Therapy is a journey of self-discovery, healing, and growth, but like any journey, it can sometimes encounter roadblocks. Whether you are a therapist or a client, dealing with these problems can be tough. Issues like slow progress, communication problems, and strong emotions can make therapy harder. However, with the right methods and a positive attitude, these challenges can help you grow even more. In this blog post, we will look at common problems in therapy and share easy ways to solve them, so your therapy journey stays on track.
Solving Problems
Depression may be viewed as a deficit in problem-solving ability or in the use of problem-solving skills (D’Zurilla & Nezu, 1999, 2010). In other words, when people feel very sad, it might be because they are having trouble solving problems in their life. Things that happen to them or conflicts they have can be seen as problems that they need to solve. They can be taught a way to solve these problems. For example, if a person thinks, "I am so lonely," the therapist can help them turn this into a problem to solve. The therapist might ask questions like, "What resources do you have? Who are some people you know? How can you meet new people? What can you do to connect with others? How can you spend your alone time in a better way?"
Taking Care of Your Health
Taking care of your health means doing basic things like keeping clean, getting good sleep, eating well, and going to the doctor. For people who are severely depressed, not taking baths or wearing the wrong clothes can make them feel even worse. Many people with depression do not eat well because they do not feel like eating or do not care about staying healthy. For example, one patient felt tired and had no joy because they did not eat well, which resulted in anemia. A therapist can encourage a person to eat small amounts of food often, even if they do not feel like it. Eating heart-healthy foods and planning meals can help. Sometimes, the goal is to “eat to create hunger” because being sad and not eating well can make someone lose their appetite. Other people might eat too much or prefer junk food, which can make them feel bad about themselves.
People who are depressed might drink too much coffee to feel less tired, or if they cannot sleep, they might drink alcohol. Many people with depression do not go to the doctor when they should, or if they need medicine for health problems like high blood pressure or diabetes, they might not take it properly. This could be because they have hidden thoughts about wanting to harm themselves. This also includes risky behaviours like unsafe sex, using illegal drugs, taking too much prescription medicine, and dangerous driving. A therapist should check if a person is at risk for any of these behaviours.
Communication and Social Abilities
People who are depressed often have trouble with social behaviour. A therapist should notice how a person greets others, dresses, listens, makes others feel good, handles relationships, manages money, and whether they complain or punish others. These problems can make it hard to get along with others and can be worked on in therapy. Learning to be more assertive is often helpful. This means practicing how to speak up in different situations, starting with easy ones and moving to harder ones, both in therapy sessions and in real life.
For people who have strained relationships, like those who are married or living together, communication training can help. This includes learning to listen actively and speak clearly, like rephrasing statements and expressing feelings clearly. Couples can also benefit from problem-solving sessions where they work together to solve issues, share responsibility, brainstorm solutions, and make plans. Learning to negotiate is also important for personal and work relationships. The book "Getting to Yes" by Fisher and Ury (1981) is a helpful guide for learning practical negotiation skills.
Trouble in Marriage or Relationships
Because problems with marriage or relationships can often lead to depression for many people, therapists might find it helpful to work with both partners together (Dattilio, 2010; Epstein & Baucom, 2002b). Therapy methods can involve teaching partners to notice, name, and encourage good things in each other like helping them create lists of things that make each other happy, planning enjoyable activities together, teaching positive ways to express feelings, teaching partners how to talk to each other better, finding and changing thoughts or ideas that cause problems, and teaching ways to calm down and talk to yourself when you are angry. Also, many couples find it helpful to learn to accept problems instead of trying too hard to make everything perfect.
Feeling Without Hope
When a therapist looks at hopelessness, they ask the person exactly what they believe will not get better and why. For example, a woman who felt very sad and could not stop thinking about things she worried about thought she would always feel sad, always think about these things, and never find love. She thought she would always criticize herself, not be able to focus, and always regret things, which made life very hard to bear. She had been in therapy and tried medicine for many years, so it was easy for the therapist to think she was right to feel hopeless. But instead, the therapist decided to treat her hopeless thoughts as ideas to test.
For example, in a session, they asked if she noticed when her mood got better, when she laughed, or when she started to challenge a bad thought:
Therapist: Did you notice you felt a bit better during today’s talk?
Patient: Yes, I think I felt a bit better, but it only lasted a few minutes.
Therapist: What if you could do some of these things on your own—maybe a little bit every day, or even every hour?
Patient: I think I might feel better than I do now.
Therapist: If you can feel better during a session when you challenge your thoughts, and if you see your mood change with the things you do, maybe those could help you feel better for a long time.
Patient: But I’ve had therapy before, and I’ve tried medicine.
Therapist: You’ve had a different kind of therapy, and you’re just starting to think about medicine. Could changing how you think and how your body works help?
Patient: I guess it might. But it’s not certain.
Therapist: That’s right. Nothing is certain—either way. Why don’t we see what happens?
Even though she still felt hopeless sometimes, she started to doubt her sadness more than before. Actually, her doubt about therapy and medicine helped her feel less hopeless. At first, the goal was to make her feel unsure about feeling hopeless.
Therapist: Just like you’re not sure about therapy, why not be unsure about feeling hopeless, too?
Patient: I never thought about it like that.
Therapist: There’s always a new way to think about things. Let’s say you will be unsure in a good way—a “wait and see” feeling.
The therapist and the doctor who gives her medicine worked together to plan her therapy. They saw changes in the medicine like tests, and they treated the things she said about herself as ideas to test. The therapist told her that along with feeling sad, she worried a lot, wanted things to be perfect, and changed her mind a lot. Ironically, she was a lawyer, so this helped her with her work, but it was hard in her daily life. But instead of trying to change how she thought, the therapist told her that because she was so good at seeing both sides of things, she would always have doubts when she made choices. These doubts did not mean she made a bad choice, even though she almost always thought they did. They were just part of how she thought. This made her feel better because now she could see her doubting as “normal” for a smart lawyer and did not mean something bad about the “real world.” After a few months, she felt less hopeless, felt less sad and regretful, and fortunately got engaged. It is important to know that she felt less hopeless and sad before she got engaged, so this was not a fairy tale ending.
Self-Criticism and Depression
Many depressed people criticize themselves for feeling that way. They might say things like “I shouldn’t feel sad” or “I should have fixed my problems alone.” This makes them stuck in a cycle of thinking—“I’m sad because I’m hard on myself, I’m hard on myself because I’m sad, and I’m sad because I’m sad.” It’s important to help them see that being sad is not something they chose. Sadness often comes from a biological part of their body. Being hard on themselves does not help them feel better. Taking responsibility for feeling sad means accepting that they feel this way and getting help. Avoiding things and putting things off are also signs that they feel sad.
Not Doing Homework
When someone is depressed, they might think, “Nothing will help, so why should I do the homework my therapist gives me?” In this situation, the therapist should first ask why the person has not done their homework. They might say, “I didn’t think it would help,” “I don’t have time,” “I’m embarrassed to show what I did,” “Homework reminds me of my problems,” “I shouldn’t have to do homework,” or “I don’t like being told what to do.” Each reason should be looked at like a thought to think about:
“What are the good and bad things about doing homework?”
“What else could you do instead?”
“What shows that homework might help or not?”
“What homework would you give yourself?”
“What would you tell a friend who feels like you?”
“How is thinking homework won’t help like other thoughts about feeling better?”
“Why do you think the therapist would think less of you if you don’t do the homework?”
“Would you try doing a bit of homework?”
The patient might do more homework if the therapist shows how to do it in a session, thinks about why they might not want to do it, asks them to do homework on why they do not do it, lets them choose what homework to do, or gives smaller assignments. Like with all homework, the therapist should say why it is good to do and say good job when it is done (Leahy, 2002c).
Being Hard on Yourself
When someone is depressed, they often think harsh things about themselves like “I’m no good” or “I always fail.” These thoughts make them feel even worse and can lead to more sadness, thinking about problems too much, feeling like they cannot change things, and feeling without hope. The therapist can help by finding these harsh thoughts, seeing what happens because of them, and finding other ways to think.
Suggestions to help deal with self-criticism and build self-esteem by Leahy (2010):
1. Identify your negative thoughts about yourself.
2. Define your terms.
3. What is the evidence for and against your self-criticism?
4. What is the advantage of criticizing yourself?
5. Replace self-criticism with self-reward.
6. Do you really need to evaluate yourself?
7. Replace evaluation with observing and accepting.
8. Don’t take yourself too personally.
9. Use self-correction.
10. Use the double-standard technique.
11. Do you have a self-critical rule book?
12. What is your core belief about yourself?
13. How is your thinking distorted?
14. Look at yourself along a continuum.
15. Humanize your mistakes.
16. Use a learning curve: Success through failure.
Feeling Unmotivated
Depressed people often say they do not feel motivated: “I can’t make myself do anything.” The part of Leahy’s (2010) book, Beat the Blues before they Beat You: How to Overcome Depression, about building motivation can help people with this common problem. The main goal is to help these people find goals and habits that would make their life better (“a life worth living”)—in other words, to become the kind of person they want to be. This approach focuses on setting goals, making choices, and being able to handle feeling uncomfortable. It also encourages giving yourself rewards when you do things that help you reach your goals.
Ideas for building motivation by Leahy (2010):
1. Rely on habits, not on feelings.
2. Identify your goals.
3. What kind of person do you want to be?
4. What did you do when you weren’t depressed?
5. Set specific goals.
6. Plan and predict your pleasure and effectiveness.
7. Make choice your choice.
8. Sample the menu.
9. Look at your excuses.
10. Do what you don’t want to do.
11. Act against your thought: “I shouldn’t have to do it.”
12. Choose your purpose.
13. Examine the costs and benefits—short-term and long-term.
14. Act to create motivation.
15. Don’t expect an immediate payoff.
Afraid of Making Mistakes
When someone is depressed, they often see their mistakes as very bad and judge themselves harshly for them. For example, when they think about doing something new, they might feel like the risk of making mistakes is too big. This makes them feel stuck in their situation. These fears come from wanting things to be perfect, thinking that small mistakes mean big problems, and thinking that one mistake is very important.
Suggestions to handle fear of mistakes by Leahy (2010):
1. Are you a perfectionist?
2. What kind of perfectionist are you?
3. What are the consequences of perfectionism?
4. Try successful imperfection.
5. What’s the worst thing about a mistake?
6. Everyone makes mistakes.
7. Aren’t standards arbitrary?
8. It’s hopeless—but not important.
9. Why are mistakes so common?
10. Mistakes are information.
11. A mistake is not the end of the world.
12. You don’t have to regret mistakes.
13. Don’t be proud of perfection.
14. Develop your “bill of rights.”
15. Make your perfectionism look dumb.
16. Being good enough is “good enough.”
17. Mistakes are part of progress.
18. Make room for mistakes.
19. Develop an accepting voice.
Trouble Making Decisions
When someone is depressed, they might have trouble making decisions. This can be because they feel unmotivated, like they cannot change things, and because they are hard on themselves. They might be afraid that choosing will lead to bad results, that failing is not okay, and that nothing they do will make a difference anyway. But not choosing is also a choice.
Ways to deal with indecision by Leahy (2010):
1. Make decisions based on goals and values.
2. Examine the longer-term and shorter-term tradeoffs.
3. Think about behavior and discomfort as investments.
4. How much information is enough?
5. Accept doubts, but act anyway.
6. Evaluate the opportunity costs of indecision.
7. Reject sunk costs.
8. See decisions as experiments.
9. Reject perfection as a goal.
10. Maybe you can absorb some losses.
Overthinking
Another big part of feeling very sad is overthinking, which can make sadness last longer and make it more likely to come back. People who overthink often believe that thinking a lot will help them understand things better and find answers to their problems. But actually, overthinking keeps them from doing things that could make them feel good and makes them feel more alone and less active.
Suggestions for patients to overcome rumination by Leahy (2010):
1. How does rumination make sense to you?
2. What are the advantages and disadvantages of ruminating?
3. Tolerate uncertainty.
4. Do you have a hard time accepting conflicting information?
5. Will rumination solve your problem?
6. Set a time limit to your rumination.
7. Shift attention.
8. Would you be better off accepting reality as “a given”?
9. Why does the past have to make sense?
10. Are you looking for THE ANSWER?
11. Are there real problems that you could solve?
12. What are you missing in life when you ruminate?
13. Practice mindful awareness.
14. Accept the intrusive thought—and act in the real world.
In conclusion, navigating challenges in therapy requires patience, understanding, and a collaborative approach between therapist and patient. By identifying and addressing issues like self-criticism, lack of motivation, and fear of mistakes, therapy can become a transformative process. It is important to remember that setbacks are normal and part of the journey towards healing. With persistence and the right support, individuals can develop new coping strategies, improve their self-awareness, and ultimately find relief from their struggles. Therapy is not just about solving problems; it is about empowering individuals to live more fulfilling lives, equipped with the tools to overcome future challenges.
References:
Leahy, R. L., & Holland, S. J. (2000). Treatment plans and interventions for depression and anxiety disorders (pp. 68, 71-75). New York: The Guilford Press.
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