Thoughts On Psychotherapy

Last autumn, the clinic contacted me regarding a follow-up evaluation for the medical study. Actually, they had first contacted me in summer, but my family and the paperwork for the renewal of my husband’s residency permit kept me so busy that it got pushed out of my mind. After their last reminder, I offered to drop off the questionnaires in person – I had an appointment with the psychiatrist anyway, and it’s less than five minutes driving distance between the two locations. That way, the clinic would have them faster than via traditional mail, and I’d feel a little less guilty for making them wait so long.

The evaluation mostly consisted of self-report questionnaires like I had filled out so many times before in therapy. The most difficult was a section where I was supposed to rate the difference between summer 2011, when the clinical trial ended, and autumn 2015. On paper, my situation sometimes didn’t look all that different, but on the inside it sure felt like a world apart.

So one dark December afternoon, I was knocking at my therapist’s office door again. I felt a lot more nervous than I had anticipated: I hadn’t seen him in three years, and still didn’t know what medical problems had caused him to terminate back in 2013, whether he’d be visibly altered.

When he stepped out of the door, he looked maybe a few pounds heavier than I’d remembered, but definitely healthy. There was an emergency meeting going on in his office, so I couldn’t go inside, and he had only a minute, but “didn’t want me to leave without saying hello”. He showered me with questions, of which I managed to answer less than half, and we agreed to meet again in January after my next psychiatric appointment.

I wasn’t any less nervous about the January meeting than I had been about the December one. It was scheduled as a follow-up, because strictly speaking he was not allowed to see me outside the medical study – the clinic has stopped outpatient treatment completely, with the exception of clinical trials. Which buried my hopes for ever going back to therapy with him for good. Since he had already received my questionnaire, he was somewhat in the loop of what had happened in my life over the past three years.

“What would you say is the biggest difference between now and then?”
I had to think about this one for a moment, then replied that I felt like I had grown up. That I didn’t let people trample all over me anymore, that the person I used to be just a few years ago seemed like a stranger now.

It’s true in many respects. I don’t have that crippling feeling of worthlessness anymore. Not that I think about how awesome I am all day long – I just don’t bother with that topic at all, neither in the positive nor in the negative sense. It’s just become irrelevant for my life as it is now.

Both the therapist and I agreed that I had responded extremely well to psychotherapy. I am convinced that a lot of the positive developments that were planted in therapy only came to full fruition two or three years later, when I was not having sessions anymore. I don’t even know how to describe it properly, other than that my brain got rewired.
He used that phrase a lot when I first started, but I only came to understand its true meaning now: in situations where everything happens too quickly to think about the best strategies, my brain defaults to different reactions than it did in the past. I stand my ground, I defend myself when attacked. All those hours of roleplaying these scenarios during the sessions are paying off.

I also have the situational analyses internalized, so when I find my mood tanking, I ask myself where I did not behave the way I wanted to, and what I could do better next time. I may sound like an infomercial that tries really hard to sell its product, but psychotherapy was the best thing that might possibly have happened to me.

Here’s the catch: it takes a long time to become fully effective. It only happens when you master a situation you would have failed previously – even when you don’t consciously register it, your brain notices that the new strategy was successful and is more likely to try a similar approach next time. So it takes a row of successfully averted crises for the new behaviour to grow roots. If you are like me and try to avoid adversity, it might take a while until you had enough exposure to such “opportunities”.

Of course, CBASP does not change your personality. I am still introverted and shy. But it gave me the tools to fix the holes in the hull that would have made my ship sink in the past.

The meeting with my therapist was over too quickly. I miss him – or maybe not him as much as what he had to offer (that sounds horribly selfish, but essentially what a therapist-patient relationship boils down to): a safe environment to try out new behaviour. Somebody who asked questions that opened up fresh perspectives. Especially the latter.

Of course, I could just start looking for a new therapist, but regardless of who I’d see, that person would never know the “old me”. The Layara who showed up on the clinic’s doorstep in 2010 was so afraid of everything that I’d never be able to properly communicate this to any other psychotherapist.

Then, there’s the question of familiarity. He is “tried and tested”, I know what to expect from him. With any new caregiver, a lot of time and effort would go into reaching that same degree of comfort.

Time is the third problem. Health insurance pays for 26 sessions every two years, and I always wanted to keep that option as my safety net. I don’t want to use them up and then be left with nothing to fall back on if disaster strikes!

And even if I decided to do that, there’s only one CBASP therapist left in my area, with long waiting lists.

When discussing this with the psychiatrist, she basically said she thinks my development over the last six months was promising enough to not necessitate any further psychotherapy right now – that I should see where the new medication and new circumstances (my husband’s new job) take me, and then make a decision. I agree with her – I certainly feel too well to use up my 26 “emergency sessions”. And for paying out of my own pocket we are too poor.

Maybe it is for the best. It took me more than a year to come to terms with the sudden end of therapy, but it also forced me to stand on my own feet. Ultimately, I was ready to do so. And in January, we parted on the promise to keep in loose contact, so unlike 2013, I did not feel like I had to say goodbye for good.

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Depression Symptoms & Antidepressant Side-Effects Assessed

It’s becoming very clear that despite taking twice as high a dosage of venlafaxine / effexor now, the timed-release capsules work much better for me. The nausea and vertigo vanished completely, and in the mornings I don’t go through withdrawals anymore either. I do feel quite drained from the experiences of the last three weeks, though, very tired and listless. I lost 6 kg (13.2 lbs) – 4 kg over the first weekend and another 2 kg since – and even though I would welcome further weight loss very much, it goes without saying that vomiting, diarrhea and skipping meals due to nausea is not exactly a healthy way to drop the kilos and at least partially responsible for the feelings of weakness. On top of that, venlafaxine also suppresses my appetite for a good part of the day, until it returns in the evening and I suddenly start scouring the kitchen for all the stuff I did not buy when shopping…
There has been no improvements of the symptoms I primarily started taking venlafaxine for yet, the cognitive impairments and lack of energy, but I do feel more emotionally stable recently. Next Friday I have a follow-up with the psychiatrist, when I’ll find out whether I’ll increase the dosage further or stay on it for the time being.

As for the welfare process and related paperwork, the main appointment at the job centre had been cancelled on Tuesday already because the lady had become sick, and the one who works on our case at the employment agency was replaced with a colleague due to illness as well. While being very friendly as well, this colleague could do little more than collect the forms we had filled out at home and the documentation we had brought. Other than that, we will have to wait for them to get back to us. I handed in the questionnaire on my medical complaints today; the question was: “Do you have medical conditions which influence your current job or have done so in the past? Please give a short description of your illness respectively your symptoms and tell us which kinds of occupation would be influenced by these.” The space left blank was less than a quarter or a page, so I could not go into much detail:

“Diagnosis: chronic recurrent depression with comorbid panic disorder.
– permanent / daily symptoms: muscle pain in legs and arms; social anxiety; slowed-down thinking; word finding problems; problems falling asleep (at least 2 hours / night); severe lack of energy; hypersomnia; decreased libido
– frequent symptoms (at least 3 days per week): stomach pains; digestive problems (diarrhea); back pain; memory problems; concentration problems; depressive emotions (sadness, emotional emptiness, hopelessness); headaches
– periodically appearing symptoms: insomnia
– under stress also anxiety attacks
– currently (since mid-March 2013) additionally vertigo, nausea and vomiting due to starting an antidepressant regime (venlafaxine)

Because of the diverse symptoms, I am physically, intellectually and emotionally affected with any kind of occupation.”

That is as accurate an assessment as I could give of my daily problems in such a small space, and each of my healthcare providers should be able to confirm them. I learned today that the medical service will first contact my general physician for information, which is a bit of a problem since at least 80% of my depression treatment has been done by my therapist; the general physician does get reports from my psychiatrist, but except for the fact that I have participated in the medical study he does not know anything about the psychotherapeutic treatment. I do hope they’ll get in contact with him as well – if our regular case worker had been present today, I would have asked her, but her colleague was not familiar with the protocol in such cases.

Back From The Psychiatrist

And thus begins the new treatment regimen with Venlafaxine (Effexor), starting tomorrow.

Everything went well; I was a little nervous first and not particularly in the mood for dealing with a stranger, but the psychiatrist turned out nice. He asked: “What leads you here?” I told him that I was in therapy for chronic  depression for two years and generally was really satisfied with it, but couldn’t get a handle on some symptoms like concentration problems and energy, and wanted to see what medication could do for me in that regard. He knows my therapist and has a superficial idea of the CBASP programme I’m in, and I guess that was enough credit to not let me do all the lab tests and ECG again. I also gave him permission to send reports to my general physician.
I recounted a brief history of symptoms and the treatment I received so far: First depressive episode at 12, second at 16 (this time with suicidal ideation), since the age of 19 / 20 only oscillating between different stages of major depression; panic attacks at 30, treated with citalopram, then therapy; therapy major success, but then the start of a slow decline. The psychiatrist asked about living situation, family, family history of depression, school education, what I am studying. Whether I smoke, drink, ever did drugs, take any kinds of medications.
He performed some tests on my cognitive capacities, because I had complained about them:
– “Spell the word ‘radio’ backwards.”
– “What’s the difference between a river and a lake?”
– “What’s the difference between a ladder and stairs?”
He had me memorize the words “street, traffic lights, flower” and asked whether I remembered those in between other questions, and had me do a chain of mathematical exercises: 100 – 7, then subtracting 7 from the result again, and again, and again. I scored 100% and obviously am not demented.
Some questions on differential diagnoses: do I see or hear things nobody else sees or hears, do my thoughts race, do I think I am being watched or that people talk about me behind my back, etc.?
The most difficult question actually was, “How do you feel these days?” I honestly had to think about that, and answered, “On average days, I feel subdued. Pessimistic.” I told him about the insomnia, problems falling asleep and the stomach aches, that I like to withdraw from people, worry a lot and occasionally get anxiety attacks because of the worrying.

All of that took about half an hour, then he proposed that due to my previous experiences with SSRI in the form of citalopram, I should try out what an SNRI does for me. He explained that SNRI give most people more energy, explained possible side-effects and finally gave me a prescription for venlafaxine. Unless I experience really bad side-effects, I’ll see him again in four weeks.

Edited to add: Yikes, maybe I shouldn’t have googled venlafaxine / effexor, because the results sound pretty bad… “The antidepressant everyone loathes to have taken.” Sounds like I am in for a bumpy ride…

A Bad Day

And I do mean bad: not-sleeping-until-5-AM-and-crying-after-waking-up-bad. I have been talking to my therapist about starting antidepressants again; even though he is also a psychiatrist, he must not treat me as such because legally therapy is “aftercare” for the clinical trial I was part of, and he is only allowed to see me as a CBASP therapist. With the kind of health insurance I have, I cannot see him as a regular patient, and I don’t have the money to cross over to his regular patient pool.
He said the antidepressants will not be able to replace the psychotherapeutic work (which I did not mean to do anyway), but might be able to aid it. He also recommended a psychiatrist to me, which makes things a lot easier as I do not have to do research and worry about whether I made a good choice or not.

Come A Little Bit Closer

The news about the TV appearance were not the only unusual part of the last session. Two years of therapy mean that eventually, the appointments start to resemble one another; the discussions are important, but you know the routine and after a couple of weeks you recall brief scenes rather than the whole meeting.
Over the course of spring and summer, the hospital wing where my therapist sits got renovated and he had to move out of his office temporarily. He’s been back in the old location since September, but had decided to furnish the room differently: the set-up of desk, armchairs, file cabinets and the exam table is mirrored now. All of this was reason enough to break the routine and to make me feel uncomfortable at first. I got so used to always having the same perspective in that room that the familiarity of sitting in that armchair gave me a sense of security. Before that background, the last session took place.

Practicing alternative behaviours is a huge part of our routine: my problem is that I tend to do nothing at all and just remain silent when I should speak up instead, and so my therapist lets me reenact scenes we discussed, but where I behave the way I should have for getting a more desirable outcome. He lets me repeat phrases until I get the words and intonation just right, and then some more to “hammer” them in.
This is by far my least favourite part of therapy as it goes completely against my instincts of hiding myself away. When the acting was still new to me, I would occasionally break out in giggle fits due to the embarrassment, but that wouldn’t let me off the hook. My therapist would just sit there with a smile on his face, wait until I calmed down, and ask me to try again. Of course, I could just refuse and sit in my chair for the rest of the appointment, but that’s not what I go to therapy for… So, the best way to handle this for me is to get it over with as quickly as possible – the more I concentrate and the sooner I get it right, the fewer repeats we’ll go through.
Last time, however, my therapist decided to take it a step further: he had me stand up from the chair. I repeated my little speech two or three times, then he said:
“Come a little closer, please.”
I made a small step towards him.
“And even closer, please.”
Eventually, the distance had shrunk so much that I could have reached out and put my hand on his shoulder; since my therapist was still sitting in his chair, I had to look down on him – a position which makes me feel extremely uncomfortable, and he knows it. I had to repeat my sentences again, then he asked:
“What did you just think?”
“I was thinking about my arms, about how I have been clasping my hands at this really weird, crampy angle.”
“Your arms looked just fine. Why don’t you try a different position?”
I tried to relax my limbs and folded my fingers in front of me, but since I had also inched back a little in the process, I had to step closer again.
“How does that feel?”
“Ok. Better than the crampy clasp.”
“Try something else – why don’t you just leave your arms hanging?”
I did, but immediately felt like they ceased being a part of my body and turned into two dead appendices rather. I stretched and flexed my fingers nervously, hid my hands behind my back and then let them hang down again immediately.
“How does that make you feel?”
“Nervous. Extremely uncomfortable.”
“But you look more relaxed and more approachable. If you fold your arms, you are creating a barrier. And to me, these positions are comfortable. I don’t feel threatened by you at all.”
In the past, we had talked about how this particular constellation – he sitting, me standing up – made me feel like I was being this huge mass ready to bulldoze him. Like a gross, obese entity crushing him under my excessively large body. I am (by now) completely aware that a lot of the negative self-image and negative thoughts exist in my mind only, and that they are very much over the top, but that does not make them go away.
“How do you feel now?”
“Still nervous.”
“Look at my face. What do I look like?”
“Neutral. Relaxed.”
“How can you tell?”
“There are no signs of stress in your face. No creased forehead, relaxed eyes and mouth.”
“It’s good that you can see this!”
We talked a few moments about how I hardly ever relaxed when sleeping either, that I often woke up with my hands clenched into fists, and the muscle pain I had from that.
“How do you feel now?”
“A little better. Still uncomfortable, but not as much anymore.”
“Good! It’s very important that you experience this!”

When I was finally allowed to sit back into the armchair again, I felt fairly exhausted. We have done similar exercises before, but never that long and intense. Rationally, I know what this is all about: by exposing me to an uncomfortable situation and having me observe that the effect on my therapist is not a negative one, my self-image gets altered. Physical proximity is not a bad thing, and I am not causing negative emotions in another person by standing close to them. At the same time, I am forced to endure a situation I’d usually avoid, so that I can experience how the discomfort starts decreasing after a while.
Strangely enough, despite experiencing mostly negative emotions, thoughts, and despite how stressful this was, I felt really good after the session. In my family, nobody would ask how I felt, and if i talked about it, the standard response would be to pull myself together. In fact, that is what I used to do – so much so that I always downplayed all of that or ignored it even, and it felt good to acknowledge the existence of those emotions and having them taken seriously.

Going Public With Depression – On TV

In the first session after my recent participation in the student class, my therapist paid me a compliment on that. He said he could see a huge difference between the way I carried myself in April and November respectively. And then:
“I think it would look pretty good when filmed, too.”
I didn’t know what to make of this comment, assuming he was talking about having a camera roll in another, upcoming student class:
“You think? I don’t know – and can’t really tell; it’s not like I’d ever watch that anyway.” (We’ve had discussions in the past about whether I wanted to see footage from the early sessions, which were all filmed. I always refused.)
“We are planning a featurette for [news show on TV] next spring and I could imagine you making an appearance as a patient.”
I was rather dumbstruck after that and don’t quite remember what my response was, something very non-committal in any case. We dropped the topic afterwards and it was only after a night’s sleep and some serious thinking that I sent my therapist the following reply via email:

“After giving the TV featurette you mentioned yesterday a lot of thought, I came to the following conclusion: should you really do this and by that time still be interested in having me in it, I would participate.
My biggest question was whether I’d be willing to have relatives (likely), neighbours (possible) and fellow uni students (unlikely) recognize me in the feature and asking questions about it. The result is that I am willing to accept that.”

And he emailed back:

“Thank you. In such a featurette, the main focus is on the treatment method and on what you learned through it. It’s great that you are going to be a part of it!”

I know the news show he was talking about very well; it’s on every day except for Sundays, in the early evening. Each region within the federal state has their own version, where they focus on what is going on in that particular area. It’s certainly not nationwide. Once per week they have reserved broadcasting space where they highlight a medical topic. One week it may be the latest development in terms of laser surgery for cataracts, the next week the specific problems of teenagers with diabetes mellitus, and after that it might be migraines or heartburn or coronary heart disease or hearing aids or dentures etc. They tend to focus on health problems which are common among the general demographic here in Germany and on treatment methods available in the area, including mental health issues, and one of the episodes planned for next spring is going to be about chronic depression and CBASP.

Generally speaking, the filming process shouldn’t be much more difficult than talking in front of the student class. It’s going to be a little different, but it does not spark any more anxiety in me than being in a presentation in front of an audience I can actually see.
However, since the exchange of emails with my therapist, I had time for contemplation and realized that the underlying issue is not so much going public, but rather relinquishing control over who knows and who doesn’t. Right now, I recall exactly whom I told about the depression and psychotherapy, and I have a pretty good idea of who told somebody else. In total, it should be about 25 people who are in on it, give or take a few. Once I appear on TV – with my real name, my face clearly visible, my voice saying the words – it will be impossible to tell who has and who hasn’t seen the feature.
For people who suffer from anxiety, it is very important to be in control of problematic situations, because that is what keeps the anxiety at bay. If I decide who is being informed or not, I also control for whom I’ll be vulnerable and who is excluded from knowing that “secret”.
There has been a similar situation in my life before: when I was in my early twenties and had to decide whether I wanted to come out of the closet or not regarding my sexual orientation. Before I came out, if I got into an argument with someone or somebody hurt my feelings, it comforted me to have a secret. They did not really know me; there was a part of me hidden from them which they could not reach, which they could not hurt. With the depression, it is the same mechanism at work.
Coming to this conclusion doesn’t change my position. I said I’d do it, and I will, but it’s always better to be clear about what is happening emotionally and to adjust one’s behaviour accordingly. I do not want my mood to tank afterwards because suddenly I feel exposed and vulnerable. And everything else is a challenge, I guess.

Looking Back At Two Years Of Psychotherapy

Exactly two years ago, I was officially accepted into the therapy programme and started sessions. I still remember the relief when signing my name under the contract – finally an official diagnosis, finally a glitter of hope.

Psychotherapy is a long process, at least when you are talking chronic conditions. At the age of 30, I had a depression history of almost two decades, and you don’t wipe those away in just a few short weeks. There were aspects of the depression which vanished within a few weeks, and others which I am still labouring around with. But generally speaking, a bad day now still is better than a good day two years ago.
Psychotherapy also is a lot of work. Hard work. You revisit a lot of bad memories. You get confronted with your own shortcomings. You have to practice both in the session and outside of it, relentlessly. I won’t lie: there have been days when I got fed up with all of this. Days when I cried, when I got frustrated with myself, when I didn’t want to do my homework. What’s worse, the majority of people you meet will never know how much effort you put into recovering from depression – be it because they don’t know you are suffering from it, be it because they don’t have enough empathy to put themselves into your shoes.
However, I do believe it was worth absolutely worth it, not only in terms of symptom reduction, but also because it made me grow. I changed more in those two years than in the ten years before. I feel like I am much more in charge of my reactions than I used to be: where I would just run a “standard response programme”once triggered by certain emotional stimuli, I am now actually aware of what is happening, of how I react, and why. I am more confident, more secure of myself.

I already wrote a post exclusively dedicated to my therapist in August 2011, and everything I said there still rings true. However, almost a year and a half later, I find that our relationship has matured. For a while, during the first therapy year, I was under the spell of transference regarding my therapist – not that I was in love with him, but I saw something like an ersatz-parent in him. He gave me the kind of emotional response I would have liked to get from my parents: protective, but not smothering me, and at the same time encouraging me to try myself out.
I think that kind of transference is not only the rule in CBASP, but actually accounted for as part of the therapy process. After all, chronic depression originates in the childhood. I believe my therapist was both expecting and aware of the transference, but never mentioned it to me, and I didn’t breach the subject either. Maybe I was more susceptible for it because at the time my husband was back in the United States and I was feeling lonely without him, and I could talk about this situation much better to my therapist than with my parents. That actually still is the case, but since my husband and I are not geographically apart anymore, the need to talk about this has naturally vanished too.

Back in the day, I would email my therapist at least once every week, to keep him up to date about my life – which had been his idea, not mine. Every other week, I’d have a session and see him in person.
Now, I have sessions in intervals of six weeks, and I email him maybe once per month, if something really important happens. The therapeutic relationship mimics that of parent and child again, and it looks like “I’m growing up” now and become independent from him. In fact, I do not need him anymore for my everyday life. The transference has faded away.
Does that mean I could do without him? Absolutely not. I am still looking forward to every session, but now in a strictly professional way, because I still want and need to work on myself. I still need the “security net” he provides, take great comfort in knowing that I could get in contact whenever the need arose. If shit hit the fan, he’d be only an email or phone call away. And I’m not quite ready to let that go. Yet.

The Jubilee Post

Today, I celebrate the 100th blog post. If the counter didn’t keep track of the statistics, I most certainly would have missed the milestone, but I’m glad I didn’t. When getting started, I had no real direction to follow and was more concerned with not running out of steam early on than with developing a writer’s voice or any long-term goals for “Lugubrious Layara”: I simply talked about what was happening in my life, in therapy and in my head.
There also was (and still is) an educational facet to the blog, even though from a strictly personal, non-professional angle. I get a fairly consistent number of hits through people googling CBASP, and I’m really happy that I can provide links, information and my own opinion – when I was about to start the therapy programme, there was very little to be found online, and nothing in regards to other blogs. Even now, the situation changed only marginally. And despite knowing that there are other people being treated with CBASP all over the world, and even at the same hospital, I have never encountered any other CBASP patient, neither online nor in the real world. If I have accomplished nothing else with this blog, at the very least it added a new voice to the plethora of mental health blogs out there.

Blogging means walkig a tight rope. How much of yourself do you put out there? And how much of the people you write about? I try protecting the privacy of everyone I mention as much as possible, even if it means that my writing sometimes suffers from the vagueness. Occasionally, I don’t post because it would mean discussing the personal history of another person more than I’m comfortable with – I can decide to put my own history out there, but not my husband’s, for example.

Sometimes, I want to post, but don’t have the energy for writing. There’s a good deal of regurgitating going on when developing a new blog post – I type, erase, type again, erase again, scratch certain formulations, phrases or entire paragraphs. And there were a few incidents where I had an entire post ready for publication but never chose to put it out there – because the situation described didn’t exist anymore, or because it had taken so long to jot the story down that I had already moved on from it by the time I was done.
And then, there are the blog posts I would like to write, but that are too emotionally exhausting to go there: for example, my sister’s “borderline meltdown” the day before my wedding. Or the post about my husband’s immigration process I started writing back in September, but the 800 words on that which I got so far only covered everything prior to our marriage day and revisiting the events make me feel depressed, so the progress on that is very slow…

Despite and because of all of that, blogging is very beneficial for me. My therapist always urges me to become “more visible”, to put more of myself out there, and the blog is one way of doing so. My friends and my husband not only know of its existence, but some of them even are somewhat regular readers. This allows me to talk about my feelings and problems at length without pushing them on anybody – they can decide when to visit, and how often.
There is a similar effect to writing about depression as visiting the student classes had; it gives me a sense of not only dealing with it, but of making it a little less like I wasted all those years with the illness. At the age of 32 years, I have spent a minimum of 20 years with the condition, about ten of them severely depressed. By sharing, it does not feel like I wasted those.

Being A Guest Speaker Again

Last week I was a guest at my therapist’s student class again. Unlike the first time in April, when he’d asked me weeks ahead of the event, this time it was on very short notice, less than 24 hours before the class. I gave a positive reply without hesitation. Appearances like that make me rather nervous, but I am a firm believer in doing something for the greater good. If my appearance helps students to see chronic depression as less abstract, if they can put a face on textbook knowledge, it makes me feel a little better about my own mental health history – one positive aspect among so many negative ones.

The class was about the same size and gender ratio as last time (women vastly outnumbering the men); very well-behaved and quiet. The April-group was maybe a little more engaging, but then, they had only seen one other in-patient before me. This month’s group had already met an elderly in-patient with treatment-refractory depression, a bipolar patient and a young woman with chronic depression in the very early stages of therapy. I was meant to be her counterpart, who could talk about the changes which happen when you go through psychotherapy in general and CBASP in particular.
I was with the students for 25 minutes only, so naturally we didn’t go into as much detail as last time, and focused less on my personal history and more on the importance of trust and the professional’s behaviour: that in the long run psychotherapy is more successful if time is allowed for establishing a trusting relationship between therapist and patient first. More often than not, patients battle anxiety in addition to the depression, and they are easily scared away for good if not handled carefully or not taken seriously by therapists and hospital staff.

It is rather ironic that despite my social anxiety, I am a somewhat capable public speaker. I know that you have to enunciate clearly and speak with moderate tempo, that you have to talk louder than in a normal conversation and that eye contact with the audience is important if you want to come across as competent. I have held a number of lectures in university in front of up to a hundred people, and have almost always been congratulated on my “professionalism” afterwards. But it is just a mask I wear and afterwards, I am terribly exhausted and crash, and it takes weeks to fully recover from this.
Generally speaking, I was not as worried this time around, even though there always is this phase a couple of minutes before actually getting started where I become somewhat panicky, cursing myself for saying yes and badly wishing I had avoided this situation. And I’m always afraid of “forgetting” crucial facts, of not being able to access the memories of the early treatment days properly. Fortunately for me, my therapist knows me so well by now that he can anticipate problematic situations and guide the conversation around them, or take the edge off by moderating.

The chart of my depression indices was shown again – I noticed that this time, it had the title of an article printed on the bottom, stating it was “in press”. (For those who are not familiar with the rules of scientific writing: an article being “in press” means it has been accepted by a journal for publication, but has not been printed yet at the time being.) From the very beginning I had known that my anonymised data would get published sooner or later, and in the beginning I was itching with curiosity. Now that I had stopped thinking about it altogether, that silent announcement took me somewhat by surprise.
I can’t help but wonder whether this obsession about the article in the early days had something to do with the urge to chronicle my own life, as mentioned in my last blog post. As if my own thoughts and ideas and feelings about the topic don’t count if I can’t back them up with written proof.

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.”