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.

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Slaying A Dragon

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Last Session Of The Year

Last therapy session of the year; the next one is on Friday the 13th (January 2012), to which my mum will accompany me. Apparently, my regular therapy is also coming to a close – I’ve had 31 sessions so far and if I recall correctly, that means only 4 more in the normal rhythm before drawing them out. Not sure about the time periods between them, but I do know that session 40 is definitely my last one. I’ll part with a laughing and a crying eye: laughing because my life improved so vastly, crying because I will be sorry to say goodbye to my therapist for good. The whole purpose of our relationship was that it would end again eventually, but I’ve grown fond of him… but, I guess that’s a bridge I’ll cross when I get to it.

We took a look at my uni schedule today, trying to find out what I can eliminate – all contact hours, homework and commuting time added up, I had a 50-hour-week and a BDI-II score of 20, with a tendency for the worse. Friday was crossed off the list completely and I’m supposed to figure out what I can do without until I reach a point where the work load does not push me into a depression anymore.
“We are pulling the emergency brake now,” my therapist said. “And if it gets too much,” he smiled, “just scratch another class off the list and go to the cinema instead.”
Eliminating classes wasn’t the problem, I didn’t need help for that. The huge difference is that if my therapist “allows” me to take it easier, I feel like I’m actually doing something pro-active and taking care of myself, whereas without discussing it in therapy, I’d have suffered from a bad conscience and felt like I was only procrastinating. That’s clearly something I still need to learn during our remaining time together: that I have a right to take care of myself and that I’m allowed to set limits.
A job is only possible in summer, because I’m going to have exams and an “en bloc” course and an excursion (probably followed by another protocol) during the upcoming semester break, and during the second semester my situation will hardly be any different…

Our roleplaying exercises were a little different today: not the usual dialogues acted out, but instead my therapist challenged me to defend my position. After I told him that I preferred learning at home over learning at the library, for example, he said: “Convince me! Why should I believe you are learning more effectively at home?” So I listed my reasons – that I felt more relaxed at home and could concentrate better because I wasn’t constantly aware of the people around me, that I didn’t have to watch my stuff if I walked out of sight of the desk, that I had more freedom on when I wanted to learn…
Later he made me stand up while he remained seated (a position I hate, because it causes me to feel vastly overweight – even though he doesn’t get that impression and it exists in my head only) and voice the effects the depression has on me as if talking to my mother: “I have troubles falling asleep and wake up in the night; the muscles in my arms and legs hurt, my joints too. I have headaches and backaches and stomachaches. My eyes are inflamed and hurt and I can’t always see properly because of that. I can’t concentrate very well either and doing my homework gets really difficult because of that. There are cognitive problems which make me forget words and sometimes I don’t even understand my homework anymore because of this.”
Only when looking back I realize I listed exclusively physical symptoms, but didn’t mention the sadness, crying and despair descending upon me. Had I spoken to my therapist directly instead of him acting as a proxy for my mother, I would probably have mentioned this, but since we hardly ever discuss intimate feelings in my family, I didn’t speak about this in therapy either.

One aspect I forgot about and which my therapist highlighted today was exercise. There is no room in my current schedule for any kind of physical activity. He described a scientific experiment to me, in which hamsters had been exposed to stress over a long time, leading to the hamsters becoming depressed. The source of stress was removed then and the hamsters got divided in three groups: group A had a nice cage, plenty of food and social contacts; group B a nice cage and plenty of food; group C a nice cage, plenty of food and an ergometer. Everyone suspected group A to show the fastest recovery rates, but in fact it was group C which was the most successful within the given time frame…
Exercise is supposed to be light and fun – no pressure to achieve any results, but regular periods of physical movement. I certainly remember how beneficial my Tae Bo classes were, even though I have nowhere near the energy for that now. But I’ll try to reserve a fixed time for swimming or cycling or something like that.

I Lucked Out

Thursday was the last session before my therapist’s vacations; the next one is going to be in three weeks. It doesn’t worry me, though, because I think I have sorted out everything in regards to starting university, and everyday life – as it is right now – doesn’t pose any insurmountable challenges anymore. And if something really bad happens, I can always call the psychiatric ambulance as I did back in May.
At the beginning of this month, my therapist going away would have been a problem; I really needed his support and expertise to keep me on track when I had to decide about my future. We role-played a scenario in which I had to defend myself and my credits in front of the docent, so that I’d be better prepared next time, and afterwards we went through a situational analysis of me telling my mother that I wanted to go back to university.

My newfound confidence is mirrored by my BDI-II score, which at 9 points was the second-lowest I’ve ever had. As always, my therapist started off by asking about the points, and when I told him, he commented that I might find him in the same area that day. It already is in the range a non-depressed person experiences during a stressful time (and for my therapist, it had been a very busy day) – the goal is to bring me to ca. 5 points and stabilize me there. Zero points are rather utopian even for people who never experienced depression; an ideal state that one might reach during moments of utmost optimism and bliss, but it does not pose any realistic long-term level of symptoms.

I asked how therapy is going to continue: the programme consists of 48 sessions, of which I have completed 26 so far. Usually, we would switch from the current rhythm of one session every other week (except for when either of us is away – then we try to have the session before the break) to one meeting per month around session 35. Optionally, one could ease the transition by drawing out the periods between appointments to three weeks from session 30 on. Towards the very end of the psychotherapy, the gaps become even longer.
If I followed the programme as intended, it would mean that by the end of the year, I’d switch to monthly sessions, but due to my return to university, we will probably opt for a different plan as I will need more support during the time of my first exams (ca. February – April). My therapist proposed an extracurricular meeting in October for figuring out an alternative treatment plan, so that I might go on longer intervals from November to January and then switch back to a tighter schedule for exam time.

It was a lucky coincidence that I found the programme at the hospital and that I actually qualified for it, because if I had undergone psychotherapy at a private practice, this week would have been my last: in Germany, health insurances usually only cover “short-term therapy” consisting of 26 sessions, anything beyond requires a special permission and is only granted if the client/patient still exhibits grave symptoms. Given my progress, I would not have qualified for additional treatment anymore: the extra-time, however, is something I need badly, because only this way I can make sure that I don’t relapse during the first semester back at university.
Health insurance is obligatory for university students in Germany (and the fees are lower for them): paying for sessions is completely out of the question for me, so without health insurance, I could not afford any of this. I am very, very grateful and feel extremely lucky that I can enjoy the luxury of such an extensive psychotherapy with a highly competent therapist with whom – most importantly – I get along very well.

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.