The Patient Did Almost Everything Right
The second attempt at treatment should first be read as a record of achievement—the patient’s achievement.
He negotiates a procedure in which he himself decides what is undertaken. He chooses to repeat the same routes, because he suspects this will make them easier—which proves correct. He walks two kilometers alone across the fields to the neighboring village, waits there in a barn, and finds that happiness sets in. From that point he feels his way forward in short walks, but stops short of the village center, because a second, different fear begins there. He sets off home on his own initiative, even works out a new route for himself, and arrives.
And then he makes the wisest decision in the entire account. The psychotherapist wants to go out to eat with him afterward; the patient declines, because he is wet, tired, and at the end of his strength and, in his own words, wants to prevent his positive impressions from turning into their opposite. He had experienced that reversal the previous autumn and had drawn the lesson from it.
The reaction to this stands in the text: the psychotherapist became downright angry; this was a unique opportunity, he said, one the patient would never get again. The next morning he drove off visibly annoyed.
With that the relationship is stood on its head. The one component of this treatment that worked was the patient’s own judgment—and it was treated as a discipline problem. Apply the standard that Carmen Heerdegen, MD, formulates in the text below—good psychotherapists make their clients into competent psychotherapists for themselves—and the conclusion is unavoidable: at the very moment the patient reached that goal on his own, he was reprimanded for it.
The Hearse
Before setting off alone, the patient asks a question that, by his own account, he had never dared ask out loud before: what would happen if he dropped dead along the way?
For a cognitive psychotherapist this is the most favorable moment in the entire treatment. The patient lays his catastrophic prediction on the table unprompted, in a single sentence, clear and testable. From here the path runs through a handful of questions: How likely is that? What would have to be the case for it to happen? How often has the prediction proved right so far, and how often wrong? What speaks for it, and what against it? At the end there stands an expectation the patient has formulated himself, one the walk will then either disconfirm or confirm.
The psychotherapist’s answer was: “Then I’ll call the hearse.”
One may take this for gallows humor, and it was probably meant that way. In substance it is the inversion of the treatment. The patient’s false conviction was not examined cognitively but acknowledged with a joke and left standing. The man marched off while continuing to hold it possible that he might die in the process. That is courage. It is not psychotherapy.
And here lies the explanation for why the success did not hold. By current knowledge, exposure works not through habituation but through the cognitive correction that precedes it and the subsequent experience that the feared catastrophe fails to occur in the situation. An expectation, however, can be disconfirmed only if it has first been stated and recorded as a testable proposition. If it remains unstated, the patient passes through the situation, arrives unharmed—and keeps his false expectation. That is precisely what happened here, and over the following months he was avoiding again.1
What Was Left to Him: A Method for Administering the Anxiety
The end of the account is the bitterest passage in the whole series, and it should be read slowly.
The man builds himself a treatment plan: twenty stages, each about one hundred fifty meters apart, remaining at each stage until he is entirely free of anxiety, and repeating that at least three times per stage. On consulting the institution he is told that this could be a step in the right direction; it would only take much longer.
He has adopted the doctrine of habituation so completely that he now applies it against himself—including the condition “until I am completely free of anxiety,” that is, precisely the quantity that was later shown to have no predictive value for treatment outcome. They did not take his anxiety away from him. They left him a method for administering it.
A line further on stands an admission that makes visible the limit of self-help without professional cognitive guidance: he had, he writes, read up on a great deal of general knowledge about anxiety disorders in recent months, but had not succeeded in putting it into practice. Carmen Heerdegen, MD, the specialist and psychotherapist, notes in her commentary that books regularly prove a poor investment here.
That is correct, and it calls for a distinction that is seldom drawn. A book addresses everyone and knows no one; it can explain general connections, but it cannot identify the individual errors of reasoning the particular reader commits. The difference between reading and written psychotherapeutic work lies not in the medium but in who examines whose convictions. A man who only reads accumulates knowledge about anxiety. A man who writes and receives professional cognitive guidance while doing so works on his own.
What This Document Establishes and What It Does Not
It is a single case and one voice. The two psychotherapists have not been heard. The patient himself expressly records in the text that the institution probably sees the matter differently, and calls that understandable. The account describes the years 2000 and 2001 and says nothing about the present condition of the institution named.
On the private circumstances. The account ends with the breakup with his partner. It belongs to the document and is therefore reproduced, but it does not explain the failure of the treatment—that lay half a year earlier and had long since occurred by then.
What the text does show is something else. The missing component of this behavioral exposure treatment was not effort. This man had that in abundance: against the authorities, against the funding agencies, against the rain, against himself. What was missing was the preparatory and accompanying cognitive work that makes intelligible to him how he learned the anxiety, that corrects his errors of reasoning, and that turns the exercises into a gratifying confirmation of his corrected thinking.1
The beginning of the series is in Part 1,2 the first attempt at treatment in Part 2.3
1 Luchmann, D.: Why Cognitive Psychotherapy for Anxiety Is a Pleasure. Psychotherapie. 08/08/2026. [See there the evidence on expectancy violation as the active ingredient of exposure, in particular Craske et al. 2008 and 2014, and on the role of the accompanying psychotherapist.]
2 Seelen, G.: Behavior Therapy: Appearance and Reality. Part 1: “I went through the Christoph Dornier Clinic, and I’ve been broke ever since”. Psychotherapie. 12/31/2001.
3 Mayer, H.: Behavior Therapy: Appearance and Reality. Part 2: A Patient’s Account of Exposure Treatment for Agoraphobia and Panic Attacks. Psychotherapie. 12/31/2001.
The patient’s account below first appeared on 12/31/2001 in the journal Psychotherapie. What follows is a translation of the German original, reproduced in full—including the terminology of the day and the plain, unliterary voice of the writer. The author’s name was changed as early as 2001 to protect his privacy; he expressly released the account for publication. The interpolated commentaries are by Carmen Heerdegen, MD, a specialist in neurology and a psychotherapist in Stuttgart; the statements there concerning medicinal products reflect the regulatory and review status of the year 2001. The account reflects the state of knowledge of the years 2000 and 2001 and makes no statement about the present condition of the institution named.
Behavior Therapy of Anxieties, Phobias, and Panic Disorders
Psychotherapy with the Christoph Dornier Foundation in Marburg—a patient’s account. Psychotherapy clinics as an expensive illusion in anxiety and panic disorders, Part 3 of a three-part series.
By Helmut Mayer*
Journal PSYCHOTHERAPIE
Continued from Part 2.
In the previous part I described my first unsuccessful psychotherapy with the Christoph Dornier Foundation in Marburg. Having lost my trust in the psychotherapist, I now stood there more or less alone again and simply did not stay on the ball. Today I know that this was a mistake. Bit by bit I then slipped back into my old pattern, which consists precisely of avoidance.
In the spring of this year I decided to continue the psychotherapy with a male colleague of hers, which, after some correspondence with the responsible authority, was also approved. I thought I might have more trust in a man and that he would also bring more experience with him.
When he introduced himself to me, I had to note that this psychotherapist was no older than 30 either, which again gave me pause. We then worked out a completely different treatment concept. It looked like this: from now on I myself could decide what we would undertake. I liked that very much. After all, I no longer wanted to have to drive around a city while I still could not manage here at home.
One day we did a great deal of walking, mostly the same routes. Because I was of the opinion that the more often I master these situations, the easier it will become—which turned out to be right. Now and then those old negative thoughts came up as well, that I would not manage any of this, but it went better from hour to hour. On the third day I wanted to walk a whole stretch alone; I had already worked out a route that seemed sufficient to me for a start. But the psychotherapist said he had thought of a different, longer stretch. It was to lead to the next village, which of course gave me a shock. Nevertheless, after a short pause for thought, I agreed. I also asked him what would happen if I dropped dead. His answer has stayed very clearly in my memory. He simply said: then I’ll call the hearse.
I did not find that so wonderful at all, and I marched off anyway. At the start I was already very nervous. After a while it went better, and I marched off across the fields all alone toward my destination. I really was glad that it was March and raining quite hard. In the summer heat I certainly would not have done it. Ever since that first panic attack in the summer of 1982 I have had trouble in great heat.
After three quarters of an hour I had reached my destination and took shelter in a barn used for farming that stands just at the edge of the village. It was a strange feeling, standing there all alone in unfamiliar surroundings. But a feeling of happiness came over me as well. I, yes I, had managed it entirely on my own, walking those two kilometers without any great trouble. Since we had arranged to meet there, I waited for the psychotherapist, who was also on foot but would certainly take longer, because he had to go the long way around. Bit by bit I felt better and better in that spot, so that I made shorter walks in the direction of the village.
But I did not dare go as far as the village center; there that fear came up again. I might, after all, run into someone I knew, since I still know most of the people there from earlier days, having served my apprenticeship in that village. To be in surroundings unfamiliar to me and then to meet an acquaintance as well, who would then be sure to ask what I was doing here in this rain, and me not knowing what to answer—no, that was too much. So I kept always within a short distance of that barn, where I could have hidden if need be.
When I had been in that area for almost an hour and the rain had soaked me through, I decided to set off home. After all, I did not know where my psychotherapist was. Perhaps he was in the village center, where I did not want to go anyway, at least not alone.
So I marched off in the direction of home, and I also had the thought that I would manage this. Simply to say, I am going home now, without thinking as I used to, I will never get home again. That was a powerful feeling. That I was a little afraid was of course clear, but there was a feeling that said to me, off you go, you can do this.
And I did it! I even worked out a different route for myself, and that was a great feeling. Not long afterward, when I was already home, my psychotherapist arrived and said that I had done the thing very well. He then wanted to go straight to a restaurant with me to eat. That again produced great unease in me, because even when I was healthy I had never liked doing that sort of thing. I told him that I did not want to; I can always do something like that when I feel like it. At that point I was also soaked to the bone, and I thought to myself that I did not want to take on much more in a single day, because I had already gathered experience about that. And before my positive impressions and thoughts could turn into their opposite as a result, I proposed leaving it at that for the day. Which did not suit him at all, so it seemed to me. I simply had the feeling that I now wanted to carry on with the psychotherapy alone.
The second psychotherapist of the Christoph Dornier Foundation likewise merely took the patient out but did not do cognitive work with him. A neighbor or the girlfriend, so the account suggests, could have done it no worse. Despite the needless ordeal caused by the lack of cognitive preparation, the patient’s own efforts are admirable. Unfortunately they are not sufficient on their own for success.
Commentary: Carmen Heerdegen Specialist in neurology and psychotherapist, Stuttgart.
By that point I was also somewhat overtaxed again, but I did not want to let it show. It is quite clear that a psychotherapy of this kind is no picnic. Since I know myself best, I knew only this much: if I had been supposed to carry on there and drive around the area again by car the next day, it would have come to the point once more where I would not have kept this psychotherapy in any good memory. No, I would simply have withdrawn again—and that was not what I wanted.
So I told him plainly what I think and feel, and that I now wanted to take my steps alone. He became downright angry: this was a unique opportunity for me, I would never get it again, and so on. But with his behavior he only strengthened my resolve to continue the psychotherapy alone. I was to sleep on my decision once more, which I did. With the same result. He then drove off that morning, visibly annoyed and angry as well.
By way of conclusion about these two therapies I could and still can say this much: it all seemed very impersonal to me. The psychotherapists did not go into my thoughts and feelings nearly enough, which, given the high costs the last psychotherapist kept pointing out to me, made it all feel as though it were simply being processed.
The feeling came over me that they had a well-rehearsed program to run through in a short time. And that a so-called therapy dropout, as he called it, would not contribute to their success. As I said, that was and still is the impression I formed. And I stand by it today. Even if the CDS probably sees it differently, which is also understandable.
I then began to carry on alone. I was out and about a great deal, mornings, middays, and evenings. Mostly on foot. Or on my off-road motorcycle. That was fun too. I always went a little farther out, but unfortunately not far enough. That fear kept coming back. There were days when I went farther out and days when I did not, because my old pattern of thinking kept breaking through.
Even in the company of my girlfriend at the time I simply did not manage it. I thought all the effort with that expensive psychotherapy had been for nothing. But it had not been, as I know today. For I do have the realization that I too can do it. Well then, it was by no means fun driving around the city, but those walks in the countryside I love were in the end very fine indeed. My goal was never to drive around a city anyway, but to gain a foothold again, gradually, here in my familiar surroundings.
And that is still my goal. Only sometimes I do lose my belief in it, unfortunately.
I see people moving about freely, driving here and there, simply doing the things they enjoy, and then a great deal of wistfulness comes over me. I feel left out, not part of things, not properly accepted, and so on.
And at the end there came the further aggravation that my girlfriend broke up with me. Because, as she said, she simply could not summon the strength anymore and saw no shared future in our relationship. Of course a world collapsed inside me. Here I had taken on all the effort and all the strain in order to have a good future with her. And now this. I thought, none of this can be happening. What am I supposed to keep working on myself for now? All the plans and dreams for the future were destroyed at a single stroke. I was sitting in a very deep hole, out of which I am now slowly climbing again, looking around to see whether the world is still there.
But I often catch myself allowing the thought, you can do it alone too, but only what for…
The thought of doing it for myself still strikes me as absurd. Or perhaps not? Unfortunately I do not properly know yet; the time since our separation is not long enough for that. I was always so happy to tell my girlfriend in the evening about my successes, even when they were only small steps. And now: whom am I to tell about my successes in future? It is a very strange state to be in, one which, as I now know, also passes. It simply takes its time. My ex-girlfriend certainly wants to go on helping and supporting me. But she does not live with me anymore, and everything is a little different.
A few weeks ago, when we had not yet separated, I made the decision to try psychotropic medication, although since childhood I have been opposed to all medicines. And then I came across a page on the internet reporting a study according to which a kava-kava product had achieved the same effects. I obtained this product. The dosage was 120 mg once a day. I discontinued my St. John’s wort tablets and took this kava-kava product over a period of three weeks. But no improvement set in even in the third week, so I decided to go back to my tried and tested St. John’s wort tablets.
Many people suffering from anxiety and panic reach sooner or later, in their desperation, for tablets, and thereby enlarge their problems. Tablets cannot change thinking. Pathological anxiety, however, is the product of misdirected thinking, and what helps out of it most effectively is cognitive behavior therapy. Incidentally, kava is suspected of damaging the liver. The Federal Institute for Drugs and Medical Devices is therefore examining a ban on kava-containing sedatives and relaxants. Against this background the pharmaceutical company Merck already withdrew its kava-containing sedatives and relaxants from the market at the end of November.
Commentary: Carmen Heerdegen Specialist in neurology and psychotherapist, Stuttgart.
Here at home, or within the radius I have set for myself, I have hardly any anxiety or none at all, but I have noticed that I am much calmer since I started taking these tablets about three years ago.
Now I have finally got to the point again where I am trying to ride my off-road machine at least out to where I was before, that is, at the end of the psychotherapy, and I am managing that reasonably well. But as soon as I want to go just a few meters farther, the saboteur reports in again and gives me the feeling that I have to turn back, which in the end is what I do.
Because a friend is soon going to give me a small car, I have worked out a hierarchy plan for myself. It consists of 20 stages. The first stage is the one where I feel the least anxiety, the second where I feel more anxiety, and so on. At each stage I have to stay until I am completely free of anxiety. And I then repeat this at least three times per stage before moving on to the next higher stage. That is my theory. What the practice will look like in my case I do not yet know. In any case I intend to try it as soon as I can call the car my own. I have worked out the individual stages so that they are about 150 meters apart. We shall see whether I manage it. On consulting the CDS I was told that this could be a step in the right direction. It would only take much longer. But I have no other choice than to help myself. Whether I will manage it I do not know, but in any case I clutch at every straw offered to me that might promise success.
In recent months I have read up on a great deal of general knowledge about anxiety disorders, but putting it into practice is something I have not managed so far.
Trying to overcome anxiety and panic disorders with a book alone regularly proves a poor investment. The market offers many books, but not one that replaces psychotherapists who lead individually to success in only 12 hours.
Commentary: Carmen Heerdegen Specialist in neurology and psychotherapist, Stuttgart.
I have only one wish, to get my anxiety disorders under control and to be able to lead a normal life again. I hope I have been able to convey to you an impression of my life, of the psychotherapy, and of what happened afterward.
*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.”
To Part 1, the opening article of this patient’s account concerning the Christoph Dornier Foundation and the Christoph Dornier Clinic.
Published on 12/31/2001.
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