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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Disclosing Depression, Part 3

The appointment with my therapist lasted no more than five minutes; we didn’t even go into his office but talked standing in the door frame. He had my note already prepared, which stated that I was incapable to work or sit exams from Thursday until Tuesday – tomorrow we’ll figure out a long-term strategy in our regular session. I was grateful that he filled in a few more days than just Friday, because it doesn’t look like I only wanted to get out of the exam this way.
I got a little glimpse of my therapist in his role as a psychiatrist, too. Usually, when I come to see him, his business as a psychiatrist is done and he takes his white coat off and sheds the whole “clinician persona” for the duration of the meeting, so the whole scene had a faint hint of strangeness to it. The psychiatrist-character appears a lot busier and, even though still being very friendly, more authoritative.

There’s no diagnosis on the note, but a huge stamp stating “[…] Clinic […] for psychiatry and psychotherapy” above my therapist’s signature, so when I hand it in on Monday, it will be known at the institute that I am being treated for mental health problems. So far, the university administration knew because I had taken a sabbatical a year ago, but none of my professors or other people at the geosciences department are clued in currently.
I am not sure how I feel about the fact that this is going to change: I like to keep some things private. It’s none of their business what I’m struggling with, but I also understand that it is better to be open about it and admit the problems I have – especially since my depression is chronic, not a singular episode. Recovery takes a long time, and I will have many more moments when depressive symptoms temporarily return, so it would probably be better to make it public and then deal with whatever consequences this has. Legally, I am on the safe side: my therapist told me more than once that they must not discriminate against me and have to treat me like anyone else. It is not open discrimination I fear anyway, but the hidden prejudices which are not expressed openly.

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”.

Disclosure Or Denial?

Sooner than anticipated, the professor who’ll rate my credits got back at me and suggested we meet Friday morning. While generally the appointment suits me very well – getting this out of the way as quickly as possible – it also means that I need to put what I learned in therapy to the test now. There’s no full-blown anxiety involved, but irrational worry about scenarios that start to sound rather unlikely once I actually spell them out: one of those thought constructs involves the professor telling me that they “have no use” for people like me, for example. Basically, a lot of my fantasies involve me getting rejected or criticized, which fills me with the vague wish to avoid the situation.
The first step is to disconnect from these thoughts, since ruminating only makes them worse. If I find myself returning to the fantasies, I try to dissect them with logic: what is it that I am afraid of? Are any of the imagined reactions likely? Have I done anything to provoke such a reaction?
In the end, I always arrive at the conclusion that I feel guilt over my failed first attempt at studying, but it is not my fault that I suffer from depression, and I am doing something about it, so there’s no reason to beat myself up at all.

Another much more valid point I wondered about was whether I should disclose the depression or not. The dates stated on my credits alone already betray that there is a very long gap between the last time I still behaved like a regular student and the date printed on today’s calendar sheet, so there is no way of hiding or even glossing over the fact that there was a serious interruption. I would prefer flat-out openness about the reasons, but asked my therapist for advice in an email. He suggested to treat the situation openly, too, since I am undergoing specific treatment. “There must be no disadvantages to you because of this,” he wrote.

It’s one thing to disclose depression to the administration, as I did when I applied for the sabbatical half a year ago. I’m just one face out of many that shows up in their office. With the professor, it’s different, because eventually I’ll see him in class again, and I’d rather he judged me for my behaviour in class than for pre-formulated notions he might or might not have. I guess I’m also afraid of being branded a “loser” – one of the fantasies again – and what helps me here is that all the credits I’m going to show him have very good grades on them: the worst I had earned back then was an A -. (Which I could easily turn into the idea that I’ll disappoint everyone if I ever get a grade which is not an A… but I won’t even go there.)

So this is what happens in my head when I don’t control the negativity: I can turn pretty much everything into a fact that speaks against instead of for me. In everyday situations, I handle myself very well by now, so this is the time when I need to take everything a step further and prove to myself that I can also master situations which bear the potential for more anxiety.

Disclosing Depression, Part 2

Last Saturday, I attended a meeting with former colleagues from my old job. It was nice, better than I expected actually; my personal criteria always are whether I start wishing I was somewhere else or feeling uncomfortable, and neither was the case.
Before leaving, I had not really been in the mood for going anywhere and the only reason I went was because I had missed my own farewell party back in February due to train strikes. I did not feel like I could cancel without a bad conscience, but the day turned out enjoyable.

I told them that I was undergoing psychotherapy for chronic depression, because I didn’t feel like hiding the fact and pretending everything was ok, always had been. The reactions were positive; I believe a few people were a little uncomfortable because they didn’t know what to say or how to react, but I didn’t mind as I can relate to that kind of discomfort, plus they were still nice about it. One of my former bosses even told me a friend of hers had been an inpatient at the same hospital last year.

Part of the reason why I mentioned it now and not when I was still working there, but already undergoing therapy, is that I do not see them as often anymore. I don’t have to deal with their awareness of my mental state every (work) day, so I can afford to disclose it since it’s not going to affect my job.

Part of the reason is that the whole team had been aware of my health problems for years – they saw me cycle in and out of severe depression without anyone having a clue what was causing the problems, including me. I was good at my job and got an excellent reference letter, despite all my issues (to be fair, they always were understanding of people being sick; not only me, but everyone) – however, I wanted them to know that I finally had an idea of what was wrong. I had never mentioned the emotional distress to them, but they were cognizant of some of the physical complaints: the muscle pain, the cognitive impairment, the insomnia alternating with hypersomnia.

Four days later, I still don’t regret disclosing that I am undergoing psychotherapy for chronic depression. The particulars of it aren’t any of their business, but I feel relieved that I won’t have to lie about what I’ve done during the past four months.

Disclosing Depression, Part 1

The last week was rather busy. Between job hunting and everyday life (for me still more than a handful to handle), I had an interview with a psychologist last Monday – the MADRS (Montgomery-Åsberg Depression Rating Scale), which is especially sensitive towards changes in symptoms brought on by antidepressants or treatment. I’m already familiar with the MADRS as I used to do the same interview before starting treatment and during the first weeks of therapy. Basically, it consists of similar questions as the self-report questionnaires I usually fill out, except that the interviewer rates each statement according to what you report and on how you appear.

I had also gotten a stack of different diagnostic assessment sheets and questionnaires to fill out at home over the past week, all of it in the name of tracking the progress of the psychotherapy. I did them before starting sessions too, so any difference will become immediately obvious.

Lastly, I also got a new questionnaire, for partner, family and friends of the patient. They are asked to judge the changes in 13 different points, as they perceive them in the patient: visible sadness, communicated sadness, inner tension, sleeplessness, loss of appetite, concentration problems, apathy, lack of emotions, pessimistic thoughts, suicidal ideation, helplessness concerning everyday tasks, hopelessness and worthlessness.
At first, I was going to give it to my boyfriend only, since he has the best insight, but then my therapist said I could also hand it to others additionally, if I wanted to. So I let my mother and my sister fill out a sheet too. I would give them to some of my friends as well, but they don’t see me that often, so points like “visible sadness” – which relates to posture, facial expressions and tone of speech – are hard to judge for them.

All three people stated significant improvement of visible and communicated sadness, the rest very much mirrors how much insight into my thoughts and emotions I allow them: I tell my boyfriend a lot more about my private feelings, for example, and so he reported a more significant improvement in the categories “worthlessness”, “hopelessness” and “inner tension” than my sister and mother did.
Overall, nobody rated any topic as worse than before the start of therapy, though.

When I got the above-mentioned questionnaire, the psychologist said I didn’t have to do it if there was nobody I could give it to; that many people had not told anybody about undergoing treatment. I was well aware that a lot of people don’t talk about it publicly, but it’s hard to imagine keeping it from your partner even. Myself, I have told most people in my personal life: my boyfriend, all my friends, my parents, sister, niece, my maternal grandmother and my aunt – pretty much all the people I would have a personal conversation with.

It took me several years to come out in regards to my sexual orientation, and back then I vowed to myself that I would never go back into the closet. Hiding who you are costs so much energy that I am not willing to do that in my private life: putting on masks for strangers is demanding enough and I want to save whatever little energy I have.

That doesn’t mean I have extensive discussions about my emotional and mental state or that I make public what I am doing in therapy to all of them (quite the opposite), but they are aware that I am suffering from chronic depression and that I am seeking treatment for it. Especially in the beginning, I’d be at the hospital so frequently that it would have been hard to come up with new excuses for every single time I was occupied this way.