Psychotherapy: a retrospective

Anyway enough of my recent moaning – self-indulgent whining has its place on this blog (after all, I am mentally ill, and sometimes I can’t help myself), but it’s not something I want to get into the habit of when there’s something – anything – else I can think of to write about.  So this post is brought to you with all due thanks to Shines Half as Long, and his recent post about therapy.  He’s in the middle of his, whereas mine came to an end a little under 2 months ago, but I’ve still been inspired to write a little bit lot about my experiences.  There are a few previous posts where I’ve talked about therapy – if you’re a real glutton for punishment, you can read those too.

The first thing I should say is that my recent experiences with Yvonne, the nurse specialist, were not my first experiences with talking treatments.  As a teenager I spent a fair amount of time involved with what, in those days, was called the Department of Child Psychiatry and Psychology, but I assume these days would be known as CAMHS.  That founding experience was mixed, to be honest.  For most of the time I had meetings with one particular psychologist (let’s call her…Dr. Hislop), mostly on my own, but occasionally with one or both parents also in attendance.  I really liked Dr. Hislop, and she taught me some relaxation techniques that I still find helpful.  My last appointment with her was also her last one with anyone before retiring – it’s a little strange and rather sad to realise, as I just have, that she’s almost certainly dead by now.

Not all my adolescent contacts with mental health services were this positive.  Some bright spark (although not my beloved Dr Hislop, who explained later that she’d been opposed to the idea, but had been over-ruled) decided that family therapy was called for.  This was absolute torture for all of us, and achieved nothing, except the ‘revelation’ that my parents were worried that they might be in some way responsible for my problems, which is exactly what I would expect any reasonable parent to feel when one of their kids has been off school for a couple of years with unspecified mental oddities.  It reached its absolute nadir when I and my mum were interviewed separately (and in my case, in front of a video camera) about whether or not I had been (or was being) sexually abused by my dad.  I can still remember the look of disappointment in the eyes of the family therapist (and the look of annoyance on the face of the social worker who’d been brought in for the occasion) when I said no, absolutely not.

My suspicion that therapists, as a class, don’t really know what they’re doing was confirmed by my previous experiences with adult MH services.  A few years ago, I was referred for help with panic attacks, and once I’d explained the situation, the response of the therapist was to say, ‘Well, I’m not sure why you’re panicking, you’ve got nothing to panic about,’ give me a leaflet, and send me home with a flea in my ear about how long the waiting list was, and so she couldn’t afford the time to see me again.  As I understand it, panicking when there’s nothing to panic about is pretty much a word-perfect definition of what panic attacks are, so I failed to see why she was so mystified.  I also didn’t quite understand why the waiting list was so long if the standard approach was to refuse to treat anyone who couldn’t give a ‘valid’ reason for being mentally ill.

More recently, I was also referred for an assessment for CBT to help with my depression, but the therapist and I agreed that it was unlikely to be helpful for me, so we didn’t persevere.  I was rather relieved by that, as I’d already decided, based on the patient information leaflet, that CBT actually stood for ‘Completely Bullshit Therapy’.  Overall, the upshot of these experiences was that I didn’t expect a great deal from therapy in general, but I did hope that if I was lucky enough to come across a therapist I could actually get on with, some good might still come out of it.

I was nervous about my referral to meet with Yvonne, because, although I’d had a fair bit of contact with therapists over the years, I’d never had any personal experience of classic “So, tell me about your father” psychoanalysis, and I wasn’t really sure what to expect.  All the information I had was based on having read a certain amount about Freud while studying for my degree (psychoanalysis is one of the theoretical ‘approaches’ to literature that tends to get taught to Eng Lit undergraduates).  I knew that as a theorist Freud had been maddeningly incapable of giving a stable definition of any of his techniques or theories, and that as a practitioner he had a well-documented tendency to invent ‘back stories’ to explain his clients’ behaviour that seemed to have no basis in fact, but I didn’t know to what extent all that Freudian baggage was still being carried around by modern-day psychotherapists.

So, I was quite relieved when I finally met with Yvonne to realise that there was going to be comparatively little of such obvious stupidity.  In fact, over the course of several sessions, and her responses to certain comments I made, it became apparent that I probably knew more about the theory of Freudian psychoanalysis than Yvonne did.  Fairly quickly I realised this wasn’t only because a lot of what I had read was out of date (although it was), but also because I had been thinking of psychoanalysis as an academic discipline that was trying to pass itself off as a science, and that as an actual treatment regime it’s a lot less pedantic and foolish than it appears in text books.  As far as I could tell from going through treatment, the only strong guiding principles Yvonne absolutely stuck to were that people are not always fully aware of the motivations for their actions, and that emotional responses to life events can take a very long time to resolve themselves.

Personally, I think the second of those assertions is just simple common sense, and I’m surprised that everyone doesn’t automatically realise it.  But reading through various personal accounts of therapy, and from what Yvonne said when I mentioned this to her, it’s obvious that for some people it does come as a revelation to realise that emotions can’t just be tidied away into neat little boxes when we think we’ve had enough of them.  We spent a certain amount of time focussing on the break-up of my most recent relationship, and Yvonne was very obviously taken aback by the fact that I was able and ready to say from the very first time it was mentioned that my emotions about it were still very raw, and that was the main reason why I hadn’t made any attempt to establish a relationship with anyone else since.  She was similarly taken aback by the fact that I could talk freely about the death of my mum, and the feelings of guilt I had about those events, and the effects those feelings were currently having.

The reason she was taken aback, I think, is that for therapists the action of ‘discovering’ and ‘acknowledging’ an emotion should automatically lead, over time, to it being resolved.  Therapists seem to be set up to expect that people will be blocking their feelings, and they seem to anticipate a response of saying or doing anything to avoid directly acknowledging them.  What they seem unable to cope with is people who aren’t blocking their feelings, who have already acknowledged them, but don’t find any peace or resolution as a result of that.  I half expected that Yvonne would be demoralised or angered by the fact that there was no real scope for the ‘working through’ she’d been hoping for, but, once she’d recovered from her shock (and had spent quite a long time probing away to be certain that I actually had worked through those things on my own, and wasn’t just pretending that I had), she wasn’t.

Something else that is supposed, according to accounts I’ve read, to be a key component of therapy are sudden flashes of insight, where the client patient suddenly understands something they hadn’t recognised before – ‘Oh, that’s why that makes me feel like this!’  Unlike with the emotional stuff, this is something I did have personal experience of.  The moment actually came when I was travelling home after a session.  We’d been talking about one of the more pressing problems I have – my fear that I will be infected or poisoned by something or someone I come into contact with – and it suddenly dawned on me that fear was connected to the fact that (amongst several other health problems) my mum had been diagnosed with cancer, and had actually died of complications arising from it.  It seems very obvious now, but my fear of having something inside me that will make me sick is clearly connected in some way to the idea of tumours growing inside my body.

This was a genuine insight, and it’s very likely not one I would have achieved without Yvonne’s help.  The insight is not in itself useful – I still have all the same problems I did, and with the same intensity – but having that extra piece of understanding has helped me to ratchet down some of the associated anxiety.  The problem was that Yvonne seemed spectacularly unimpressed by it, as it stood on its own.  She was really pleased (even excited) that I’d had the basic insight, but started trying to wrap it around with what I thought of as meaningless psychobabble bullshit.  So, she decided that what I was actually frightened of was that ‘my insides’ were being made vulnerable by therapy, despite the fact that my fear of poisoning and contamination had begun before I had even been referred for therapy, and had got no worse during it.  She also decided that my fear of being poisoned was a fear of losing control of myself in public.  I am fearful about that (she knew about it, because we’d discussed it), but I can’t see any hint of a possible connection to a fear of poisoning or infection.  (I can see how it might be a manifestation of social anxiety, but that’s not what she was saying.)  I’m sorry to say that this was one of the points at which I lost my temper with Yvonne, but it was only because I felt that I had actually made some (for me) relatively important progress, but because it didn’t fit with her presumptions, it had to either be ignored, or twisted to fit.

That wasn’t the only time I lost my temper, I’m afraid.  I don’t feel especially good about having used Yvonne as an emotional punch bag, but on least a couple of occasions she was deliberately trying to make me angry, and I took a semi-deliberate (and semi-uncontrollable) decision to allow myself to get annoyed.  So, we had arguments about the nature of the unconscious, where I said I could accept the idea that people didn’t always think about their motivations, and that in some cases they might deliberately avoid thinking about them, but not that there was a whole separate realm of thoughts and ideas and motives that they couldn’t access even if they wanted to, and Yvonne disagreed.  Another time we argued about the nature of time, with Yvonne arguing that time actually runs at different speeds for different people (i.e. the hands of the clock physically move slower or faster), and me arguing that what varies from person to person is their perception of time.  (And yes that did come up because I commented on the fact that one of our sessions seemed to be lasting forever…)

If it seems like these are very obscure and philosophical things to be arguing about in the middle of a therapy session, that’s because they are.  In any discussion that wasn’t about something wholly abstract, I was always pretty much incapable of losing my temper.  This is because I was, throughout all of my sessions with Yvonne, in an incredibly anxious state, and I was basically too scared to do anything except agree with everything that was said.  The best I could manage in terms of expressing an opinion was to stress that I was sure what she was saying was true for lots of people, but it wasn’t true for me.  I’m sure this refusal to engage must have been very frustrating for Yvonne, and the philosophical arguments (in which her positions were always fairly arbitrary and, I think, designed to be deliberately provocative) were, I’m sure, partly intended to provoke me into doing or saying anything.  But I also think they were designed as a way of proving to me that the sky wouldn’t fall in if I expressed an opinion.  Yvonne was always very concerned that I was so particularly uneasy in our sessions, and as it took a while for me to come clean about the reasons for that (which she eventually described as having ‘a psychotic edge‘ to them), the arguments were, I think, a way of trying to explore the issue.

My unease during the appointments always was fairly obvious.  One of the perennial bugbears of anyone undergoing therapy are the long silences, but I think I found them more difficult to deal with than some people do.  Certainly Yvonne suggested that was the case (and it was one reason why she felt I wasn’t a good candidate for group therapy).  On one occasion, our session came to an abrupt end when I apologised and walked out because I just couldn’t bear the silence.  It wasn’t that I was worried about what I might say, or what Yvonne was thinking about, it was just that during the silences I became acutely aware of all the noises I could hear through the windows, and from the rooms around and above the room we were in, and started to think that if I could hear them, then they could hear me when I was talking, and I just couldn’t cope with the idea of being overheard or ‘monitored’.  I began the next session by trying to explain what was going on, and this was the start of the gradual process of me outing my less straightforward symptoms.

A big part of why I felt able to eventually talk about those things with Yvonne was that I had come to feel I had a really good relationship with her, and a big part of that was pretty much accidental.  In terms of her attendance record, my therapy with Yvonne was less than ideal.  What started as one missed session as a result of a planned holiday turned into three when she was off sick for the next two weeks.  Then we had one session, during which she became obviously upset when I started talking about my mum’s death (so I changed the subject – I’m not completely heartless), and at the end of which she said that she might be having to take some more time off.  After that there were another two missed sessions, but this time the reason the letter gave was that Yvonne was absent on ‘bereavement leave’.  After that, sessions resumed for a couple of weeks, and then there was a four week annual break over the summer.

All of that stopping and starting was certainly unfortunate in terms of the effect it had on my anxiety (one of the ways I keep my anxiety at bay is by following a strict routine, and planning things as long in advance as possible).  It’s obviously also really sad that Yvonne suffered a bereavement during the course of our therapy, but to be completely selfish about this, it had a really positive impact on our relationship.  Partly that was because it had the effect of humanising Yvonne for me – up until the point at which she became upset in a session (and we’re talking tears in her eyes here, not a complete meltdown), I hadn’t really thought of Yvonne as a person with a life outside therapy.  Initially I was worried that realising she did could only have a negative effect – I couldn’t see how I could justify talking about my problems to someone who had been so recently bereaved – but then I started thinking about what I could do to make the sessions between us beneficial.  The conclusion I came to – that I would start to pretend that she was helping me a lot more than she actually was so that she would have something to feel good about – was fairly stupid, and patronising, and it’s not what I actually ended up doing.

On the first session back after her bereavement leave, after asking how I’d been, Yvonne broached the whole topic.  She did the very useful thing of putting into words what I had been thinking but had felt that I wouldn’t be able to mention.  So she wondered if I might be feeling that areas of my life (like the death of my mum) had to be excluded from discussion, and, which cut much nearer to the bone, if I was worried that I needed to pretend that things were going better than they were so as to avoid becoming a ‘burden’ to her.  I admitted that I had been thinking those things, and she reassured me that I didn’t have to worry about her ability to cope, and managed to do it in such a way that I actually believed her.  It also became the basis for a more wide-ranging discussion, which exposed the fact that I had been taking a very inflexible approach to therapy, and what could be achieved in the course of it.

Specifically, we discussed the fact that I had tended to see myself as ‘broken’, and her as the ‘mechanic’ who would ‘fix’ me, but had at the same time resented her for (as I saw it) thinking she had the ability to fix what I hadn’t been able to fix on my own.  It emerged that she didn’t want me to think of myself as broken (although she did think I had certain specific problems, and some were outside her area of expertise), and certainly didn’t think of herself as having some magical ability to fix me.  Instead, she wanted me to see both of us as going on a ‘journey’ together, over the course of which we might learn some things that might be useful.

Now, I have to be honest, if I hadn’t started the session with a determination to be tolerant of anything and everything she said, I probably wouldn’t have made it through the speech without defocusing my mind and thinking about something else.  All the talk of ‘journeys’ and ‘learning together’ sounds exactly like the kind of sanctimonious psychological claptrap that has always put my back up.  But because I was actually listening I realised that, behind the perhaps unfortunate way she chose to express herself, was an idea about therapy being a process rather than an event.

I realised that because I had been seeing therapy as an event with a definite outcome, I had also felt that it had to be either a complete success or a total failure.  Since I could see no way in which it could fix every problem I had, I had decided that therapy was bound to be a total failure.  By thinking about it as a process, I was able to realise that, although by the end of it I would very likely still be as ‘broken’ as I always was, the process itself would be valuable, and might help me to find new ways of coping.

I should say that I didn’t discuss most of this with Yvonne directly.  When she talked about us being fellow travellers, I think all she meant was that she wanted me to get away from the idea that we were in some way on different sides.  I’m pretty sure she was clear in her own mind that we weren’t equal partners on this journey, that she would be my guide, and that basically my role on the journey was to sit up straight and take notice whenever she drew something to my attention.

We carried on having disagreements about things, usually when she came out with some kind of unreconstructed psychobabble that was too much for me to take.  I was still very anxious in our sessions, and did most of my serious thinking on the way to them and the way back, because I was always too on edge to think when I was actually in the room.  But the change in the way I thought about therapy had been a big help in getting me out of my usual black-and-white, everything-must-be-either-one-thing-or-another way of thinking, which meant that I was at least open to the possibility that therapy might be a bit helpful, even if it wasn’t going to be the complete solution to all my problems.

Even though I finished therapy almost two months ago, I think I’m probably still too close to it to reach any firm conclusions.  In lots of ways I’m still as sceptical about it as I always was.  I simply don’t believe in the existence of the unconscious, and the unconscious is, I think, a central concept for most psychotherapists.  I just don’t accept that I’m still fighting childhood battles, and the primacy of childhood experiences seems to be an article of faith in psychotherapy.  I am surprised that anyone could be genuinely surprised to realise that their emotions are complex, and persistent, and untidy.  Most profoundly of all, I don’t believe in the psychological model of mental illness, and so I think all anyone can ever hope to achieve through therapy is better coping skills.  I don’t think therapy, on its own, can be the cure for anyone or anything.

On the other hand, I now have first-hand knowledge of it, and I know that the experience of therapy really was helpful for me.  Just because I don’t think therapy can ever change anything fundamental, that doesn’t mean it hasn’t helped.  I think it has helped me to re-examine the way I think about the way I think, if that makes any sense.  I’m still convinced that the theory of psychoanalysis is largely nonsense – none of the theoretically-informed guidance Yvonne gave me seemed worth the breath it was spoken with – but the experience of spending 50 minutes a week talking with someone I (basically) trusted about things that were important and difficult and uncomfortable was helpful.

At the time our sessions came to an end, I was worried that the positive effects of them would also come to an end.  To some extent Yvonne shared those fears – she told me that 20 weeks was a fairly short time span for psychotherapy, and that she would have liked to have longer with me – but, actually, the benefits have lasted.  I know I’ve been finding things difficult to manage over the last little while, but I’m still aware of an improvement.  Somewhere underneath all the layers of depression, and anxiety, and paranoia, and all the other stuff, somewhere at the very core of myself, I have more confidence in my ability to find a way to cope, and that fundamental confidence in myself is what I learned in therapy.

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3 Responses to Psychotherapy: a retrospective

  1. cellar_door says:

    I always wondered what happened in psychotherapy…that was interesting, thanks for sharing. Glad it was a positive thing for you.

    The crying in sessions thing…that’s something I need to sort, for the same reasons you identify. I don’t want to be putting that pressure on my patients…

    http://notanotherstudent.blogspot.com/2008/11/crying-on-placement.html if you didn’t see it :0) (plug plug plug)

  2. Thank you for a very informative account of your experiences in therapy.I have had CBT in the past & am supposed to have some more soon for OCD. I am not convinced CBT has been helpful for my depression/anxiety.Not sure if it will be with OCD to be honest either.It’s good to hear that you’ve had positive experiences of psychotherapy.I hope your confidence continues.

  3. Welshy says:

    I wonder if you’ve ever thought about Dialectic Behavioural Therapy. I’ve just come to the end of my therapy (5 years, although 3 is the norm – it’s not a light undertaking!), and it’s been enormously helpful. You mentioned finding relaxation techniques helpful, and as DBT is based on Zen, you might find it interesting. I also remember the ‘What do you mean you weren’t abused? You MUST have been!’ look from various professionals in the past, so I was cynical when I started, but DBT is very much about being in the moment (which means it will be useless for any psychotic symptoms you’re having), and dealing with your day-to-day life (I found it helped during periods of anxiety). Anyway, thanks for the post and if you’re not already familiar with DBT Wikipedia has quite a good entry, or just google ‘Marsha Linehan’

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