How Mental Health Difficulties Can Interfere With Therapy
Mental health difficulties can affect not only a person's daily functioning but also their ability to engage in psychological treatment. The symptoms associated with different conditions may create barriers to therapeutic progress, even when a person is motivated to improve. Understanding these barriers — rather than mistaking them for a lack of effort — is an important part of effective, compassionate care.
How Different Conditions Can Affect Engagement in Therapy
Depression. Low motivation, fatigue, hopelessness, and reduced concentration may make it difficult to attend sessions consistently, complete therapeutic tasks, or maintain progress between sessions [1].
Anxiety disorders. Excessive worry, fear of judgement, avoidance, and intolerance of uncertainty may make it difficult to discuss distressing experiences, try new strategies, or engage with challenging situations [2].
Anger and emotional dysregulation. Impatience, frustration, impulsivity, and difficulty tolerating discomfort may interfere with the therapeutic relationship, reflective thinking, and the gradual process of behavioural change [3].
Trauma-related disorders. Hypervigilance, mistrust, avoidance, and heightened emotional responses may make it difficult to feel safe, establish trust, or explore distressing experiences [4].
Obsessive-compulsive disorder (OCD). Intolerance of uncertainty, perfectionism, and the need for reassurance may interfere with accepting uncertainty, resisting compulsions, and engaging in exposure-based interventions [5].
ADHD. Difficulties with attention, organisation, planning, and impulse control may affect session engagement, remembering therapeutic strategies, and completing tasks between sessions [6].
Substance use disorders. Cravings, withdrawal symptoms, impaired judgement, and reliance on substances to manage distress may affect consistency, emotional regulation, and the implementation of treatment strategies [7].
Personality-related difficulties. Fear of rejection, sensitivity to criticism, unstable relationships, or difficulties with trust and emotional regulation may complicate the therapeutic alliance and make it harder to sustain engagement [8].
Psychotic disorders. Difficulties with concentration, motivation, reality testing, or suspiciousness may affect a person's ability to participate in therapy, depending on symptom severity and stability [9].
Practical Strategies to Support Engagement
Recognising these barriers is only the first step. In practice, therapists can draw on a range of strategies to help clients stay engaged even when symptoms are working against them:
Psychoeducation and normalising the barrier. Explicitly naming a difficulty as part of the condition being treated — rather than a personal failing — can reduce shame and strengthen the working relationship, particularly for clients experiencing depression, trauma, or personality-related difficulties.
Collaborative, achievable goal-setting. Breaking treatment into small, realistic steps (rather than large or abstract goals) helps maintain momentum for clients facing low motivation, concentration difficulties, or executive functioning challenges, such as those with depression or ADHD.
Trauma-informed pacing. Prioritising safety, predictability, transparency, and client choice in the pace of sessions helps build trust gradually, which is especially important for clients with trauma histories or heightened suspiciousness [4].
Supporting uncertainty tolerance gradually. Using graded exposure and collaborative experimentation — rather than demanding immediate change — helps clients with anxiety or OCD build tolerance for distress at a manageable pace [2][5].
External supports between sessions. Written summaries, reminders, session recordings, or simple take-home tools can help clients with attention or memory difficulties (e.g. ADHD, concentration difficulties in depression or psychosis) retain and apply strategies outside of sessions.
Flexible structure and format. Shorter or more frequent check-ins, telehealth options, or adjusting session length can reduce the burden of attendance for clients with fluctuating energy, motivation, or symptom severity.
Motivational approaches for ambivalence. Motivational interviewing techniques — exploring a client's own reasons for change rather than imposing them — can help address ambivalence common in substance use disorders and low-motivation presentations.
Explicit attention to the therapeutic relationship. Regularly checking in on how therapy itself feels for the client, naming ruptures early, and tolerating a slower pace of trust-building can help sustain engagement for clients with relational sensitivities, including trauma-related and personality-related difficulties [8].
Monitoring stability and adjusting intensity. For clients experiencing more acute symptoms (e.g. during psychotic episodes or severe withdrawal), adjusting the structure, pace, and goals of sessions — rather than pausing care altogether where possible — supports continued engagement at a level the person can tolerate [9].
Reframing the Barrier
Rather than interpreting these difficulties as a lack of willingness or cooperation, it is more accurate — and more helpful — to understand them as potential manifestations of the very difficulties being treated. Adapting the therapeutic approach, setting achievable goals, building trust, and proactively addressing barriers to engagement can meaningfully improve treatment participation and outcomes.
References
National Institute of Mental Health. Depression. nimh.nih.gov/health/topics/depression
Lee, J. K., Orsillo, S. M., Roemer, L., & Allen, L. B. (2010). Distress and avoidance in Generalized Anxiety Disorder: Exploring the relationships with intolerance of uncertainty and worry. Cognitive Behaviour Therapy, 39(2), 126–136.
American Psychological Association. Anger. apa.org/topics/anger
Substance Abuse and Mental Health Services Administration (SAMHSA). Trauma-Informed Approaches and Programs. samhsa.gov/mental-health/trauma-violence/trauma-informed-approaches-programs
International OCD Foundation. What is OCD? iocdf.org/about-ocd
Kolberg, J. (2002). ADHD and Organization: A Collision Course? Attention Magazine, CHADD. chadd.org/attention-article/adhd-and-organization-a-collision-course
National Institute on Drug Abuse (NIDA). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition). nida.nih.gov
Euler, S., Wrege, J., Busmann, M., Lindenmeyer, H. J., Sollberger, D., Lang, U. E., Gaab, J., & Walter, M. (2018). Exclusion-Proneness in Borderline Personality Disorder Inpatients Impairs Alliance in Mentalization-Based Group Therapy. Frontiers in Psychology, 9:824.
Beck Institute for Cognitive Behavior Therapy. Insight Is a Predictive Variable in Cognitive Behavior Therapy for Psychosis. beckinstitute.org/blog/insight-is-a-predictive-variable-in-cognitive-behavior-therapy-for-psychosis
