On Psychotherapeutic Literacy

“There are experiences that transcend words, those that elude the grasp of language. For instance, when a child enters a therapist’s office for the very first time, he may find himself unable to respond to any inquiries, his voice rendered mute. He struggles to comprehend the therapist’s probing questions, as these queries delve into realms he has never explored before in his young life. To this child, everything within the context of the situation remains ineffable…” — from Swallowing Practice: A Memoir by Jeannie Park

In 1999, I stumbled upon a rack of pamphlets outside the faculty office of the Archaeology and Art History department in Building 14. These pamphlets, colored in blue and purple, bore bold white lettering: “Anxiety,” “Sadness,” and “Obsessive thoughts.” If these were diagnostic labels, I couldn’t help but wonder if I deserved the assessment and counseling program offered at the student center as advertised in those pamphlets. I tucked them into my backpack, though it took me some time to muster the courage to call the number listed.

Eventually, I made the call, and an appointment was scheduled for me. I was assigned registration number ’47f.’ So that meant I was already the 47th female student seeking assistance at the center while it was only March, the first month of the new semester. I was matched with a 30-year-old trainee clinical psychologist with a master’s degree.

This marked the beginning of my second year at the university in Seoul, and beneath my facade of academic pursuit, I was grappling with depression, homesickness, eating or not-eating problems, and suicidal thoughts. Despite having been a student writer immersed in foreign literature and philosophical inquiries, I had reluctantly chosen this university, majoring randomly in Child Development and Family Studies, due to a dismal SAT performance and financial constraints. I took various non-major courses in psychology, literature, and art history, but the feeling of not belonging only grew stronger.

The counselor, a rather awkward individual, did his best to play the role of an effective psychotherapist, though his noticeable Southern accent hinted at his rural background. So the two of us, newcomers from our respective small city homes, sat face to face in this unfamiliar setting for a form of care I hadn’t experienced before. It was a peculiar, uncomfortable, and baffling encounter. Why was he sitting in front of me, waiting for me to initiate the conversation? Why did he act as though he genuinely cared about me? I felt like a failure—not thin enough, unattractively dressed, and thoroughly lost in university life. Was he just pretending? And if so, why? Was it simply because it was his job? Was he a volunteer counselor? Who would willingly pay him to listen to and console someone like me?

I once mustered the courage to ask, hesitatingly, “Are you volunteering…?”

“No,” he replied with a hint of amusement, and added, somewhat proudly, “I can say I’m a kind of civil servant because I’m employed at this national university.”

His response only left me more bewildered. What was this “public service” available to troubled students like me? What did he intend to do with me? What were his expectations? Why wouldn’t he just offer straightforward advice on how to feel better? I was still grappling with unspoken pain and confusion, so why didn’t he make an effort to name and address it directly? I desperately wanted, in fact, I expected him to read my mind, to decipher what I couldn’t understand myself. So I poured out all the hints and evidence materials I could find—my diary, drawings, old pictures, and more. Curiously, he seemed captivated by a few quotes from books I had jotted down in my diary, but our sessions continued to be a quiet standoff, a battle of nerves to see who would break the silence first.

Betrayal marked the first emotion I had to confront in my inaugural therapy sessions. The moment of truth arrived when I ventured into the campus bookstore, seeking answers about the essence of psychological counseling and what my counselor expected from me. What I found in some books was as embarrassing as it was shameful.

According to those texts, clients like me tended to behave unexpectedly. While there were certainly rules to follow and an unspoken agreement between therapist and client, in most cases, clients entered the therapeutic relationship without the faintest understanding of psychotherapy’s conventions. It was a wholly unfamiliar dynamic they had never encountered before. The therapist was there to assist willingly, but clients were cautioned not to become overly dependent. Clients should be well aware of the responsible boundaries separating them from their therapist. It was akin to having Jesus suddenly appear before their eyes and flatly demand, “Do not touch me.”

One of the books listed typical client behaviors that therapists needed to handle with care. What if your client brought you a gift? What did the gesture signify? What did you believe to be their intention behind it? However, as a rule, you shouldn’t accept presents from your client, the book asserted. So why did I give him gifts? He graciously accepted them, but what might he have thought about my behavior? I felt like a terrible, shrewd, and manipulative client.

The second most agonizing aspect of betrayal arose from my profound disappointment in the therapy sessions. They fell short of the promises, and the therapist failed to meet the expectations set. Throughout our ongoing silent standoff, my depression spiraled into a more severe state, and eventually, I reached an unwavering conclusion: there was no longer any hope for my rescue. The dreadful physical symptoms of severe depression, including cognitive decline and impaired eyesight, overwhelmed my existence, and I started to keep a naive collection of aspirins and over-the-counter sleep aids for ending my life. On the D-day, I arrived at the therapy room, with the pills inside my backpack, as perhaps the gloomiest person in the world, secretly but sincerely hoping that he could decipher the cries of my mind, which had been muted. Yet he greeted me and bid me farewell with his familiar smile, as he always did. I reluctantly returned to my dormitory room with the pills I had to swallow.

“You will become a ‘skilled helper,’ won’t you?”

During those pivotal years, I immersed myself in psychology books and became well-versed in psychotherapeutic knowledge, though I harbored mixed feelings about it. After a tumultuous episode of a hasty suicide attempt, I was promptly referred to a clinical psychology professor at a university in my hometown, who happened to be the senior alumnus of my former therapist.

Though he was just in his early 40s, this professor struck me as an older, composed figure, radiating a sense of disillusionment and melancholy. He belonged to the generation shaped by the pro-democracy movement, spending his 20s in the tumultuous 1980s amidst tear gas-filled street protests, besieged and ravaged campuses, and mourning the loss of friends. Then, by the 1990s, they found themselves adrift, cast aside by the relentless tides of neoliberalism.

Many of his peers turned to Buddhism, focusing on changing their own minds rather than the world around them. This weary professor introduced me to Albert Ellis’s personal experiments, where he tested his fearful predictions, and encouraged me to apply his Rational Emotive Behavior Therapy (REBT) techniques to my situation. While I struggled to distill the complexities of my life into concise sentences for the ‘D’ (Disputes) and ‘E’ (Effective Belief) sections of my assignments and the professor noted that my homework read “poetic,” he didn’t seem to view it as a failure.

One day, while reviewing my reflections on Gerard Egan’s The Skilled Helper from my homework, he chuckled and inquired about my thoughts on the book. He casually remarked, “You’re reading it, so you could be a skilled helper!” I felt a pang of shame, fearing he might view me as audacious for aspiring to grasp knowledge that seemed beyond my reach.

He frequently reminded me that newcomers to psychotherapy or students embarking on the study of psychology often yearned to become psychotherapists themselves. Yet he emphasized that not everyone needed to follow that path. I grasped the essence of his message, but on the flip side, I couldn’t help but wonder if my own psychological struggles rendered me ineligible to be a therapist.

Trends in Diagnosis

One day, I mustered the courage to ask him if my assumption that I might have borderline personality disorder was accurate. He chuckled and retorted, “You think you have borderline personality disorder? What makes you think that?” I mumbled, “I read about its characteristics in books, and they all seemed to…” He interrupted with a knowing smile, “It’s a common phenomenon among young college students. They read psychology textbooks in some basic psychology courses and nervously identify with the descriptions of various psychopathologies. But you don’t have borderline personality disorder.”

Yet, all the elements describing that cursed disorder, except for the tendency to engage in random fights with strangers, appeared to mirror my own self. Ashamed of my propensity to take myself too seriously, I decided to cast aside the cursed diagnosis. However, more than 20 years later, I stumbled upon that very diagnosis in my patient record, documented during my stay at the nation’s first eating disorders inpatient clinic from the end of 2001 to March of 2002.

The psychologist who assessed and interviewed me had concluded her preliminary assessment with three diagnoses: 1) Atypical Anorexia, 2) Borderline Personality Disorder, 3) Depression.

Reading this decades later while in the midst of penning my memoir, the revelation struck terror into my heart. I felt as if every last drop of blood had been drained from my body, leaving me cold and dizzy. If that diagnosis was accurate, it meant I’d lose control over my own narrative. The air grew thin, and I was beginning to doubt my very existence.

Driven by sheer horror, I approached my psychiatrist at the time and blurted out, “It says I have BPD. What do you make of it? If I had BPD, I couldn’t even trust my own thoughts!” “No way,” he responded firmly. “Do you truly believe you have BPD? No, you don’t.” He was right. At that point, I couldn’t fathom myself as having BPD at all. Nevertheless, the experience of my self-assurance collapsing abruptly lingered within me.

The psychiatrist’s rationale was as follows: for each period in time, he said, there tend to be a couple of popular diagnoses. Back then, during my hospitalization at the eating disorder clinic, borderline personality disorder was one of those common diagnoses. Later, bipolar disorder took its place. It was frustrating, he said, to witness young anorexic patients who were initially diagnosed with bipolar disorder at university hospitals, only to end up seeking his help after the initial treatment failed and their conditions worsened.

‘Clients’ vs ‘Patients’

What drove me to consult a psychiatrist for the very first time in my life, instead of seeking out psychologists, especially at the university student center or within the psychology faculty? In 2001, my life was already ensnared by worsening eating disorders, relentless depression, and self-inflicted wounds. I continued to see a new psychotherapist at the student center, the seasoned female counselor whom my former therapist, the professor, had recommended. Strangely, she was rather stern with me, and I found myself needing to prepare positive epiphanies in advance for our sessions to avoid her confrontations. Once, I introduced the metaphor of a Tamagotchi, explaining that I had come to see myself as taking care of my own well-being like nurturing a Tamagotchi with care. Another time, I discussed a news segment I had watched on TV the previous day. President Bush had been extolling America’s resilience and unwavering strength in the face of adversity. I likened my mindset to the same idea, and she appeared content with my admission.

As winter neared, I made a pivotal decision to venture into one of the few psychiatrists’ clinics in Seoul specializing in eating disorders all by myself. I selected one whose website exuded a sense of bureaucracy. There was another clinic whose website and public forums buzzed with activity, filled with the chatter of day hospital patients, their troubles laid bare almost daily. I was already a silent admirer of theirs, delving into their quasi-diaries frequently, trying to discern the identities behind the characters. Yet I lacked the courage to immerse myself fully, opting instead to maintain a distant, dissociated stance as my own guardian, steering me toward the other clinic.

I can’t pinpoint exactly when this realization dawned on me, but the most astonishing distinction between assuming the role of a therapy client and that of a psychiatric patient, to me, was that as a patient, you were allowed to be less responsible and entirely ignorant of the interpersonal dynamics of psychotherapy. Psychiatry tends to be more patronizing than psychology, setting significantly lower expectations for patients. Contrary to the psychologists I had seen, who seemed to fear the possibility of me losing my sanity, in the psychiatric clinic you could be as mad as possible, and regardless of what unfolded within the clinic’s walls, the psychiatrists seemed to have no fear, self-assured in their belief that they could treat their patients no matter how irrational their behavior might be.

After all, medicine was more physical than psychology. It oversaw a realm beyond language. In psychiatry, you could be free not to speak because the spoken testimony of the patient doesn’t carry the same weight as it does in psychology.

As fate would have it, the clinic’s psychiatrist had recently inaugurated the very first inpatient program for eating disorders. I was chosen as the promising model patient for his ambitious new project; the preliminary outpatient discussions led directly to the decision for hospitalization. My mother and I, seated in the backseat of the psychiatrist’s sleek black sedan, embarked on a journey to the newly furnished inpatient ward, which was a 30-minute ride away. A nurse and a male administrative staff member, who actually functioned as a temporary nurse, hurriedly greeted us. They promptly took charge of my belongings, removing cosmetic bottles, a nail clipper, and my cell phone. Items made of glass or with sharp edges. Their foresight astounded me, as they seemed to anticipate a far wider range of possibilities than I could have ever imagined regarding myself.

What do the customs of psychotherapy perform, and for whom?

I authored and published my memoir amidst a surge of “illness memoirs” in Korea, particularly those written by young female writers. This genre began to gain momentum around 2017, when self-published personal narratives sold only at some local bookshops found the readership, as far as my knowledge goes. However, psychotherapy or psychiatric treatment weren’t native concepts rooted in our local context. Therefore, individuals grappling with mental health issues had to learn and adopt the roles and rules of psychotherapy on their own to potentially benefit from the unique social relationship it promised.

Publishers who reviewed my final draft often suggested that I should make it more accessible to a general readership. Some even anticipated that I would transform it into a sort of user manual for novice clients or patients unfamiliar with psychotherapy. Interestingly, the most popular and best-selling illness memoir about the author’s dysthymia treatment actually detailed her sessions alongside her psychiatrist’s prescribed medications.

It’s akin to, let’s say, an ancient Roman custom evolving into the most widely accepted social system for addressing a problem, leaving sufferers with no other credible alternatives. This ancient custom defines the problem in its distinct way, and if you don’t internalize that definition and willingly assume the expected role, you can’t seek help in any other manner.

However, while those who find relief in this solution and envision a brighter future without doubt proudly express themselves with eloquence, sometimes absurdities occur. In Korea, “You Were Born to be Loved” is considered one of the most popular “healing” songs, like a form of protest chant, almost nursery-rhyme famous, but it is, in fact, a contemporary gospel song. People love singing it together with their hearts warmed up, but they rarely complete the song. That’s because, after the first verse, which joyfully concludes with “You were born to be loved and you are receiving that love throughout your life,” the next verse follows, beginning with “The love from God that has been present since the beginning of the world becomes connected with us as we meet each other.” Being Christian isn’t the norm in Korea, so many people are embarrassed to sing that part of the song.

On Christmas in 2001, when three of us were the only patients in the homey inpatient ward at the newly launched eating disorders clinic, we gathered in the living room with a small cake; a sweet gesture from the nurse on duty, but none of us dared to take a bite. We also attempted to sing the song, and it did touch us initially. However, as the awkward part of the song approached, we all burst into laughter, giving up on singing with flushed faces.

When someone suggests that you’re depriving yourself of self-love and self-care to the point of causing your own suffering, what does that imply? While the ‘problem’ is neatly defined, I have my doubts about the best possible solution. Why do you suffer? What should be provided to you if we want you to be cured? And what should you do to be cured? There have been many hypotheses, and the loose, contaminating, and inseminating words play magic all through the cultural narratives.

As the secularized gospel song persuades, did I suffer because I failed to love myself? And if we accept the point of view that all of us are lovable, can we heal everything? What did the psychiatric professors at university hospitals see in their young anorexic patients whom they considered as ‘bipolar disorder’ patients? Will we be able to finally accept the concept of paid kindness—the concept that we can buy the service of listening ears, consolation, and friendship that might be the most loyal and unconditional but is conditioned to be ethereal when the sessions expire?

Or the awkward encounters might keep happening. Because you’re angry and disillusioned, not just depressed. You’re not quite ill enough to be diagnosed but can’t return to your old routine life by yourself. You don’t know why you are not ‘crazy’ but still need to pay for therapy sessions. You want to change this world, but at the same time, you are told to behave more shrewdly not to lose your ground. The last thing was what I heard from my psychiatrist the other day. I complained about my never-rewarded workload and the misogyny in the workplace, then he advised me to be aware of my too-harsh wordings. I almost shouted at him, “That advice can’t be applied well to the socially weak!” I meant that too much endured unfairness and anger rarely leaves space for shrewd interpersonal strategy.

And when the child who was led to sit in his therapist’s office, as I mentioned at the beginning of this essay, finally becomes psychotherapeutically literate, that is, when he becomes fluent in his role and almost talkative as the proper client of his therapist, all his earlier problems—and of course, the boy himself, too—will be found to have already changed so much that nobody recognizes them.