The Psychotherapy Application
The email arrived on a Sunday at 11:14 p.m. It ran to four pages, came with an attachment, and bore a subject line that looked like a case number.
Dr. Friedrich Weihenruh read it twice. The first time because it was well written. The second time because it was a purchase order.
The sender, Dr. Cornelia Berthold, forty-four, a criminal defense attorney in Lucerne specializing in white-collar crime, devoted two pages to her situation, one page to the state of the research, and the last to the procedure she wanted: in vivo exposure treatment accompanied by a psychotherapist — that is, practice rides on real trains with a psychotherapist sitting beside her. She named her diagnosis herself, using the technical term: panic disorder with agoraphobia. She wanted eight sessions, starting with short distances. The attachment contained a list of three psychotherapy clinics, complete with waiting times. Her closing question was whether he offered this procedure, and within what time frame.
He replied at 11:31 p.m.
Dear Ms. Berthold, I do not offer that. But I will gladly explain why not. For this I set aside four hours, in two blocks of two hours each; we will schedule the second once the first is over. Two conditions. First: you pay for all four hours before the first minute. Second: you may stop at any time, even after ten minutes, and everything remains paid for regardless. There is nothing to bring except a willingness to contradict me. Since you cannot make the trip, we will do it by video.
The reply came four minutes later.
How do you know I cannot make the trip? And payment in advance is an unusual clause.
Weihenruh smiled to himself and wrote back.
In four pages you mentioned three times how to get from Lucerne to Rapperswil, and not once that you would come. The clause is not unusual, merely impolite, and it has a purpose: whoever has paid in advance no longer calculates, in the third hour, whether it is paying off. He listens and pushes back. That is exactly what I need from you.
The confirmation came with no salutation, no sign-off, and no further discussion: Wednesday, 2 p.m.
The Engagement
The fee arrived on Tuesday morning.
At two o’clock on Wednesday a rectangle appeared on Weihenruh’s screen: in the background a bookcase of legal commentaries, in front of it a woman in a white blouse, and beside her a notepad, a ballpoint pen, and a bottle of water.
She presented her case the way one presents a case. First panic attack three years ago, on an InterCity to Zurich, just before Rotkreuz, stranded for eleven minutes between stations by a signal failure. No train since. Instead: car, taxi, a car service on subscription.
“Once a taxi to Milan,” she said. “I would rather not name the amount.”
“Nor is it the problem.”
“No. The problem is Lugano. We are opening an office there, I am supposed to run it two days a week, and the way there leads through a fifty-seven-kilometer tunnel. Seventeen minutes, if it’s on time. No stop, no way out, no daylight.” She looked away for a moment. “My partners are patient. They are not infinitely patient.”
“Understood.”
“There is one more difficulty. From Lucerne I have to change trains in Arth-Goldau. Seven minutes on a platform, with a train home on the next track.”
“Then the change is the most valuable part of your trip.”
“It is the worst part.”
“Both. Remember those seven minutes; we will come back to them.”
“Then my question. Will you ride with me?”
“No.”
What followed was the kind of pause that occurs when someone has been trained to let pauses occur.
Cognitive Psychotherapy
“You know the treatment guidelines for anxiety disorders,” she said.
“I know them, and I do not dispute them.”
“You don’t dispute them, and you don’t follow them. In my profession, that amounts to the same thing.”
“Not in mine, and the difference is the reason you wrote to me. The guidelines describe cognitive behavioral therapy. It runs two proceedings side by side: one against the judgment that has been entered in your head, and a second against its enforcement, that is, against your avoidance. With anxiety, the second is called exposure, and the psychotherapist sits next to you while it is done. What I offer is cognitive psychotherapy. I challenge only the judgment. Once it is overturned, the enforcement has no basis.”
“So, half a treatment.”
“The whole treatment, by the shorter route. On a case, you don’t contest every single enforcement measure either if you can get the judgment overturned. Your behavior is not a second case alongside your thinking; it is the enforcement of it. Once the thought has been examined, your everyday life clears away the rest — every day, without an appointment and without a fee. If it has not been examined, you practice enduring under my supervision and take the conviction home unchanged. So I do not dispute the guidelines. I dispute that my presence would give you what you expect from it. I will come back to that. First I would like to know what you are actually afraid of.”
“The train.”
“I don’t believe you.”
What Exactly Is Supposed to Happen
“I’ll have a panic attack,” she said.
“That is the name of a state, not an event. I want the event. What happens?”
“My heart races. My chest tightens. The feeling that the floor is going soft.”
“And then?”
“And then it happens.”
“What does?”
She was silent long enough for him to hear the foehn, the warm wind off the Alps, working at the window outside.
“I lose control.”
“Ms. Berthold, you have been laying out the facts of cases for a living for sixteen years. Lay out this one for me. What would a witness sitting in the same car see?”
She picked up the pen, as if she felt better with something in her hand.
“I collapse. I scream. I faint, and nobody helps.”
“Three allegations,” said Weihenruh, writing them down. “And now the question you ask first in every case: how exactly would we know that one of them had occurred?”
“You’d see it.”
“Good. That gives us a criterion: a stranger would have to be able to see it and name it. Let us put that on the record, because it is worth more than anything I will tell you today. A fear that does not say what is supposed to happen cannot be refuted. That is no oversight. That is how it is built.”
“You’re imputing intent to my fear.”
“Not to your fear. To the statement. Statements have no intentions, but they do have a construction, and this one is particularly solid: there is no condition under which it would be false.”
“You’re interrogating me like a prosecutor.”
“On the contrary. The prosecutor asks whether you are guilty. The defense attorney asks what has been proven. I am doing your job until you take it back yourself.”
She wrote something on her pad. He could not see what.
“Let us stay with the third allegation,” he said, “fainting, because it can be disposed of in two sentences. Fainting requires that your blood pressure drop and too little blood reach your brain. What does your circulation do during an anxiety attack?”
“It races.”
“Pulse and blood pressure go up. So your body does exactly the opposite of what fainting would require. There is one well-known exception, blood phobia, in which the arousal can be followed by a second phase with a drop in blood pressure. Are you afraid of blood?”
“I do white-collar defense. Nobody bleeds in our line of work.”
“Then for three years you have been afraid of the opposite of what is happening inside you. I am not saying you believe that now. I am only saying that it can be checked, and that your cardiologist will confirm it.”
“He has. Twice. Stress EKG, Holter monitor, everything normal.”
“You have two findings and believe neither.”
“That makes me sound unreasonable.”
“It makes you sound as if you hold a conviction that admits evidence only when the evidence agrees with it. There is a technical term for that, but you know it better from the courtroom than from psychology.”
The Bookkeeping
“How often in these three years did you expect it to happen?”
“Often.”
“I need a number. You may estimate it, but you have to name it.”
She was visibly doing the math. Almost daily at first, she said, later less often, but every time she drove past a station, every time she thought of Lugano.
“Three hundred. More, if anything.”
“And how often did it happen? Not: how often did you feel wretched. I will take your word for that. But: how often did you collapse, scream, lose consciousness, in such a way that a stranger could have testified to it?”
“Never.”
“Three hundred to nothing.”
“Because I got off,” she said at once. “Because I got out in time. It didn’t happen because I prevented it. You are keeping statistics on a danger and leaving the protective measure out of the equation.”
“That is the best objection you could have raised at this point,” said Weihenruh, “and I would have been disappointed if it had not come. It is wrong nonetheless, and I will show you why with an old joke.”
The Elephants
“A man is sitting on a train, throwing little paper balls out the window at regular intervals. The passenger across from him asks what that is for. He says: It keeps the elephants away. The passenger says: But there are no elephants here. The man says: See? It works.”
She laughed, briefly and against her will.
“The fallacy is called post hoc ergo propter hoc. After this, therefore because of this. Because the rescue followed the measure, the measure is taken to be the cause of the rescue. The man on the train has an excuse: he is stupid. You don’t have one.”
“That’s rude.”
“It is a compliment, because it asserts the opposite: you are not stupid. That is precisely why no one can do this accounting for you — and an accounting it is, as you are about to see. Three hundred times you made a prediction. Three hundred times it failed to come true. In any other area of your life, a prediction with that track record would be called an error. In your head it is called experience. And that is because every time you used the same journal entry: Didn’t happen, because I got off. Didn’t happen, because I sat by the window. Didn’t happen, because I had the pill with me. You don’t have three hundred receipts for the danger. You have three hundred receipts against it, and a bookkeeping system that consistently posts them to the wrong side of the ledger.”
“And how would you know it wouldn’t have happened if I hadn’t gotten off? You weren’t there.”
“You were there. Three hundred times. You are my only witness, and an excellent one. So let me ask you, Ms. Berthold: suppose the prosecution puts before you three hundred incidents in which your client demonstrably did nothing, and concludes from them that he is dangerous. What do you do?”
“I move for acquittal.”
“Then move for it.”
She said nothing for a while. Then: “That is a rhetorical trick.”
“Of course. Test it. If it doesn’t hold up, tell me, and we will strike it.”
Why Cognitive Psychotherapy Needs No Accompanied Exercises
“I would like to come back to my question,” she said. “You answered it with one word. One word is no argument.”
“You will get the argument in the form of a question. Suppose I come along. I sit next to you, we go through the tunnel, and nothing happens. What do you think afterward?”
“That it went well.”
“The whole sentence, please.”
She hesitated, and the hesitation already held the answer.
“That it went well because you were there.”
“Exactly. I would be the next paper ball. An especially expensive one, with a state license.”
“There are people it helps.”
“There are people it helps at first, and who afterward cannot ride without the person they rode with. What you need is not an escort. It is a refutation that belongs to you. A refutation that someone else produces for you sits like an exhibit in someone else’s case file: you can cite it, but you cannot get your hands on it.”
“And if I break down and nobody is there?”
“Then you will have broken down, and we will have learned something we did not know before. I consider it unlikely, but I do not rule it out, and you are not supposed to take my word for it. You are supposed to check.”
“You’re asking me to work without a net.”
“I am not asking for anything. I am telling you what the net costs. The decision is yours.”
The Equipment
She listed what she carried whenever she went anywhere at all: water, always. A seat near the door, always. Knowledge of every exit along the route. Her sister, reachable between seven-thirty and ten, though no one had ever said what for. And in the side pocket of her handbag, a pill her family doctor had prescribed three years earlier.
“How often have you taken it?”
“Never.”
“Then it is the most effective medication in the world. It heals without being taken. Ask yourself what it is treating.”
Her face closed, and it was not hard to see that he had gone too far.
Weihenruh put his pencil down.
“That was my mistake. I took something away from you before you could set it down yourself. What you do with that box is a matter for you and your doctor; I give you no advice whatsoever on that question. I am only telling you what it does in your head, and I stand by that, because it is true: every one of these measures is a statement you sign with your body. You cannot claim that it is safe and memorize the escape route at the same time. One of the two is insincere, and your body believes not what you say but what you do.”
“And the fear of fear? Because that is exactly what it is by now. I am not afraid of the tunnel. I am afraid of what happens inside me when I am in the tunnel.”
“That is the most accurate statement you have made today, and it is excellent news.”
“Why on earth?”
“Because this object travels with you. A tunnel is in one place. Your circulation is wherever you are. So you can test it anywhere, anytime, without a ticket and without me.”
The Timetable
“All right,” she said. “Then I’ll start small. Lucerne to Ebikon. One stop.”
“No.”
“Now you’re being unreasonable. Every textbook starts with small steps.”
“Small steps are reasonable when you are approaching a danger. They are pointless when you are approaching an error. Every cautious step tells your body: careful, there is something here. You would concede the point to your fear thirty times before you contradicted it once. You do not approach an error cautiously. You put an end to it.”
“And if I had not examined the belief we took apart today?”
“Then I would not advise a single minute on a train, not even as far as Ebikon. That is the one mistake in this work that cannot be undone: exposure before cognitive correction. Everything else can be fixed.”
She looked at her pad, then back into the camera.
“Then I’ll take the Gotthard.”
“I did not propose that.”
“No,” she said. “I am proposing it.”
“Then I need three lines from you, and before departure, not afterward. First, the prediction: what is supposed to happen. Second, the criterion: how a stranger would recognize it. Third, after arrival: what actually happened. No report on your feelings. A log.”
“And the seven minutes in Arth-Goldau?”
“They get a paragraph of their own. They are the only point on the whole trip where you are free and still have to decide. Write down what your body does there — and what it does as you board.”
“And if I get off along the way?”
“Then you get off and write it down. That is not a relapse; it is a data point. And one more thing, Ms. Berthold, so that we do not misunderstand each other: you are not traveling in order to endure it. Any donkey can endure. You are traveling in order to check.”
“And the second block?”
“When you are back. Not before.”
“And if I don’t go?”
“Then we sit together for two hours and figure out why not. It is paid for either way. You do not have to earn the second half.”
Seventeen Minutes
The log arrived ten days later, at 9:40 p.m., without a cover letter.
Prediction before departure: In the tunnel I lose control, collapse, scream, faint. Criterion: A stranger present would have to be able to see it and name it.
5:39 p.m. Departure, Lucerne, Track 2, Voralpen-Express toward St. Gallen. Pulse high, hands damp. Thought: “I should have started smaller.” Noted, not acted on.
Along the way I notice that I have been watching the doors for twelve minutes. I look out the window instead. My pulse stays where it is. My pulse does not care where I look.
6:11 p.m. Arth-Goldau, Track 6. Now the paragraph you asked for.
The seven minutes are the worst part of the trip, and for the reason you gave: I am standing on a platform, every option is open to me, and there is no tunnel to make the decision for me. Track 6 to Track 3, underpass, a hundred meters. The board shows the EuroCity to Milano Centrale, and on the opposite track stands something that goes back to Lucerne. I read both boards. I read them three times.
Then, boarding, the full treatment: my heart pounds so hard I feel it in my throat, my hands are wet, my legs belong to someone else. According to your prediction, this is exactly the moment when blood pressure rises rather than falls. I sat down and did nothing. That is not heroism but stinginess: it was the first usable opportunity to check, and I did not want to give it away.
6:18 p.m. Departure, Arth-Goldau, Track 3, EuroCity toward Milano Centrale.
6:45 p.m. Entering the Gotthard Base Tunnel. It turns dark at once, and very quiet.
Around kilometer nine: the panic. Racing heart, tight chest, soft floor, the whole thing. For the first time in three years I did nothing against it. I watched what it does. It does nothing. It is loud and it claims a great deal, but it does nothing. After about two minutes it became boring, which I hereby enter into the record as the greatest surprise of my life.
7:02 p.m. Exit. Seventeen minutes, as scheduled.
7:28 p.m. Lugano, Track 2. Balance by criterion: collapse, none. Screaming, none. Fainting, none. Witnesses: the gentleman across from me slept from Arth-Goldau to Bellinzona.
I was disappointed. For three years I was afraid of something that cannot even find a witness.
Postscript, written on the way back: same route, same change of trains, no particular reason. It was the next train.
The Last Session
The second block began fourteen days later, again at two o’clock. The same rectangle appeared on the screen, with the same bookcase. There was nothing next to the laptop. Weihenruh noticed and said nothing.
“What was the hardest moment?” he asked.
“Not the tunnel.”
“What, then?”
“The coffee afterward. I was sitting on the piazza in Lugano that evening, it was still warm, and it dawned on me that I had built three years of my life around a single belief that did not survive seventeen minutes of scrutiny. Three years of car service. A taxi to Milan. A career that nearly came to grief over it.” She paused. “And then came the really uncomfortable question.”
“Which was?”
“What else I have never checked.”
Weihenruh nodded slowly.
“That is the treatment. The tunnel was only the evidentiary hearing.”
“I do have one more question. You predicted that the change of trains would be the most valuable part of the trip. How did you know?”
“I didn’t know it. I expected it. In the tunnel you stay in your seat because you have to; that proves nothing, however bad it feels. In Arth-Goldau you stay because you choose to. That is why seven minutes on the platform count for more than seventeen in the tunnel.”
“You didn’t tell me that beforehand.”
“No. Otherwise you would have served the seven minutes instead of living them.”
“Since then I have rewritten two closing arguments,” she said. “Both were too well written and too poorly supported. I delivered them that way for sixteen years because they worked.”
“That is the same bookkeeping error,” said Weihenruh. “It turns up in better firms than you would think.”
She laughed, this time without reluctance, and gathered up her things the way one does when a conversation is coming to an end.
“Dr. Weihenruh, one more thing. You didn’t teach me anything.”
“No?”
“You asked me how I keep score. I did the rest myself.”
“I know. That is why I insist on payment in advance.”
“You’ll have to explain that.”
“When this work succeeds, it looks afterward as if it had never been necessary. In three months you will say it was all perfectly self-evident. Anyone who sends an invoice at that point looks shameless.”
“Well, it is all self-evident, and completely logical,” she said. “That’s the annoying part.”
The picture froze for a moment, and then the window was empty. Weihenruh stayed seated in front of the dark screen and realized that he had never seen this woman on a train. Not for one minute. Nor had there been any need to.
Down by the lake a train ran along the shore toward Zurich, minding its own business. Weihenruh watched it go the way one watches a colleague who has done his job properly.
* * *
Why a clever person’s anxiety is better built than an ordinary person’s - and why precisely that makes it easier to treat - is explained in the article The Anxiety of Clever People: Why Giftedness Doesn’t Make You More Anxious, Only Better at Building Your Fears. Why, of all authorities, the Health Directorate of the Canton of Zurich describes public education about effective psychotherapy of this kind as “misleading and therefore impermissible” is set out in the article Cognitive Warfare by the Association of Swiss Psychotherapists (ASP).
Dr. Dietmar Luchmann, LLC, the publisher of this journal, itself offers cognitive psychotherapy via video — with a written summary of every session, for self-pay patients, in German or English.
1. Understand the Method
2. Check Your Suitability
3. Apply for Admission
Dr. Friedrich Weihenruh is a literary alter ego through which the author gives narrative form to his experiences as a psychotherapist. The stories are based on true events but have been fictionalized: to protect privacy and professional confidentiality, names, locations, and details have been changed. Any resemblance to actual persons is entirely coincidental.
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