A Second Opinion

The group I’ve had the most difficulty in so far was the one I’d hoped I’d find the most helpful, CBT for Anxiety, and I’ve been dreading going back ever since. It’s led by Joanna, a matronly bespectacled lady from the north of England. This week our little group has one more member, Amanda, a tall, slim, pretty, dark-haired girl who’s traveled down from Aberdeen to stay as an inpatient. She suffers from body dysmorphia she told us over the weekend, and can’t stand the sight of herself in the mirror. She joins Jack, who’s begun to open up about his failing marriage and his shameful desire to dress as a woman, Ashleigh, still glued to her phone 24/7 but who maddeningly reports feeling better and better after each session, Cathy (considering becoming an inpatient after a week attending as an outpatient) and Yvonne, who surprisingly disclosed last week that her husband is an alcoholic. (Not surprising that she disclosed it, it’s that kind of place after all, but peoples’ stories are so diverse and I just hadn’t imagined a confident, capable, career-minded lady such as Yvonne, with an alcoholic for a husband.)

 

As Joanna produces the same stopwatch from her bag as last week, my heart sinks. Once again, she asks us to focus our attention on our breath and count how many times we exhale over the course of one minute. She then goes round the circle and asks each of us how many breaths we took and to rate how anxious we feel just now from 1-10. She writes our names on the flip chart and marks our scores next to them. I took 20 out-breaths and my anxiety is a 7.

 

Joanna then leads us in an exercise designed to slow our breathing down. She asks us to focus on our posture as we sit in our chairs, make sure our legs are uncrossed and our feet are making good contact with the floor, our shoulders are relaxed, with one hand placed gently on our bellies, and our eyes closed. She instructs us to consciously slow the breathing down on the out-breath. “The hand on your belly should move up when you breathe in, as if you are filling up a balloon. Make sure you don’t lift your shoulders as you inhale; rather, breathe into the tummy before slooowwwlly emptying out every last breath then pausing and gently inhaling again.”

 

We do this for 5 minutes.

 

Afterward, she gets her stopwatch out once more and asks us to repeat the counting of our out breaths over the course of a minute. Then she marks down our scores again, for the number of exhales and for the level of anxiety. It seems obvious that the point of the exercise is to show that by focusing on breathing more slowly our anxiety levels decrease. As Joanna makes her way round the circle again asking for people’s scores, this is borne out:

 

Jack, pre slow breathing exercise took 24 out-breaths and his anxiety level was a 5. Post slow breathing exercise, he took 18 breaths and his anxiety level is a 3.

 

Amanda pre-exercise was 26 out-breaths, anxiety 7. Post-exercise she was 20 out-breaths, anxiety 6.

 

Ashleigh was 22 and 4, afterward, she was 19 and 1.

 

Cathy was 26 and 8, afterward, 22 and 6.

 

Yvonne was 18 and 4, afterward, she is 14 and 1.

 

As Joanna makes her way 'round the group, marking up everyone’s improved scores (and hence more relaxed state) hunched shoulders drop, slight smiles appear on faces and furrowed brows cautiously unfurl. I, on the other hand, remain tight, stern-faced and furled, as an encouraging Joanna turns finally to me for my scores.

 

“The first time I took 20 out-breaths and my anxiety was a 7.”

 

“Okay, and now?” She asks.

 

“I took 17 breaths.”

 

“Good” replies Joanna, “and your anxiety?”

 

“9.”

 

I want to cry.

 

The room tenses up as the squeak of the marker pen stains the flip chart with my failure.

 

“Okay, well, like I said last week, the point of the exercise is not that your score for anxiety reduces, but that you simply notice and are present with whatever level of anxiety you’re experiencing right now.”

 

Bullshit, I want to scream in her face, absolute utter fucking bullshit, and you know it!

 

“Yes.” My jaw is wired so tightly shut I barely manage to squeeze the word out through my teeth.

 

As with last week, the rest of the session is entirely lost on me. I spend the next hour physically present in the room, but I’m not really there. Instead, the already shattered and fragmented pieces of my mind, till this point of the day in uneasy truce with one another, launch themselves into all-out civil war. Defenses are breached, victory flags planted, and conquered civilians led off to basements in chains. Hard evidence, as if it were needed, has finally been produced to prove the hopelessness of my case, marked, in stark contrast to how the exercise helps those who are not beyond saving. To make my misery complete, I’ve forgotten to bring the handkerchief I’ve grimly stuffed in my pocket every morning of these last three weeks to discreetly wipe the sweat from my brow in the wake of yet another failed relaxation, and I’m forced off my seat and into the middle of the room to pull a paper hanky out of the box supplied for our communal tears.

 

The group now over, the others dispersed, a concerned-looking Joanna approaches. “What are your plans for the rest of the day Kenny?”

 

It’s all I can do to look her in the eye as tears begin to well at the direct address.

​

“I’m spiraling.” It comes out on a sob. It’s not a term I’d heard until a week ago, let alone used, but it describes precisely what I’m experiencing now: a heightened sense of unreality, lack of control, whirling increasing speed, and outright terror. It’s like I’m on the world’s biggest rollercoaster with no seatbelt on.

 

“Okay. And what can you do, at this moment, to ground yourself?” Another new word in my ever-expanding vocabulary of Psychology.

 

“I don’t know.”

 

“I heard a couple of the others saying they might be going to the gym. Could you go with them?”

 

“I don’t know. Maybe.” Although at this point, I’m not sure I can manage to stand up out of my seat, let alone consider running on a treadmill.

 

“Why don’t you do that. That would be a good use of Behavioural Activation.”

 

And she leaves me to consider my options.

​

#

​

A couple of nights later and I’m sitting in the patient lounge, with the telly on in the background. I’ve had dinner as early as possible to give me time to prepare for the meeting. Straight-talking Margaret has reassured me that she’ll come and get me. A tad worryingly, it’s taken a suicide attempt for her to warm to me, almost as though it were proof of an upset state of mind, which she’d previously doubted. (Having said that, I’m sure the nursing staff treat us mental health patients kindlier than the addicts on the ward, their judgment often leaking out of the sides of their mouths despite the best efforts of their professional smiles.)

​

I’m trying to focus on the six o’clock news when Donald and Al bicker their way into the room like an old married couple. They’ve formed something of an unlikely double-act in their time together which has provided the rest of us with a much-needed injection of lightness, with Donald ceaselessly poking fun at Al’s dour and depressed demeanour, while Al resists with the well-practiced stubbornness of a grouchy old donkey.

 

“I just can’t get my head round the idea of God, even though it’s ‘as I understand him’. It’s fake!”

 

“You’ve just got to play the game, man, and not take it all so seriously.”

 

“That’s worked out well for you over the years I see!”

 

“Ah, Alasdair, my friend, you must be confusing me for someone who gives a fuck. I gave up on the idea of being saved by a pseudo-scientific religious organization many years ago.”

 

“Then what the F are you doing here?”

 

“Drying out. And enjoying the life-enhancing effect of mixing with ebullient characters such as yourself while enduring the pain of an enormous syringe being jabbed into my backside thrice daily to bring me back to some semblance of sobriety.”

​

Al opens his mouth to protest when a female head pops 'round the side of the door and scans the room.

 

“Kenneth?” She hazards a guess, looking in my direction.

 

“Dr. Harris?” I ask, making my way across the lounge to meet her.

 

“Yes. Shall we go along to your room?”

 

“Yes, of course.”

 

She takes a step back and gestures with her hand, “Lead the way.”

 

#

 

Two things strike me hopefully as we sit. One, Dr. Harris has taken the seat farthest away from the door, which makes her departure from the room slightly less simple―not that I’m planning to hold her against her will, of course. (I’m probably reading too much into it but it’s in stark contrast to Dr. Mukherjee, who either remained standing throughout our meetings or sat in the chair nearest the door, for an easy getaway.) And two, she’s taken her coat off.

​

“If I can just start by asking, what is it you’re hoping to gain from meeting with me?”

 

The question surprises me a little, but of course, she’ll know I’ve been seeing a fellow psychiatrist and is perhaps keen to establish expectations early on.

 

“I don’t really know, I feel like I’ve been getting worse since I came here and I don’t know what else to do.”

 

“Okay.” She seems satisfied by my entirely nonspecific answer. “Do you want to tell me what’s been going on?”

 

“Well, like I said, I seem to be getting worse since arriving here.”

 

“Okay.”

 

“I’ve done Cognitive Behavioural Therapy in the past, and not got a lot out of it, or found it difficult, or something. And when I came here it was a bit of an emergency, so I didn’t really consider the nature of the help I would be given, I just knew I needed to be somewhere safe. So then, Dr. Mukherjee said that CBT was what I needed to do to get better, and he also said that drugs—medication, I mean—wouldn’t help and I’ve just been really struggling...”

 

“Uh-huh.”

 

“Could I...is it okay if I give you a bit of background?”

 

“Yes, of course, that’d be really useful.”

 

“It started in relationships, romantic ones, where I flipped from needing to be in them to not being able to bear being in them. I would focus on the tiniest of things—”

 

“Like what?”

 

“Like, anything, anything to pick holes in the relationship. Like a thought, like, our sense of humours don’t match, or I don’t make her laugh enough or she doesn’t make me laugh, when that was never an issue before, in actual fact we were well matched and we did make each other laugh. But when the flip happened, every issue came flooding in one after the other and I was just overwhelmed. Or she didn’t show an interest in current affairs, which had never even occurred to me before, and Jesus, I chastise myself for not being interested enough in what’s going on in the world, but now I couldn’t stop thinking about that, for example, or that her accent wasn’t quite right, or just absurd things that felt so pathetic to be worrying about. But, I mean, not just worrying, obsessing. They just became overblown and utterly dominating to the point where the pain was so much—”

 

“The thoughts did?”

 

“Yes, the thoughts. Constantly, from the moment I woke up until I went to sleep at night. I couldn’t focus on anything else in my life: work, friendships, everything dominated by this protesting in my brain, and all the while I’m trying to pretend everything is okay, which is hard enough when you’re just chatting or watching telly or going for a walk, but then things, like more intimate moments, like making love, you know, having sex, while trying to contain this tsunami in my brain was a fucking nightmare, so that I eventually felt completely cornered and I had no option but to leave. It felt like I had this stark choice to make, between sanity and madness. As much as I didn’t want to do it, I knew that ending the relationship would stop the chaos and whirling and 24/7 criticism that made relaxing in the relationship utterly impossible. That would all disappear, which was such a relief. Then I was left with mourning the relationship of course, which was extremely sad, you know, but a sadness I could ultimately deal with.”

 

“And sorry, did you say you’d been in therapy?”

 

“I’m...yes, I have been in therapy, a few times.”

 

“Could you tell me a bit about that?”

 

That she’s sitting here, this psychiatrist, with her coat off, asking me to tell her more is music to my ears. I feel like a nervous kitten in a new home being encouraged to come out from under the bed.

 

“At first it was psychotherapy, when I was in London. I focused on the thoughts that came up and tried to get to the bottom of them, but I ended up just tying myself up in worse and worse knots.”

 

“How do you mean?”

 

“Well, I would focus, I mean we, me and Mary, the therapist, would focus on the content of the thoughts, and try and get to the bottom of them that way.”

 

“You mean like the thoughts you mentioned before?”

 

“Exactly, like she’s not amusing enough, or we don’t share exactly the same views on all the same issues. Mad stuff, that I knew wasn’t rational but it didn’t make any difference.”

 

“And what happened, when you focused on the content of the thought?”

 

“It just felt like I ended up chasing my tail. And then to my horror, over the course of those two years in therapy, instead of getting better, I ended up getting worse. It had started off as an issue that raised its head in romantic relationships but it got to the point where I couldn’t bear to be in one to one situations with any people in general and I had to be in groups, but then even being in groups became problematic, I was just picking holes in everything and everybody all the time. I couldn’t stop it and I ended up completely breaking down. I couldn’t operate.

I moved back to Glasgow with my parents initially. I thought I was going mad and I met with a psychiatrist, who said it was anxiety and depression. I told him I was thinking about more psychotherapy with this therapist I’d spoken to a few years before in Glasgow, when I first decided to get help and who I really trusted. He didn’t think it was a good idea and thought I might dig myself into an even bigger hole. So I tried some CBT on his advice, but it wasn’t helpful, then I decided to start seeing Derek, this psychotherapist who I had some trust with. And I got better through that period of therapy, up here in Glasgow, and that was when I focused less on the content of the thoughts, ‘cos I realised the content was irrelevant, by and large, and the point was, of my anxiety, was to zero in on and get tangled up in thoughts and thinking so that I would stay in this...tangled up mess. And slowly I got better, but it was so difficult to trust that the content of the thoughts didn’t mean anything, but I managed to do that more and more, over time.”

 

Dr. Harris appears to be listening intently. I press on.

 

“Eventually I was able to get back to work, I’m an actor, I mean I was an actor. Then there was a relationship with an Australian woman, where I experienced the familiar flip from needing to be with her to not being able to cope. I went out to Australia to see if we could make it work out there, but it was too much. So I came back to Glasgow, then about a year later I moved down to London again, but I broke down, I only lasted a month. I was overwhelmed with anxiety and I hoped by acting decisively and only staying a month, I’d cut the anxiety off at the pass, but it was too late. It was like the ball had started rolling down the hill and I couldn’t stop it. It took me pretty much four years to recover, and even then, I wasn’t able to get on stage. I was turning down acting work and just managed to do bits of volunteering and then some support work for adults with learning difficulties. I decided that I had to leave acting and I started working for a homeless charity, just part-time. That went really well for about nine months or so, so I decided to apply for a postgrad in social work. I started the course in September of last year, and again, it was just like the move to London. It was too much and I totally flipped into full on 24/7 anxiety again.

I knew I had to leave the course, which I did after one week, but again, it seemed like the wheels were in motion and I just couldn’t stop them. It was like coming apart at the seams. I couldn’t bear to be around people because the internal negative commentary about them and criticism of my thoughts were overwhelming. I’d developed lots of positive coping strategies in therapy but nothing seemed to be working this time, you know, arresting the slide, and it just felt more severe than ever before. I started having thoughts about killing myself, and of course, I didn’t want to do that, but they were more than just fleeting thoughts and I told my friend who I was staying with at the time, and my sister. I just wasn’t coping. The pressure in my head just built up so quickly that I’d be in tears four or five times a day just to release the tension. That’s when Ruthie, my sister, she brought up the possibility of coming here and I didn’t know what else to do...so I did.”

 

Dr. Harris is nodding thoughtfully.

 

“My one saving grace is that I’ll always talk, you might have noticed. Probably bore the pants off people, but I can’t keep things bottled up if the pressure becomes too intense.”

 

“And what’s going on now?” Dr. Harris asks. Her northern English accent seems to match the straightforwardness of her question.

 

“Well, Dr. Mukherjee told me that pills wouldn’t help and that CBT was absolutely the thing that I needed to do to pull me through this. I’ve been trying so hard but I feel like I’m getting worse, I’m just picking holes in everything and everyone to such a scary and insane degree, and doing some of the CBT exercises seems to just fan the flames.”

 

“How do you mean?”

 

“I try and visualise a calm place, for example, and then a hundred fucking, sorry for swearing, a hundred fire-breathing, serpents or something will appear and ruin it for me. Doing relaxation exercises or breathing exercises is just torture. And now when I go to bed at night I automatically say ‘fuck God’ in my head on every out-breath and I can’t stop it. I’m barely getting any sleep.”

 

This has been the latest terrifying development, and airing it now to Dr. Harris, I have to work hard to suppress the rising sobs. 

 

“All these exercises and avenues for help I’m closing down for myself and my world is just getting smaller and smaller. Derek, my therapist in Glasgow, his son died and then I tortured myself for thinking about his son while I was in a session with Derek, just the thought of his son coming into my head, would bring me out in sweating and I would have to tell Derek that I’d had the thought.”

 

“And what were you thinking about?”

 

“Nothing, just his name, Joe, coming into my head was enough and I would panic and need to tell Derek, which was awful because I knew bringing it up would be hurtful but I’d created this bind for myself, telling myself that I have to bring up everything that comes into my head, like that was the point of therapy and if I didn’t do that I might miss something. And the same thing happened Dr. Mukherjee. His colour became an issue as soon as I heard his name, because I was scared I would think ‘black bastard’ or something like that, or even just the word ‘black’, whenever he was with me.”

 

“And did you?”

 

“No. I’m just...desperate. I can’t get any peace. I can’t read my book, I can’t focus on the telly, without saying to myself ‘You’re not listening, you’re not paying attention!’” I pull a hanky out of my pocket. “Sorry.”

 

Dr Harris looks thoughtful. I’m done, for the moment, as far as I can tell. I’m relieved that I’ve been listened to. Dr. Mukherjee listened, of course, but there’s a quality to Dr. Harris’s listening that’s different. Maybe it’s simply patience. She doesn’t give off any suggestion of hurry. She’s here, and she doesn’t appear to have any pressing engagements that she needs to attend elsewhere.

 

“I think what you’re describing, what I’m hearing you describe, is a form of obsessive-compulsive disorder.”

 

I shift position in my chair. “Okay.”

 

“There are, generally speaking, two different types of OCD,” she gently continues. “Behavioural OCD, you know, the more commonly known kind where, for example, you won’t let yourself stand on the cracks on the pavement, or you might need to check the door is locked exactly fourteen times before you leave the house. These are behaviours or routines that we call ‘compulsions’ that people engage in to prevent something bad from happening. At least that’s what they believe. They understand it’s irrational but can’t stop themselves from doing it.”

 

“Sure.”

 

“Then there is what I would call Cognitive OCD, which is what I hear you describing. You might have heard it called ‘Pure O’?”

 

I’m open-mouthed.

 

“I don’t like getting tied up with names, but basically with this type of OCD, the person experiences obsessive, unwanted thoughts without any accompanying compulsions or rituals. And that’s what I hear you talking about.”

 

“Okay. Wow.”

 

“The first thing to say is that it’s the people who are least likely to act on these subversive thoughts that are the most troubled by them, precisely because they find them so abhorrent. All of us, I mean everybody, not just those with OCD, experience unwanted thoughts from time to time but the difference is, those of us who don’t have OCD can easily dismiss them. Like I might have a fleeting thought about stabbing a passerby in the chest, but I can shrug it off or think, “Oh, isn’t that weird how my brain works like that—”

 

“Which I can do, when I’m well!”

 

“—but with OCD, what distinguishes the person is the anxiety that sort of attaches itself to these thoughts, which then creates this huge distress for the person experiencing the thought.”

 

“Okay.” I’m glued to my seat, like at the climax of a riveting film.

 

“As well as the fleeting thoughts that all of us have, there’s a percentage of the population, I can’t remember precisely the figure, that experience more intrusive thoughts and aren’t troubled by them, and then there’s a small percentage of those people who are, and they’re the ones who are prone to OCD.”

 

“Fucking hell.”

 

“Oh, you poor thing. And the other thing to say is that there are drugs, drugs can help. And while CBT is the recommended treatment for OCD, it can prove problematic, particularly in this type of OCD where your tendency is to get tangled up in thinking and massively over-complicate things. I mean, that’s the illness. Thought Recording is one example of not being that helpful with your kind of OCD.”

 

I’m struck dumb.

 

“You poor thing. Well listen, let’s see if we can get you on some different drugs to start with.” The way she says drugs, like “droogs” reminds me of my Penrith nieces. “What did you say you’re taking just now?”

 

“40 mg of Cipramil, and occasionally small doses of diazepam.”

 

“Well, there are a couple of different options we could look at. Clomipramine is an anti-depressant that has...it’s proved useful for people with OCD. I think that would be worth trying, but what I’d like to do is try and get you some more immediate relief. There’s a drug called Quetiapine that’s really helpful in calming down distressing thoughts. It’s an anti-psychotic—”

 

“Okay.” I stiffen a little.

 

“—but it’s often used in much milder doses for people who aren’t diagnosed with psychotic illnesses, like yourself, but who are in quite an acute stage of a neurotic illness and it acts like a sedative. It just sort of dampens things down a bit, so you’re not quite so susceptible to being overwhelmed by intrusive thoughts or thinking. How does that sound?”

 

It sounds fucking amazing.

​

I lift my hanky to my eyes again but for the first time in four months it wipes away tears of relief, gratitude and hope rather than tears of pain. “That sounds good.”

​

“We’ll have to take a few days to wind down from the Cipramil before starting you on the Clomipramine, but there’s no reason we can’t get you going on the Quetiapine straightaway. And in the meantime, keep going to the groups, so long as they’re helpful, but if you feel yourself struggling or getting too tangled up in your thinking, just leave. And you can say that Dr. Harris said that it’s absolutely fine for you to do that.”

​

I could kiss her.

​

“Is that okay for now?”

​

“Yes, thank you.”

 

“You poor thing.” What might sound patronising from Dr. Harris feels nothing but empathetic and completely sincere. I’m sure the Northern tones and cadence help. “Okay, well, I’ll go along to the nurses’ station and get you a new prescription written up and we’ll check in again in a few days to see how things are going, okay?”

​

“Yes, of course. Thank you.”

​

#

​

“We knew you should have been on something stronger.” A couple of hours later and Clare is smiling as she is giving me my first dose of Quetiapine. “It sounds like Dr. Harris is going to up your dosage gradually, but you should feel the effects of this pretty soon.”

 

“How soon, by tomorrow?”

 

“No, no, in the next hour or so.”

 

And sure enough, by the time I put my head on the pillow, I’m feeling agreeably half-cut and sleepy. I make a half-hearted attempt at sabotage with the ‘Fuck God’ thoughts’, but what shook me to the core and kept me gnawing at the bedclothes for the whole of last night now certainly protests loudly for a bit, but eventually stomps off, angry at not being able to raise the alarm. In relative peace, I drift off to sleep.