Reasons for Seeking Therapy

Depressive symptoms are not limited to sadness. Some people experience a persistently low mood; others mainly feel empty, frozen inside or as if their own life no longer really touches them. Interest, pleasure and curiosity can fade. Even familiar activities or encounters that once meant something may leave them indifferent or become an almost unmanageable effort. The experience of time and the way the future is seen often change too: the present feels stuck, while hope and imaginable possibilities recede further and further.

Exhaustion, withdrawal, rumination, sleep problems or marked self-criticism may also occur. Feelings of guilt and doubts about one's own worth can sometimes take up so much space that people see themselves almost entirely in terms of perceived mistakes, omissions and shortcomings. Others feel not so much a distinct pain as an inner absence: outwardly they continue to function, but barely feel alive. Depressive symptoms are not a sign of a lack of willpower. They may be connected with current pressures, losses and disappointed hopes, as well as with long-standing inner conflicts or experiences in relationships.

Anxiety is a natural part of human life. It warns us of danger, sharpens our attention and can help us to protect ourselves. It becomes a problem when the internal alarm system signals danger even where there is objectively no threat, or none proportionate to the alarm. Thoughts and bodily responses then become increasingly geared towards anticipating possible dangers, maintaining control or avoiding uncertainty. Life can become more and more restricted as a result.

Anxiety may concern particular situations, social encounters, illness, loss or the future. It can also arise without any clearly identifiable trigger. A panic attack is a particularly sudden and overwhelming form of this sense of alarm. A pounding heart, breathlessness, dizziness or a feeling of being about to faint may be accompanied by the fear of dying, losing control or ‘going mad’. After such experiences, a fear of fear itself sometimes develops. Places and situations are avoided, even though the person would like to be able to move about freely again.

Obsessions and compulsions are distinct from these experiences, but may also be connected with anxiety, responsibility and a wish for certainty. Intrusive thoughts, images or fears are experienced as distressing and are often at odds with what the person actually wants. Repeated actions, checks or mental rituals are intended to reduce the resulting tension or prevent a feared event. They may bring short-term relief; in the longer term, they often strengthen the inner compulsion to keep establishing a sense of safety.

Distressing experiences can shake a person deeply without necessarily leading to a mental health condition. These may include loss, neglect, violence, abuse, severe humiliation or situations that threaten a person's very existence. Prolonged experiences of insecurity, dependence and feeling at the mercy of others or circumstances can also leave their mark. Whether an experience has a traumatic impact does not depend solely on the external event. What also matters is whether, at the time, what happened overwhelmed the person's capacity to cope with it and process it internally.

After a traumatic experience, the past can remain present even though the event is objectively over. Memories or bodily sensations intrude unbidden; certain situations suddenly trigger intense fear. Others live in a constant state of vigilance or try to avoid anything that might remind them of what happened. Emotional numbness, gaps in memory, shame, feelings of guilt or a sense of being cut off from one's own body and feelings may also occur.

Prolonged or repeated experiences of violence and dependence can also affect a person's self-image, emotion regulation and capacity for trust and closeness. What happened then concerns more than individual memories: it can shape how someone perceives themselves, other people and the world.

Close relationships can offer a sense of belonging, security and aliveness. At the same time, they touch on particularly sensitive aspects of a person's experience: the fear of being abandoned, rejected, engulfed or hurt. Relationship difficulties therefore do not show themselves only in open conflict. They may also take the form of recurring loneliness, a strong dependence on relationships or difficulty being alone. Conversely, an emphasis on independence may serve to keep disappointment and one's own need for others at a distance.

Some people long for closeness and withdraw as soon as it develops. Others adapt themselves extensively to avoid putting a relationship at risk, losing touch with their own wishes and boundaries in the process. It may be difficult to trust, accept support, tolerate conflict or set boundaries without immediately fearing separation or the loss of love. Similar experiences often recur in different relationships, even though the person consciously wishes for something different.

The way closeness, reliability and independence are experienced is not a fixed personal trait. Expectations about whether one's needs are welcome, whether others can be relied on or how much closeness is tolerable develop over the course of life and can continue to change through new experiences. They often become particularly apparent when another person becomes important, dependence is felt or a relationship seems threatened.

Body and mind are not separate domains. Emotional distress influences bodily experience, while physical symptoms can in turn affect feelings, relationships and everyday life. Psychosomatic symptoms are therefore neither imaginary nor ‘just psychological’. Pain, dizziness, exhaustion, a pounding heart, gastrointestinal symptoms, muscle tension or sleep problems are genuinely experienced in the body and can significantly impair a person's life.

Sometimes no physical changes can be identified that adequately explain the nature and extent of the symptoms. In other cases, a physical illness is present, while its course and the distress it causes are also influenced by stress, anxiety, experiences in relationships or unresolved inner tensions. Organic and psychological factors can coexist and reinforce one another. Appropriate medical assessment therefore remains important.

The term somatisation describes the process by which emotional distress is experienced predominantly, or initially, in physical form. This does not happen deliberately. Sometimes the body expresses something for which words or clearly recognisable feelings are not yet available. This does not mean, however, that every physical symptom carries a hidden psychological message or can be traced back to a single cause.

Experiences of detachment and unreality involve a temporary or persistent loss of the familiar, taken-for-granted sense of one's own existence. In depersonalisation, one's own self, body, thoughts or feelings seem alien and distant. Some people feel as though they are observing themselves, feel as if they are functioning automatically or have the impression that they are not fully present within themselves.

In derealisation, the surroundings appear altered. People, rooms or objects may seem unreal, artificial, flat or dreamlike. Although the world is outwardly unchanged, it no longer feels familiar or as self-evidently real as before. People often know that it is their experience that has changed. This very contrast between knowing that everything is real and feeling a sense of unreality can cause considerable anxiety. Depersonalisation and derealisation are the two main clinical terms for these experiences.

These experiences may occur in connection with intense anxiety, panic, traumatic experiences, depression, being overloaded or exhaustion. The inner distance may initially be a protective response when feelings and impressions become too overwhelming. If it persists, however, the protection itself can become a burden: painful experiences are muted, but closeness, involvement and aliveness are lost as well.

Sexuality encompasses far more than sexual functioning or particular behaviours. It includes bodily experience, pleasure, wishes, fantasies, inhibitions, sexual orientation, personal values and the way a person experiences themselves in their body and in intimate relationships. Intimacy refers to the possibility of revealing oneself physically and emotionally to another person, allowing closeness while maintaining one's own boundaries.

Difficulties may take the form of a lack of sexual desire, pressure to perform, shame, fear of closeness or uncertainty about one's own wishes. Some people experience a conflict between what they long for and what they can allow themselves. Others put their own needs aside, fear rejection or find it difficult to recognise and communicate their boundaries. Physical illnesses, medication, earlier relationship experiences and the current relationship can also influence sexual experience.

Sexual diversity, personal sexual wishes and different consensual ways of living together do not in themselves require treatment. What matters is whether a person finds their experience distressing, feels restricted or is unable to shape their sexual life in keeping with their own wishes, boundaries and values.

Self-esteem refers to a basic sense of being valuable and worthy of respect as a person. It is not the same as self-confidence, capability or outward assurance. Someone may appear competent at work while still feeling inadequate or easily shamed within. Conversely, stable self-esteem does not mean always feeling sure of oneself. It is also reflected in the ability to tolerate mistakes, limitations and criticism without devaluing oneself as a whole person.

The sense of self is broader. It describes how someone experiences themselves inwardly and physically: whether they feel entitled to take up space, take their own needs seriously and stay in touch with what they feel. It also includes the sense of being truly present, able to act and connected with oneself.

Difficulties may show themselves in constant self-criticism, perfectionism, shame, excessive guilt or a strong dependence on approval. Some people adapt themselves extensively to others and experience their own wishes as an imposition. Others fluctuate between self-devaluation and feeling that they must defend themselves against any hurt to their self-esteem or uncertainty. Praise can then be just as difficult to accept as criticism.

Self-coherence refers to a sense of inner cohesion. A person experiences themselves as the same person across different roles, moods and stages of life. Even contradictory aspects can be felt to belong to one's own self. Coherence therefore does not mean always being the same or entirely free of contradictions. Rather, it allows a person to tolerate change and inner complexity without losing a sense of how the different aspects of themselves fit together.

Identity concerns the question of who someone is and wishes to be. It grows out of their life history, important relationships, personal values, affiliations, decisions and ideas about the future. Identity is not found once and for all. It continues to develop as new experiences are encountered, earlier self-images are reconsidered and aspects of oneself that have so far found little expression are discovered.

Difficulties may arise when different aspects of oneself seem incompatible or when one's self-image depends entirely on whom one is with at a given moment. Some people feel that they are constantly adapting without knowing what they themselves want. Others experience inner emptiness, frequently changing self-images or a rupture between their past, present and future lives. Transitions, losses and life-changing experiences can intensify these uncertainties. The distinction from self-esteem lies in the central question: self-esteem concerns the worth I attribute to myself; self-coherence and identity concern who I am and how the different aspects of myself belong together.

Emotion regulation refers to the ability to recognise and tolerate feelings and respond to them in ways that fit the situation. It does not mean suppressing feelings or remaining calm at all times. Grief, fear, anger, shame and guilt are also part of human experience. What matters is whether there can be room for feelings within a person, without those feelings becoming completely overwhelming or remaining entirely inaccessible.

Difficulties can take very different forms. Feelings may rise so quickly and intensely that thoughts and actions seem almost impossible to control. They may persist for a long time, change abruptly or lead to impulsive reactions, withdrawal and distressing rumination. Others feel predominantly numb, cut off or empty. They know that a situation ought to affect them emotionally, but cannot access the corresponding feeling. Physical tension or psychosomatic symptoms may take the place of a feeling that can be consciously experienced.

Successful regulation does not consist of a single correct strategy. Depending on the situation, people need to be able to express feelings, contain them, soothe them, tolerate them or allow them in the first place. This also involves being able to distinguish between a feeling, the impulse to act that arises from it and the action itself.

Life crises often arise when familiar sources of security, roles or ways of coping no longer provide support. They may be triggered by separations, losses, changes in working life, moves, family upheavals or difficult decisions. Even transitions that have been consciously chosen or are regarded positively by society can be unsettling. A new beginning brings possibilities, but often also requires letting go of what is familiar.

During such periods, grief, anxiety, a sense of being overwhelmed and a loss of direction may coexist with relief, hope or curiosity. A person's sense of identity can become unsettled: who am I when an important relationship, role or vision of life falls away? What should remain, and what is allowed to change? Earlier losses and unresolved conflicts may be felt again, even when the current crisis has a very different cause.

Not every crisis is a mental health condition. Crises are part of a life in which relationships, possibilities and certainties do not remain unchanged. Support may nevertheless be helpful when the strain exceeds a person's own resources, decisions remain blocked or earlier painful patterns recur.

The wish to find direction does not arise only in acute crises. Some people lead outwardly well-ordered lives and yet feel that they are not living out their own possibilities. Decisions feel determined by others, important wishes remain unclear or different possible ways of living seem mutually exclusive. A sense may develop of mainly meeting expectations, while no longer being sure what is personally meaningful.

Finding direction does not mean finding a clear answer to every question. It describes a growing sense of which values, relationships and activities give one's life direction. This also involves being able to tolerate uncertainty and developments whose outcome remains open. Personal development is therefore neither self-optimisation nor a straight path towards an ideal version of oneself.

Not every question about finding direction calls for psychotherapeutic treatment for a mental health condition. Where no mental health condition is present, counselling may provide a more appropriate setting. Development is not prescribed from outside. It emerges from a deeper engagement with what is seeking expression, change or further unfolding in one's own life.