Just A Quick Update

I’m still alive, but very busy. Lectures at university started again – not that I had a lot of free time during the “break”. I attended an extracurricular class in zoology and passed the exam for that, and I didn’t pass the second attempt of physics because I was just too burned out and my brain didn’t cooperate at all. As a result, I opted out of taking maths again.
Currently, I’m writing a report on the field trip I took in February; the text is as good as done, but I still have to put in pictures and so on.

Then, of course, I got married and had a lot of family drama going down the day before the wedding, all of which deserves a dedicated post.

Finally, my therapist invited me to join a class for psychology students next week – as a “living exhibit”. They’ll present my data, including the clinical tests I took (the results of which I’ve never been told), and I’ll be there to answer questions. Bring the person to life, I guess, because according to my therapist, most of these students have no real idea of what it is like to be depressed and what it is like to undergo CBASP therapy. Besides the scientific data, I can provide insight into all of that. Strangely enough, I’m looking forward to this.

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Slaying A Dragon

Yesterday was a very significant day for me – one I had worked towards since April last year: I told my mother that my boyfriend and I wanted to get married. This was problematic in several respects, not only because of the generally difficult communicative patterns in my family, but also because my mother is decidedly against marriage (never mind the fact she’s been married to my father for over 30 years). At her most irrational, she claimed she’d “outlaw” it if she ruled the country. My sister’s failed marriage didn’t do much for swaying her in a more favourable direction either.
In most families, the news that their daughter wanted to get married would be regarded as happy news, but I wasn’t so sure about that and thus the topic had been fraught with a lot of anxiety. The range of possible reactions just was too broad to predict a likely outcome.

To make you understand the scope of this, I’ll have to go way back to spring 2011. My boyfriend and therapist actually met ever so briefly once – hardly more than a greeting and shaking hands – at the visitor lounge at the psychiatric hospital, so my therapist was able to put a face with the name. After my boyfriend had to leave Germany at the end of March because his tourist visa expired, my therapist had assumed a quasi-parental role and questioned me on our relationship in the first therapy session after the separation.
I summed it all up in an email to my boyfriend the next day:

Each of our sessions start with him asking me about my depression index – whether it went up or down, and what I did to get there. The philosophy in CBASP, my treatment programme, is that your mood always is a result of things you do or don’t do (when usually, one tends to assume it the other way around).

I told him that you had to leave again and that my points probably would be lower if not for that. And he said with a major change like this, we must have done a lot of things right or else I would probably have bounced back quite a bit, to 20 or possibly even higher.
So I related to him everything that went down since my last session – how we had looked into ways to get an extended or permanent visa, how we found out that you had to leave again and still tried to make the best out of the last week. I told him about the trips we made […] and he asked what the goodbye was like, whether we cried – whether we *could* cry, because the inability to cry signals deeper depression than bursting into tears. If you cannot cry even though you feel like it, it means your access to your emotions is disrupted: crying always is a good sign in their books.
He went off on a little tangent here, explaining the differences between “primary emotions” like happiness, sadness, fear, anger etc. and so-called “social emotions” to me: the former are understood by all humans in the world and elicit the same reaction, and they are also “contagious” to the people around us. Every time we display one of those, we radiate it off to other people, too. That is why being around happy people can make you feel happier and why sometimes one person can get a whole group down. “Social emotions” are defined by culture. He gave me an extreme example: a member of a cannibalistic tribe will have no problem eating human flesh, while we would have to torture ourselves into it and endure very strong feelings for doing so.

My therapist proceeded to ask about our contact and very much approved of daily Skype sessions, then went on another tangent by telling me that he had a short relationship with an American girl from New York City when he was a student and that the costs for phone calls almost ruined him back then. He even did an internship in New York City and got an unlimited visa for the States then (that was during the early Clinton administration – wouldn’t happen anymore today, and his is not valid anymore because he left the States again). That’s also part of the CBASP programme, that you get to know your therapist on a personal level, because it helps you discriminate between different people’s reactions instead of just assuming that everyone will reject you.

Finally, he asked what we had planned for the future and I told him that you wanted to come back and that there were basically only two ways for you to stay here other than a tourist: either by job offer or by marrying me. He asked a lot of question about you to get a better picture, and I told him that you had worked as a historian and then, recently, for [international company]. He said you must have incredible skills to handle the [international company] job and was very impressed. He wanted to know what social climate prevailed in [my boyfriend’s current location] and when I said “Bible belt” and that originally you came from [city in New England], via [different state], he said he couldn’t blame you for having difficulties. He is very familiar with [city in New England] and called it “my city” – I think he has been there quite a few times on business trips and for workshops, and also said that it was rather European compared to other places in the States he has been to.

Eventually, my therapist came to the conclusion that I already communicated to you yesterday. He thinks that we have a very healthy relationship and that in his opinion, the key for lasting relationships lies in how well you get along in everyday life, and how well you support each other there. Everything else is secondary – no matter how good you are as a couple on holidays, for example, if everyday life together does not work, there’s nothing you can do.

That is only a rough overview; strewn in between were always small “lessons” for me. For example, when I said that our goodbye at the airport was very teary, he asked if I could have cried in front of my mother, too, and I said I wouldn’t. I’d try to hold it back there with all my might.
Or we compared and contrasted our situation with a hypothetical situation where we would not have sorted out all the legal stuff and lived in uncertainty.
In his opinion, we made the absolute best out of what we were dealt.

Anyway… just so you know what we were talking about yesterday. I personally feel very glad we spoke about all this in therapy, because it helps me process, and I am also glad that we had a whole session just for “understanding” what has happened here.

Unfortunately, I don’t have access to the first email I sent my boyfriend directly after the session, so I might have forgotten details. I do remember that we focused on behaviour a lot and also that my therapist asked about my boyfriend’s language skills, job perspectives, health management  etc. And I do remember that he advised me to not suppress or try to conquer emotions, and to cry when I feel like it, for example, because “trying to be strong” and suppressing costs too many resources and too much energy. In the end, he came to the conclusion that there were “no pathological structures” in our relationship, with an emphasis on the fact that he’d tell me if he detected anything like that.
Over the following weeks, we roleplayed me telling my parents about it, and he assigned me the task of making a list with reasons why I’d want to marry my boyfriend – because I’d been dumbstruck in the session when he’d ask me that question. “Because I love him” wasn’t enough of an answer, and so I started writing down arguments and categorized them into topics: “Because he respects me as a person: my sexual orientation; my feelings, opinions, ideas and wishes; my personal belongings; my privacy.” [On physical appearance:] “He likes me the way I am and doesn’t expect me to conform to some ideal standard.” [On depression:] “He can handle my depression and endure it, even if I’m feeling significantly better or worse than he does.” I had close to 50 reasons when I stopped.

Another email I sent my boyfriend, about two months after the one mentioned above. In the session, we’d talked about some unexpected news my boyfriend had received and how they’d influenced me:

We had some administrative stuff to sort out then, but at the very end – I was already half out of the door – he asked: “Can I say something about you and [your boyfriend]?” I stepped inside the office again, closing the door once more: “Of course you can!” Inside, I must confess, I got a little nervous at that moment, wondering what he possibly might want to say.
“I don’t know [your boyfriend] personally, even though he has been very ‘alive’ in our sessions through the way you spoke about him. I mean, I have seen him, but I don’t know him from personal contact. Still… I just wanted you to know how very deeply I am touched by the relationship between you and [boyfriend]. In my profession, I see so many relationships every day, but…” – he shook his head here – “…what you two have… this is what is important in life.” At this point I was just stammering ‘thank you’ and how much this meant to me, taken completely by surprise and once again speechless, so that I repeated the same two phrases at least three times. We said goodbye again, and just before I opened the door once more, “I believe [your boyfriend] is a really good person. I don’t know him personally, but I have a feeling that this is the right stuff.” And he smiled.

I remember leaving the therapy session that day, feeling like I was walking on clouds. I was just utterly touched by what he’d said, and the fact he did say it at all. In CBASP, one of the therapist’s roles is to heal emotional-behavioural damage in the patient through making them experience healthy behaviour in sensitive situations, and that was one the most important moments I had together with him. I knew I could completely trust every word he’d uttered to be sincere, that he had no reasons for bullshitting me, and this kind of openness was one of the great “healing moments of my therapy.” There was a lot more going on at that moment than is visible on the surface – every person in love likes hearing nice things about their relationship and partner, but apart from the content of the sentence, I felt being taken seriously and listened to. I felt I and my future happiness were important enough to someone that he’d trouble himself with examining it closely.

With so much support in my back, it should have been easy to just tell my parents – after all, I was in the unique position of being able to cite a mental health professional’s opinion. Nobody could accuse me of being deluded by my own romantic feelings. However, it wasn’t easy for me at all. I made a couple of attempts, but at the last moment, the words just got stuck in my throat.
There was one notable Sunday which I’d looked out as the date when I’d tell them: I’d be alone with my parents in the afternoon, with plenty of time for talking. I bought a cake for us and wanted to create a pleasant atmosphere. Everyone was ready when I noticed I’d forgotten something and ran out of the room, returning literally a minute later, but those 60 seconds had been long enough for my parents to get into a petty argument over something really insignificant. Frustrated, I ate my slice of cake in silence and retreated without bringing up the subject.
Weeks went by, turning into months. Stuck with waiting for some important document on my boyfriend’s end, there was no imminent pressure to come out with the truth – it was something present in the background, but I didn’t feel any need to act immediately, and thus the anxiety prevented my saying anything at all. Only when said document was suddenly approved and I received an express-delivery of my boyfriend’s paperwork, I knew I had to get moving – yet it took almost another four weeks and the flight to Germany getting booked until I could finally realize it. Fortunately, my boyfriend was cognizant and understanding of my difficulties and didn’t push me; he appeared more confident than I ever felt that eventually, I’d manage.

It happened on the way home from a farm shop where we buy most of our vegetables. My mother doesn’t have a driving licence, so I chauffeur her there, and it looked like a good opportunity: we were not going to be disturbed in the car and, in order to ensure the security of all passengers, my mother couldn’t have a complete melt-down there. Still, my stomach slowly twisted into a tight knot and nausea started to rise up. I was only a heartbeat away from breaking into a cold sweat, and there was this imaginary voice screaming in my head: “Stop as long as you still have a chance to do so! Just don’t say anything! Abort mission!”
We were literally two minutes from home only when I swallowed all of the silent terror, took a deep breath and said: “Mum, I need to tell you something… [Boyfriend] and I want to get married.” The rest is only a haze and I do not remember it very well – as I wrote in previous posts, stress and anxiety tend to wipe the memory out. I do recall that my mother said something like, “I thought so, I was kinda expecting that.” And, “You two need to know what you want.” Which I answered with a simple but convinced, “We do.” She asked a few practical questions about finances, health insurance; she was rather anxious about us wanting a huge celebration (which, considering the facts that we’ll get married on short notice whenever the paperwork goes through and that our finances are limited, is not the case at all). What I remember very clearly is that I parked the car in front of our house and that the last thing she said before getting out of the car was: “After that I need a cup of coffee now.” And I replied, with full emphasis: “Me too!”

After I was back at my own place, I updated my boyfriend, therapist and some friends via email. I have to credit one of my friends especially: we had been emailing back and forth this past week and also that morning, talking about my problems opening up to my mother among other things, and she had reasoned with me that the situation couldn’t really get any worse than what I was already experiencing. And she was right.
The huge wave of relief one might expect did not come, at least not so far. Maybe it will take a little longer until I really feel it, maybe that’s not going to happen. That was a huge dragon to slay and a lot of personal angst I had to confront – really one of the most difficult things I did in my life. Intellectually, I’m just glad to be done with it finally, the emotional reaction might or might not come still. Right after talking to my mother, I was in some turmoil as a direct result of the stress: shaking knees, slightly trembling hands and a little agitation, but none of it too violent.

When I turned 30, I looked at the decade behind me which supposedly defines what kind of person you are, and all I saw were missed opportunities, failures and loneliness. Years lost to depression. I don’t want to do the same when I turn 40, and so I try to push myself – no matter whether it takes 2, 20, or 200 attempts to realize my goal. The only way I can ensure a better future is to change something in the present…

Dared To Ask

After asking whether or not it was indeed me who featured in the article my therapist wrote (it wasn’t – full story here), we had a very good conversation via email. Somewhere in the process I realized it had not been the question of the case example’s identity which bugged me so much – it really doesn’t make much of a difference whether it’s me or just someone I can strongly identify with – but the fact that I really wanted to ask him on the one hand and was hesitant doing so due to fearing negative consequences on the other hand.
Some people constantly fight with their therapists, oppose them, challenge them. Not me. It’s very important to me that we get along well and that I can attend sessions without having a negative “vibe” in the room. The downside is that if in doubt, I tend to hold back questions or emotions or anything I believe might at least temporarily trouble our relationship. My therapist keeps encouraging me to express myself more openly and tells me that I’ll find out when I’m crossing a boundary, so I tried being more courageous and actually sent him a couple of questions via email: whether he minded patients reading his articles (he doesn’t), whether I may ask him questions about it (yes), whether it’s me in the article (nope).
He wrote back, then I explained to him how I’d felt about his reply and that I was really relieved to have asked, because suddenly I could move on from the topic. It wasn’t important to know anymore, because the real reason behind my thinking about it had been the inability to simply inquire. He commented: “McCullough [the inventor of CBASP] would ask you: “What have you learned from this?”
I think the most important lesson I learned from this is that asking rarely has the bad consequences I anticipate (at least with my therapist). I actually felt more connected to him than before.

At some point, though, I felt like it was my duty to wrap the conversation up. I’d gotten what I wanted, and some more, and the man actually emails me in his breaks between hospital duties… So I closed with: “On the way home I remembered that today is the first anniversary of our first therapy session together. Until recently, anniversaries and especially New Year’s Eve had been rather depressing occasions, because they made me aware of how unhappy I was with my life. This time it’s completely different, because I can say that a lot of things changed for the better and that I reached some goals. I never thought I’d be discussing university exams with you a year later! In that light, I’d like to thank you especially for helping me to change my life so much.”

A Severely Disturbed Patient

My therapist wrote an article together with a colleague, which was recently published as part of an anthology / publisher’s edition on psychiatric disorders and different treatment approaches. I have reason to believe that I am featuring as a case example in it: of course, everything is anonymized and no personal information is given other than that the patient is female, but there’s nothing in the case example which doesn’t match my diagnosis and specific problems, so unless he has another patient who is very, very similar to me, there’s no doubt about that.
I can’t quote the article or example here because it would reveal my therapist’s name and location, but the “severely disturbed” patient with double depression is described as emotionally distant (meaning the patient expresses no emotions towards the clinician) and detached (i.e. making no emotional connection to the clinician in order to deal with anxiety that’s triggered by other people), as well as exhibiting behaviour predominated by submissive characteristics. Interpersonal avoidance is cited as well as social fear. All of this could still be coincidence, but what makes me as certain as I can be without actually asking him is that the case example features “rules” describing my (pre-treatment) behaviour which we worked out in the beginning of therapy. Detached or submissive behaviour are part of the standard features for chronic depression and could be detected in quite a number of patients, but those rules were personal….

I have nothing against this – quite the opposite. When I signed up for the programme, I knew my data would be used and I knew they were doing clinical research even when I first picked the hospital as a possible treatment facility. I gave blood for a worldwide clinical research project which tests how genetic factors influence the efficacy of antidepressants, so that in the future psychoactive drugs can be tailored to measure the patient’s individual genetic disposition – since citalopram caused a lot of side-effects for me and left much to be desired, chances are that I am someone whose response to such medication is rather poor due to genetic reasons. Actually, before I started therapy and was completely ruled by depressive thinking still, I thought by myself, “You’ll probably never manage to get a university degree and do scientific research, so it would be cool to contribute your part to science as a ‘test subject’ instead.”
However, I’m uncertain whether to flat-out ask my therapist about it or not. It’s not like the article is a secret project; he links to it under his profile on the hospital website and the full text is accessible for reading. The reason I read it in the first place is because he told me about the results of an US-American clinical trial cited in the article and I was simply curious about it and wanted to know more details. So I started reading and after a couple of pages suddenly saw myself confronted with a very familiar case example.
Given the date of publication, he must have written the text early this year; it quotes other works from 2011. So it is very well possible that this is indeed my case, and I would understand why he didn’t mention it to me then, because quite frankly I might have felt even more “defective” than I already did. CBASP works under the premise that chronically depressed patients are stuck or get set back to an earlier developmental stage of thinking because of adverse conditions they endure repeatedly or over very long periods of time, and when I first learned about this in therapy, I felt ashamed for “having an immature brain”. So, had I read phrases like “severely disturbed patient” about myself back then, it would indeed have caused me distress. These days I can look at it and accept it for what it is, though. I wouldn’t have ended up in therapy had it been any different – or at least not in this programme – and my therapist gently gave me feedback on behaviour that made me figure out my deficits over time without being crushed by the realization.
I’d like to have certainty about this. One can only change if aware of what’s wrong with oneself, and over the last year I have often been in situations where I had to realize that my own perception of myself differed quite fundamentally from the feedback I received from others. If anything, the knowledge that this is indeed a professional description of my condition would be an additional source of feedback, because here nothing is sugar-coated. And if I’m a case example in a book on psychiatric disorders, I want to know, out of sheer curiosity alone – which means I’ll have to write him an email.

Update:
After bringing up the courage to ask him, I received a very nice email back, explaining that this was actually written in 2009 already, but published only now. The case example is based on a CBASP patient from “long ago” and it’s pure coincidence, “even though you’ll certainly find yourself in that too.”
So apparently there’s a former patient who had made up the same rule for herself – because there’s no reason I shouldn’t believe my therapist. He wouldn’t lie to me about that.

All of this made me think about how, even though I know my therapist has treated and still treats quite a number of other patients with CBASP, I have never met anyone else – neither personally nor online – who was diagnosed with chronic depression and did a CBASP therapy.

Pre-Treatment Diary

Since it’s been almost exactly a year since my first psychotherapeutic session (the anniversary will be on Tuesday), I added a new section to the blog, a “Pre-Treatment Diary“. Originally a collection of messages written for a group of friends, it gives some insight into the process of seeking help, the side-effects citalopram had on me, how my moods kept crashing time and again as well as various clinical tests, interviews and my first MRi-scan at the hospital… Unfortunately, I lacked the energy to describe those first CBASP sessions in greater detail –  something I rather regret now – but it helps giving a more complete picture of my recovery process prior to the existence of this blog.

Exam Grades & Misguided Sense Of Duty

Friday’s session was a little different – my therapist wrote a letter to my health insurance (which wants to “promote” me from student fare to their standard fare, because I’m “too old” for being a student), stating that I had substantial health reasons rendering me “unable to study at all times prior to September 2011” and that it is very important for my recovery to not put obstacles in the way of finishing my education. I also have a letter from my general practitioner documenting the treatment with antidepressants, so I’m fairly optimistic that this will come to a good outcome.

The rest of the session we just talked: usually, we focus on situational analysis and solutions related to the problems in relation to the SA, but this time we just sat there and had a conversation – I could provide more than ample material for that. I am very much aware of the limitations of a therapeutic relationship and do not think of my therapist as a friend – but there’s no denying that I like him and that I enjoy talking to him beyond the fact that he cures me of an emotionally painful illness this way. He is very easy to converse with, both because he is professionally trained to “say the right thing” and because I stopped worrying about coming across as awkward – he knows I sometimes can’t find a word right away and expressing myself sometimes proves difficult, and we two are aware of the reasons behind that. But apart from the relative effortlessness of our exchanges, I find it interesting to discover his perspectives on life and the world in general.
As I said before, CBASP actually utilizes the therapeutic relationship as a tool for achieving the patient’s recovery, and you get to know your therapist’s background this way. Friday, we spoke mostly about university and the challenges going back poses to me. Knowing that I put a lot of pressure on myself, he warned me to not focus on grades too much and burn myself out again quickly in the process, and told me about his time at university and his grades in the final school exams (called “Abitur” here in Germany):
“Do you want to know my Abitur grade?” he asked.
“If you’d be willing to share it,” I replied.
“You know what you need to do,” he responded.
“Yes, I do – I need to ask you. Would you please tell me what your Abitur grade was?”
That’s how these conversations are used as short training sessions, because one of my “hot spots”, my areas of major problems, is that I retreat into myself and have a very hard time coming out of my shell. By making me ask, which happens very frequently, my therapist also makes me practice becoming more visible and active, and because I experience that nothing bad happens when I express interest in another person, I become more courageous outside of the sessions too. The third effect this exchange has is that by revealing his grade – which is good, but by no means as inhumanly good as I most likely would have assumed – he illustrates the fact that indeed good grades are not everything, and leaves no room for assumptions about my own perceived inferiority.

It’s already become apparent in the emails that I had temporarily slipped back into behaviour and thoughts which are typical for chronic depression – globalized thinking like “I will never succeed” or “I am not good enough for this”. It had not played much of a role anymore during the summer when I wasn’t facing as many challenges as I do now, so this is something where I definitely need to pay more attention. My BDI-II score had already risen to 12 points and doubtless would have gone up even more had I not pulled the emergency brake chain and stayed at home Thursday and Friday.
My next appointment is in three weeks, but afterwards I’ll be on a tighter schedule again for a while, to give me more support. And in between, I am to report via email about how I am doing every week.

My therapist strongly advised me to stay at home and recover properly from the sinus infection instead of going on the excursion which was planned for Saturday: “You belong in bed with a hot water bottle, not in a cave or quarry. If you’d broken your leg, you wouldn’t think twice about going…” I was hesitant, even though of course he had a very good point, but eventually cancelled my attendance. It’s going to create some complications and I’ll have to ask if there’s something I can do as an alternative, but in the end health goes first. The worst case scenario would be that I have to repeat the excursion next year.
What tipped the scale in favour of cancellation was that if I had gone, it would not only have meant an entire day outside when being sick, but it would most likely have affected my performance in the written protocol afterwards too. I’d have laboured – for months, possibly – on the fact that the result would not have reflected my true potential: it’s an open invitation for depressive thoughts.

Health Insurance, Waiting Lists, And The Media

My sister finally has a therapy placement – starting December 2012. That’s quite a long waiting time for someone who needs helps – ideally as soon as possible – but hardly unusual here in Germany, because of our health care system.

Health insurance is mandatory here for every employee and a couple of other groups, for example university students. We have a system of two different health insurances: one is called “legal health insurance”, where you pay a monthly fee on a sliding scale according to your income and receive the “standard treatments”. Additionally, we also have a so-called “private health insurance”, where you pay a fee based on your personal risk (age, sex, occupation, pre-existing illnesses, etc.). I’ll call them LHI and PHI in this text respectively.
The majority of Germans have a LHI, as it usually is a little cheaper and also covers spouses and children who don’t have an income of their own. In LHI, all the covered treatments are specified by law, whereas in PHI, you make individual contracts with the insurances, so that their coverage and fees can differ vastly. Also, for LHI patients, the doctors will get their money directly from the insurance company, whereas PHI patients often pay out of their own pocket first and later get that money back from the insurance.
The LHI pay a doctor € 40.- for each of their patients they see – for each quarter year, no matter how often these patients use their services during this time. Individual treatments are reimbursed separately, of course, but for a PHI patient, the doctor gets money every single time they see him or her, just for saying hello. Also treatments for PHI patients usually bring the doctor more money (because they pay more for their insurance, they also get more fancy treatment options), which leads to some health care practitioners opting to see exclusively “private patients”. Doctors are giving the PHI patients preferential treatment since they want to keep their “money cows”, which results for example in them having much shorter waiting lists etc. for specialists, if any at all, while the LHI patients will have to stand in line.

This is, in a nutshell and somewhat simplified, the current situation in the German health care system. Psychotherapy is very time-consuming and expensive, so that in this sector you have a large percentage of therapists who’ll see PHI patients only, and the waiting lists for the remaining ones get even longer as they are hopelessly out of capacities. Waiting a year and longer for psychotherapy is pretty much the standard – unless you’re an affluent private patient willing and able to shell out money.
My relatively quick start with therapy (six weeks from the first phone call to the first session) and the programme I attend are only possible because my data goes into a study which looks into establishing CBASP as a standard method for treating chronic depression for the LHI and the costs for it are covered by third parties, so I was very lucky to qualify for one of their vacant spots. Had I not taken the route via this programme, my earliest possible session would have been in April, and I would only have been granted the standard therapy. I hit jackpot in this regard. Unfortunately, my sister has no such luck.

It goes without saying that in my opinion such long waiting times are scandalous, and recently it has come into the focus of the media too. Ralf Rangnick, a high-profile football coach, suddenly resigned from his job mid-season because of Burnout Syndrome (even though he never used the word in his official statement), so that now it’s a frequently discussed topic and concerns are being voiced that it takes entirely too long until mental health patients are receiving adequate treatment.
Whether the attention will bring lasting change remains to be seen. When Robert Enke, goal keeper of the German national football team, successfully committed suicide after years of severe depression in 2009, it very much highlighted the topic for a while, but eventually the media moved on, and so did the public interest. It’s become but a tragic footnote in the history of German sports.

On My Therapist

After writing about why therapy is so important to me, I wanted to focus on my therapist as a person today, because at the time I was trying to figure out treatment options, I wondered a lot about what a relationship with a therapist actually is like. There’s plenty of information online and in print which explains the characteristics of different schools of thought or styles, but very little that gives insight in what it is like to attend sessions. As a result, I decided to write about a person who appears in the background of most of my posts, but has never been the subject of much discussion.

The role of the therapist in CBASP is different from other approaches in so far as you get to know the therapist as a person. This doesn’t mean that we chat away for an hour during our sessions, but he offers me insight into his personal experiences when we are discussing my problems, for example.
The key word is “controlled personal involvement”, because obviously the therapist needs to take care that everything remains professional, but building the relationship is actually part of the therapeutic process. It’s based on the assumption that chronic depression is the result of an “absence of felt interpersonal safety” – in simpler words, one is afraid of getting hurt, shamed, punished or abandoned by other people. Through the relationship with your therapist, you interact with another person without falling into old patterns of fear or avoidance, and eventually start to transfer this into everyday life and other relationships.
I know where the taboo of the personal involvement stems from historically, and also understand why it is so important for psychoanalysis. However, I am very glad and relieved that in CBASP, the therapist does not remain such a stranger as this would only reinforce the pathological thought patterns. When trapped in a cycle of negative self-beliefs, for example, the patient/client would only create more negative thoughts about him- or herself because there is nothing to interfere with them. In contrast, during a CBASP session you receive a lot of feedback about yourself and how you behave, and the therapist will repeatedly ask if you noticed his/her own behaviour when you interact. Through this, you are forced to acknowledge the reaction you actually evoke in the therapist, as opposed to the negative expectations you usually might have harboured. And it also works the other way around, when you are asked how certain behaviours by the therapist made you feel.
Additionally, the disclosure of personal information and experiences “balances out the scale” a little more: I experience my therapist as human and fallible – a person who faces challenges and problems as well, but manages to overcome them. If he was this “black box” where you only see what goes in and comes out, but not what goes on inside, I would have cast myself in the role of the “flawed one” while attributing to him the role of a superior being, thus putting myself down. Since I do hear about his struggles too, though, there’s no chance of this happening and ultimately, it allows me to be more open about my perceived shortcomings as I know he is not perfect either.

The first time I met my therapist, he struck me as very cordial. More than just friendly; he radiated kindness. In fact, this caught me somewhat off guard… he was treating me like I was a special guest, but not over the top at all.
Much later, we had a discussion about mindfulness and he mentioned Thích Nhất Hạnh’s “The Miracle of Mindfulness”, citing a story by Tolstoy which is printed in the book. In this story, an emperor searches for the answers to three questions which, if he found them, would grant him the wisdom to never stray in any matter. The three questions were: “What is the best time to do each thing?” – “Who are the most important people to work with?” – “What is the most important thing to do at all times?”
In the end and after adventurous plot twists, the answers are revealed to the emperor by a hermit: the most important time is now, because the present is the only time over which we have control. The most important person always is the one you are with at the moment, because you never know if you’ll ever deal with any other person. The most important thing to do is making the person next to you happy, because “that alone is the pursuit of life.”
When I read this story, I suddenly could put my finger on what makes my therapist’s behaviour stand out: he treats me according to the principles from Tolstoy’s story. In our sessions, he’s always fully concentrated and there; I can’t remember a single moment when he wasn’t. And during the hour we have together, he makes me feel like I’m the most important project he has going on – by listening carefully, by taking what I have to say seriously and not dismissing anything casually, by not straying from the topic, by respecting my feelings. He gives me positive feedback and praise when I did something right; not inflationary, but always in relation to a result. He doesn’t create spaces where negative thoughts could creep in, and he appears genuinely happy for my successes. When we bide each other goodbye, he will often say sentences like, “I’m already looking forward to our next session / to your next situational analysis.” In short, he makes me feel appreciated and like he values our time and work together.

Therapy scenarios are designed to create intimacy: two people meet in a secluded room and talk about highly personal things, some of which could be considered secrets. You make yourself vulnerable, sometimes without having planned to. If you are sitting in this room with the wrong person, I don’t think much good can come out of it – trust is a fundamental requirement and if there is anything about your therapist which undermines its development, you will not work with, but against the therapist through avoiding or openly resisting him or her. Or stop seeing the therapist.
During the first sessions, I would discuss facts without holding back because I wanted to do whatever necessary for recovery. By that time, I thought I was already laying myself out in front of my therapist, but later I realized that disclosing facts is different from disclosing emotions, and the latter was something I had to learn first and still am learning. Head knowledge gets you only so far, but to let someone see and feel your emotions I only managed through experiencing my therapist session after session as a person who would not take this and use it against me.

Situational Analysis: University Appointment

I have been talking about situational analysis before, but never actually posted one, so that’s what I’m going to do today. I had a meeting this morning about the university credits, and the situational analysis will relate everything about how that went.

My therapist had offered me to take a look at the SAs whenever I wanted to send one per email in between sessions, and today was the first time I actually did that. Two minutes after stepping out of the building, I started thinking it through, and by the time I arrived home, it was finished and I only had to write it down.

Assessment phase:

1. What happened?
The docent in charge of rating the credits and me were sitting in his office, facing each other over his desk. He asked me to name all the classes I had taken. Among them I mention a class on Quaternary geology which I had finished with an oral exam and the grade A -.

Docent (surprised): “Whose class was that?”
Me: “Professor L.’s.”
Docent: “That must have been a long time ago that Professor L. gave this class. I don’t know if I can grant you this credit, that’s not… Did you take the ‘gravel class’? No? Well, nope, that merely adds up to prior knowledge.”
Me: “Oh…”

2. Interpretation (how did I feel, what did I think, what does the situation mean to me):
– I felt nervous (sweaty hands, rapid heart beat).
– I felt worthless and degraded, as if my knowledge and credits were not worth anything.
– I was angry because he wouldn’t look at the credits which I had brought and questioned me instead about them.

3. Facial Expression and body language:
– I sat on my chair, hands folded in my lap, looking the docent in the face with an expression of surprise, staring for a few seconds without saying anything.

4. Actual Outcome:
I didn’t say anything, so the docent continued to question me.

5. Desired Outcome:
I would have liked to state – with a self-confident voice – that this class was a regular credit like all the others too, and that it had counted as relevant content for the diploma students who had taken the class together with me as well, even if Prof. L. usually teaches a different class.

6. Did you get what you wanted?
No.

7. Why?
Because I got taken by surprise and didn’t dare protesting afterwards as I felt too intimidated.

Solution phase:

8. Are the interpretations accurate and relevant?
All interpretations are accurate, as they are all about me. I did not engage in mind-reading, nor did I globalise / generalise or engage in emotional thinking.
All interpretations are relevant, since I really did think them in the situation, and they are about the situation.

9. Did my interpretations help or hinder me in getting what I wanted?
The feelings of nervousness and worthlessness hindered me; they caused me to not speak my mind.
The anger helped me getting in the right direction, since anger pushes you towards taking action. It was not enough, though.

10. What would help me getting what I want next time a similar situation occurs?
Next time I get taken by surprise, I need to have an automated response and think “stand up [for yourself]”, so I can take action before the other person moves on, and also so I do not get trapped in a cycle of negative self-belief.

11. In which similar situations can I practice this?
The final evaluation of my credits will happen only after I officially enrolled, so there will be a second chance. Before that, I can practice on a small scale every time someone behaves differently towards me than I anticipated, for example with family and friends.

12. What did I learn from this situation?
I learned that, as in other situations before, I need to stand up and speak out for myself, or it will make me feel frustrated and feed negative self-beliefs.

This might appear a rather tedious exercise at first glance, but has proven very helpful as I came to master it. The situational analysis breaks up every situation into tiny pieces, which you can assess individually then. This makes you find out where your personal problems lie: some people may have difficulties with their behaviour and come off as very hostile, for example, so they need to work on building a calmer appearance in order to not constantly set off the people they interact with. Others frequently want to get something out of a situation that cannot be realistically achieved, so they need to find out what they can expect and what not. Some, like me, are too timid or shy and have to develop strategies to counteract the urge to withdraw.
The situational analysis is not only useful for finding out where you went wrong after the situation happened, but it eventually hightens your awareness of behavioural patterns as well, so that you observe certain characteristics while they are playing out, which helps you modifying your reactions on the spot. Learning and internalizing the procedure takes a while, but you gradually get better.

Back on the topic of my appointment: obviously, I came out of it with mixed feelings. Despite of the docent being perfectly mannered, he gave off a rather serious air, entirely devoid of emotion. It intimidated me – which, given my own feelings of inadequacy, did not help with building confidence.
I got the assessment I need for enrollment, however, and my credits will get the definitive rating only once I’m enrolled, so I have another month to practice showing my claws and fangs if necessary.

The docent didn’t ask about the reasons for my long break, by the way.

The One Where I Almost Cried In Therapy

In therapy, I talked about the upcoming changes in university, explained the original plan of taking my time for coming to a decision about my professional future (which the therapist said was a good strategy) and how I’d chosen continuing university when forced to decide immediately. As a result of the week’s events, the BDI-II score was up to 17 points today.

Half of the session was, as part of our usual routine, spent on a situational analysis of the phone conversation with my mother on Monday morning. This one had been special because even though what I’d felt and thought had set me up for failure (panic, doubt, flight instinct kicking in), I’d managed to get the best out of the situation that was possible considering the circumstances: ending the phone call without making the situation even worse through offending my mother, and thus giving myself time for thinking.
My therapist asked me why that was so, and I couldn’t come up with any other explanation than my reaction being an automatism, developed through seven months of therapy.

I explained my sentiments about prehistoric archaeology and how I felt that changing not only to a different degree, but also to a different subject was necessary if I wanted to go back to taking classes. I had not been entirely certain what he’d think about the latter, but he supported the notion completely and shared some personal experience afterwards concerning his own career choice and how he’d made a new start by becoming a psychiatrist / therapist after he’d started out in a different medical profession which, despite his huge interest in the subject matter, had not made him happy simply because of the way everyday work was shaped. And he said I might actually become able to enjoy archaeology again as a hobby or passion in the future if I liberated myself from all the dreadful negativity and bad memories connected to it.

At one point, I got very close to crying while speaking about this: my voice died mid-sentence and I sat there with a frown and moist eyes, looking out of the window, but my therapist just calmly repeated what I’d last said and I caught myself again. He clearly noticed what a highly emotional topic this is for me and from our discussion I can tell that he understood its significance.
Strangely, I was ok with getting this emotional in front of him – actual crying might have embarrassed me, but I felt no negative response inside myself for displaying so much sadness. Becoming obviously moved is something I rarely do, and never if I can prevent it, because it is very difficult to make myself vulnerable like this without immediately wanting to put the defensive walls up again. The fear of being shamed or hurt is just stronger. Him not fussing about it certainly helped – he acknowledged it afterwards, but didn’t make me talk about it.