Behavior Therapy: Appearance and Reality. Part 2: A Patient’s Account of Exposure Treatment for Agoraphobia and Panic Attacks

The Day Everything Worked, and the Day After

The two days of treatment described in the account below should first simply be counted, without being judged.

Day one. The patient crosses the boundary of his radius of movement. Beyond it the panic comes, he weeps, the psychotherapist waits calmly, and after two or three minutes it is over. They walk on almost as far as the next village. He fetches himself a stick and knocks pears down from a tree. After the lunch break they choose a route he had avoided even more strictly and walk some three kilometers through the woods. Part of the way he goes alone. That evening he feels, in his words, like a new man.

Day two. It is raining, so they drive. The villages of the area, individual streets within them, the shopping centers of the small town, the industrial park, the visit to his brother, whose apartment he had never been able to call on. A scant hour for lunch. Then fifty kilometers of autobahn, then Koblenz with its commercial district, then another town, then two hours back across country.

By every behavioral measure, the second day is the triumph. A fear hierarchy for which weeks are budgeted elsewhere has been climbed in a single afternoon. Not one item was avoided. The catastrophe failed to occur everywhere.

The result reads: “It was all too much, everything I experienced in that short time.” And before it the sentence that matters: “By that point I had stopped caring about almost anything; I simply let it wash over me.” The next morning he breaks off. The trust is gone.

This document thus furnishes the cleanest evidence for a fact that is seldom stated in anxiety treatment: the situation mastered is not the treatment outcome. The outcome is the cognitive change, the insight the patient gains from it. On the first day he gained one—he could have moved mountains. On the second day he gained none, because no strength was left for thinking and recognizing. From the outside, both days looked like progress. Learning took place on only one of them.

The Sentence in Which the Patient Corrects His Own Treatment

Between the two days stands a remark that is easily read past because it is phrased so casually: “As I now realize, it would have been better for me to break off the therapy for that day and process the experiences I had gained.”

Here a man with no professional training whatsoever asks for precisely the psychotherapeutic step that was withheld from him. To process means: to go through what one had expected, what actually occurred, and what follows from that. This is the cognitive work that cognitive psychotherapy¹ performs, and without it nothing remains of a successful outing but the memory of a strenuous day.

That he lacked not only this evaluation but the cognitive preparation as well had already become apparent in the preliminary interview. He always had so many questions he wanted to ask, he writes, “but they were never really answered.” He would have liked to know where his anxiety came from in the first place. The reply was that one should not go rummaging around in the past; the fear was simply there and could be brought under control only by living through it again.

This answer ignores every precondition of a successful psychotherapy for anxiety and panic disorders: first making the development of the patient’s anxiety intelligible to him as a learning history gone wrong, and correcting the errors of reasoning and false convictions he acquired in its course. That is what the cognitive preparation of any exposure consists of.

Carmen Heerdegen, MD, who commented on the account for the editors in 2001, named the standard in a single sentence in the text below: it counts as psychotherapeutic malpractice to conduct exposure with a patient without adequate cognitive preparation.

What This Document Establishes and What It Does Not

It is a single case, and it is one voice. The two psychotherapists have not been heard; their view of the treatment is not available. The account describes the year 2000 and was published in 2001. About the present condition of the institution named it says nothing.

What it does show is something else, and more important. It shows that the pleasure of overcoming anxiety is not an invention of providers. It arose here unbidden, on the first day, in a treatment that failed—and it arose most strongly at the moment when the patient had walked a stretch alone. Why this is so, and why it can be produced by design, is set out elsewhere.²

How this account came about, and what other former patients of the same institution wrote, is in Part 1.³ How the second attempt at treatment went, in Part 3.⁴

Appearance and Reality in the Behavior Therapy of Anxiety and Panic

Psychotherapy with the Christoph Dornier Foundation in Marburg—a patient’s account. Psychotherapy clinics as an expensive illusion in anxiety and panic disorders, Part 2 of a three-part series.

By Helmut Mayer*

Journal PSYCHOTHERAPIE
December 31, 2001

Continued from Part 1.

I want to try here to explain my problem with the anxiety disorder. It began in 1982, it was August and very hot. I was driving my car along an access road toward my workplace. Ahead of me a traffic jam, nothing was moving anymore, and then that heat. All at once something strange rose up in me, a feeling of fear, of constriction, of panic.

I thought: this is the end. And of course I wanted to escape as fast as possible from this situation that felt so life-threatening to me, which I managed to do, because the jam cleared and I was able to get away at full throttle toward my workplace. The panic still had hold of me during that drive; it eased once I had arrived. But then it took me quite a while to find my way back to myself.

Unfortunately I failed to confide what had happened to anyone. I thought it was surely a one-off and that something like that certainly would not come back. And as a man, even at only 22 years of age, you are not allowed to have anything like that; you are supposed to be strong.

What is described is the typical onset of an anxiety and panic disorder. As a consequence of stress, a panic attack occurs for the first time. The perceived loss of control leads to the fear that it might happen again. Had a good psychotherapist been consulted at this point, the nineteen-year history of suffering would have been nipped in the bud in one to three therapy sessions.

Commentary: Carmen Heerdegen Specialist in neurology and psychotherapist, Stuttgart.

And so the days, weeks, and months went by. My job also required me to drive a truck fairly often, which was not exactly easy after that dreadful experience. I kept thinking about that situation, but somehow I managed to keep it all together. I should mention, though, that at that time I did not lead a particularly healthy life: a lot of work, stress. Alcohol and nicotine almost every day. On the day in question too—it was around midday—I had already been drinking beer at our branch office. Today I see it with quite different eyes, that I had a physical reaction like that.

Then, after three years, a year of unemployment came my way. I already had trouble registering as unemployed, since that meant going into the county town. It was a feeling of constriction when I had to present myself at the employment office, but I somehow got it done all the same.

During that period I would only drive anywhere if I had drunk at least five or six bottles of beer; there was no other way. I was simply afraid to leave my familiar surroundings, into which I withdrew more and more.

Then, to my surprise, I received an offer from my old boss to take over the branch where I had often helped out before. That was a great feeling, of course. It was about 12 kilometers each way. And it worked quite well—at first. I came to feel more and more comfortable at work. I dealt with customers a lot and it was fun. If only it had not been for that drive from my workplace to home and back. That drive, which kept getting harder for me.

What I did: I drank beer again in order to get home. Then it went reasonably well. Going to work in the morning I did not have that much trouble. And then came more and more days when my courage simply failed me and I could not drive to work at all. There were more and more days off. And one day it had to come to this, that I received my notice. Somehow I was even relieved not to have to take the strain on myself every day.

I withdrew more and more and still told no one about my problems. I did not even register as unemployed. After all, I would have had to make my way into town again and perhaps even take up a new job. All of that I sidestepped by not registering.

Shortly after being let go I also had to report for a reserve duty exercise, which was of course a horrifying prospect for me. My journey was to take me almost as far as Flensburg, where I had been once before. After much back and forth and arguments with my parents I did set off. A friend of mine agreed to drive me there in his car. Naturally I had to numb myself with beer again, but it worked.

The years went by, and I lived in my small world. It was not so bad, really. I always had enough to eat, friends came to visit, and now and then I earned a few marks at home repairing cars, which I had once trained to do, or helping my neighbor with his house. I came to terms with my illness and the situation.

Of course it was not always easy for me, having to invent excuses again and again whenever I was asked for a favor that would have required me to leave my familiar surroundings. Nobody knew exactly what was wrong with me, not even I did.

I also always had enough distraction in the form of gardening, cutting firewood, or my animals. Of course it has advantages and disadvantages when, like me, you live well outside a village, practically in the woods. Over the years I really did get used to the situation of no longer driving anywhere, no longer visiting friends or my siblings and so on. But somehow something was missing all the same. I simply felt cast out of society.

At some point people also stop asking. They think he does not want it any other way, this is how he wants to live. And in part they are right. You have hardly any responsibility and can do almost anything you feel like.

In October, by chance, or perhaps it was fate, I met my girlfriend. She moved in with me shortly afterward. And I had the feeling of being needed after all. It was a very good time for me. During the day I could get on with my work around the house, knowing that in the evening my girlfriend would be with me after work. At last I had found someone I could tell my problems to. And I was already feeling much better. Now and then I did have to pull myself together and drive somewhere with her, even if it was only to her parents, who lived about four kilometers away from us. But that too worked only if I had had some alcohol beforehand.

Then on one occasion, just outside her parents’ house and despite the alcohol, I had a panic attack that threw me badly off course. From that moment on I resolved not to drink any more alcohol when I wanted to go somewhere. But that then led to my being unable to undertake anything of the kind with my girlfriend at all. We did take walks in my familiar surroundings, but that was all. No visits to friends, no going to a pub or a club, no going out to eat and so on, the things other couples take for granted. She had great understanding for me. So we simply stayed at home. She kept trying to build me up and to encourage me. For all her efforts she did not succeed in freeing me from my prison.

I did want to change something, but how? Somehow I saw no way out of my vicious circle.

Then I saw a report on television about the Christoph Dornier Foundation for Clinical Psychology in Marburg (CDS). From then on I knew that there are many more people, men even, who have the same problem and who can be helped.

Those affected mostly learn only through media coverage or from books that they suffer from an ordinary anxiety disorder that is highly treatable. This is the deplorable and typical reality of care. Family doctors are often incompetent when it comes to psychological disorders and, with superfluous examinations and pills, delay the psychotherapy that is required.

Commentary: Carmen Heerdegen Specialist in neurology and psychotherapist, Stuttgart.

And from that moment on I resolved to do something about my anxiety problem at last. I contacted the CDS in Marburg by telephone. In a conversation with a psychotherapist employed there I learned that I too could be helped, even though my anxiety disorders had already lasted so long. That gave me courage and hope, and more of an appetite for life came back as well: to do all the things I used to do, above all together with my girlfriend. That really was a great feeling. At that point I had no idea yet what was going to come at me.

But now there was a large hurdle in front of me, which of course discouraged me again. Who pays for a therapy like that? Since I was neither registered as unemployed nor covered by health insurance, I turned to my responsible regional pension insurance office (LVA) in Speyer, which, after a good many letters back and forth and of course many months of time, arrived at the conclusion that I should be referred to a psychosomatic clinic in the Saarland.

That offer was one I could not possibly take up, since I was unable to leave the radius of some 500 meters I had set for myself. But of course the case officers had no understanding for that whatsoever: no, they had never heard of an illness like that. That struck me as very odd.

A therapy of the kind the Christoph Dornier Foundation for Clinical Psychology in Marburg provides would not be recognized by the LVA, and so of course there was no question of its covering the costs. All my hopes of becoming a healthy person again were taken from me once more.

Then, with my girlfriend’s help, I made contact with a social worker in our district. She came to see me and we had a long conversation. She could not hold out much hope either that any agency would cover the costs. But she said she would try. And so it came about that she was able to persuade the public health officer responsible for our district to visit me. Which then happened within a short time. The public health officer then managed to convince the district social welfare office to fund a psychotherapy for me.

That was a weight off my mind, of course: at last it could begin. Once that hurdle too had been cleared, I still had to wait several months until the CDS had an opening for my therapy.

In September of last year the time finally came, and a psychotherapist from Marburg came to see me for an initial interview. In the course of an hour she tried to convey to me what was going to come at me, and of course she had formed a picture of my illness beforehand.

Three weeks later it was supposed to begin. We sat down together at my place once more and talked everything over calmly. Even at that point I still did not know anything more specific. I always had so many questions I wanted to ask, but they were never really answered. I thought: these people are trained and surely know what is right. I would also have liked to learn from her where these anxiety disorders might come from in the first place. All I was told was that these fears are there now and that one should not go rummaging around in the past, which in the end would not produce any concrete solutions. You have this fear, and the only way to get it under control is to live through it again, that is, to go into the situations that trigger the anxiety. She then had me write down which situations I could imagine to be really terrible.

It counts as psychotherapeutic malpractice to conduct exposure with a patient without adequate cognitive preparation. The account shows that the psychologist from the Christoph Dornier Foundation never “really answered” the questions that were essential to this highly motivated patient’s indispensable understanding. Qualified cognitive preparation enables those affected, in the overwhelming majority of all cases, to master their problem situations successfully on their own. Dramatic accounts such as this one merely illustrate needless suffering caused by improper practice.

Commentary: Carmen Heerdegen Specialist in neurology and psychotherapist, Stuttgart.

So the next morning it was down to business. At my own wish we simply set off walking. Once I was past my boundary, my stomach already felt distinctly queasy. I told her so, which was the right thing to do.

She said: we are going on. And when we were about 500 or 600 meters from home and I could no longer have fled quickly enough from this situation, the spiral of fear came at me in very large strides. Everything welled up. First the feeling of what are you doing here, you are not in your safe zone anymore, you cannot get out of here quickly at all. I thought my final hour had come.

I wept, I was in despair, and I looked at this psychotherapist, who to my astonishment stood there perfectly calmly and, as it seemed to me, waited for my reactions. But it was only two or three minutes and then it slowly began to pass. I had to look around me. After all, we were in the middle of open farmland. I was also supposed to keep imagining that I was about to collapse and so on, always the worst. It felt very strange to me.

Then we walked on. I was in a daze, but somehow it worked. I thought, you have to get through this. It must be right, what she is doing with you here, it is part of it. I also thought that if I were to get out of this again, which at that point I could not imagine at all, I could tell my girlfriend about it that evening with real pride. And that gave me strength.

We then walked on almost as far as the next village. There stood a pear tree, and I thought, fetch yourself a stick and knock a few pears down, which I did with pleasure. Perhaps I also wanted a bit of distraction. That is how I see it today. Then we marched on, and it even slowly began to be rather fun, walking on my own the stretch of road I had been avoiding for years and used to drive almost daily. There was nothing else I could do at that moment; I would rather have been at home.

With these first impressions behind us, after a lunch break we chose another route, one I had avoided far more strictly. Because cars and walkers were constantly going back and forth to an inn out in the woods. Once again I had the fear of fear. But to my astonishment I noticed that the really big fear simply failed to come; it was quite remarkable. It was a strange feeling, but it worked. There was also the unfamiliarity of it all; so much had changed in recent years. We walked about three kilometers through the woods, and all the new impressions were somehow fascinating.

Then I also had to walk a good stretch alone, which to my astonishment I managed. That evening I felt like a new man. I could have moved mountains, that is how good I felt.

The next morning I hoped we would walk the same route or at least a similar one. It was raining, and the psychotherapist decided that we would go by car, which of course sent a shiver of fear through me. But to my astonishment it went relatively well. That strange feeling was there again, because in my imagination this situation should have been a horror trip.

We drove—with me as the passenger—to the individual villages in my area. In the villages themselves we then drove along individual streets, and I was also able to watch people, which again was very unfamiliar to me. In the next small town, about eight kilometers from me, we drove up to the individual shopping centers, parked there, and watched the people going in and out. It was very strange again, and I could not have gotten out either, or so I thought at that point, which I did not have to do anyway.

At my own wish we then also drove into the industrial park. Again I was able to gather a great many impressions, because there too, as in the town, a great deal had changed in recent years.

I then suggested to her that we might drive on to another village, because my brother has lived there for four years now and I had never been able to visit him. And so we did. I got out alone and went up to his apartment. After I had been with him for about 15 minutes, we drove back to my house.

During the scant hour of the lunch break I could not take in everything that was coming at me in the way of new impressions. As I now realize, it would have been better for me to break off the therapy for that day and process the experiences I had gained. But as I said, that was only my opinion, because after the break we drove onto the autobahn; there too that strange feeling was back, but this time it worked. The really big fear failed to come this time as well. Of course it was there, but not as strongly as I had painted it for myself. The whole time we kept up a dialogue, as we always had. She asked me about my thoughts and feelings. I could only report them as I felt them at that moment.

When we had driven some 50 kilometers, we turned off toward Koblenz. Of course I felt very different when I saw all those cars driving past us or coming toward us—and me in the middle of it. There was a feeling of constriction in me, but what was I to do: I could not flee. After that we drove through the whole city, and Koblenz is a hectic city. All the people, it really was very, very strange to experience all of that. Koblenz also has an enormous commercial district, which we then drove through as well. There were a great many new impressions, all the shops and firms one had known only from advertising brochures and by hearsay, now to be seen live.

Then we drove on to the next town, and I have to say that by that point I had stopped caring about almost anything; I simply let it wash over me. It was all too much, everything I experienced in that short time. From there we drove home across country, which took about another two hours.

That evening my nerves were so shot and I simply had no strength left. I fell asleep that evening still doing 180, and woke up at the same speed, to put it in my own words. It was simply too much for one day. And in my opinion the psychotherapist ought to have known that. I simply had no strength left, and the next morning I told her that I could not go on and wanted to end the therapy.

Which is what we did. Over the following days I remained in telephone contact with her. Because I wanted to carry on alone, since my trust in this lady was gone!

Loss of trust and failure were the foreseeable result of an exposure treatment that merely took the patient out but did not make his errors of reasoning, or the psychophysiological connections with his anxiety disorder, intelligible to him. That is why he could achieve no success in the exercise, either with the psychotherapist or without her—and capitulated.

Commentary: Carmen Heerdegen Specialist in neurology and psychotherapist, Stuttgart.

My girlfriend and I also made a car trip to the next village, which I managed very well. We likewise went for a long walk, which apart from the usual initial difficulties also went well. After that I no longer wanted to make contact with this psychotherapist.

*Name changed to protect the individual’s privacy.

We thank the author for the courage and the effort it took to write this documentation, “in order to be of help to other patients with anxiety disorders.”

Read in Part 3 how the second attempt at psychotherapy with the Christoph Dornier Foundation likewise remained unsuccessful.

Published on 12/31/2001.

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