Exhibit B: A (Not So) Hopeless Case

Exactly a week ago I appeared in front of a group of 19 psychology students as an example for chronic depression, but was (still am) so swamped with homework that I didn’t have the opportunity to write it down yet.

I went to the hospital straight from university, so I was a good half hour too early and had plenty of opportunity to get nervous. It was a part of the hospital building I did not know too well either, so I did not dare going to the restroom out of the irrational fear I would miss my therapist. Fortunately, we had about ten minutes to spare when he came to pick me up…
We spoke a few minutes outside – about how I was doing in general, and about being nervous and how curiosity got the better of me. We also discussed which personal information my therapist was allowed to disclose (he was very discreet, though, and spoke only of my “significant others” instead of naming a person, and he did not talk about anything personal). I gave him free range on whether he wanted to wear his white coat or not and on whether we’d sit at a table or not, so my therapist decided to recreate the therapy setting – no white coat and no table.

As mentioned, the group was rather small, creating a somewhat intimate setting – as far as that is possible given the circumstances. My therapist acted as a moderator, introducing me and my diagnosis, and I smiled a hello into the round. They had already learned about the characteristics of depression before and seen an in-patient earlier that day, who had also volunteered to talk about her depression. The in-patient, however, had been an example for biological reasons behind depression: a disturbed transmitter chemistry and psychiatric treatment with cipralex. I had come in as a representation of environmental and character-related factors, with the biological components playing only minor roles.
I started off recounting how I got misdiagnosed by my former general physicians, how I suffered from panic attacks in summer 2010, got on citalopram but could not shake the depression, and finally got in contact with the hospital. My therapist elaborated on the importance of behaviour in medical caregivers – had my first contact not been such a positive one, I might never have followed through with everything that followed.
There was a sheet with the results of all the clinical tests I did during the first 48 weeks of therapy – BDI-II, IDS-SR, MADRS and possibly some more I forgot, plus the results of the “therapy cards”. My therapist was not supposed to know the results until recently, because they evaluated the level of trust between him and me, but from the beginning of their evaluation (from therapy week 4 on), they had shown I trusted him. All the other tests showed the same pattern: a very high score in the beginning, then a steep decline over the course of a few weeks only, and a long phase of slowly fading out. Towards the end, my scores went up a little again, when I decided to go back to university.
We spoke about how important it is to trust the therapist and I listed some of the irrational fears the therapy setting could have evoked – fear of being ridiculed, getting yelled at, not being taken seriously, or cancellation of therapy as a punishment for increasing depression symptoms, for example.

I did surprisingly well during the presentation. My biggest fear had been to just freeze or being unable to get proper words and sentences out of my mouth, but I spoke with a loud and clear voice, looking at all the faces around me and also taking in their reactions. Everyone looked friendly, some even smiled encouragingly, and I found it easier to open up than expected. Of course, we did not discuss anything private, but considering that in university I have not told anyone anything that is even remotely close to the truth, it was a pretty huge step for me. Part of what kept me calm was that I knew no matter the outcome, the people would learn something from my appearance. If I could talk about it all, they’d learn from my report, and if I froze up completely, they’d get a demonstration of what depression can cause.

Today, I had a regular therapy appointment, and my therapist said he could tell the very moment I relaxed during the presentation just from observing my body language. He gave me quite a lot of praise and also thanked me for doing this: “Half a year ago, I wouldn’t have asked you. Not that you couldn’t have done it back then, but the risk would have been too high.”
There are several reasons why he asked me: for one, I’ve been long enough in therapy to know the process very well, to have recovered enough for being able to reflect, and something he has been stressing a lot over the last weeks is the fact that I went back to university. Last month, he told me about a colleague’s patient who had a similar diagnosis as I do, and she actually quit her job – whereas I went back to a place that terrifies me quite often. On about four days per week, it gets so far that I think I can’t take it anymore. I fantasize about quitting. But, there’s no realistic alternative, and so I struggle from week to week. My therapist knows this – he gets to hear plenty about that, of course. University was one of the catalysts which propelled me further into depression, so he thinks that it is of utmost importance now that I confront those situations and master them. He never influenced my decision on whether I should go back or not, but clearly approved of it afterwards.

One reason why he asked me might have been that the outlook for me without CBASP would have been pretty bad: “Early-onset chronic depression with life-long co-morbidity of panic disorder.” He called it a “horrible, horrible diagnosis” which without this special therapy programme would be pretty much treatment-resistent. CBASP actually works on both a personal and an environmental level, whereas other schools of psychotherapy concentrate on one aspect onely: classic Freudian psychoanalysis operates on the personal level only, classic cognitive psychotherapy on the environmental level. Neither of them would have been sufficient for me.
They didn’t even put me through pre-treatment self-evaluation as they usually do, because they thought it would trigger my flight instinct and drive me away. Yet, despite the very bad odds, here I was – more or less functioning now, and definitely able to talk to a bunch of strangers without running away.

At the very end of the presentation, everyone clapped and I blushed and looked down to the floor, until my therapist told me: “Look up and take it in. This situation will be over soon, so this is your only chance at grasping of how well it went. You need to take this memory home with you.”

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Finances, Fear, Family, Frustration

I’ve been in financial trouble lately, culminating in a letter threatening to turn off my gas and electricity if I didn’t pay within the next few days. It came as a really unpleasant surprise, because I was under the impression that I had already paid all I owed last month, but apparently had been mistaken. My boyfriend was able to cover for that and so we’ll continue having warm water and heating, but it still weighs down on me. My mother barks at me that I have to quit university and get a job, my therapist tells me it’s of utmost importance that I finish university, as does my boyfriend… I’m tired of being stuck in the hamster wheel, tired of the perpetual financial strains.

And I feel guilty because I do not have the stamina for handling both a job and uni. I can’t even hold up university alone…

Last week I saw my therapist for a few minutes because he had to give me a doctor’s note so I’d get out of the second attempt of the chemistry exam. He puts a lot of emphasis on the fact that I learn to put up boundaries towards other people and learn to defend myself so I can actually do what I need to make myself feel good. Which is a lot easier said than done, especially since my brain just “empties” under stress and I become completely speechless, in the very sense of the word. It is a reaction to the cortisol surge one experiences under stress: long-term exposure to this stress hormone damages the brain cells in the hippocampus, which results in memory problems, and it also impairs retrieval of already stored information.
This morning, I was crying after receiving the letter from the energy supplier, and despite my boyfriend asking me to talk to him and say something, I just was not able to. I could not form a coherent sentence, neither in English nor in German. Even now, it is difficult to describe what is going on in me in these situations – one should assume that once the problem is taken care of, everything is alright. And my boyfriend echoed what my therapist tells me as well, that I have to stay in the present and not make this about everything that went wrong in my life, but I am not always able to do that immediately. The fear and despair can be faster than any rational thought.

Money is not the only source of stress – there also are the uni exams, of course, family situations, and the fact that the bureaucratic process for our marriage is very frustrating. I had to hand in a statement from my parents that they supported me financially, which got “lost” – even though I handed it in, it never arrived at its destination. Then I brought a second copy of the statement, only to be told that I had to re-write it. It is almost ridiculous that my boyfriend’s American documents are all fine, but my German documents create all kinds of problems…

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…

You Better Watch Out, You Better Not Cry…

Christmas usually is an especially difficult time of the year when it comes to family relationships. The stress prior to the actual holidays brings out the extremes in our behaviour. My mother regularly explodes on December 23rd because she has problems delegating tasks, but gets overwhelmed by the load and vents her frustration and stress violently…

Thursday, December 22nd

Twelve minutes into Christmas break on the way home from university, I slipped on the escalator leading down to the tram station and twisted my right leg, while simultaneously tearing my left arm (which was still grasping the handrail). I could still walk, but only with a heavy limp, and had to have my sister pick me up from the tram station in my home town so she could carry my bag.
Over the course of the evening, I got rather upset because while my mother was rather worried, it was over the fact whether I would be able to drive her and my grandmother to the supermarket the next morning, and she didn’t express any concern regarding the pain I might feel. Functionality trumps pain – her problem with my depression was that I didn’t function anymore, too. Now that I appear functional again, my feelings become secondary once more.

Friday, December 23rd

At 9.30 in the morning, I found myself at an overcrowded supermarket. Finding empty space in the parking lot had already been a challenge, especially since my grandmother uses a rollator walking aid and wants to park as close to the entrance door as possible. The situation inside was worse rather than better.
With the need to pull myself together for uni temporarily suspended, my mood had started tumbling down quickly, and the longer we were inside the grocery store, the worse I felt. My swollen foot pulsated with pain and the constant bickering between my mother and grandmother – who were both affected by the general atmosphere as well – grated on my nerves.
After about half an hour, it took a really insignificant event only to push me over the edge: I was waiting for my grandmother to finish her business in the butcher’s section and just biding my time, when suddenly I felt the gaze of a middle-aged man on me. As he noticed that I caught him looking at me, he winked at me. No idea why it upset me, but it did. I wanted to yell at him to stop looking or winking at me.
I hid in the only empty aisle I could find and actually started crying. Because of the limping, I was always behind my mother and grandmother anyway, so nobody missed me, but in order to not rouse suspicion, I couldn’t stay there for long. Managing to pull myself together until it was time to queue at the check out, where people were standing in long lines already, I excused myself and went to wait in the car: officially to rest my foot, but really for calming down. I switched the radio on and concentrated on the music, so that by the time my mother and grandmother had finished their shopping, I had regained my composure.
In the late afternoon, I got once again into my mother’s crossfire when she repeated her threat that I had to move out if I didn’t get a student loan, which caused me lots of anxiety again.

Saturday, December 24th

Christmas Eve is the main event of the festivities in Germany, with big family dinners and the exchange of presents in the evening, and it started even worse than the previous day for me. I was already crying in the shower, with no clue how I was supposed to get through the day, and poured it all into an email to my boyfriend, which I felt guilty for later – waking up to your girlfriend’s hysterics doesn’t make for the most relaxed Christmas either. (He was utterly lovely about it, though.) Somehow I managed to dry my tears and leave, though, so I could help my mother with the preparations for dinner, but what happened then took me by surprise:
The conversation turned to my 10-years-old niece, who had exhibited rather ill-spirited moods that morning too. I remarked that I’d occasionally wondered if she didn’t suffer from the same condition as I do, but had never said anything because that was a hunch rather than something I could back up with solid facts. And that’s the truth – there are certain gazes or the way she holds her head or looks at people that feel utterly familiar to me, like the seed of all that avoidant behaviour, but I cannot present any evidence.
My mother nodded, then asked: “Where does this come from? Is it me?” (My mother looks after my niece when she isn’t in school.) I was completely flabbergasted and utterly at a loss. There are basically three reasons which cause chronic depression: 1.) genetic predisposition – which I certainly have from both sides of the family; 2.) neglect in infancy and childhood – which I can exclude for myself; 3.) repeated experiences of helplessness over long periods of time, concerning “significant others” like parents or other very close family members – which is very much the case with me. I had never told her what caused my chronic depression, because that’s simply too damn difficult a task – I don’t want to hurt my parents, because I know they had to endure a lot worse from their parents and never had a chance to not become slightly messed up either, but I could name dozens of situations that led to me becoming depressed and developing patterns of avoidance. My mother probably noticed that I was looking for the right words a little too long, and when I finally answered, it was just the three points mentioned above without connecting them to any personal experiences.
This was the worst time possible for this conversational topic to come up; on a different day, I might actually have welcomed the chance for broadening this point with her, but NOT ON CHRISTMAS EVE…
Myself, I started feeling better in the afternoon and got through the evening ok. We had all agreed to not buy any presents for each other because money is tight, so the big emotional climax was missing, but at least nobody fussed about it and I wasn’t reminded to get a job either…

Sunday, December 25th

I slept like a stone, until noon almost. The day was quiet, but pleasant. In the afternoon we went to see my grandmother and aunt, and in the evening I met one of my school friends who is home for Christmas. I didn’t feel like crying.

Monday, December 26th

Boxing Day is a national holiday too in Germany and at least in my family entirely dedicated to laziness. This year was in so far unusual as the family had a bowling tournament with Wii Sports – my mother isn’t much of a computer user and doesn’t even have an email address, while the rare behaviour for my father was to actually come out of his office for a family activity. So it was rather strange to see them playing a console game, but I really enjoyed the whole enterprise!

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So that was my Christmas, in a nutshell. In a little while I’m leaving for meeting another friend; I’m trying to fill the days with pleasant and diverse activities, so that my depression index goes down again and I will be fit for the last month of uni and exams once Christmas break is over, because if I learned one ting in therapy, it is that you must “fake it until you make it”.

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.

A Square Peg In A Land Of Round Holes

Thursday evening I came home to emails from my palaeontology professor and the geology department, offering me an alternative place in a different excursion two days later. I eagerly accepted, counting myself lucky that for once, a problem had taken care of itself before I’d even had a chance to do anything about it.
The excursion was surprisingly pleasant – relatively mild emperatures and a bit of sun in the afternoon, and it reminded me of how much I’d loved doing “field work” once upon a time. The decision to cancel a week ago had been right, though, because it was a physically demanding day and I wouldn’t have made it through the programme in the state I was in.

A few of my fellow students started saying hello to me in classes and striking up short conversations. I’m actually grateful, because most appear to be decent people and it would be nice just to be able to connect a little. I’m not expecting to make lifelong friends there, but having people you could ask about the maths homework or physics deadline and stuff like this would make my uni life easier. And I guess it would also be pleasant to just have someone to talk to once in a while.
I still don’t manage making the first step and starting a conversation myself, but when people say hello, I try being as open as I possibly can and to not appear arrogant or uninterested. For example, in one of my geology classes we were supposed to work in small groups, but since I keep to myself mostly, I had no “partner”. While I was still trying to figure out how to solve that problem, my neighbour said, “Why don’t you come closer? I’m not going to bite you.” I didn’t answer, but sat down next to him with a facial expression somewhere between apologetic smile and awkward grimace. The rest of the class went ok, I actually managed…. well, not an animated conversation, but I would talk a little to the people around me.
The most awkward experience so far was in a physics lecture, which we future geoscientists attend together with students pursuing degrees in medicine, pharmacy, geodesy, molecular biomedicine or biology. I was sitting next to this teenaged boy just fresh out of school and had gotten lost in thought when suddenly he spoke to me, “What do you study?” Startled, I had to ask him to repeat his question, then said, “Geosciences… [trying really hard here to untilize some of the stuff I learned in therapy and not come across as completely aloof] …and you? What do you study?” – “Geodesy.” – “Oh…” I nodded, tried a smile, but my conversational skills had already been exhausted and foolish replies like, “Nice!” or, “That’s cool!” got stuck in my throat before I could utter them. His one-word-answer didn’t really help either. After staring in his general direction for another two seconds, I realized he wasn’t going to continue the smalltalk and that his conversational skills most likely were not any better than mine, so I slowly turned back to my college pad.
And then there are the times when on the outside, everything goes well, but on the inside I suddenly start deconstructing the situation. Like this other physics lecture where a girl I’d never seen before offered me a chewing gum. I smiled, “No, thank you!” For about a minute I was completely fine and even thought by myself, “Well, that was kind of her.” And suddenly, the doubts kicked in: “Maybe she offered you a chewing gum because you have really bad breath?” (My boyfriend confirmed I do not have bad breath, so the girl must have wanted to be friendly.)

The headline paraphrases a quote from one of my favourite books and films, Oscar and Lucinda, and is a very apt description of how I feel on most days. There actually is a story connected to it which I might tell another day.

Looking Back

The first week is finally over. Those were difficult days, but compared to my last attempts (yes, the plural is correct) at studying over the past few years, I have been doing better. I have not skipped classes because I was afraid, I have gone to lectures where attendance was not mandatory, and I have managed this week on my own, without talking to my therapist about it. I’m going to see him next week for a regular session (the intervals between them are three weeks now), but I don’t want to become someone who depends on the therapist for every decision – my therapy goal is to become more independent… I’d lie if I claimed I didn’t think about what I’d tell him, but I’m glad things didn’t become so bad that I had to contact him.

Something I learned from this week is how relative success really is. For the majority of my fellow freshmen, this simply is another step in their education. They go to university, sit their exams and eventually graduate, and to them it means a lot of hard work and adapting to a new way of life and new working methods. To most of them, the biggest challenge will be an intellectual one: a certain class or project they’re going to find difficult. Other than that, they don’t struggle with being a student.
If (when) I graduate, however, the real triumph will not be in reaching a certain level of education, it will be the fact that I actually beat my anxiety and stayed in university long enough to reach graduation day.

Prior to Monday, I hadn’t attended a class in a year and a half… Exactly two years ago, in October 2009, I started my last attempt at finishing my old degree in prehistoric archaeology and got assigned a rather demanding project – holding a lecture called “A Diachronic Comparison Of Small Houses On Mineral Soil”, presenting settlement patterns and building structures throughout prehistoric times with a special focus on how those patterns might reflect socio-economic structures. It was a demanding project, both intellectually and in terms of energy invested, cost me most of the Christmas holidays and saw me working 16 hours a day on it towards the end.
I hadn’t been depression free since the age of 12, but around Christmas 2009 one of the better phases – which had allowed me going back to university in the first place – came to an end and I started slipping into depression rapidly. I still managed my presentation at the end of January (which I got the best grade for), but when I was told I had to hand in a written version of it before receiving my credits, it was too much. Every day I told myself I’d start typing it, but there was so little energy in me left and the depression got worse so quickly – I just could not do it. February 2010 was the last time I attended a class. I was depleted, burned out, empty.
It had been the last audible cough of a dying beast, but the deadly wound had been inflicted years before. In spring 2002, my aunt died from leukaemia after a short ailment and an even shorter but nonetheless dramatic decline, leaving behind two children aged 10 and 16. It was a rather sad time for the whole family, naturally, and this sadness somehow morphed into depression as the months went by, because I was also hypothyroid back then. I had no energy for studying and my job caused me social anxiety, all augmented by my malfunctioning thyroid. Even as the thyroid medication was well-adjusted, I never managed going back to university for more than a couple of weeks and a few hours per week at a time despite the best intentions.
Despite some anxiety and some tears this week, it has already been a success, because I haven’t attended so many classes in almost ten years.

I Will Not Cease From Mental Fight

The dreaded 10th of October is almost here and in about ten hours I’ll find myself sitting in a room full of freshmen at university. As I told both my boyfriend and my oldest friend, I feel like I’m about to start a three years long prison sentence tomorrow rather than the education of my choice, fighting anxiety all weekend long. It is time to gather courage and put myself to the test, I guess…

I re-read a few inspirational lines from Schiller’s The Robbers, which – without the beauty of the original language – translate as follows: “Should I die from fear of a painful life? Should I grant misery the victory over me? No, I will endure it! May the agony wane in the face of my pride! I will accomplish it!”
Rather too long for acting as one of those thought-commands we are creating in therapy when I need to come up with a catchphrase that will disrupt the depressive thought pattern and remind me to behave as I want to, but it keeps my mind on the goal. I can’t run away from everything I’m afraid of for the rest of my life.

If I examine my fear and ask myself what it is that I’m so afraid of, I find that tomorrow doesn’t hold much that would warrant more than just the littlest bit of nervousness. There will be introductions only and nothing that I haven’t done before. Nothing I can’t do. So it’s rather that this day stands as a symbol for the inevitable, for that fact that if I sit in this room tomorrow, it means I have definitely dedicated myself to this.

The two people mentioned above – my boyfriend and my friend – both sent me very kind emails full of encouragement, which I really appreciate. They’ve both been so certain that I’m going to manage, and manage well, that I am just going to accept their words for it and try my best.

The End Of The Chain

Originally I had planned writing about my therapy session this weekend, but my sister had a borderline-related meltdown again last night. She called at 1.30 AM from some place about two hours away she’d gone to with some friends, crying. I gave her the phone number of “my” hospital’s psychiatric ambulance, because quite frankly I was at a total loss: I still don’t know what exactly happened that made her cry, and I have only limited insight into the ways a borderline personality brain works and she doesn’t tell me everything either.
If she had not been that far away, I would have gone to pick her up, but was entirely too tired for spending four hours on the autobahn, and if fatigue isn’t dangerous enough already, the emotional distraction does the rest. So I didn’t offer to bring her home and only hoped she would actually call the psychiatric ambulance. I’ve consulted them twice myself – once in December, when I was weaning myself off citalopram and had a question on medication, once in May when I was freaking out over the first experience of euthymia – and they were really helpful both times. What’s more, you speak with professionally trained experts there who know how to handle this and who know what’s going on, while I can offer sympathies at best and otherwise clutch at straws.

Ever since her last episode in July, I have been repeating at least once per week that my sister should get professional help while she is doing relatively ok, not wait for the next emergency to happen. Obviously, she did not, so that now we have exactly the situation I warned her about. Additionally, I go back to university in a week and that means I do not have the time anymore to help or accompany her the way I could have done it during the summer months.

The consensus on Borderline Personality Disorder / Emotionally Unstable Personality Disorder is that for the majority of concerned people it is caused by sexual abuse, with a small minority of cases reporting no abuse, but disturbed communication in the family. For chronic depression, there too is a high prevalence of emotional / physical or sexual abuse. Before starting therapy, I had to fill out a couple of surveys and did interviews asking me about my childhood: my sister and me did not grow up in the classic neglectant family. We were clothed and fed properly, taken to the doctor and generally cared for materially and emotionally. I can with certainty claim that neither my sister nor me were abused.
However, since July I’ve been thinking a lot about how we grew up, and been quietly observing the behaviour of all people involved and comparing it to memory, with the result that I believe that in our family, there are some serious flaws in the way we communicate and share – or don’t share, rather – emotions.

My father is basically unable to talk about his emotions at all when sober. It’s not that he’s cold or distanced, but very impersonal, and since he doesn’t seem able to handle his own emotions, we children couldn’t learn anything about this from him.
My mother is rather different, but only when it comes to venting negative emotions. She’ll leave no doubt about how it makes her feel when you disappoint or annoy her, but she too has problems voicing positive emotions.
I don’t blame my parents, because they both are only the products of their own upbringing through my grandparents, and those again were damaged by their parents and WWII… My sister and I merely are the ends of a long chain.

We also don’t touch each other in my family. We got hugged and cuddled with when we were children, but around the age of 10, this kind of affectionate behaviour started to fade out and by early adolescence, it was completely gone. I have been wondering if this wasn’t one of the triggers that caused my first depressive episode at the age of 12. I haven’t hugged either of my parents in 20 years and the rare moments of physical contact are exclusively left to casual brushes of dirt off a shirt, or similarly meaningless gestures. The one exception are birthdays, when we shake hands, but on all other occasions we remain physically distant.
Over the years, this kind of distance crept into all my relationships safe for that with my niece – but she’s only 10 years old now, so she’s still in the “zone” anyway (she’s more outgoing than I was and comes to get her hugs if she doesn’t get them, though). It’s not easy to admit, but there were times when she was the only person in my life I would get in physical contact with, and when my boyfriend came to Germany, I had to literally learn touching him. During the first few days, I would even direct myself when talking, “Touch his arm. He needs to feel that you like him physically, too.”

Of course, we don’t say the German equivalent of “I love you” to each other either. Loving one another is something you do in my family, but you don’t express it – neither physically nor verbally.

When I was doing the examinations which evaluated my family background, I had not been aware of any of these patterns. In fact, I was too pre-occupied with the pain my daily existence caused to pay any attention to them, but now that I’m recovering, I can take a look at them and observe…
I do believe that both my parents and my sister need psychotherapy too, but doubt that my father or my mother will ever undergo it. For my sister, however, I hope that she gets a chance at it soon.