Exam Grades & Misguided Sense Of Duty

Friday’s session was a little different – my therapist wrote a letter to my health insurance (which wants to “promote” me from student fare to their standard fare, because I’m “too old” for being a student), stating that I had substantial health reasons rendering me “unable to study at all times prior to September 2011” and that it is very important for my recovery to not put obstacles in the way of finishing my education. I also have a letter from my general practitioner documenting the treatment with antidepressants, so I’m fairly optimistic that this will come to a good outcome.

The rest of the session we just talked: usually, we focus on situational analysis and solutions related to the problems in relation to the SA, but this time we just sat there and had a conversation – I could provide more than ample material for that. I am very much aware of the limitations of a therapeutic relationship and do not think of my therapist as a friend – but there’s no denying that I like him and that I enjoy talking to him beyond the fact that he cures me of an emotionally painful illness this way. He is very easy to converse with, both because he is professionally trained to “say the right thing” and because I stopped worrying about coming across as awkward – he knows I sometimes can’t find a word right away and expressing myself sometimes proves difficult, and we two are aware of the reasons behind that. But apart from the relative effortlessness of our exchanges, I find it interesting to discover his perspectives on life and the world in general.
As I said before, CBASP actually utilizes the therapeutic relationship as a tool for achieving the patient’s recovery, and you get to know your therapist’s background this way. Friday, we spoke mostly about university and the challenges going back poses to me. Knowing that I put a lot of pressure on myself, he warned me to not focus on grades too much and burn myself out again quickly in the process, and told me about his time at university and his grades in the final school exams (called “Abitur” here in Germany):
“Do you want to know my Abitur grade?” he asked.
“If you’d be willing to share it,” I replied.
“You know what you need to do,” he responded.
“Yes, I do – I need to ask you. Would you please tell me what your Abitur grade was?”
That’s how these conversations are used as short training sessions, because one of my “hot spots”, my areas of major problems, is that I retreat into myself and have a very hard time coming out of my shell. By making me ask, which happens very frequently, my therapist also makes me practice becoming more visible and active, and because I experience that nothing bad happens when I express interest in another person, I become more courageous outside of the sessions too. The third effect this exchange has is that by revealing his grade – which is good, but by no means as inhumanly good as I most likely would have assumed – he illustrates the fact that indeed good grades are not everything, and leaves no room for assumptions about my own perceived inferiority.

It’s already become apparent in the emails that I had temporarily slipped back into behaviour and thoughts which are typical for chronic depression – globalized thinking like “I will never succeed” or “I am not good enough for this”. It had not played much of a role anymore during the summer when I wasn’t facing as many challenges as I do now, so this is something where I definitely need to pay more attention. My BDI-II score had already risen to 12 points and doubtless would have gone up even more had I not pulled the emergency brake chain and stayed at home Thursday and Friday.
My next appointment is in three weeks, but afterwards I’ll be on a tighter schedule again for a while, to give me more support. And in between, I am to report via email about how I am doing every week.

My therapist strongly advised me to stay at home and recover properly from the sinus infection instead of going on the excursion which was planned for Saturday: “You belong in bed with a hot water bottle, not in a cave or quarry. If you’d broken your leg, you wouldn’t think twice about going…” I was hesitant, even though of course he had a very good point, but eventually cancelled my attendance. It’s going to create some complications and I’ll have to ask if there’s something I can do as an alternative, but in the end health goes first. The worst case scenario would be that I have to repeat the excursion next year.
What tipped the scale in favour of cancellation was that if I had gone, it would not only have meant an entire day outside when being sick, but it would most likely have affected my performance in the written protocol afterwards too. I’d have laboured – for months, possibly – on the fact that the result would not have reflected my true potential: it’s an open invitation for depressive thoughts.

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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.

Situational Analysis: University Appointment

I have been talking about situational analysis before, but never actually posted one, so that’s what I’m going to do today. I had a meeting this morning about the university credits, and the situational analysis will relate everything about how that went.

My therapist had offered me to take a look at the SAs whenever I wanted to send one per email in between sessions, and today was the first time I actually did that. Two minutes after stepping out of the building, I started thinking it through, and by the time I arrived home, it was finished and I only had to write it down.

Assessment phase:

1. What happened?
The docent in charge of rating the credits and me were sitting in his office, facing each other over his desk. He asked me to name all the classes I had taken. Among them I mention a class on Quaternary geology which I had finished with an oral exam and the grade A -.

Docent (surprised): “Whose class was that?”
Me: “Professor L.’s.”
Docent: “That must have been a long time ago that Professor L. gave this class. I don’t know if I can grant you this credit, that’s not… Did you take the ‘gravel class’? No? Well, nope, that merely adds up to prior knowledge.”
Me: “Oh…”

2. Interpretation (how did I feel, what did I think, what does the situation mean to me):
– I felt nervous (sweaty hands, rapid heart beat).
– I felt worthless and degraded, as if my knowledge and credits were not worth anything.
– I was angry because he wouldn’t look at the credits which I had brought and questioned me instead about them.

3. Facial Expression and body language:
– I sat on my chair, hands folded in my lap, looking the docent in the face with an expression of surprise, staring for a few seconds without saying anything.

4. Actual Outcome:
I didn’t say anything, so the docent continued to question me.

5. Desired Outcome:
I would have liked to state – with a self-confident voice – that this class was a regular credit like all the others too, and that it had counted as relevant content for the diploma students who had taken the class together with me as well, even if Prof. L. usually teaches a different class.

6. Did you get what you wanted?
No.

7. Why?
Because I got taken by surprise and didn’t dare protesting afterwards as I felt too intimidated.

Solution phase:

8. Are the interpretations accurate and relevant?
All interpretations are accurate, as they are all about me. I did not engage in mind-reading, nor did I globalise / generalise or engage in emotional thinking.
All interpretations are relevant, since I really did think them in the situation, and they are about the situation.

9. Did my interpretations help or hinder me in getting what I wanted?
The feelings of nervousness and worthlessness hindered me; they caused me to not speak my mind.
The anger helped me getting in the right direction, since anger pushes you towards taking action. It was not enough, though.

10. What would help me getting what I want next time a similar situation occurs?
Next time I get taken by surprise, I need to have an automated response and think “stand up [for yourself]”, so I can take action before the other person moves on, and also so I do not get trapped in a cycle of negative self-belief.

11. In which similar situations can I practice this?
The final evaluation of my credits will happen only after I officially enrolled, so there will be a second chance. Before that, I can practice on a small scale every time someone behaves differently towards me than I anticipated, for example with family and friends.

12. What did I learn from this situation?
I learned that, as in other situations before, I need to stand up and speak out for myself, or it will make me feel frustrated and feed negative self-beliefs.

This might appear a rather tedious exercise at first glance, but has proven very helpful as I came to master it. The situational analysis breaks up every situation into tiny pieces, which you can assess individually then. This makes you find out where your personal problems lie: some people may have difficulties with their behaviour and come off as very hostile, for example, so they need to work on building a calmer appearance in order to not constantly set off the people they interact with. Others frequently want to get something out of a situation that cannot be realistically achieved, so they need to find out what they can expect and what not. Some, like me, are too timid or shy and have to develop strategies to counteract the urge to withdraw.
The situational analysis is not only useful for finding out where you went wrong after the situation happened, but it eventually hightens your awareness of behavioural patterns as well, so that you observe certain characteristics while they are playing out, which helps you modifying your reactions on the spot. Learning and internalizing the procedure takes a while, but you gradually get better.

Back on the topic of my appointment: obviously, I came out of it with mixed feelings. Despite of the docent being perfectly mannered, he gave off a rather serious air, entirely devoid of emotion. It intimidated me – which, given my own feelings of inadequacy, did not help with building confidence.
I got the assessment I need for enrollment, however, and my credits will get the definitive rating only once I’m enrolled, so I have another month to practice showing my claws and fangs if necessary.

The docent didn’t ask about the reasons for my long break, by the way.

The One Where I Almost Cried In Therapy

In therapy, I talked about the upcoming changes in university, explained the original plan of taking my time for coming to a decision about my professional future (which the therapist said was a good strategy) and how I’d chosen continuing university when forced to decide immediately. As a result of the week’s events, the BDI-II score was up to 17 points today.

Half of the session was, as part of our usual routine, spent on a situational analysis of the phone conversation with my mother on Monday morning. This one had been special because even though what I’d felt and thought had set me up for failure (panic, doubt, flight instinct kicking in), I’d managed to get the best out of the situation that was possible considering the circumstances: ending the phone call without making the situation even worse through offending my mother, and thus giving myself time for thinking.
My therapist asked me why that was so, and I couldn’t come up with any other explanation than my reaction being an automatism, developed through seven months of therapy.

I explained my sentiments about prehistoric archaeology and how I felt that changing not only to a different degree, but also to a different subject was necessary if I wanted to go back to taking classes. I had not been entirely certain what he’d think about the latter, but he supported the notion completely and shared some personal experience afterwards concerning his own career choice and how he’d made a new start by becoming a psychiatrist / therapist after he’d started out in a different medical profession which, despite his huge interest in the subject matter, had not made him happy simply because of the way everyday work was shaped. And he said I might actually become able to enjoy archaeology again as a hobby or passion in the future if I liberated myself from all the dreadful negativity and bad memories connected to it.

At one point, I got very close to crying while speaking about this: my voice died mid-sentence and I sat there with a frown and moist eyes, looking out of the window, but my therapist just calmly repeated what I’d last said and I caught myself again. He clearly noticed what a highly emotional topic this is for me and from our discussion I can tell that he understood its significance.
Strangely, I was ok with getting this emotional in front of him – actual crying might have embarrassed me, but I felt no negative response inside myself for displaying so much sadness. Becoming obviously moved is something I rarely do, and never if I can prevent it, because it is very difficult to make myself vulnerable like this without immediately wanting to put the defensive walls up again. The fear of being shamed or hurt is just stronger. Him not fussing about it certainly helped – he acknowledged it afterwards, but didn’t make me talk about it.

Haunted By Memories

Lately, I have been really fatigued – so tired that I fell asleep in the afternoon twice this week, and my energy levels have been very low.

Last weekend, I had started re-reading old letters and emails, purely out of sentimentality. However, afterwards I found myself unable to let a couple of those memories go and put them to rest again. My head started spinning, and so I emailed my therapist after a couple of days, asking if we could talk about that in the next session. He suggested I treat them just like recent events and run them through a situational analysis, always in relation to what they mean to me today.
Doing so put me a great deal forward, because I realized that one situation was only stuck on my mind because of the emotional impact it had made on me, but that I was otherwise happy with how I had handled it. For another situation I realized that even though I’d handle it better today, I did the best I could back then. I managed to let both of them go after the situational analysis.
There was one incident, however, where I was rather upset with myself: a couple of years ago, someone very close to me revealed a serious health problem, which had stunned me literally speechless. Instead of expressing what I really felt and saying how sorry I was, I had started a bombardment with factual questions about treatment options and only expressed my feelings about two hours later. In retrospect, this struck me as rather cold and insensitive, even though I most definitely was neither; I just had handled the situation very poorly. Knowing I would do it better now was not enough, and so I wrote this person an email expressing and explaining my sentiments about this particular conversation, saying how sorry I was that I’d gone about it all wrong. The reply was favourable, and that was when I could move on from this as well.

Usually, it would have taken the whole session to discuss the situational analysis step by step, but today we managed to talk it through without even writing on the flip chart, and we were done after about 15 minutes, moving on to developing strategies for counteracting the fatigue that has recently plagued me.
According to my therapist, many people underestimate how much work psychotherapy actually is, and that it would have been unnatural to not get tired after all the mental sorting. He suggested that I take at least two days off before the next session and do something recreational, as if I was on holidays: go to a museum or visit a new place, for example. The weather forecast is rather bad for the next couple of days, so it’s probably going to be something indoors – plus, my finances don’t allow anything fancy.