15 Vignette

Maggie arrives on time for her second visit with you and produces her client manual as soon as you invite her into the office.

“Did my homework!” she says. “Do I get an A?” She’s laughing, but you detect her anxiety lurking beneath the question.

“All honest effort earns an A in this office,” you say, as you both settle into your chairs. “Tell me, how was your week?”

“Kind of stressful, I guess. We had a problem at Theo’s school which had me pretty freaked out.”

“Oh? What happened?”

“He’s in what they call an MH class, which stands for ‘multi-handicapped.’ All the kids in the room have severe brain injuries. Most have CP, like Theo. One little girl, Cara, is Theo’s age, and she was perfectly healthy until she was seven, and then she drowned on a family vacation. Can you imagine?” She shakes her head sorrowfully. “Paramedics were able to bring her back, but she was without oxygen for too long, so she’s in really bad shape now; blind, deaf, a quad. Very sad. Her parents are super nice people. Anyway, all together there are eight kids in the room, with one head teacher and three paras.”

“Paras?”

“Paraprofessionals. Teacher’s assistants, basically. And that’s what stressed me out. Because of Theo’s feeding problems, he has a special para assigned to him at lunch. Jackson has worked with Theo for four years, since he started school. He really understands Theo’s feeding needs. He likes Theo, and I know Theo likes him. But Jackson was out for three days in a row, so they had another para trying to help Theo at lunch, and of course Theo choked, because he has to be fed very slowly, and his mouth needs to clear before you put more food in. After he chokes badly, he sometimes rejects the rest of his meal, so the teacher called to tell me what happened, and I had to leave work for an hour to make sure he was okay and get his lunch into him. I have family medical leave – do you know about FMLA?” You nod. “Well, FMLA gives me the ability to take time as I need it to manage Theo’s issues. Thank God his school is only about ten minutes from work – that’s actually the reason I took the job – so I was able to get over there quickly to make sure he was all right, and for the rest of the days that Jackson was out, I left work at lunch and fed Theo myself, and then went back to work after his meal. It wasn’t a problem, really, but I worried about it all week. Worried that I was inconveniencing work, worried that Theo had to wait for his lunch, because his class eats at eleven but I wasn’t able to get there until noon each day… Then I started worrying about what was going on with Jackson and why he was absent for so many days, and what will happen when he moves on, because he’s already stayed in the class longer than most paras do, and it’s not realistic to expect that he’s going to be there forever. So…Just worries on top of worries.” She laughs with a brittle edge. “Which is why I’m here, right?”

“Which is why you’re here,” you agree. “Anything else we need to talk about before we get down to work?”

Maggie shakes her head. “This may sound weird, but I’m really excited to get started. In the middle of all the craziness of the past week, particularly at night as I was getting ready to fall asleep, I started feeling something kind of unfamiliar. And I was trying to figure out, you know… what’s that feeling? And I decided… this sounds so hokey, but I decided that the feeling I was having was hope, you know? I started feeling hopeful that I could get on top of the worry. So, I’m really looking forward to getting started. I brought my workbook, and I finished that State-Trait scale. You want it?”

She hands you the workbook, at you set it in your lap. “I’m delighted to hear that you’re feeling hopeful about treatment. There’s a lot to be hopeful for; as I said last time, most people are able to get significant relief from their symptoms using this protocol, and I have every expectation that you will too. Before I take a look at your homework, though, I want to talk to you for a minute about the structure of our time together, which will be consistent from week to week. First, we’ll have a quick check-in, as we just did, to see how your week went, and we’ll look at your homework. Then, we’ll turn our attention to skill-building. I’ll share some information with you about the skill of the week, and then we’ll practice it together here in session so you feel confident that you’ll know what to do when I ask you to practice at home during the week. Then, we’ll usually end with a talk about how different aspects of your anxiety impact your relationships with others. How does that sound?”

“That sounds fine,” she says. “I really like the structure. It reminds me of work, staying focused on tasks and following specific protocols so we know that our patients get the right care.”

You open her workbook and flip to the appendix, where you know from long experience that you will find the initial STAI. You’ve used these workbooks for years, and have them practically memorized. “Give me just a minute to take a look,” you say, and add up the raw scores for her state anxiety and trait anxiety. Glancing quickly at the STAI percentile ranks sheet which you placed on your desk prior to the session in anticipation of this activity, you see that Maggie’s S-anxiety raw score is 46, which puts her in the moderately severe range at the 82nd percentile. Her T-anxiety raw score is 62, which puts her in the severe range at the 100th percentile, and is a strong confirmation of your diagnosis of GAD.

You explain the difference to her between state anxiety and trait anxiety, and interpret the scores for her. “This confirms for us that your level of anxiety at the time you took the test was in the moderate range, and that your general level of anxiety is pervasive and severe. As I said to you last week, you’ll take the STAI again at about the midpoint in treatment, and then one more time at the end, so we’ll be able to measure your improvement as we go along. What do you think of the scores you got this time?”

“Well, it’s not a big surprise,” Maggie admits. “I mean, I know I’m too anxious. I guess I’m just looking forward to getting those scores down to a more manageable range, so I spend less time worrying and more time living my life.”

You move to the next part of the session, and provide Maggie with psychoeducation about scheduling worry time. You explain that some aspects of worry can be functional, as a method of focusing her anxious distress, and that by scheduling short periods of time in which she concentrates completely on her worries, then she will also eventually develop the ability to turn her worry off when it doesn’t serve her. You explain that she should practice worry time every day for fifteen to twenty minutes, focusing on one worry or dilemma which is particularly preoccupying her. You explain that, at the end of the fifteen to twenty minutes, she should turn her mind to something else, and reassure herself that she has another worry time scheduled for the following day which she can devote to that worry or dilemma.

“I think I understand,” Maggie says. “It’s going to be hard to just make myself stop worrying, though. It’s such a bad habit by now.”

“It’s definitely going to take practice,” you agree, “which is why I’ll ask you to schedule a worry time every single day for the next several weeks.”

“Maybe I can do it when I’m washing dishes after dinner,” she muses. “Naldo does homework then, and I usually set Theo up with a video so I can clean the kitchen and get lunches ready for the next day.”

“That sounds like a great possibility,” you say. “It’s your choice; you decide when worry time fits best with your schedule. Just be sure to limit yourself to that fifteen-to- twenty-minute period, and then turn your mind to something else. Let’s practice together for a few minutes now, so you can get the hang of focusing on a specific worry, maybe one that you’d feel relieved to come to a resolution about. Talk about your worry out loud, and I’ll just reflect what I hear you saying, so you know I understand. Any questions?”

She nods and is quiet for a moment. Then, “I guess… a big worry that I have all the time, but never talk about, is how I’ll manage Theo as he gets older.”

You pause and then reflect, “you worry about what the future holds.”

“That’s right. And I don’t just mean after I’m gone. I mean even in the next couple of years, how will I continue to take care of him? He’s nine years old and weighs fifty pounds and he’s already more than four feet tall. He can help a little when I need to transfer him to or from his chair, but it’s not easy to do. He’s getting bigger and heavier, and I’m not getting any younger and stronger. Naldo tries to help, bless his heart, but it’s not fair to push Theo’s care onto him. What happens next year, or the year after? How will I manage him?”

Reflecting again, you say, “as Theo gets older and bigger, you worry about how you’ll continue to meet his needs physically, and provide care for him.”

Tears suddenly flood her eyes. “I have a best friend, Sarah. She’s sort of like my soul sister because we have so many things in common. Her little guy, Joey, was in Theo’s class for a couple of years, but then she moved him to a pediatric nursing home a couple of hours from here. Joey’s worse off in a lot of ways than Theo because he has a vent and a feeding tube, and it just got too much for Sarah to try and care for him at home. It broke her heart to send him away, but she likes the place she found for him and says she’s glad she did it. It’s terrible to say, but I feel jealous of her, sometimes. She just does normal stuff with her daughters during the week, they get their nails done and go out to dinner or whatever, and she visits Joey on weekends. Her life is so much easier now, and I know it would be that way for me too, but the thought of sending Theo away gives me a panic attack. I worry about it all the time. I’m petrified about making the decision, but the bigger and heavier he gets, the more I have to consider it.”

You allow another brief period of silence as Maggie dabs her eyes with a tissue.

“The idea of moving Theo to a nursing home is really distressing, but you know you need to consider it as a practical possibility because he’s getting bigger.”

“It reminds me of what happened to my parents, I think,” she says suddenly. “I never really put that together before, but I think I get so panicked by the idea because they were sent away from their parents, and they both told me how it hurt them so much. Theo is pretty low-functioning, so it’s hard to know what he really thinks or understands, but I never want him to feel rejected or unwanted.”

Reflecting again, you say, “because of your family history, it’s especially important to you that Theo always feels loved and wanted.”

She nods and is quiet for several moments. “Sarah has invited me a couple of times to go with her to see the place. It’s called Hills and Hollows Child Development Center. She’s shown me pictures, and it looks really nice, and I know they take good care of Joey. I’ve always told her I can’t take time away from the boys on the weekend to go with her to see it. But really… I think I’m worried that I might like it and might decide it would be good for Theo, and the thought of that just breaks my heart.”

Gently, you reflect, “since you know that Joey is well cared for at the center, it’s painful to think about visiting him, because you might consider it a suitable place for Theo, too.”

Openly crying, now, Maggie nods. “I think I worry about it so much because it’s almost inevitable that I’ll have to make that decision one day, but I just want my kid to know that I did the best I could for him, for as long as I could. That I didn’t give up until I absolutely couldn’t do it anymore. I worry about knowing when the right time will be.”

Reflecting one final time, you say, “you struggle with the dilemma of knowing when will be the right time for Theo to live away from home.”

“That’s right,” she says tearily. “The dilemma is how to decide when the timing is right.”

You pause for a long moment, marking the conclusion of the activity. Then you say, “You did a good job on that activity. Do you see how spending some time with the worry, really concentrating on it, helped you come to a place of focused clarity? You started by worrying in general about how to manage Theo as he gets older, but you were able to condense that to the heart of your concern, which is how you’ll know when the time is right for him to live away from home.”

She nods. “I think, in a way, that I resist thinking about it, so my thoughts and worries just go ‘round and ‘round like a hamster on a wheel, keeping my mind busy so I never get to the point of having to make a decision.” She looks down, studying her nails.

Maggie has just achieved an important insight, and you want her thoughts to linger there, so you nod slowly and, again, take the pause. Three-quarters of being a good therapist is timing, and most of that timing relates to being still, silent and non-distracting while the client works things out in the privacy of her own head.

Eventually she looks up. “Okay,” she says. “I’ll practice that more at home, fifteen minutes a day, while I’m working in the kitchen after dinner. What’s next?”

You explain the daily worry record to her, pointing it out in her workbook and asking her to identify on a 0-10 scale her average degree of worry each day, as well as her peak anxiety. “Doing this toward the end of the day would be helpful,” you tell her, “and it’s important to complete it every day, rather than waiting until several days have passed and then trying to remember what you felt like.”

“I get it,” she says. “Don’t fudge the documentation!”

“That’s right,” you agree. “An important rule for both nurses and counselors!” You move on, then, to the discussion about worry and personal relationships.

Specifically, you ask Maggie to explore any connections she sees between her worry and her relationships with others.

“Well, sure,” she says. “I worry about everyone in my family, like we’ve already talked about. I think part of loving people is worrying about them, right?”

“So, love and worry are completely intertwined?”

“Hmm,” she says. “That doesn’t sound so good, does it? I don’t like to think that if I love someone, then I automatically add to my worry. But, in a way, I guess that’s true. I absolutely worry about my mom and my kids. I worry about them all the time. And I worry about what signals I missed with my dad, that he could have been in so much trouble and I just had no idea.”

You ask who generally makes her worry better, and she identifies her friend Sarah. “We have a lot of laughs together, and have a ton in common. She’s a nurse, like me, and she has a disabled kid like me. She’s someone I really relate to and trust. She was totally in support of therapy when I told her I was coming here. She saw a counselor herself,

around the time she put Joey into care.”

Maggie tells you that she generally doesn’t share her worries with anyone except Sarah, and that she especially tries hard not to burden her mother with any of her worries, because of her sense of her mother as a fragile person. “She’s taken care of me for my whole life,” Maggie says, “so at this point, I want to be someone who she can rely on, not the other way around.”

It’s almost 40 minutes into the hour, now, and time for you to summarize the session. You reinforce the “worry time” concept, and ask Maggie to share her feedback about the session. She tells you that she was surprised by her emotional reaction to the practice you did together, and especially the sudden insight she had about the fact that she has avoided thinking much about the possibility of sending Theo to a residential care center because of her parents’ experience of being sent away from home when they were small. She also tells you that she likes using the workbook as a supplement to the sessions you’re having together. They’re well-organized, she says, and give her a sense of the possibility of regular progress and relief from her symptoms.

Finally, you explain Maggie’s homework for the upcoming week. You remind her to practice worry time each day and to complete the worry record each day, and to bring the worry record with her to therapy next time. You also ask her to begin a therapy journal, where she’ll document any thoughts or questions she has about the skills she’s learning as she moves through the week. Next, you ask her to read the “preview to session 3” in her workbook. She nods her acceptance and understanding. “I see what you mean about needing to invest time in between sessions,” she says. “But I get it. I’m not going to stop worrying by magic. I’m only going to be able to change my patterns by investing time and effort in the process.”

“Exactly right,” you agree. “So, what time works for you next week?”

You make an appointment for the following week and then see her to the door of your office. You have only ten minutes to document the session before your next patient arrives, so you head immediately to your desk and begin to write a progress note.