39 Vignette

Maggie presents to her tenth visit as scheduled. When you go to the waiting room to escort her back to your office, you see that she’s holding an orchid plant in a glazed ceramic pot, which she hands to you as you walk together down the hallway to your office. “I know you’re not supposed to take gifts,” she says, apparently anticipating an objection, “but I asked Sarah, and she said she gave her therapist a plant when they finished their work, and it was okay.”

“Thank you,” you tell her. “It’s lovely.” The implications of accepting – and rejecting – gifts from clients are immensely complicated, and all the counseling disciplines, including social work and clinical psychology, have articulated ethics statements regarding the acceptance of gifts from clients. In general, therapists may accept “token gifts” from clients without running afoul of the professional rules, but are discouraged from accepting gifts of “substantial financial value,” a description which is admittedly open to wide interpretation. As for yourself, you’re comfortable accept client gifts which have been handmade by the client, as well as plants and baked goods (which you almost always deliver promptly to the staff lunch room for all to enjoy). You’ve had to decline some expensive gifts (tickets to live theatre, and once, tickets for a week-long cruise), but for the most part, clients who choose to express their appreciation through gift-giving manage to stay within acceptable bounds.

When you get to your office, you place the plant on your desk, and Maggie sinks into the recliner. “I can’t believe this is our last visit,” she says, pulling out her workbook and binder. “I remember when I first called for help. Dr. Munson pushed me into it because I’d just had that meltdown at work. I told her I didn’t think I needed it, but she put her hands on her hips and said, ‘really, Maggie, how long can you keep going on like this?’ And then she told me about you. She said we’d get along well, and we did.” She looks at you shyly. “I’ll miss you,” she says, a blush coloring her cheeks. “You’ve helped me such a lot.”

“Thank you,” you say. “I’ve enjoyed working with you, too. But please keep that credit where it’s due. You’re the one who’s done the work.”

“I know,” she says. “But you showed me what to do. I re-read my therapy journals all the way back from the beginning, and it was amazing to see how my perspective has changed in so many ways. It’s funny; I feel better, but I also think differently and see things differently, too.”

“That’s what I love about CBT,” you say. “It takes a lot of work, but in a relatively short time, people can make amazing changes.”

Maggie hands you her workbook. “I did the last STAI,” she says. “Grade it, and tell me how I did.”

This time, Maggie’s S-anxiety raw score is 24, which puts her in the low range at the 10th percentile, and her T-anxiety raw score is 29, which puts her in the low range at the 25th percentile. She’s made tremendous improvement from her initial STAI, when her S-anxiety raw score was 46, which put her in the 82nd percentile, and her T-anxiety raw score was sixty-two, which put her in the 100th percentile.

“These scores reflect normal levels of anxiety,” you tell her. “Congratulations! If I met you for the first time today, and completed a diagnostic interview, you wouldn’t meet criteria for GAD.”

Maggie basks in the glow of her achievement. “I feel really proud of myself,” she says. “This was hard work, and I did it. Now the big question is, how can I make sure I stay in a good place?”

“That’s a great question, and a great introduction to our topic for today, which is relapse prevention.” You provide psychoeducation about the recovery model, in which the goal is to give clients the skills they need to manage their anxiety over the long term.

“Of course, you’re going to experience anxiety-provoking situations in the future,” you say. “That’s life, and we don’t want to set you up for disappointment by suggesting that you’ll never experience anxiety again. However, if you’re successfully able to deploy your CBT skills when you experience anxiety, you’ll be able to prevent yourself from having the severe symptoms you were experiencing when you first came to treatment.”

You encourage Maggie to continue doing what has worked for her in treatment thus far, and she nods in agreement. “Worry time and relaxation,” she says. “I’ll keep doing those forever, because they work for me incredibly well. Worry exposure is helpful too, because it turns rumination – just worrying with no end – into hopefulness, when I

imagine a happier outcome.”

“That’s excellent,” you say. “It will also be helpful for you to stay alert to anxiety triggers as well as warning signs that your anxiety might be rising to an unhealthy level. What warning signs might you notice?”

She considers for a moment. “If I start having panic attacks again, that’ll be a sign that I’m not managing myself well.”

“Good. Anything else?”

“If people who know me well, like Sarah, or my mom, Dr. Munson tell me that I’m getting too wound up.”

“Very good. Remember that you can also check in with them periodically, rather than waiting for them to come to you.”

“Great idea,” she says. “That’s a more proactive than waiting for them to come to me.”

“You might also want to consider taking a STAI once a month,” you suggest. “In just ten minutes or so, you can take the temperature of your anxiety and get a sense of how your anxiety is trending over time.”

“I definitely can do that,” she says.

You talk for a while longer about triggers, supports and warning signs, then review her thought record and worry record. “My lowest average on the worry record was a two,” she says, “and my peak was an eight. I hit the peak when I thought about graduating from therapy. I guess I’m nervous that I’ll backslide if I’m not accountable every week.”

“How might you resolve that?”

“I could use Sarah as an accountability partner,” she says. “We pretty much tell each other everything anyway. And if things really get out of hand, you said I could come back.” She hesitates. “You really meant, that, right?”

“I really did. It’s perfectly normal and perfectly okay for you to need periodic therapy tune-ups. If some visits would be helpful, just call the office. That doesn’t mean you’ve failed, or that you’re not doing recovery the right way. Periodic sessions, especially during stressful times, are a way of keeping yourself in good shape.”

“I can definitely see myself needing some extra support if – when – Theo gets placed away from home,” she says.

“Okay,” you say. “So, when the day comes that you need a little tune-up, you call the intake office here at the center, and they schedule an appointment for you. No big deal.”

“And you’re not planning to retire any time soon?”

“Retirement is quite a way off,” you tell her, grinning. “I’m pretty sure I’ll still be around should you need me at some point.”

You close the session with a review of her program satisfaction questionnaire. She identifies her symptoms as “extremely improved,” and describes the treatment protocol and the skills she’s learned as “extremely useful.”

“It’s been good,” she says. “Way better than I expected. Life-changing, really. And really,” she says, standing and reaching out to shake your hand. “Thank you. Really.” For the last time, you walk together to the office door. You open it and she slips through. She doesn’t look back as she strides confidently toward the waiting room.

You close the door and stand for a moment in the office, savoring the quiet satisfaction of a job well done. You notice the pretty orchid on your desk, walk over to it, and run your finger over the soft petal before sitting to complete your paperwork.

Two documents are due today; the closing note for today’s session and the discharge summary which condenses the entire course of care. The treatment summary also closes the record, and will signal to the front office staff that you have an opening in your schedule. Within a day or so, there will be a new face sheet in your EMR, and by the end of the week, a new client will have taken Maggie’s place on your schedule.

You reflect for just a moment on the way of things in a counselor’s work; the coming-and-going, the promising beginnings and bittersweet endings, over and over and over again. Then you begin to write.