I saw my psychiatrist last week, and she’s discharged me back to my GP. I’m reasonably happy about this. With my mood and energy levels stable, it doesn’t seem like the best use of my time or NHS resources to have me trekking out to the hospital every couple of months. In an ideal world, I’d like to remain on her books without regular visits to see her, and to be able to phone for an appointment when and if I experience any mental health issues, but the NHS just doesn’t work that way.

I did ask whether my recent episode had changed her opinion about me taking antidepressants in the first trimester of pregnancy. It hasn’t, although she now wants me to be referred back to her as soon as I become pregnant, even if my mental health is good. She seemed to be saying that I could wait until I’m actually pregnant to come off the meds, but I’m a bit confused about that because she also said I should reduce the dose gradually over a month to avoid withdrawal symptoms. Surely that would defeat the object of not having mirtazapine in my system during the crucial first month when the embryo is developing and the risk of miscarriage high? The thing is, my main concern isn’t getting through three months of pregnancy without medication – that’s a relatively short period, and I know some women find the hormones actually help their mood – but coping without meds for potentially months and months of failed fertility treatment. Anyway, I’ll see what she’s written in the letter to my GP and what my GP and the fertility clinic advise.

That’s the easiest part of this post out of the way. It’s going to be much harder to write about group therapy, because I’m still struggling to make sense of how I feel about it and what I want.

For some time now – maybe since about November? – I’ve been questioning whether the therapy group is right for me. The first reason is that I just don’t feel I’m getting much out of it. That might be an odd thing to say when my mental health has improved so dramatically, but I honestly don’t feel the group has had much to do with it. In the past, when therapy has helped, it’s been obvious to me how and why it’s helping. Talking about the bullying, and coming to a new understanding of what happened to me as a child that doesn’t place the blame on me, cured me of social anxiety disorder and there’s no doubt in my mind that that’s why I no longer have difficulties socialising and making friends. On a less radical scale, learning some CBT techniques for coping with depression has made depression easier to cope with (duh) so that it no longer has such a devastating impact on my life. With the therapy group, everything’s more tenuous. I have developed some new insights which may well have helped me to change but the link is far less obvious. This is something I need to explore further.

The second reason is that I’m not sure whether group therapy of any kind is the best approach for me, or not as the main mode of treatment. In the past one of the things I’ve really valued about therapy is that it’s a space just for me, where I can be ‘selfish’ and talk through whatever I need to talk through, without having to worry about other people’s needs or whether I’m monopolising the conversation. In a group I don’t have any of that. Arguably, group therapy is the ideal place for me to learn how to get my own needs met in a mutually supportive environment, how to get the balance right between giving and taking, but it can feel like a catch 22 in that to get the therapy in the first place I already have to resolve the issue to some extent. I don’t talk about my own problems as much as I should, both for this reason and the one below, and that may be one explanation for why I’m pretty sure the recent improvement in my mental health has little to do with therapy.

The third reason has to do with the psychoanalytical orientation of the group and the NHS service, and it’s the hardest to pin down. I guess I can sum it up by saying that for a long time I’ve been preoccupied by the following questions:

• There are many areas of my life that I think I’m reasonably happy about when I’m well, but when I’m depressed they not only get me down, but I view them as a likely cause of my depression. Is this just the ‘depression talking’ (distorted thoughts and beliefs) and me grabbing at straws to make sense of things, or are these real problems that I’m refusing to tackle and which do indeed make me ill?
• The psychoanalytical therapy I’ve had so far has been known to stir up difficult and painful stuff and I have subsequently relapsed into depression (I’m thinking in particular of the individual assessment sessions with Group Therapist here). Is this stuff that needed to be addressed, and would have made me ill sooner or later anyway, or is dwelling on things which don’t bother me in my day-to-day life unhelpful and misguided?

What I would really like is to be able to talk these questions through in a safe and non-judgemental environment. The problem is, I don’t feel Group Therapist is a safe person to discuss this stuff with, not only because he’s implicated, but because psychoanalytical theory (to the best of my knowledge) has set views about this. It’s all about the importance of the subconscious, of issues we’ve pushed out of our minds which continue to affect us, and of the need to stir up difficult and painful stuff and for things to get worse before they get better. From my perspective, though, I don’t think these are questions that can or should be answered easily. I don’t think there can ever be a ‘one size fits all’ answer that applies to every person and every situation, and I also think the answer in any one situation is unlikely to be black and white. It’s quite possible, for example, that when I see myself as well I am brushing a particular issue under the carpet, but that at the same time it’s not as big a problem as I think it is when I’m depressed, and is only a minor factor in me relapsing. I don’t know, I might be doing Group Therapist a disservice here (trust issues, much?) but I’ve seen him work very hard to persuade other group members of things and I don’t want to put myself in a situation where I feel pressured into accepting a particular explanation or belief. Another thing I’ve really valued about the therapy that’s helped me most – which was all person-centred – is that I did have the space to come to my own conclusions. Even if Group Therapist is right about everything, I feel it’s more likely to ‘stick’ if I have that opportunity to realise things for myself and not feel as though they’re being forced on me.

I became disillusioned with the NHS approach to CBT because I didn’t feel it was flexible enough – I was taught helping coping techniques, and the practical side of things was good, but there wasn’t the opportunity to talk about painful childhood experiences if I needed to, nor anything else to try if a thought record / behaviour experiment didn’t help with a particular issue. The psychoanalytical service seems to be just as inflexible, just at the opposite end of the spectrum (I know I’ve made the comparison with communism and fascism before). Now that my mood and energy levels are fine, what I really want to do is focus on the practical stuff – make sure I’m taking good care of myself, make sure I’m not pushing myself too hard. Since the fatigue went away, I’ve been doing a lot of that. I read a self-help book about body/eating issues and am implementing the ideas in that which are really helping. I’ve admitted that on mirtazapine I really do need nine hours of sleep most nights and am making sure I go to bed early enough. I’ve acknowledged that getting overwhelmed can be a big problem for me and so prioritising is vital, and I’ve found a prioritising system that seems to work. I’ve recognised that the long days teaching in another city were really draining me last year so this year I’ve arranged to only ever teach one workshop in a day, not two. But this is all stuff I’ve done and figured out on my own, because my therapy group is emphatically not about taking practical steps.

What are the reasons for staying in group therapy, then?

1. As I said above, I can’t be sure that the group hasn’t helped. I’ve left a lot of therapists in the past and I don’t want to cut and run again for what may be the wrong reasons.

2. I can’t afford to see someone privately at the moment, so the group (or individual therapy at the same service) is my only option for a long-term talking treatment. I could access shorter-term counselling through a local charity, but with my mental health being so changeable and cyclical, and with one of my main goals being to understand why I relapse and whether it can be prevented, I feel I really do need something long term.

3. I really like some of the others in the group and can relate to them a lot. Contact outside the group isn’t allowed and I would very much miss them.

4. The idea of having to discuss my issues with the therapy and reasons for wanting to leave in front of the whole group – a place which still doesn’t feel safe even after seven months of treatment – is extremely daunting. I’m worried that Group Therapist will pressure me and the other patients will be upset or think they’re to blame. OK, this isn’t a good reason for staying but the group does feel a bit like Hotel California sometimes…

5. I’m worried that if I leave the group and decline the option of individual psychoanalytical therapy – especially if I’m not arranging my own counselling straight away – I’ll be viewed as ‘non-compliant’ and this will cause problems accessing NHS mental health or fertility treatment in future.

6. I’m also worried that if I leave the group, then relapse and need more support, I won’t be able to get it and may really regret my decision.

According to WordPress I’ve written close to 2,000 words. I will leave this now and allow the dust to settle in my head, but any comments or feedback would be welcome.

P.S. If you follow me on Twitter you may know that I recently suffered a bereavement. I’m not blogging about it publicly for privacy reasons but I do really appreciate all your support. The death was expected and I’m coping with it well but it’s still a sad time for me and my family.