The Recovered Voice: 12 Narratives on How Psychotherapy Works

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What happens in psychotherapy and when it is helpful? With twelve case reports covering the most frequent disorders requiring psychotherapy, the prominent psychiatrist, psychotherapist, and psychoanalyst Rainer Matthias Holm-Hadulla shows how success can be achieved with the flexible integration of different psychotherapeutic methods. The focus is on individuals in their social context, with their various biographies, life situations, and creative potentialities. The narratives revolve around an 'ABCDE' model and highlight the following aspects of modern psychotherapy: therapeutic alliance, behaviour change, cognitive reflection, psychodynamic analysis, and existential understanding.

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Tale One: Stress Reaction with Anxiety and Depression: A Singer Loses her Voice

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“It was a trauma for my self-confidence”

A conference on psychiatry and psychotherapy in Berlin. The building cool and functional, the usual comings and goings: speakers striding to their next venue, interested psychiatrists, psychotherapists, and psychologists hurrying from one talk to the next. The reception is nice enough, wine and finger-food, small talk, all vaguely boring. Back at the hotel, I check through my emails. One of them is a surprise: “I do apologise for bothering you, but I'm a singer and I've lost my voice. I feel awful. Can you give me an appointment?” Her name is Saskia and the mail gives me a pretty full account of the unhappiness and despair she is labouring under. She has read one of my books and hopes I can help her find her way back to herself. Normally, I never see patients outside my rooms, but in this case I make an exception and suggest that we meet the next morning at a nearby café. “Great!” she answers. “I never thought it would work! 11 a.m. at the café.”

 

Tale Two: Adjustment Disorder: A Medical Student Suffers from Crippling Jealousy

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“I'm down and out”

Klara, a twenty-four-year-old medical student, has been suffering from massive insomnia for two to three months. She has a diffuse sense of anxiety and feels permanently out of sorts. In the night, she wakes up bathed in sweat and is “down and out”. Her thoughts revolve around exam questions. She believes that her complaints are connected with the stress involved in preparing for her first-part finals in medicine.

The second major problem she describes is crippling jealousy. This, too, stops her from sleeping. Frequently, she thinks of her boyfriend's female acquaintances, compares herself with them, and finds it almost impossible to free herself of her self-doubts. She finds pretty brunettes with brown eyes and large breasts particularly dangerous rivals because these women are more erotically seductive than she is: “Why should my boyfriend resist?” She finds herself less attractive, there are many things about her that she dislikes: “a bit too big, breasts too small, blond hair”. Sometimes, she makes an exhaustive attempt to find the reasons for her jealousy, mustering other women “almost obsessively” to find out what is seductive about their gestures and alluring about their physical appearance.

 

Tale Three: Social Anxiety: A Business Management Student Fails Whenever Things Come to a Head

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“I feel best playing computer games. They shut out the whole world”

Joachim is a twenty-five-year-old business management student. He has just failed his oral exams. He felt “completely blocked” and could not answer even the simplest questions. The professor examining him is astonished to see his student go to pieces in this way. Joachim has always been an excellent student: his first-part finals earned him an A grade, “as everyone had expected”. After the disastrous orals, he reluctantly allows his professor to make an appointment for him with me.

At our first encounter, Joachim is reserved and suspicious. He is very tall and slender and makes a troubled, unsettled impression. Avoiding eye contact with me, he reports stumblingly on the exam he has just failed: “There's no future left for me, having to go to a shrink is as bad as it gets. If they try to put me in a psychiatric ward, I'll jump out of the window first.” He appears badly scared, his hands are shaking and he can hardly sit still. “I just don't know what's wrong with me,” he says.

 

Tale Four: Anxiety and Avoidance: A Pianist is Afraid to Demonstrate her Prowess

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“Things are going downhill fast”

Maria (twenty-eight) comes to me for psychotherapeutic treatment because, in the past few months, the “subliminal anxieties” that have dogged her for years have got worse. She says she has always had difficulty making new acquaintances. Slight changes in her environment make her feel helpless. She would like nothing more than “to show what I'm capable of” but she now believes that there is something pathological about her nervousness, which is compounded with palpitations, trembling, and sweaty palms. At school, she would invariably blush when the teacher asked her a question. For many years, she has also been subject to a fear of being alone. Driving a car gets her “uptight”; she avoids air travel. In the past few months, things have got “really bad”. Various doctors have “not found anything” and prescribed tranquillisers, but this cannot be a long-term solution. She is getting more timid all the time; sometimes she feels “really desperate”. She is afraid of becoming dependent on the tablets. In the past few years, she has also been the victim of frequent infections, rashes, and back pains. Things are “going downhill fast”.

 

Tale Five: Slight to Moderate Depression: A Young Woman Doctor cannot Explain Why She Feels so Low

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“It's as if I'm standing next to myself, and that's when I get scared”

In the past few weeks and months, Monika has been to see her family doctor on various occasions. He prescribes psychotherapy. She tells me that for years she has been suffering from an “odd kind of tension and anxiety”. Sometimes, she feels really low and cannot say why: “It's as if I'm standing next to myself.” She has never attached any great significance to all this, but this changed during the stressful preparations for her first medical degree examination, which brought about stomach troubles, irregular menstruation, and violent headaches. First she feared she might have abdominal cancer, later a brain tumour, or something like that. Both her family doctor and her gynaecologist did their best to reassure her, telling her that the symptoms were caused by stress. Various tranquillisers and homeopathic remedies proved ineffective. The antidepressive drug amitriptyline did calm her down a little, but she feels “as if I'm not there”.

 

Tale Six: Psychosomatic Symptoms: A Housewife in Pain for Decades

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“My husband puts me in the shade”

A sixty-five-year-old woman (I shall call her Hilde) calls me and asks for an appointment to discuss “marital troubles”. She has always done everything for her husband, but he has had a girlfriend for years: “There's nothing I can do about it.” In addition to the distress she has on this score, she complains of a variety of physical ailments and lives “in constant fear of cancer”. She goes to the doctor's almost every day. “Everything hurts. If it's not my back, it's my head.” At our first interview, it strikes me that she talks exclusively about her husband's life. She tells me how successful he is at his job, enumerates his preferences and inclinations. I ask her questions about her own life, but she ignores them as if they were not worth talking about. “My husband puts me in the shade,” she says, her tone implying that this is what she deserves.

At our second session, she continues in this vein; I have no idea how to get in touch with her. This time she mentions not only her husband, but also a son. He has a chronic illness and “keeps her on her toes” although she never interferes in his affairs. Hilde's voice is monotonous and accusing. I feel rather bored and irritated. My attempts to bolster her self-confidence with appreciative remarks get me nowhere. I advise her to lead a more independent life, but my own counsels sound vacuous to me. The third session brings no change. Hilde is immaculately turned out and talks exclusively about her husband and her son's health issues. Again, I am assailed by feelings of boredom and futility. I trot out some “technical” recommendations about how to live in a relationship, but they sound flat and stale. To combat this emptiness, I let Hilde carry on talking and attempt to pay greater attention to my inner moods and images. After a while, I am actually rewarded by the emergence of a graphic scene played out in my mind's eye. I see a big stage on which Hilde's husband plays a variety of roles. He is not only the actor, he is also the director, occasionally he turns up in the auditorium, and he is in charge of the props. The son also makes a brief appearance. But where is my patient? I start to look for her. Is she back there in the shadows, in the recesses of the stage?

 

Tale Seven: Narcissistic Personality Traits: A Law Graduate Sees no One but Himself and Despairs

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“My mother and I: a wonderful couple!”

Johann, a young law graduate, is “totally desperate” and no longer capable of systematic activity. He consults his family doctor because of tormenting moods, lack of drive, sleep disturbances, poor appetite, and weight reduction. His doctor sends him to me. His symptoms began after an additional course of study in England. He finds it important to emphasise that he was studying at an “elite university” and that he was the best graduate in his year. In England, he was offered an attractive research post, but he wanted to work in Germany. Before his return, he became increasingly insecure and started debating with himself what he should do professionally. Then it occurred to him that he would prefer to study music. He had played the cello at school and felt that as a musician one probably had more opportunities to “shine”.

However, for weeks now, “hardly anything seems to be working.” He takes no pleasure in his activities, feels listless, can no longer sleep, and sees no prospects for the future. The worst thing is his compulsion to “brood”. “I'm just going round in circles,” he says. It looks like a moderately serious depressive episode. Accordingly, I offer Johann psychotherapeutic sessions and recommend an antidepressive to help deal with his tormented self-interrogation and lack of drive. Only in the later course of therapy do I realise how serious his narcissistic conflicts are.

 

Tale Eight: Histrionic Personality Traits: A Student in Search of Constant Thrills

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“There has to be glitz and glamour”

Christian comes to see me because of an ill-defined feeling of vacuity and despair. Although as a student he is quite successful, he feels that his life is pointless. Sometimes, he thinks it would be “chic” to take his own life: “I am completely alone.” He has no difficulty making contact with others, but after a while everything turns stale and tedious. “When I see a fantastic-looking woman, it bowls me over completely,” he says. But after the first few exchanges, the glamour disappears: “I hear myself talking and it sounds vapid.” He often has the impression of acting on a stage and not really being there. He does not know whether he is exaggerating his feelings and making a drama out of everything or whether he really has a problem. Even his thoughts of suicide do not feel authentic: “I don't know how close I am to doing it.”

At the first few sessions, Christian describes his life in glowing colours. It is easy to establish a trustful relationship and he appears to find the interviews beneficial. He also feels accepted and acknowledged: “My self-esteem is coming back…” In the third session, he recounts the following dream:

 

Tale Nine: Impulse Control Disorder with Don Juan Syndrome: An Architect Intends to Shoot Himself

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“Only when I feel the radiance of pleasure do I exist”

Richard, a fifty-year-old architect, approaches me for help because his wife has “inexplicably” left him after years of marriage. The marriage was largely loveless and he has always had affairs, but this new development has knocked him sideways. His feelings veer between consuming rage and debilitating sorrow. Following an inner compulsion, he takes his hunting gun out of its cabinet every night and sticks the barrel in his mouth “to make an end of things”. Then he thinks of his children and puts the gun away again: “A drink or two always bring me to my senses, it's a help.”

At the first interview, the contrast with this desperate account of his situation on the phone could hardly be starker. Richard is suave and self-possessed. He talks of his success as an architect, his energy, his capacity for hard work. “The only problem,” he says, “is that I always try to please everyone.” He is genuinely committed and helpful, selflessly supporting various social institutions. In my presence, he takes immense care to capture and hold my attention and has little difficulty in doing so. His stories about himself are colourful, original, and immaculately tasteful. However, soon I have the impression that his fascinating account of himself is an attempt to engage my sympathy. As he chats on entertainingly, I begin to sense the helplessness and despair beneath the surface. I feel an urge to put my arms round him and assure him of my solidarity. As the interview wears on, the pressure on him increases; he becomes extremely fidgety, twists his hands, and stares at me with wide-open eyes. He asks me whether sedatives might not be a good idea.

 

Tale Ten: Severe Depression Plus Burnout: A Company Employee is Completely Burnt out and Sees no Hope for Himself

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“They took the ground away from under my feet”

Wolfgang is a fifty-five-year-old company employee who likes to be called “Wolf”. Reorganisation by his firm has reduced his status to that of a marginal figure. He feels offended, hurt, and humiliated. A feeling of helplessness has taken hold of him: “They've taken the ground away from under my feet.” Within a few weeks, he experiences a serious bout of depression and lapses into increasing despair: “I feel completely changed.” He is cut off from his own feelings: “I'm no longer myself.” He sees no prospects for the future and tosses and turns all night, unable to sleep: “In the morning I'm absolutely worn out.” Since the onset of his depression he has been drinking too much, one large bottle of wine a day, sometimes more. This is something he has never experienced before. He prefers “not to face up to” the question of how serious his thoughts of suicide are. He sought the advice of a psychiatrist. The supportive exchanges with his doctor and treatment with antidepressive drugs and sleeping pills were helpful to a certain extent, but after months of treatment he still “sees no light at the end of the tunnel”. His psychiatrist was committed to his cause, even writing a letter to the company management complaining about the way his patient had been treated. After almost nine months off sick, the company offers to pension him off ahead of time. He is uncertain whether this “would do me good and take the pressure off me”. On the other hand, the pension he would receive at this stage in his career would be insufficient for him “to make ends meet”. He opts in favour of a new course of psychotherapy.

 

Tale Eleven: Psychotic Episodes: A Musician Seeks Ecstasy and Ends in Chaos

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“How can I find my way between fascinating thrills and dreadful horrors?”

After a long plane flight followed by a “psychedelic” party with unlimited amounts of alcohol, Berthold, a twenty-five-year-old musician, “freaked out with a vengeance”. He had to undergo a five-month course of treatment at a psychiatric hospital far away from his home. Although this therapy helped him, he is determined never to experience another “horror trip” like this one. At the hospital, he was soon able to calm down, but his inner isolation scared him. The medication made him feel “woozy” and he found the diagnosis, “schizophrenia”, frightening in the extreme. He does not want to go through such horrors again. He had previously gone in search of psychotherapeutic treatment but terminated a brief course of therapy because his (female) therapist made sexual advances to him.

Berthold makes a timid and desperate impression. At the same time, he comes across as rather contemptuous and patronising. However, I have a good feeling about the connection between us, and we are soon operating in a trustful atmosphere. Initially, of course, the deeper roots from which this understanding relationship springs remain unconscious. Berthold is obviously looking for someone to stabilise and guide him. He expects me to help him get on top of his mood swings and avoid chaotic states. At the same time, he senses that it is up to him to change his behaviour. He also wants to understand his feelings better. While I naturally intend to honour my professional obligations, I know that this will only be possible with empathy and understanding. I also see it as a challenge to accompany him on his path to creative self-realisation.

 

Tale Twelve: Borderline Personality Traits: Long-Term Psychotherapy Helps to Understand Feelings and Relationships

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“I can't control myself and I'm afraid of bursting open”

The patient in this last of my narratives in this book is someone I have known for thirty years. Mara was the first person with whom I embarked on a course of psychotherapy after finishing my training. I was in charge of a student counselling centre, and counselling and brief therapy was all I was called upon to perform. Outside my regular job, it was also the first time that I had had a chance to embark on long-term psychotherapy where I saw fit to do so. Mara phoned to ask for an appointment as soon as possible: “I can't control my feelings any more and I'm afraid of bursting open. If this goes on, I really can't say where it might lead…”

With these descriptions in mind, I was taken aback by Mara's independent and laid-back attitude at the first interview: “I don't really need anyone.” She tells me that alongside studying to be a teacher, she was an active party member and supported the women's rights movement. The thing is that she is always quarrelling with her (women) friends and ultimately feels unable to establish any lasting relationships. She has been for therapy before but her therapist fell ill and had to break up therapy. As a small child, the impression she had of her mother was of someone unapproachable and constantly overtaxed. Physically, she found her mother unappealing and “somehow repulsive”. Things were easier with her father. For a long time, she was his favourite child and she could talk to him about anything and everything. Accordingly, she has no trouble holding constructive conversations with male intellectuals: “But if they get too close, I start panicking.” Brief sexual encounters were “brill” but afterwards she felt “like a puddle of vomit”: “I can't stand closeness.”

 

Conclusion: An Integrative ABCDE Model of Psychotherapy

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Myths, religions, and philosophies contain any number of narratives that tell us how we can prevent or treat psychic disorders. Buddha, Confucius, Lao-tzu, Socrates, and Plato are illustrations of the fact that, in all high cultures, wise individuals have accompanied the depressed and confused on the path towards understanding their own feelings, ordering their thoughts, and giving their lives a meaningful shape. Cultural techniques with a psychotherapeutic impact figure very early on in the history of ideas. Physicians in ancient Greece acted in accordance with psychotherapeutic principles that sound astonishingly modern. They advocate (a) ongoing personal counselling from expert individuals, (b) health-supportive behaviour, (c) striving for clarity of mind, and (d) emotional equilibrium, plus (e) acceptance that life is a creative challenge.

These culturally ingrained therapeutic principles turn up over and over again in different guises and new degrees of sophistication. Unlike shamans, traditional and progressive psychotherapists do not recite magic spells or indulge in mumbo-jumbo. Their approach is rational and hard-headed. They treat psychic disorders on the basis of scientific principles and provide their patients with professional support as they set out on their quest for a healthy lifestyle, self-realisation, and social fulfilment. Many of them employ what is known as a “maieutic” approach (from the Greek word for midwife) and “deliver” their patients of the potential slumbering within.

 

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