Behavior Therapy: Appearance and Reality. Part 1: “I went through the Christoph Dornier Clinic, and I’ve been broke ever since”

What One Patient Knew Seven Years Before the Research Did

In June 2001 a woman wrote to the editors who, in 1996, had become aware of the Christoph Dornier Clinic in Münster on account of an anxiety disorder and had been treated there as an inpatient. Her account contains three sentences that should be read one at a time, because each of them anticipates a finding that research had not yet formulated.

The first sentence reports what had been explained to her as the working principle: “Through the habituation effect my body would learn that this is not a dangerous situation.” Habituation means getting used to something. What is meant is the expectation that physical arousal subsides of its own accord if one remains long enough in the feared situation, and that the fear goes with it. The 2001 report describes this sentence as the single most important instruction the patient received in her psychotherapy.

In 2008 a group led by Michelle Craske reviewed the evidence for exactly this assumption and reached a conclusion that pulled the ground out from under the practice of the day: neither the extent to which fear declines within a practice session nor the level of fear at the end of the session predicts treatment outcome.¹ What does predict it is the disconfirmation of an expectation—a process in thinking, not in the body.² The sentence handed to this patient as her working principle was withdrawn as a working principle by research seven years after she wrote her letter.

The second sentence describes what she actually did during the exercises: “I only ever endured the anxiety situations by rescuing myself mentally across the time.” In today’s terminology she has described a safety behavior—a measure, that is, which calms a person in the moment and for that very reason deprives him of the experience that would matter. That this is not theory has been tested experimentally: patients who gave up their safety behavior during an exposure lost their catastrophic convictions far more markedly than those who retained it.³

The whole tragedy of this treatment thus stands in two lines. The woman completed the exercises—and while doing so did the one thing that renders exercises ineffective. She did it not out of resistance but because no one had told her what she was supposed to be learning. And no one could have told her, because it had never been established what she actually feared—no cognitive analysis and preparation had taken place.

The third sentence is the most important, and it is regularly read past: “After the exercises I was never able to take any pleasure in my success; instead I was already occupied with the next anxiety exercise.” Here is the diagnostic mark. A person who tests a conclusion of his own and finds it confirmed feels satisfaction; a person who survives a stretch of time in a state of alarm feels exhaustion. The absent pleasure is therefore not a trait of the patient’s character but a piece of information about the treatment.⁴

What the Letter Writers Knew Before Their Treaters Did

What is remarkable about these letters is that the senders were not professionals and named the error clearly all the same.

One reader wrote in January 2001 that he had broken off his treatment “because the exposure began with the worst anxiety situation. On the cognitive level there was no therapy at all.” He names two things and takes the first for his complaint. The complaint, however, lies in the second sentence. Beginning with the worst situation is not an error but the more efficient procedure: a man who no longer fights his anxiety, because he has understood that it is the product of his own errors of reasoning and therefore cannot harm him, does not need the small intermediate steps and only loses time with them. What this presupposes, however, is precisely what was omitted here. Without cognitive analysis and preparation every step is too large, even the smallest; with the right thinking none is too large. Another reader asked simply, “What am I doing wrong?”—and received, by his account, no satisfactory answer.

From this the report below already formulated a standard in 2001, and it has not changed since: in phobias and in anxiety and panic disorders, relying primarily on exposure without adequate cognitive preparation is a common and consequential error. Carmen Heerdegen, MD, the specialist consulted at the time, named the criterion of quality in it: good psychotherapists measure themselves by how far they have managed to lead their clients out of their problems and to make them competent psychotherapists for themselves, so that they can go on along the road of success alone.^5,6

This standard is not a matter of taste. It follows from the mechanism of action: if what works in exposure is the refutation of a conviction, then the patient has to know which conviction is being tested—otherwise he has entered the situation but experienced nothing. That knowledge must necessarily be acquired from a prior analysis of his cognitions, over which cognitive psychotherapy teaches the patient to assume control and command, so that he can cure his own anxiety and panic disorder.⁷

What This Text Establishes and What It Does Not

Three qualifications belong at the front, not in the fine print.

First, letters to an editor are not a sample. Those who write are dissatisfied; those who were cured rarely write to a journal. The editors recorded this themselves in 2001, and it holds unchanged. What gave them pause at the time was not the number of letters but the fact that no other institution generated a comparable quantity.

Second, the text describes the years 1996 to 2002. The institutions named have changed since then, as every institution changes over a quarter of a century. About their present condition this document says nothing, and it is not meant to. The statement the clinic saw fit to issue in November 2002 is reproduced in the text.

And third, the polemical tone of 2001 has been left standing—dogs, restroom attendant, suckers and all. It belongs to its time and is not smoothed over after the fact here.

What remains of this text, therefore, is not a verdict on a single psychotherapy clinic. It is the answer to the question of why this treatment had to fail. Exposure works not because the patient grows accustomed to the fear but because a particular apprehension turns out to be false. But a man who has never stated what exactly he fears cannot experience its failure to occur either; all that is left to him of the exercise is the effort. This is why cognitive work on thinking is not an agreeable preliminary conversation that could just as well be skipped, but that part of the treatment which makes the exercise effective in the first place. And this key function of cognitive work was confirmed not by the opposing camp but by behavioral exposure research itself—the very line of research from which the practice described here came.

Psychotherapy Clinics as an Expensive Illusion: Behavior Therapy at the Christoph Dornier Clinic for Psychotherapy in Münster

Behavior Therapy: Appearance and Reality—“I went through the Christoph Dornier Clinic, and I’ve been broke ever since.” Part 1 of a three-part series.

By Gottlieb Seelen

Journal PSYCHOTHERAPIE
December 31, 2001

The business magazine knew it for certain. “Millions of people suffer from anxiety. They wait years for a cure. Yet behavior therapy can help 80 percent of the afflicted within a few days,” writes Magnus Heier in CAPITAL: “In the best case, one week of therapy is all that separates a person rendered unfit for life by the fear of fear from an entirely normal existence—provided he receives the right treatment.” But that is not easy to come by, not even at the supposed top clinics whose names the journalists keep copying from one another.

In Germany, alongside physicians holding the psychotherapy qualification, there are more than 25,000 licensed psychological psychotherapists, roughly half of whom are in private practice as members, admitted or authorized under social insurance law, of the Associations of Statutory Health Insurance Physicians. Even if only 1,000 of these psychological psychotherapists—a mere four percent—deserved to be called genuinely good, it would be absurd to hold up psychotherapy clinics such as those of the Christoph Dornier Foundation for Clinical Psychology in Marburg (CDS) as a model: expensive and unsuccessful is what patients call the therapy they received there.

But since, as everyone knows, a new sucker is born every minute, there will always be enough people who believe everything they read in the papers. Whether any reader has grown rich from studying this business magazine is beyond my knowledge. In any case, according to the idiosyncratic view of Magnus Heier, the editor responsible for the Modern Living section at CAPITAL, they are supposed to become free of anxiety very quickly at the Christoph Dornier Clinic for Psychotherapy (CDK) in Münster. And in this manner: “Good is whatever causes fear. Better is whatever causes more fear. The visitor to the Dornier Clinic gets his first impression in a room of about five square meters: locked from the outside, without light and without windows—alone. Here many who suffer from anxiety disorders fall into panic. But that is only the prelude” (CAPITAL, 1/2002).

A prelude to what? At the editorial office of PSYCHOTHERAPIE we recall having received, year after year, emails and letters from people who followed naive and starry-eyed press and television reports about the Christoph Dornier Foundation for Clinical Psychology in Marburg and its Christoph Dornier Clinic for Psychotherapy in Münster—and paid dearly for it.

Merely to be given a diagnosis and a treatment proposal, prospective patients at the Christoph Dornier Clinic for Psychotherapy in Münster must undergo a two-day inpatient intake assessment costing 635.64 euros. Accommodation adds the daily rate of 203.49 euros on top. Before inpatient therapy begins, an advance payment of 2,556.46 euros is also required. The clinic, which is however no more than “a private hospital licensed under Section 30 of the Trade Regulation Act,” holds no contracts with the statutory health insurers, the pension insurance carriers, or the employers’ liability insurance associations. For many patients whose insurers do not reimburse the costs—which, with the separately billed therapeutic services, easily add up to a five-figure sum—a large hole gapes in the household budget afterward.

A search of the PSYCHOTHERAPIE inbox turns up, across several years, exclusively messages in which readers report having experienced this form of behavior therapy as disastrous or even ruinous. Naturally the selection we quote from here cannot be regarded as representative. It does, however, give us considerable pause that we have received no comparable quantity of letters from disappointed patients regarding any other clinic.

Expensive and Unsuccessful: Patients on the Christoph Dornier Clinic for Psychotherapy in Münster

“I have a washing compulsion and am currently undergoing psychoanalytic therapy after a failed behavior therapy at the Christoph Dornier Center in Münster,” wrote Juliane König* on 11/14/1997, asking for advice. We advised against psychoanalysis, which is well known to be unsuitable for obsessive-compulsive disorders, and recommended engaging better psychotherapists who work with cognitive behavior therapy.

Carsten Beyer* asked on 09/30/1999: “I am 26 and have had this damned anxiety for nine years now. Is there any chance for me of getting out of it? I did the Christoph Dornier Clinic, and I’ve been broke ever since on top of it. I would be very grateful for even a small tip!”

On 11/27/2001 Stefan Rummel* reported: “For about 12 years I have suffered from social phobia. Various attempts at therapy have been unsuccessful so far. Some years ago, out of sheer desperation, I underwent exposure therapy at the Christoph Dornier Center in Münster, unfortunately without success. Since then I ‚manage‘ my daily problems, such as shopping and trips to government offices, with alcohol.”

Klaus-Dieter Koch* likewise wrote to PSYCHOTHERAPIE in despair on 01/22/2001: “I suffer from agoraphobia and panic attacks. Some years ago I broke off a therapy at the Christoph Dornier Foundation. Because the exposure began with the worst anxiety situation. On the cognitive level there was no therapy at all. [...] I would so like to get out of this vicious circle of fear at last and have a therapy that helps me!”

Rita Stark*, who had already tried in vain to cure her anxiety disorder with a psychoanalyst, described her dismaying experiences to us on 06/17/2001: “In 1996 I heard about the Christoph Dornier Clinic in Münster and was immediately enthusiastic about the possibility of working on my fears in practice together with a therapist. The therapist promised me unlimited mobility after the stay and guaranteed me a new and improved quality of life. Following the intake assessment, my treatment plan was drawn up with the exercises, all of which I got through first with an escort and then on my own. At the CDK they explained to me [...] that through the habituation effect my body would learn that this is not a dangerous situation. During the therapy and afterward as well I was highly motivated to go into anxiety exposure exercises. But what did I actually learn?

I only ever endured the anxiety situations by rescuing myself mentally across the time. My thoughts then run in the direction of hoping I will soon be home again, or able to do other things, that I only have to bridge the anxiety period. After the exercises I was never able to take any pleasure in my success; instead I was already occupied with the next anxiety exercise. There were some exercises after which I said, I will never do that again. The fear never really came down; often it diminished only to a certain degree, it was always a process of holding out and holding on. In no exercise did I lose control, which is very important to me. After the inpatient stay at the CDK I was told that I had not so far achieved the desired success because I was unable to let go of my feelings and my history was, after all, too chronic. [...] I continuously avoided more and more situations and have today reached the level of avoidance I had before the CDK stay. As a person I am highly performance-oriented, someone who fundamentally feels a great appetite for all the things that trigger anxiety. My fear of fear is still enormous; at present I can leave the house only with great anxiety, I am unfit for work and facing occupational disability.”

Good Psychotherapy Dissolves Individual Errors of Reasoning

It is remarkable how casually—not to say irresponsibly—the psychotherapists of the Christoph Dornier Clinic in Münster evidently promised this patient “unlimited mobility” and guaranteed her “a new and improved quality of life.” In fact, by her own account, she finds herself after treatment “facing occupational disability.”

Experienced cognitive psychotherapists can read a whole series of treatment errors out of Rita Stark’s* account, among them, typically, that no cognitive work was evidently done with her to anything like the necessary extent; instead she was simply placed in her anxiety situations so that the panic could be allowed to rattle itself out—as though she were a dog being trained. “Through the habituation effect my body would learn that this is not a dangerous situation,” the patient reports as the single most important instruction of her psychotherapy. Her errors of reasoning and the psychophysiological connections with her anxiety disorder, by contrast, appear never to have been made comprehensible to her. That is why she could achieve no success in the exercises, either with or without a psychotherapist.

“Good psychotherapists meet clients and their problems where those clients are. And good psychotherapists,” explains Carmen Heerdegen, MD, a specialist and psychotherapist in Stuttgart, “measure themselves by how far they have managed to lead their clients out of their problems and to make them competent therapists for themselves, so that they can go on along the road of success alone.”

Little of this is discernible in the present accounts by former patients of the Christoph Dornier Clinic for Psychotherapy and of the Christoph Dornier Foundation for Clinical Psychology. On the contrary, in Rita Stark’s* case the psychotherapists of the Christoph Dornier Clinic, so full-throated at the outset, steal away from their responsibility with the incredible and unacceptable justification that her “history was, after all, too chronic.” What is presumably true instead is that the psychotherapists of the Christoph Dornier Foundation for Clinical Psychology, with their habituation, were not in a position to dissolve the individual errors of reasoning of their highly motivated patient and to lead her to therapeutic success.

By now it is generally known that phobias and anxiety and panic disorders are very treatable and can be treated successfully. Thus Berlin’s senator of the interior, Ehrhart Körting (SPD), wanted to curb the unjustified early retirement of civil servants on such grounds, the Berlin daily B.Z. reported on 07/25/2001 on page 4: with phobias in particular, Körting said, the suspicion arises ‚that private preliminary assessors push the case in a particular direction, which a subsequent review by the public health officer can then scarcely correct‘.

A further reader’s letter reached PSYCHOTHERAPIE on 09/04/2001 from Helmut Mayer* with the question: “What am I doing wrong? Last autumn and this spring I underwent behavior therapy at the Christoph Dornier Foundation in Marburg, which in the end likewise did not lead to success. I have suffered for 15 years from agoraphobia, which expresses itself in my not being able to leave my accustomed surroundings by more than about 400 to 500 meters without this fear reappearing. I went through my fear together with the therapists as well. Now I stand where I stood before, only with the knowledge that such situations can be managed. But when I now want to make contact by telephone, neither therapist works at the institute any longer. Rather odd. I would also have preferred a really experienced therapist, one who might have taken a little more time for a patient’s particular problem. Now I shall have to continue my therapy alone, like it or not, and whether I can manage that I do not know. I would be very grateful for good advice.”

In a document without parallel, Helmut Mayer* has described at length, for PSYCHOTHERAPIE, the development of his anxiety disorder and the depressing experiences he had with the expensive but unsuccessful therapy administered by two probably inexperienced psychotherapists of the Christoph Dornier Foundation for Clinical Psychology in Marburg. He has explicitly permitted PSYCHOTHERAPIE to publish this very honest account of his “behavior therapy with the Christoph Dornier Foundation [...]. It is my aim to be of help to other patients with anxiety disorders as well.” Although Helmut Mayer* would even have consented to the use of his real name, we have refrained from doing so in order to protect his privacy.

“A Patient’s Right to an Answer”—Cognitive Behavior Therapy

To his question, “What am I doing wrong?”, Helmut Mayer* evidently received no satisfactory answer from the two psychotherapists of the Christoph Dornier Foundation for Clinical Psychology. Which is hardly surprising, for “on the cognitive level there was no therapy at all” is the complaint of other former patients of the Christoph Dornier Clinic for Psychotherapy as well. Yet it is a common and fatal error, in phobias and in anxiety and panic disorders, to rely primarily on exposure without adequate cognitive preparation. Such brutal sledgehammer techniques from behavior therapy’s past may still be good enough for editors in search of a few dramatic television images or an exciting story, but in the age of cognitive psychotherapy they are no longer appropriate to the matter. Under a properly conducted cognitive psychotherapy, even patients with long-standing phobias or anxiety and panic disorders are able, in the overwhelming majority of cases, to manage their problem situations alone, without therapeutic escort and quite undramatically—and to do so successfully and for good.

The favorite example CAPITAL cites, that Johann Wolfgang von Goethe too, with his fear of heights, “climbed the tower of Strasbourg Cathedral and stayed at the top until the fear had gone,” overlooks the fact that in the great Weimar thinker an indispensable individual process of insight had taken place beforehand, known today as cognitive preparation, which can be intensified very conveniently by suitable psychotherapeutic support. The techniques applied here are psychological ones that purposefully bring faulty thinking (cognition) to awareness and help to correct it, which is why one speaks of cognitive psychotherapy. The plain service of having oneself locked up alone for a while, like a rabid dog, in a room “without light and without windows” can be had far more cheaply from almost any restroom attendant for one euro.

A very gifted dog can associate up to 50 words with particular actions. Everything beyond that in the way of abilities or behavior, especially in less gifted dogs, requires language-free conditioning for its success. Unlike some editors, many of our contemporaries have meanwhile come to realize that the more highly developed human being, with his capacity for thought and his finely differentiating language—which by no means needs to encompass the entire vocabulary of a Goethe dictionary—is amenable to a subtler form of guidance than the brutal conditioning that Ivan Petrovich Pavlov first demonstrated more than 100 years ago in the reflex experiment with “Pavlov’s dogs” that has since become a classic.

Pavlov’s Dogs—the Psychotherapeutic Competence of the BDP?

Against this background, one might regard as a noteworthy warning the notice printed throughout the materials of the Christoph Dornier Clinic for Psychotherapy in Münster, from the letterhead to the intake questionnaire, stating that the operation is conducted “with the participation and support of the Professional Association of German Psychologists (BDP).” Anyone who has occasionally visited the psychotherapists’ forum run by that association’s Association of Psychological Psychotherapists—VPP within the BDP for short—is likely to have been divested of any desire for psychotherapy with “experts” whose cultural conditioning appears to have stopped at Pavlov’s dogs and whose communicative competence culminates in calling one another “Scheißkerle” or “Scheisskerle” twelve times within fewer than 20 posts.

The promotional leaflet of the Christoph Dornier Clinic in Münster for patients with anxiety disorders is headed—not inappropriately, in this connection—with the exclamation: “I can’t stand this! I have to get out of here!” A cry of alarm that might equally have come from a visitor who had brushed against this forum of BDP psychologists, whose “participation and support” the Christoph Dornier Clinic for Psychotherapy boasts of.

Despite the disappointment Helmut Mayer* experienced with the simple habituation and conditioning practiced by the Christoph Dornier Foundation for Clinical Psychology, he too can still learn to overcome his anxiety disorder with a good psychotherapist working with cognitive behavior therapy. Then his fear and the unsuccessful “exposure” administered by the psychotherapists of the Christoph Dornier Foundation will be, for him, a specter of the past.

In order to help those affected, their families, and above all the many lay readers among us in understanding this detailed account, PSYCHOTHERAPIE asked Carmen Heerdegen, MD, to comment on the former CDS patient’s narrative and to explain the therapeutic background.

Carmen Heerdegen is a specialist in neurology and a psychotherapist in private practice in Stuttgart. From her outpatient experience she knows: “Cognitive behavior therapy can permanently cure phobias and anxiety and panic disorders in more than 90 percent of all cases in fewer than 12 hours.” In a contribution to PSYCHOTHERAPIE of 06/30/2001 she explained that, given “correct diagnostics, there is no reason whatsoever to admit people with phobias or with an anxiety disorder to a clinic or to treat them with medication.” In fact, she argues, such handsome sums are earned today from anxiety disorders—the second most common psychiatric illness—in every sector of the health care system precisely because they are so consistently treated wrongly.

Even Severe Phobias and Anxiety and Panic Disorders Can Be Cured Successfully on an Outpatient Basis, Without Psychotherapy Clinics

In the CDK leaflet on the “treatment offering of the Christoph Dornier Clinic for people with anxiety disorders,” “two to three weeks of inpatient intensive therapy” are routinely suggested as necessary after “initial consultation and diagnostics,” which already cost around 1,000 euros—with “6 to 10 hours daily at the beginning, initially under direct therapeutic supervision.” Anyone whom the subsequent “six-week self-control phase” has still not brought to success is pointed toward the “possibility of an interim refresher treatment at the Christoph Dornier Clinic,” a route that drives the costs still higher.

Yet an efficient psychotherapy today requires no expensive clinic. Particularly with anxiety and panic disorders, social phobias and specific phobias, as well as obsessive-compulsive disorders and depression—all of which can be treated on an outpatient basis with outstanding success by cognitive behavior therapy—psychotherapy routinely need not cost more than 1,500 euros. And by no means, as at the Christoph Dornier Clinic, ten times that at some 10,000 to 15,000 euros! If one believes everything one reads in the papers, the nonsensical steer given by the business magazine CAPITAL, to go to the Christoph Dornier Clinic for Psychotherapy with anxiety and panic disorders, can cost a great deal of money—quite apart from one’s health.

CAPITAL’s author Heier tops it all with the dangerous recommendation to entrust oneself to one’s family doctor with psychological problems: “Concretely, the road to recovery leads in every case to the family doctor.” Ever since Hans-Ulrich Wittchen presented the results of the world’s largest study of primary care for anxiety disorders and depression (GAD-P) at the Max Planck Institute of Psychiatry in Munich on 06/25/2001, the unsuitability of a visit to the family doctor for psychological disorders has been established. The road to the family doctor is to be regarded rather as the most consequential and most expensive error one can commit with anxiety and panic disorders—if one wishes to stay ill as long as possible and become a chronic case. In the GAD-P study, 558 randomly selected physicians and more than 20,000 patients were surveyed in detail. The appalling result: physicians recognize only one anxiety disorder in three, and then mostly treat it incorrectly!

Concretely, with psychological problems the road to recovery leads in every case not by way of a business magazine, nor to the family doctor, nor indeed to a superfluous psychotherapy clinic, but to a qualified cognitive psychotherapist in private practice. The moving personal account we reproduce below is intended to sharpen awareness of the need to question press and television reports far more critically as a matter of principle.

Addendum of 11/14/2002—Christoph Dornier Clinic: “This is regrettably true”

After PSYCHOTHERAPIE reported on 12/31/2001 on the remarkable discrepancy between the grandiose self-presentation of the Christoph Dornier Clinic for Psychotherapy in the press and on television and the actual and shattering failures repeatedly described by former patients of the Christoph Dornier Foundation and of its Christoph Dornier Clinic in Münster, the Christoph Dornier Clinic saw itself moved in November 2002, on the “manifold” urging “of patients and referrers,” to issue an official statement:

“Not all patients of the CDK could be helped in the past. This is regrettably true.”

Christoph Dornier Clinic, Münster Statement of November 2002.

Despite having its own press office, the Christoph Dornier Clinic in Münster required more than ten months of “reflection” to arrive at this public admission, which by its own account was brought about only by “manifold suggestions from patients and referrers.” This delicate paraphrase of the fact that only public pressure made a glimpse behind the brittle marketing façade of the Christoph Dornier Clinic possible reveals the astonishing lack of self-criticism and self-reflection among the CDK’s psychotherapists.

For clients of the Christoph Dornier Clinic in Münster and of the Christoph Dornier Foundation with branches in Berlin, Braunschweig, Cologne, Marburg, Münster, Siegen, and Tübingen, this expensive disillusionment is a truly terrifying exposure therapy. Anyone taken in by the aggressive media work of the Christoph Dornier Foundation, expecting to find experienced psychotherapeutic professionals there, is in fact regularly confronted with young psychologists who cost little and who are themselves—in part at the psychological institute of the local university—still in training.

PSYCHOTHERAPIE will stay with this subject and continue to shed light on the gulf between appearance and reality in psychotherapy—for better quality in psychotherapeutic care.

Read the account of the two unsuccessful courses of psychotherapy with the Christoph Dornier Foundation in Marburg in Part 2 and Part 3.

*Name changed to protect the individual’s privacy.

Published on 12/31/2001, addendum of 11/14/2002.

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