Social Media & Social Anxiety

Where is this blog going? What does it say about me? Since blogs also are representations of their authors (or at least embody certain aspects of their personalities), it is important to me that it looks like something I can identify with, that I want to be connected to. After checking out other blog designs over the last couple of weeks, I finally decided to make the transition to a new look. I really liked the compact layout of the old blog theme, but had grown tired of the colour scheme and tiny font. The new one has a more elegant typography and no visual clutter, and the so-called responsive design ensures that it can be comfortably read from a variety of devices, from desktops to smartphones.
Lugubrious Layara also got an organisational makeover during the holidays: I streamlined the “About Me” section a bit, and reorganized the side-column. After almost two years, the scope of topics written about here became too broad to be faithfully represented by the tag cloud any longer, so I took it out. The “Social Anxiety” tag got turned into a full category, as it is too important a topic about which I write. I added share buttons to the posts and a contact info with an email address to the side-column. Finally, I designed my own header.
And then, I also joined Twitter in an effort to promote my blog a bit. This step I was not sure about, as tweeting does not come naturally to me. I will give it a try and see how I like it in a month’s time, and whether it actually is worth the effort.

I am old enough to still remember the way the internet was when it first became widely available for private homes – back when you could not receive phone calls while being online and loading graphic-heavy websites was a real test of patience. The era of dial-up, when surfing was so expensive that I was limited to two hours per month (sic), and when I could not even have imagined some of the programmes and games I use routinely now. Before web 2.0 became a reality, the internet was a much easier place for people with social anxiety, like me. One felt much more anonymous back then, and conversations took place on message boards or forums. If you wanted to lurk from the shadows, you did just that, and if you wanted to join in, you had plenty of time to formulate a response.
Nowadays, very many places on the internet feel like the virtual equivalent of a party in full swing. Social media live off rapid-fire smalltalk, and like with a real-life party, those who are best at this kind of conversation shine, whereas the rest awkwardly stare at their feet. On a message board, you could drag posts from the archives and revive threads which had been dead for years, and the discussion would simply continue if some other forum members had sufficient interest. On Facebook, a status update becomes obsolete after a few days at the latest (depending on the size of your friends list), and on Twitter the half-life of a tweet is a few hours only.
I am terrible at smalltalking, both in real life and online. I never know what to say, or how to phrase it, and I am also very shy about approaching another person. Fear of rejection, fear of humiliation, fear of boring the other person… the whole palette of social anxiety at work. And social media have a much lower threshold in that regard than old-fashioned forums. Facebook is ok for me in so far as I know all the people there, and the update tempo on my timeline is not quite that high. But Twitter is difficult, because I do not know what to say: for the mindless quips and joking, I’m not nearly funny enough, and generally too long-winded for anything of substance. Some people have the gift to be profound and deep in 140 characters – but I don’t.
However, it’s not only Twitter which freaks me out. I can’t play any kind of online game where I would have to interact with other players; it is especially stressful because I am supposed to be leisurely around them, but can’t relax in such a setting and tense up. I am also very shy on other people’s blogs, more often than not leaving without commenting because a wave of social anxiety washes over me: “What if they don’t like what you are going to say? I’m sure they’ll find it boring as hell! Oh, look, there already are three comments, and they’re all so much wittier than what you were going to write. Just leave before anyone notices you have been here…” Even on my own blog, I sometimes worry about my own replies to visitor comments.

Both in real life and on the internet, I prefer moving in social circles I am familiar with – among friends, I can become surprisingly chatty. Among strangers, no matter how amiable they may be, it takes quite a while until I will start opening up, and one of the advantages of the internet is that through blogs or forum posts, you can get to know another person a little before you even exchange the first greeting. Social media which put more emphasis on exchange than on content (I am somewhat simplifying here, for the sake of the argument’s clarity), like Twitter or Facebook, are not any different from real life conversations to me, in terms of difficulty. Virtual worlds or MMORPGs are even more stressful than attending a party.
The truism that increased internet usage equals increased loneliness is too simplistic in my opinion, because its default assumption is that online interaction is less meaningful than offline interaction. When you suffer from social anxiety, however, chances are that – given a conducive internet usage – you actually are going to have more meaningful contacts with strangers than in the real world, while experiencing less stress at the same time.
Do not misunderstand me, I am not arguing for the superiority of internet contacts. If given a choice, I will always take a face-to-face meeting with my friends over emailing or messaging them. However, the media tend to paint a picture missing crucial details, both when praising the new interconnectedness and when condemning the arbitrariness of the new online platforms. For many people out there, the reality is much more complicated.
Despite occasional bouts of anxiety, I value the contacts I have through my blog, because they make me feel less isolated regarding my mental health problems, because I can learn from other people’s experiences, and because they allow me dealing with my social anxiety on a smaller, controllable scale.

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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.

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.

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.”

Old Routines

It’s amazing how we spent the better part of a year in different countries, yet settled back into the old routine so fast that it feels like my boyfriend’s never been away. It doesn’t feel like he’s been here for only 48 hours either, so there are moments when the ten months which passed in between morph into a slightly surreal memory which might as well have been an intense dream. He accompanied me to therapy too yesterday – one more reason to feel catapulted right back to last year’s winter, because he was my regular companion on those trips to the hospital.

After having to cancel on me twice in a row, yesterday’s appointment was only 20 minutes long and not counted as a proper session. The situation at the hospital is rather chaotic at the moment, worse rather than better compared to the last weeks. My therapist usually is very neatly groomed, but this time I noticed that he was not properly shaved, probably because of a lack of time.
My boyfriend and I were waiting in the visitor lounge, talking, when my therapist walked by – he knows this is where I am waiting until it is time to go to his office, and he wanted to tell me that he would be a few minutes late. It made me happy to see my therapist and boyfriend exchange a few sentences – they become a little less abstract to each other this way.
I have a new appointment for early February, the first regular one in over two months: the session in December counted as an informational meeting only. Due to the restricted time frame we had yesterday, we only discussed which kinds of behaviour had a positive influence on my depression indices: the BDI-II score is down to 14 from previously 20. It was only just enough to give a rough overview, but for me it was more important to have the personal contact with my therapist, however brief that may have been. Very early into the meeting, when I was just sitting down, he said: “You are looking well!” And I believed him; he doesn’t make insincere compliments, and I felt happy enough to believe it possible that I was looking good too. Not to forget that the last time I saw him, I was so mentally and physically exhausted that it showed on the outside – so that was a valuable feedback for me that I was back on the right path.

On My Therapist

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

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

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

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

Intelligence & Intellect

Thursday night I informed my parents that I wanted to make a new start at university, which went better than expected. My mother stressed that I had to get my act together this time around, but the conversation wasn’t unpleasant.
It was one of the few times when my therapist had actually told me what to do: “You need to talk to your parents, soon.” I had been afraid of doing so, mainly because I’m prone to worst-case-fantasies and after a while I can’t tell anymore what’s a realistic expectation and what’s just exaggerating imagination. The biggest problems (by far) in the equation are money or related to money: how everything’s going to be financed and whether I’ll be able to still get a job after all those years. I am going to try applying for a student loan; I don’t like the idea of accumulating debts, but on the other hand it would mean a stable “income” and I could concentrate on the actual classes.

The anxiety is finally gone. I still feel nervous about my cognitive deficits, but try to tell myself that at a time when the depression was not quite as pronounced, I had no problem handling the intellectual part of university.
The irony of it is that I grew up being told how intelligent or smart I am, but instead of becoming convinced that this is true, I live in constant fear that some day people will find out that in fact I am not nearly as intelligent at all and it was just a huge misunderstanding… It might just be a manifestation of chronically low self-esteem, coupled with what I experienced when I was at the absolutely lowest and my concentration was so poor that I could hardly read two lines from a text. The letters would start dancing before my eyes, flowing into unintelligible gibberish.
The topic came up in session and my therapist told me that he had gotten to know me as an intelligent person. “Did anybody ever tell you?” – “Quite a lot of people told me, actually,” I replied, “But… well….” He asked me to guess how many out of his CBASP patients had been able to do a situational analysis alone on the flip chart after a comparable number of therapy sessions, with hardly any help or correction from him, as I had the week before. I was clueless. “None,” he said; then, after a second’s reflection, “No, you are the only one.” He explained that even though a considerable number of his patients with chronic depression were highly intelligent people, I was the first to take the knowledge and transfer it that quickly.

Rationally I know that my intellectual capacities used to be above average, and I also know that I am not the smartest person alive – not even the smartest person I know.
There are three aspects I worry about: first, depression changes the cerebral structure and I worry that the last years, when I had more symptoms over a longer time than before, “damaged” my brain so much that it will never fully recover.
One problem lies on the side of perfectionism, because less than excellent results would feel like a failure in the past. So, I don’t wonder if I’ll manage to pass exams, but I worry if I’ll be able to get good enough grades to not make me feel disappointed in myself.
The last aspect is whether I’ll be able to control my nerves in exam situations, because it has happened that I got so nervous that there was nothing but “white noise” in my brain, like a temporary amnesia – I literally couldn’t remember anything, even though I knew it was somewhere in my brain. My therapist explained to me that this happens when your brain is too busy with too many different things at once: if you are sitting an exam and suffer an anxiety attack at the same time, the brain will eventually tend to the anxiety only and neglect everything else, because the anxiety starts a lot of instinctive reactions in the body. Instincts, however, always have priority.

Yet, a part of me is also looking forward to studying again; happy that I get a second chance at higher education and doing what I used to love so much when I was younger. There is a little glitter of hope on the horizon.

Do It Yourself

Even though it appears that my BDI-II score lingered in the same area since March, there has been a great shift when looking at the individual topics of the assessment. The points used to be evenly spread over a lot of categories, but out of the 11 points I scored on Monday, 7 resulted from somatic reactions to stress: fatigue, lack of energy, hypersomnia, inflamed eyes and muscle pain. They will go away or at least get better if I manage to reduce the stress and relax, but are not related to negative thought patterns.
That means only 4 points are left where we need to work on the way I perceive myself and the world around me: the most persistent over all those months has been the self-dislike category, where it took the longest until any change occurred at all, and where I have never been down to a score of zero. Currently, I rate myself as 1 – “I have lost confidence in myself”. Which is pretty good in my book already, but my therapist thinks it could be even better… He knows that I have strong tendencies towards ruminating over the past and constantly reminds me of staying in the present, “I did not notice anything in the last months that you should blame yourself for.”

A lot of things that used to be very difficult or intimidating have become a lot easier: I am not constantly obsessing over the camera which records our sessions (for documentation and supervision purposes) anymore – though I hardly ever forget that it’s there for longer than a few minutes. I also write the situational analysis on the flip chart myself now, which I always avoided, and even the dreaded role-playing exercises are not quite that bad anymore. For months, my therapist would ask, “Would you like to write on the flip chart?” And I would reply, “I’d rather not.” But now he’s changed to, “Why don’t you write on the flip chart?” And so I did, and it was ok.

I told him about the nice feedback I had received from a former colleague last week, and he emphasized that it was me who had put the new batteries into me, nobody else. According to the theory that depression is “learned helplessness”, people get depressed when they feel that it doesn’t matter what they do, they’ll fail or suffer afterwards anyway – one of the main focuses of CBASP is making you realize that your behaviour does make a difference.
He’s right in so far as nothing we did in therapy would be worthwhile if I didn’t apply it to my everyday life. I have worked hard on myself, and I worked for therapy too: doing my homework, being prepared, being very willing to work with my therapist and not against him.
I agree that the progress has been my doing, but I couldn’t have done it without professional help. After almost a year of most severe depression, I was so depleted that I couldn’t have helped myself even if I’d known what to do, and I also think without guidance, I might have given up trying soon. It was necessary to hand over the planning to someone else and trust that they’d know what to do. For the first three months, I just followed the lead until I was well enough again to even start thinking about how to take my life into my own hands.

Don’t Think, Act!

That’s the new rule I brought home from therapy yesterday, being the result of a ten-days-long relapse. I even did two assessments of BDI-II scores, one evaluating the usual time period (the past two weeks), the other only for the day of the session, because there was such a difference between them: my relapse had brought me back to 21, while yesterday I was at 8.

Due to growing frustration over failing to stand up for myself and effectively communicating my wishes, I had begun feeling increasingly depressed again. What helped me getting better was talking to other people about it – my boyfriend and friends, who all listened, understood and gave me feedback in kind words. And it was the realization that this was not a simple failure at work here, but that I was uncovering a fundamental behavioural pattern: I’m trying to please other people to such a degree that I panic when I’m forced to express opinions / wishes / emotions that run counter to what I believe the other person to feel or want from me. I do, in fact, expect punishment or abandonment for expressing “unpopular” opinions.

As a combat method, we created the above-mentioned new rule in the session, so that I speak out or act before second thoughts have a chance to shut me up. Intellectually, I know what to do or say, but the emotional part of me ends up in utter terror: my therapist likened it to riding a horse galloping away with you – once it’s on the run, it’s hard to gain back control. So my efforts are now going into preventing the reaction pattern from getting kick-started.

We did a lot of roleplaying yesterday, which always makes me uncomfortable, self-conscious and awkward, but yesterday was the first time I said “I cannot do this.” Not that it saved me, because the response was a smile and simple assertion: “Of course you can. Try again.” And since I always aim to please and am generally motivated to do what it takes to get better, I did try again, resulting in a giggle fit – when I am embarrassed, that sometimes happens. I sat in the chair, covering my face with my hands and convulsing in hilarity while trying to re-focus, but it took a while until I actually succeeded. And, of course, for the rest of the session he kept “proving” to me that whenever I did something he asked me to, it was because I had acted instead of dissecting it mentally: “What did you think when you just told me this?” – “…. Nothing.” – “See? You could speak your mind because you acted instead of thinking about it.”

It appears that the focus of our sessions is going to shift towards behavioural training and feedback on verbal and non-verbal expression in the future. The situational analysis is still just as important, but my therapist remarked that intellectually, I had grasped the procedure and did not require any assistance identifying the crucial elements of situations or interpreting them.

This means even more roleplaying in the future, and other exercises which offer only marginally less potential for awkwardness. Yet, no matter how much I dislike doing this kind of training, I cannot dispute its effectiveness, and I still like going to the sessions.