Medical Service Appointment

The worst part is over now that the appointment with the medical service is behind me. It went by no means great, but at least I did not cry afterwards like last time.

The physician took a little more time to ask questions, about 15 minutes, which was the one positive aspect of the appointment. On the negative side weighs in that she tried putting phrases in my mouth that I didn’t mean to say, kept interrupting me, and generally had a brash demeanour.

I wasn’t feeling my best to begin with: slept badly the night before because of anxiety about the appointment; kept confusing words; couldn’t remember which dosage of escitalopram I take, etc. And the doctor’s behaviour made everything even worse.

For example, I had tried to explain why I had not gone back to psychotherapy – that I want(ed) to, but for reasons already discussed on this blog haven’t. She tried to twist it into me saying that because I’d had such a positive experience with my first therapy, I was resisting seeing someone else now and idealising the first treatment. Absolutely not true. If health insurance wouldn’t limit the number of sessions I could have, I’d be way more willing to try things out. And even if, ultimately it was my psychiatrist who suggested to wait with that – and she knows me a helluva lot better than someone who judges me based on a 15-minute-meeting.

The doctor also had never heard of CBASP and when I said that the general consensus is that chronic depression is largely treatment-resistant with standard behavioural therapy, she called bullshit. Whatever, I don’t really care. It’s what the scientific papers say, not my personal opinion. Not trying to convert anyone, least of all her.

Also, she said I was “talking in diagnoses”, not how I felt. Well, last time I tried that with her colleague, he wouldn’t even let me finish. Also, it’s really hard for me to open up to strangers about such personal stuff. There’s a reason why my therapy sessions worked out so well, and that is that he took the time to make me comfortable. I realise the medical service was never meant for that kind of in-depth, trust-gaining discussion, but I had told her half a minute earlier that I suffered from social anxiety, and how at uni I would devote 75% of my energy to not freaking out and 25% to following lectures. It’s kind of a low blow to hold “talking diagnoses” against me after I just divulged that strangers freak me out.

Seven hours since I got out of there, and the knot of anxiety in my stomach only slowly starts dissolving.

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Thoughts On Psychotherapy

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Two Years

Two years since my last blog post. Two years since my mother suffered a sepsis due to necrosis in the foot, caused by undiagnosed diabetes type 1. We didn’t know whether she would live or die – she lived, minus an amputated foot. I could not write about it back then and don’t know whether I want to now, as it was a very saddening and stressful experience and it took this long to come to the conclusion that I might have digested it properly enough to move on. Maybe I will go into more detail one day, maybe I won’t. For now, the above must suffice.

A lot has remained the same since then: I am still married. I am still on welfare. I still haven’t been back to therapy.
Some things changed: I am off venlafaxine now and on escitalopram. Venlafaxine didn’t do me much good and a lot of bad, and the side-effects of quitting it were horrible. Escitalopram works really well for me, though. I also have a new psychiatrist who I am more pleased with than the previous one.

So that was my life in a nutshell these past two years, as far as it is relevant to this blog. I hope to write more regularly again – I missed it, but the mental hurdles were just too difficult to take at the time.

At War With The Job Centre

Dear Mrs […],

hereby I lodge an objection to your refusal of my application for welfare.

On Tuesday, April 2nd, 2013 at 3.51 PM, I received a phone call by a job center staff member (phone number: […]), informing me that the appointment for Friday, April 5th, at 9 AM, had to be cancelled because you had become sick. When I asked when my alternative appointment would be, he informed me that you would get in contact as soon as you recovered and returned to your work place. This did not happen.
My husband, Mr Layara, and I had two appointments at 8 respectively 8.30 AM for that very same Friday with the employment agency in the same building, which we attended; there was absolutely no reason we would have missed the appointment at 9 AM with you had we been informed that it was on again. During the entire time, you could have reached me via mobile phone and mail.

The incoming phone call from April 2nd, 2013, is being archived in my mobile phone for the duration of one month and can thus be proven.

Kind regards,
Layara

On Tuesday I got a letter from the job centre, informing me that I had missed my appointment, when it clearly had been cancelled, and as a result – because I neglected my cooperation duties despite having been lectured about the legal consequences, and because I “refused cooperation” and made it “excessively difficult” (WTF?) to come to a resolution of the case – my application for welfare would be refused. I would have one month to hand in written protest.
Since the job centre is closed to the public on Wednesdays, I went there this morning and left the letter which I have translated above; trying to call the lady in question remained fruitless as she didn’t pick up the phone either on Tuesday or Wednesday.

After receiving the letter, I got initially so mad that I wanted to punch someone in the face. I had not done anything wrong, but merely acted according to what I had been told by representatives of the job centre, and yet I was the one who had the hassle of proving my innocence even though the error was clearly on the side of the staff – due to poor internal communication at best, or simple incompetence on their side. As if I did not struggle enough with fulfilling my daily tasks already…

Depression Symptoms & Antidepressant Side-Effects Assessed

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

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

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

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

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

The End Of An Era

Yesterday, I exmatriculated from university. Thirteen and a half years of fighting, and then it took all of 58 seconds to leave – there is a form you print out, fill in your name, address and student-ID number, give the reason for exmatriculation (I checked “illness”), and hand it over to the student secretary. She double-checked with my student-ID, stamped the form, gave me a formal statement that I had left uni, said goodbye, and that was it. My niece, who had accompanied me, timed the procedure.

That was in the afternoon, however. The morning my husband and I spent at the job centre, where we had an official appointment to start the welfare process, and saw someone from the employment agency afterwards. She might help my husband find a job, and I had to see her to work out the procedure regarding the “impaired working-ability” label. We got a total of about 50 form sheets we have to fill out: the actual application, and different questionnaires on just about every aspect of our existence, from the flat we live in (size, number of bedrooms / bathrooms / kitchens, how much rent we pay, what kind of heating it has, how much we pay for water and electricity, etc.) over our respective job résumés and occupational histories to a questionnaire on my depression history. We have to bring bank account activity statements for the last three months, and attestations of my health insurance, my husband’s integration class, the exmatriculation from university, a copy of my rental contract, yadda yadda yadda. And all of that has to be ready by Friday next week, because then we have the next appointment.
The procedure regarding my medical status will be that I formally release my general physician, therapist and psychiatrist from their obligation to secrecy, so that the job centre’s medical experts can inquire about my depression history, the treatments and my current status. They will then write a formal assessment, based on these facts, and I will get an invitation for discussing the results. If the results are clear and nobody objects, I will not have to undergo any further examinations through a medical officer.
The lady from the employment agency was very nice and sympathetic; she even inferred that she had personal experience with it – I just could not tell whether she meant depression, panic attacks or both. Regardless of what was the case, I felt treated with respect and in a non-judgemental way, which certainly is a first in my dealings with bureaucracy outside of the mental health sector. She’ll also remain our contact person for the rest of the process, so I’m doubly glad about this.

We were at the job centre for over two and a half hours, with over an hour of waiting in chairs in between. I had not taken the venlafaxine that morning, because I didn’t want to go into a side-effects frenzy during the appointment, but halfway through the withdrawal set in and my brain started buzzing like a mobile phone. I hope that for our appointment next week the timed-release capsules will prevent that scenario.

Welfare & No Therapy

Yesterday I mentioned going on welfare, and that I had been in the process of writing a blog post about it when the news of my therapist’s illness made some of that draft obsolete. Here follows the part which still is relevant:

Financial troubles have been a steady companion for a long time: I cannot work a job on top of uni, and my husband wants to work, but is currently handicapped by a lack of language skills (even though he is making a lot of progress since he started integration class). We have been living off my husband’s savings, support from family members, and once we also had to borrow money from a friend. Our life is rather frugal: 80% of what I buy is on offer or from the “reduced box” – groceries which are about to expire soon and hence reduced in price. We do not go out or buy anything that is not absolutely necessary.
A while ago, my therapist came up with the idea of me going on social welfare, which would roughly equal the salary of a student job. I could not object based on pride as I am not in the position to turn up my nose at any kind of support available. But I kept putting off visiting the department of social services because frankly I was afraid of doing so. For starters, I have a bit of bad history with administration and it is a very anxiety-laden topic for me. But also, the idea of having a place to turn to in even harder times was so comforting that it was difficult letting go the promise of relief at the expense of possible rejection. It is a pretty stupid concept and I would advise everyone to just get it over with as quickly as possibly if being told this story. Inside my own head, however, things are not always straightforward.
Fortunately, I finally managed to drag myself there, with the result that the state support my therapist suggested is not even available for me. As a student, I fall into a different category of welfare which I have to apply for at the employment agency instead, so the journey continues for a while.

To repeat from yesterday’s post, I need a statement from my therapist that I am not capable of working a job; usually, it would be the employment agency’s own doctors who have to come to this conclusion as a result of their examinations, but with mental health problems, that is hardly possible.
Going on state support was not a decision I made easily, or even voluntarily, but it’s the only practical solution left. It would be great if someone gave my husband a job instead with which he made enough so that we could exist from that income, but that’s unlikely in the current situation. All I know is, if I have to work, that is the certain end of my university career – I tried before, and the result was that I prioritized my job over classes, because “without the money I can’t stay enrolled in uni either”, and I had not enough energy for both. And I do not have it in me to make a third start from scratch, should this second attempt fail. It is all or nothing in regards to uni now.

Life goes on, with or without me. With or without therapy. No matter how unfortunate it is that my therapist got ill just now, when I would have liked to be able to write to him about the whole welfare business, I need to try without him the best I can.
My last therapy session was in early December; the one scheduled for January didn’t happen, and it was a bit of a warning sign already when it took three weeks before my therapist could tell me when he’d have the next opening – we were supposed to meet at the end of March again. He’s been chronically overworked for at least a year: last spring / summer it was pretty much the same, when I’d have a session in April, then an emergency appointment in June, and then nothing until September. My blog is full with comments on staff shortage at the hospital. What’s sad is that on the last day we emailed, he told me he was currently working in a new colleague and that he hoped that we could have “at least one session per month” from April on.

I guess this post is rather all over the place, but all of this has become one huge “cluster” to me anyway.

On My Own

Since last week Monday, I had been waiting for my therapist to reply to an email I sent him concerning a statement I need from him to go on welfare (that is a post I meant to write in the meantime, but had not quite finished yet when events took a turn). In about 95% of all cases, I would get a reply within 48 hours, if only to tell me that he’d read my message when he was especially busy. Important emails like this one would always prompt a fast reply, though, and if he was not at the hospital, there would be an automated message about how long he’d be gone and who to contact during his absence in case of an emergency.
This time, however, the days went by without any sign. I was wondering about this, but since it is currently flu season and almost everyone is currently getting sick or recovering from it, I did not follow up on my original message – he would get in touch as soon as he could. My email had been flagged as high priority, too, so there was nothing else I could do.
This morning, as I checked my inbox, I saw an email from the psychologist who had organized all my appointments and psychological tests when I started the programme two years ago, and at that moment I knew something was not quite right. I called her back, and it turns out that my therapist has fallen seriously ill and will not be seeing any of his out-patients for the next three months. He has not been working for the past two weeks and will only return for reduced hours in March. I don’t know what happened to him – the psychologist did not tell me, and I did not ask since that felt like a transgression.

This has been a shock on several levels. To begin with, I can’t wait for that statement for three months. I don’t have anyone else who could give me one either, as my general physician knows hardly anything beyond the diagnosis, and I am yet to meet the psychiatrist for the first time. The psychologist, who will be organizing my therapist’s affairs while he is away, promised she would take care of the problem and work out a solution with him.
Then, I feel a bit like the rug has been pulled from under my feet: all of a sudden, my security net is gone. Since starting psychotherapy, I have been operating under the assumption that help and support is only an email or phone call away. And despite having gone for several months without sessions before, I feel better when having regular appointments every couple of weeks.
Finally, I am worried on a personal level. Even though our relationship is a professional one, I do not want anything bad to happen to him.

It will be a while until I have digested this. Not that anything about my everyday life changes, but psychologically this is a different situation now. I’m really glad about the psychologist’s involvement, to have someone to ask organisational questions this way. She’s really friendly and I trust her; just one problem: as the independent rater of the medical study, she must never know whether I received therapy or medication, and thus talking to her is a bit difficult as we can only use vague terms. I had “appointments” or “meetings” with my therapist, not “sessions”, and instead of “psychotherapy” or “medication”, it is just “treatment method”.

Help Me, Zopiclone

I did not think it was possible, but the last night was almost worse than the one before. It started promising: Got tired and went to bed at 10.20 PM, read for half an hour and switched the lights off at 10.50 PM. Fifteen minutes later, I was asleep – until 1 AM, when I woke up and was so alert that I could not force myself back into the realm of dreams. Got out of bed for a couple of hours, then back into bed, where I read until 6 AM. Lay awake for another hour and finally dozed off just after 7 AM again.

At least I did not cry this time, but it was even more confusing than simply staying awake. So for tonight, I asked my sister for one of the zopiclone pills she got prescribed for her insomnia last autumn. A definite first, as I never took any kind of hypnotic agent before, but I just cannot go on like this. I have tried everything to rectify my sleeping cycle and it only got worse, and even though I am generally not keen on using pills, I feel like I am going to lose my mind if I don’t get back to normal hours soon.

In other news, I have an appointment with the psychiatrist in four weeks. As the psychotherapy is covered by the fundings of the clinical trial, he has pretty much free reign to do with me whatever he deems fit, because with the exception of the citalopram two years ago, the health insurance did not have to pay for anything yet.
I’m not quite sure how I feel about all of this yet. I would have prefered to see my therapist as the psychiatrist as well, because nobody else knows my mental health history as well as he does, and quite frankly it would save me the hassle of having to get to used to another “stranger”. However, I have hardly any right to complain, and maybe it will even be good for something to keep the two treatment fields separated.

A Bad Day

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