and try to promote the strengths. But also let people know that this concept of willpower is overbaked. It's it's just uh not not realistic. Uh that you can, as long as you can actualize your potential, which is an old psychological term by a famous psychologist, uh, uh that that's the best thing you can do. You know, I've seen uh young young people in high school have come in with depression and anxiety and disappointment in their grades because they worked so hard to get an A, they came home and their mother or father said, How come you didn't get an A plus? You know, rather than getting uh complimented on getting the A, or if they worked real hard and they got a B, uh, be congratulated for getting the B. Um if you didn't work and you got a C or a D, that's another story. But um unfortunately we have a society that uh tends to uh emphasize uh willpower and accomplishing things uh uh sometimes greater than one's capabilities. And now that we're in the era of social media, uh we've got uh kids who are dealing with how many likes they get on TikTok or Facebook. I mean, that's a boy, that's a tough situation. I mean, the when I was a kid, the only thing I got were pen pal letters, and that was that was my reward for interacting. But um uh our job is to help individuals understand that human beings are not perfect and that being imperfect is the norm and not the abnorm. Experiencing depression is not that abnormal, having anxiety is not that abnormal, and recognizing that um you're coming in to take care of it is really important for a step.

SPEAKER_00 15:30

So one of the first things that I know we do is help people, as you say, deal with the fact that uh as far as we know, we're all human, and we all have imperfections, and some uh people have imperfections in area A, and some people have them in B or C. And the reason why you're here in my office right now is because you're a human. Life can be very complicated sometimes. It gets to be very uh difficult and sometimes tragic. And uh not always are we capable of dealing with it with uh without experiencing pain and symptoms and such as anxiety and depression, and even feeling like ill-equipped to figure out how to deal with things or or move forward. So that's why you you're here in my office. And even if it's embarrassing, even if you feel ashamed, even if you feel uh mad at yourself that you need to be here, uh you're here. And so we're gonna make the best of it by acknowledging these things and trying to remove as much of the resistance that you have in in the process so that we can really make this thing better and actually quicker. The less we have resistance in the way, actually the more we can make this process a quicker one and uh a healthier one. So we have to address resistance. And many mental health professionals don't do that. They just don't talk about it, they just hope that it goes away or they try to go around it. And those are the some of the reasons why people drop out of therapy early. You know, where'd that patient go? Well, you know, whether it's three sessions or ten sessions, uh there wasn't an awareness of the resistance factor. So the people uh decide, you know, I I I gotta get out of here. And typically they just don't show up or they don't make a next appointment and they disappear. And the main reason is the resistance factor was too much, and it was easier for them to avoid getting help than to go through the process. We all have resistance.

SPEAKER_01 17:37

Yeah, and emotional pain is uh as severe as physical pain. And and many of the individuals you describe who I've I've seen as well, will will sometimes not come back because they talk about the emotional pain being too great. And it's just uh it's easier to duck and hide than to deal with it head on. And many of these individuals will ultimately come back at a future point and address it uh head on. But another area of um obstacle to adequate care and resistance is an area that that uh that gets me into trouble as psychiatrists because a lot of what I do is to deal with the biological medical aspects of mental health issues prescribing medications. And and we've talked about this before, but a lot of people that I'll see will come in um and and will just seek a quick fix. You know, give me a medication to make me better. Where the reality is that maybe medication could help, but attending to either the life issues they have or helping them recognize that they've got a number of maladaptive personality traits, defense mechanisms, psychological factors over the years that have gotten in the way that they have to work on in psychotherapy, talking therapy. Um but we've got a society like a lot of other Western societies that's looking for a quick answer and a quick fix. And that's tough. Um and then I'll see this very, very often when somebody comes into my office with uh an anxiety disorder where they have lots of worry and overthinking and catastrophic thinking and maybe even panic attacks. And I'll tell them that, you know, the the the approach to this, the ideal approach really is uh specif specified type of therapy called, as we've said before, cognitive behavioral therapy. Um medication can help, and oftentimes combining the medication with the cognitive behavior therapy can assist each other. But individuals have to be willing to retrain their brain. And and and and going for the quick fix with a pill, you'd like it to be the case, but it unfortunately most of the time it's it's not. Um there are disorders where medications make a big difference. Um but even in attention deficit disorder, which we've talked about before, you can get on a medicine for that, which will help your attention concentration. But it's kind of like if uh if if you want to get more of a performance out of your race car, you can tune the engine up, but if you don't know how to shift the gears, you're not gonna get the power. So likewise, you know, you can take a medication for attention concentration distractability, but you still have to work on time management organizational abilities and work on the secondary psychological impact of having ADHD from a number of years before it was recognized that it had an impact upon self-confidence, beliefs in your academic abilities, et cetera. So um RA will often let individuals know that, you know, you you need to pursue the talking therapy aspect of care in addition if you want medication too. And then it develops another area of of that's an obstacle, which is um uh not everybody uh can afford talking therapy. Um and a lot of people will say, I want to use my insurance company, and then they have to find out if they've got a specialist within the insurance company who could take care of the particular problem they have. And you really never never really know for sure if you're getting somebody who is that kind of card-carrying expert in that particular area. So, you know, the whole insurance regime has changed uh mental health care for the last several decades. I know in in psychiatry, I can't prescribe a medication without then having to do an authorization with the insurance company, which could take days and paperwork and require appeals and lots of hair pulling. But um that's that's a separate obstacle that we'll I'm sure we'll be talking about later.

SPEAKER_00 21:23

You know, there's the opposite end of the spectrum on the issue you just talked about with medication, and that is some people have resistance to taking medication to begin with. They see medication as either an indication of I'm really sick, I'm really defective, or uh they see it as a sign of weakness, or they see it as um the the the silver bullet model, and or they see the dosage amount as an indicator of I'm really not doing well, if I need. A higher dose, et cetera, et cetera. And doctor, how fast do you think I'll be able to get off the medicine? And so, you know, there's a natural resistance on that end as well to taking medicine. And what I often have to do, and you do as well, is to say, look, you know, this isn't a function of your personality. This is there's something going on in your nervous system, your brain, in this particular case, which is just another organ, just like if it was your liver or your heart. And sometimes medication is used to help the process along. It's not an indicator of how crazy you are or something like that. So you have to be aware of resistance on both ends. It's people are afraid to do the things that uh they need to do to get better, more so, I believe, in in mental health than in other areas of medicine, unless you're telling somebody, you know, they need some kind of major surgery. And then the fear mechanism is obviously there as well.

SPEAKER_01 23:03

You know, you just reminded me of the value of the cases that you and I have worked on together, because uh the reality is most psychiatrists who will work with the therapist, um, the therapist knows the individual more intensely than the psychiatrist. Think about it. You know, the most therapists will work with somebody once a week, and psychiatrists who get involved are taking care of medication may see somebody once a month or once every three months. And so I the many times I've relied upon you helping out with a patient who has reluctance about medication to help reassure them that it doesn't mean that they're impaired or sicker than they should be, or that the medication's going to take their personality away or change them as an individual. But the reality is uh the many of much of the time the individual will have a greater initial trust in the therapist than in the psychiatrist. Um and and that's okay. I mean, that's the nature of of the situation. Um unfortunately, um, it's not uncommon for the psychiatrist and the therapist not to communicate. And that's a problem. We do all the time. We we do all the time. Well, that's that's because we're talking about but you know, that for for me to be able to call you up and say, what do you think about Joe Schmoe or Jane Schmoe and what's going on with them is helpful for me. And likewise, you'll do the same thing with with with me. And um the the nature of of private practice and mental health care is is unique in that, you know, if you're an internist, um, you'll you'll see uh patients in your office, but you'll make rounds in the hospital and you know, you you're not isolated. But mental health care for professionals is relatively isolating. You know, you're in your consultation room six to eight hours in the day seeing individuals, and you don't necessarily get out. And so it's an isolating um type of experience. And so the the the importance of reaching out to talk with another mental health professional who's involved in the care of your of your patient is absolutely critical and uh and very important. And I know it's helped both of us over the years, and uh one of the reasons we've been excited about having a team of mental health professionals that we work with together at our centers is the fact that we're able to meet regularly and talk about cases and share um both clinical problems, but as well uh to reinforce each other. I mean, the being a mental health professional is not an easy job. There are stresses involved. You know, the stress of just somebody sharing the secrets of their life with you is quite a responsibility, but then dealing with individuals who are in a lot of emotional pain, self-destructive, uh having suicidal thoughts, et cetera. Uh, but being able to be together and share the concerns helps tremendously. When you're isolated in your office, you don't have that opportunity, it it could take a toll and it can be a burden. So um I urge mental health professionals to always reach out and and keep an active dialogue among the individuals who are working on with the same individual that you're working with.

SPEAKER_00 26:03

Case example, we you have the patient we share, and uh the dosage was supposed to go from 37 and a half milligrams to 50. And when I saw the patient subsequent to that, uh they were this person was saying, Well, geez, you know, 50 instead of 37 and a half. That that that must mean I'm really a medicine. And I I sometimes use humor. So I uh with this person I could and I said, Well, hold on, let me look this up. And it's to see uh if uh that um extra amount meant you're crazy. So I looked it up, made believe I was looking it up. I said, Nope, you're not crazy.

SPEAKER_01 26:48

You never make believe you're looking it up. But you know what I do is I I I tell people, how many milligrams uh do you think is in an aspirin? And then I tell them it's 325 milligrams. Oh my god. And I said, so it's all relative. It's it's not it's not the number of milligrams, it's the therapeutic range. And I make a point of letting people know for most medications what their therapeutic range is so they have an idea of what's high and what's low.

SPEAKER_00 27:12

The bottom line is we don't always appreciate how scary it is for patients to go see somebody like us. And uh speak for yourself. And that is why uh people, you know, sort of put one toe in the water, and some don't go any deeper, and some people go deeper and deeper and deeper. But we are aware of that, and that's what we work with, and we uh appreciate it, and that's why we are talking about today resistance.

SPEAKER_01 27:42

And that's why uh I'm Dr. David Gross, psychiatrist. And I'm Dr. Andrew Rosen, psychologist. And we are two shrinks on a mic.

SPEAKER_00 27:50

The Two Shrinks in a Mike podcast is for informational and entertainment purposes only. The views expressed are those of the hosts and guests and do not constitute medical, legal, or professional advice.

SPEAKER_01 28:04

Please always consult a qualified healthcare provider before making any medical or wellness decisions. Our content is not a substitute for professional medical guidance, even though our mothers tell us we have the best advice possible.