Looking back over group therapy part I: the assessment

Already it’s been almost a week since I left my therapy group. It’s sad to go, because I’d come to really care about that group of people, and to connect with one or two in particular. But at the same time I don’t regret my decision. I learned a lot during my time in the group, but it was keeping me stuck, and I have no doubts that saying goodbye was the right way to move forwards.

I want to write some sort of summary of my experiences in group, to look at what I’ve learned directly and indirectly and come up with a road map for the future. I’m not really sure of the best way to do that, so these posts are something of an experiment as I look back over my blog.

First, to set the scene, this is what I wrote about my individual assessment sessions with Group Therapist in February 2011:

The NHS psychotherapy service, [compared to my previous person-centred therapy with F], really is traditional. The guy who’s assessing me has a couch in his office (mercifully, he hasn’t asked me to lie down on it). He doesn’t say much, as apparently my silences and the things I say to fill them are important. When he does interject, though, it’s to say things that probably have a lot of truth in them but that make me squirm. He asks about my dreams and draws parallels between apparently unconnected areas of my life. I have gained some potentially helpful insights from sessions with him already, but those insights were stated by him and I thought, “OK, yeah, that’s true actually,” rather than me discovering them for myself as I did with F. I find things much harder to take in this way. Maybe there are things I’m not yet ready to learn about myself.

On the plus side, I think he has a really good understanding of my issues. It’s obvious he’s carefully read the reams of questionnaires I had to fill in and remembered what was in them (not exactly rocket science, but it’s surprising how many people fail to do this…) He seems to ‘get’ me and squirmy things I’ve pushed out of my mind notwithstanding, the things he says about my problems are perceptive and accurate. He takes my issues far, far more seriously than any mental health professional I’ve ever seen before.

On the negative side, I feel he doesn’t really acknowledge how far I’ve come and the progress I’ve made in my recovery. I don’t think he disputes it; it’s more as though he feels it isn’t relevant. He makes references to my self-harm and my bulimia when those things are 6+ years in the past. He isn’t interested in whether or not I know my thoughts and feelings aren’t rational, and there’s an interesting spectrum here. The CBT I had was all about learning to challenge my thoughts and look at things rationally – a skill I find quite useful but sometimes invalidating. My approach since therapy with F has been to try to find a balance between validating the way I feel and not losing sight of rational fact. C, however, is at the other end of the spectrum where rationalising masks the true issues and should be avoided, at least in the therapy room. I feel that in a way, therapy with him is a bit like the CBT in that one model is rigorously adhered to and everything else is discarded, much like the similarities between the far left and the far right (oops – humour is a defence mechanism and also best avoided in the therapy room). He says I’ve been pulling myself together all my life and I suspect – though really must ask whether – he thinks a lot of the help I’ve had before has only changed things on the surface. He takes my issues far, far more seriously than any mental health professional I’ve ever seen before.

It’s really interesting to read that back now. A couple of sessions into my assessment, I already had a handle on what would turn out to be the advantages and disadvantages of the whole experience. I loved how seriously GT took my issues, that he’d obviously read my questionnaires closely and remembered what was in them, and that he seemed to understand what I struggled with. He was the first NHS professional who, I felt, recognised the extent of my problems and was willing to help me for as long as it took. At the same time, he didn’t seem to acknowledge my strengths or show much interest in the things that had helped in the past. His ‘style’ of therapy was uncomfortable, and so very different from what had worked for me before – I was open to trying something new, but I still worried that perhaps he was adhering to a model just as rigidly and inflexibly as my CBT therapists had refused to budge from theirs. You’ll notice that the final disadvantage I gave was also one of my advantages: “He takes my issues far, far more seriously than any mental health professional I’ve ever seen before.” This turned out to be a real double-edged sword.

Probably one of the first things I learned from GT was that I have a cycle of pulling myself together and falling apart again, which he compared to bingeing and purging:

I’ve been thinking about what my therapist said about my lifetime of ‘pulling myself together’, and he’s right. As I look back over the years I can see a pattern of falling apart then picking myself up and putting the pieces back together again. Sometimes this is in very big ways (breakdown during finals, took years to rebuild my life), sometimes very small ways (oops, I took on too much last week, I’ll take it easy this week), and everything in between. I suppose the question is how much of this is normal. I’ve observed before that trying to find a balance in life isn’t something you can do once and stick with it; things constantly need reassessing and adjusting. That has to be normal, because a tightrope walker can’t just find his balance at the start then plough across the rope regardless. I guess what concerns me is how difficult and counter-instinctive it is for me to find balance and how much I’m still wobbling around all over the place. Does this mean I need more therapy, or is it just a question of practice? I feel I’ve been practising for years and not improving.

I love the feeling of getting back on track and starting to pick up the pieces (which is where I am with my debts right now), but then I get carried away and take on too many things, and the cycle repeats itself. Perhaps what worries me most is when I first realise it’s all too much, I force myself to keep going and it’s very difficult to acknowledge I can’t cope.

Knowledge of this cycle has been very useful to me. It’s allowed me to take a step back and look at the big picture of my struggles rather than constantly hone in on the details of coping in the moment. In particular, I’m much more aware of the “bingeing” and “must keep going” phases of the cycle and this has helped me to make more sensible choices. I’m very grateful to GT for this piece of information.

My comments on tightrope walking and how to maintain a balance, though, came entirely from me – and were very perceptive. Whereas GT seemed to view my cycle as purely pathological, I think some falling apart and picking up the pieces is going to be inevitable in life. What I’ve come to realise is how my difficulties in ‘set shifting‘ (thank you, Katie, for teaching me that term!) cause me to wobble more than most people. At some point, I’d like to find out more about the cognitive remediation therapy that Katie mentions.

In my next assessment session, GT stated that I use the cycle to avoid feeling. I’m still not sure to what extent this is the case, but I had to acknowledge that one emotion – shame – is problematic for me:

I could write pages about all the different ways I take care of myself when I’m depressed, but with shame there are really only two options: block it out or make changes in my life to make myself acceptable NOW.

There are some other conclusions in that post which I now think may have been erroneous, or at least overstated. I’ll look at those later, when I write about the period where I started to suspect the therapy group wasn’t right for me. For now, I’ll skip ahead to the goals I set for treatment:

  • I want to be able to let myself experience what I’m really feeling, and know that I can cope with it.
  • I want to break the cycle of taking on too much, falling apart and putting myself back together again.
  • I want to get close to people and let them support me without being frightened that my desperation and neediness will scare them away, or that they’ll take advantage of my vulnerability. (People can’t always be trusted, so I guess this also comes down to trusting that I will cope if someone does screw me over, and still being able to reach out to others afterwards.)

It wasn’t long after this that I decided on group therapy. I didn’t see GT again for some time, but I’d like to mention a post I made in the interim. In The one about coping skills, I recognised how being betrayed by people I thought I could trust had rekindled my difficulties in reaching out to people, and acknowledged the impact this was having on my ability to cope:

Yesterday, I said I had not forgotten my healthy ways of coping. I saw pain/stress/dodgy mental health as outweighing those coping skills not because I’d lost skills, but because my circumstances had changed – either life is just more stressful now, or my mental health is inherently worse. I suspect now that this may have been a little white lie.

In 2007 [I was] daring to develop my career after years when simply making it into any kind of job was an achievement. I was winding things up with my private therapist and felt pretty damn well recovered. But perhaps the biggest difference of all is that I had and used a support network. I was an active member of a depression forum, a fantastic group – I thought – of people. I was also working on talking to the people in my life about how I was feeling. The usual pattern was I would sound things out online first, then venture on to the scarier task of face-to-face conversations. I was aware of a need to lean on the internet less and develop my real-life relationships more, but I saw this very much as something within my grasp, as a continuation of a journey that had already been set in motion.

In early 2008, I was very badly betrayed by the owners of that forum. To be strictly accurate, the betrayal had occurred about nine months earlier but I was only just discovering the web of vicious lies they had spread about me while being warm and supportive to my face. On the surface of things, I coped with it very well. I recognised that this was about them and not me; I had not done anything to deserve it. In therapy I had come to realise that I wasn’t a bad person after all, I wasn’t fundamentally unlikeable and I hadn’t done anything to cause the bullying and abuse of my childhood, and when it was put to the test, this view of myself held up. I was also able, for the first time, to confront the bullies and feel proud about it.

It has taken some time to spot the damage that was done, the extent to which I have stopped trusting people and stopped reaching out. I planned to join some sort of more private forum, but there was never really anywhere that seemed right. There was always a tangible reason why a place wasn’t right and it has taken a long time to recognise that perhaps those were only surface reasons. It has taken even longer to realise that my plans to develop my relationships with real-life people, to be more open with friends and relatives and lean on them more, got shelved somewhere along the way.

This realisation has also been very important in helping me figure out what I want to work on and where to go from here.

A few weeks before joining the group, I met up with GT again and we discussed my current episode of depression, leading to some unexpected (but, I feel, accurate) conclusions on self-care and validation:

I suggested that actually, I take care of myself far better when I’m depressed than I do most of the time. I can make sense of depression and I know, through past experience, what helps when I’m feeling this way and what doesn’t. Although my self-critical thoughts increase, I recognise them as part of the illness and in a way I’m forced to stop, or at least slow down, and look after myself. My therapist commented that perhaps becoming depressed after a period of pushing myself too hard could be a healthy thing.

My suggestion then led us in two interesting directions. One was to do with validation. He observed that almost as soon as I realised I was depressed, I began to think about what could have caused it. He agreed with me that this can be useful in terms of understanding how to get out of the dark place and how not to end up there again, but I also agreed with him that my need for self-understanding runs deeper than this. If I can make sense of the way I feel, I can cope with it. It’s when I can’t find an explanation for a strong or negative feeling that I really struggle. I feel that I have no “good reason”, I “shouldn’t” be feeling that way, and then I start to question whether I really am feeling like that at all.

Finally, following my last individual session, I pondered what needs my perfectionism might be serving:

I have a very firm idea in my head of how I ‘should’ be. When I’m depressed and non-functioning it’s a million miles away, which is oddly easier, because when I’m well it’s tantalisingly close. If I just push myself a little bit harder, if I just stretch myself a little bit more, I’ll be there. I’ll be ‘good enough’. Well done! The problem is that deep down I know I’ll never be there because the goalposts move. It’s always ever so slightly out of reach.

Why do I operate this way? I think a large part of me believes this is what’s needed to motivate myself. That if I didn’t set myself so many goals, if I didn’t always push myself, if I didn’t hold myself up against an image of a Moon Tree who’s just slightly better than I am now, nothing in my life would ever improve. And then what? I’ve been trying to think about a different way, a way where I trust myself, where I am mindful and allow myself to be motivated by what I truly want. I’m not talking about hedonism here – there needs to be a way of taking future needs/wants into account as well as present ones, and of resolving any conflicts. I have an idea that this could work, and that maybe it’s how ‘healthy’ people operate, but I’m not sure of the specifics yet.

The first paragraph sprang from a discussion with GT, but the ideas in the second paragraph – about why I still operate in this way, and what the alternative might look like – are all my own. I don’t think I ever brought them up in group therapy, possibly because I sensed he would disapprove. But that’s a topic for another post, because I’ve reached the end of writing about our assessment sessions and it’s most definitely time for a break.

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One thought on “Looking back over group therapy part I: the assessment

  1. Pingback: This Week in Mentalists – The Let’s Celebrate Madosphere Positivity Edition « This Week in Mentalists

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