18 Vignette

Maggie arrives on time and as scheduled for her third session. As you greet her in the waiting room and walk with her down the hallway into your office, you detect a slight change in her physical posture; a small degree of relaxation in her shoulders, less tension in her face. A good sign.

Your office is a calm and safe space with potted plants, natural light, a comfortable couch and recliner for clients to relax in.  You gesture for her to make herself comfortable in the soft leather recliner where your clients usually sit, and you settle into your own chair. “How went the week?”

“It was… different. Remember last time when we talked about making specific time for worrying?” You nod. “Well, I did that. I practiced every day, after dinner when the kids were busy; that’s my time for washing up and making lunches for the next day. And when I noticed myself worrying at other times, I was really stern with myself and said, ‘not now! You can worry after dinner!’” She chuckles. “Sort of weird, I guess, but it helped me. I knew that I’d have that time which I could completely devote to my worries, and that freed up my mind during other times. Like, Naldo had to do a project for the science fair, and I spent part of the weekend working on it with him. Before, I might have helped him in sort of a distracted way, and not been totally ‘there’ with him, because most of my mind would have been like the hamster on the wheel, just worrying and worrying about a million different things. But instead, I just told myself to stop worrying and really be there with him. I wasn’t perfect at it, but I definitely noticed that I’m getting the idea of…” – she forms a box in the air with her hands – “… containment, sort of. Like, there’s a time and a place for worry, instead of letting it hold me hostage 24 hours a day.”

“That’s really excellent! Looks like scheduling worry time has been a good strategy for you so far.”

“Well, I’m not perfect at it, and I still worry way too much. But I’m just beginning to pay attention to my thinking, and to realize how out of control my worry has become, so the idea of creating some kind of box for that, making a time and a place for it, has really been helpful.”

Maggie is describing metacognition, or the ability to consciously think about her own thinking. This is a fundamental skill in CBT, which begins with developing the client’s awareness of her thought patterns and belief systems, and recognizing those which are inaccurate, unhelpful or unrealistically negative. Once those thoughts and beliefs are oriented more positively, the client’s feelings follow; when the feelings tilt in a healthier direction, the behavior follows right along. In her first session, some of Maggie core beliefs (“I’m not capable…” “I can’t do it…”) were on full display. Those negative thoughts about herself led to a troubling state of pervasive anxiety, and the anxiety led to behavioral disturbances such as irritable outbursts, nightmares, insomnia, and panic attacks. This, you know, is the classic neurotic cycle (negative thoughts drive painful feelings; painful feelings result in disturbed behavior) which CBT seeks to address.

It’s a positive indicator that Maggie is thinking about her thinking, and making small but noticeable behavioral changes, after only a few CBT sessions. Most clients – not all, but most – respond well to CBT, and it seems that Maggie will be one of those who are able to use it successfully. This, more than almost anything else, keeps you continually excited about and energized in your work. It’s absolutely fulfilling to watch a person like Maggie, wracked with worry and overwhelmed at the start of treatment, begin to make changes which will vastly improve her quality of life.

“Sounds like you did a great job with your homework,” you affirm. “Did any major issues come up during the week that we should talk about before we get started with our tasks for the day?”

She shakes her head. “I don’t think so. Theo’s feeding para, Jackson, finally came back to school, which is a big relief, and I got to spend a little time with my friend Sarah. Otherwise, it was pretty quiet.”

“That’s good,” you say. “So, let’s talk about the agenda for this session. Just like last time, we’ll take a look at your homework, and then I want to share some information with you about relaxation. We’ll practice a relaxation exercise together – “

“ – And then I’ll have to practice it at home, right?” She laughs.

“You’re right! I’ll ask you to practice it at home between today and our next visit.

Then, toward the end of our time today, we’ll talk about the connection between relaxation and your relationships with friends and family members. How does that sound?”

“Sounds great,” she says. She reaches into her bag and brings out her workbook and a three-ring binder. “I’ve got everything right here.”

You spend a few minutes together talking about the relaxation self-assessment in the workbook which she completed as part of her preparation for today’s session. She identifies that she frequently has a hard time relaxing, and she often notices physical tension in her body. She doesn’t generally get sick or have digestion problems. What she most wants to change is the ability to unwind at the end of the day.

“Very good work,” you say. “Now, let’s look at your worry record. How did you manage with that?”

She opens the binder which is sitting on her lap. “I decided to copy the worry record pages and put them in a notebook, so I could easily see the patterns from week to week without having to spend time flipping back and forth through the workbook,” she says. “I wrote the worry record entry and my journal every night after I got into bed, so I could spend a quiet minute thinking about the day and evaluating how I did. Is that an all- right way to do it?”

She’s seeking reassurance, which you noticed last week as well, and you wonder if she felt anxiety when she was a small child about being ‘good enough’ to earn acceptance and approval from her parents. “That sounds terrific,” you tell her. “Use whatever method works best for you.”

“I want to get better,” she says earnestly. “I really want to beat this anxiety, so I’m taking therapy seriously. One of my friend Sarah’s favorite sayings is, ‘nothing changes if nothing changes.’ It means that you have to do things differently if you want different results.”

“That’s a wise saying,” you agree, “and you’re wise to invest this time and effort in yourself, because you’re absolutely right in thinking that your success in beating the anxiety is directly related to how much effort you put into the work of therapy.”

“I get that,” she says. “I don’t want to waste your time, and Lord knows I don’t have any of my own time to waste.” She opens the notebook. “So, in my worry record, my levels of anxiety ranged between 70 and 90, and my peak levels of anxiety were all 90 except one day which was 100.”

“All right,” you say. “What do you notice in terms of trends?”

“Well, I’m more anxious on workdays than on weekends. And the other thing I noticed was that most of my ‘peak anxiety’ episodes happened during conversations with other people. What’s really interesting is that I would have guessed that my worst anxiety would happen when I was spending time with the kids, worrying about them like I always do. But actually, none of the ‘peak anxiety’ episodes happened when I was with them.”

“That’s an important awareness,” you tell her. “What do you think about your anxiety level overall?”

She laughs. “I think it’s way too high! I didn’t get below a 70 during the whole week. But scheduling worry time has been really helpful, so I’m guessing that my anxiety level was even higher before I started doing that. It’ll be interesting to see what happens as I learn new skills and get better at managing it.”

You nod in agreement. “Let’s turn now to your therapy journal. Is there anything you’d like to share from that?”

She flips to a different section of the binder, and you see that she’s filled several pages with small, neat handwriting. “I guess the most important thing in here has to do with something we talked about in our session last time. Remember when we practiced the worry time together, and I talked about Theo’s future at home?”

“I do remember that.”

“Well, I think I told you then that it’s something I hardly ever talk about, because it’s so hard and scary to even think about, never mind telling another person. But I realized after talking about it out loud here that afterward I actually felt less anxious about it, and less…” She pauses. “I guess the word I’m looking for is ashamed. I don’t know if you know, but there’s a lot of shame and stigma involved for moms who have a disabled child, especially when it comes to the possibility of having your child live away from home. Everybody pushes inclusion and the least restrictive environment, so it’s easy to feel judged, or like a bad mom, when you get to the point of having to consider that your child may need to live in a setting away from you.”

She tears up, and you nod slightly and wait. After a moment, she continues. “So, I got to spend a little time with Sarah this weekend, because Naldo was visiting a friend and I left Theo with my mom for an hour. I told Sarah that I talked to you about her son Joey, and Hills and Hollows, the nursing home where he lives. That’s the time in my worry record when my peak anxiety was 100, during that conversation with Sarah,

because I told her that I’m not ready yet for Theo to leave home, but that I do want to go with her to visit Joey next time she makes the trip. Just so I can see the place for myself. It was so hard to have that conversation with her, but after I told her and I made the decision just to go and have a look, I felt relieved and so much less worried. Like, I’d been putting it off and putting it off, and when I finally decided to go look at the place, all the worry about deciding whether or not I should see it just… evaporated. So that’s my big awareness for the week from the journal.”

“That’s a big awareness,” you agree. “Instead of being the hamster on the wheel, as you’ve described, you decided to take some action instead of getting stuck in the worry cycle.”

She nods. “I’m nowhere close to ready for Theo to leave home,” she says. “That’s going to be a long process for me. But instead of being in complete denial about it, and avoiding the whole subject, I feel better that I’ve made the decision to go to Hills and Hollows and take a look. I’ll visit Joey and have a tour while I’m there. It’s a first step, and I feel good about it, even though it’s really hard.” She begins to cry, and you wait quietly, with patience and support written across your expression, until her tears have passed.

After a few minutes, Maggie signals her readiness to continue with a nod. You move to the next item in the agenda, providing psychoeducation about relaxation. You talk to her about the continuum between physical tension and physical relaxation, and what she feels in her body when she’s tense as opposed to when she’s relaxed. She notes that she carries most of her tension in her neck and shoulders, and she generally feels most physically relaxed in the moments just before sleep. “Except for my jaw,” she says. “I clench my jaw even when I’m sleeping. The dentist had to give me a night guard so I don’t ruin my teeth.”

You introduce the practice of progressive muscle relaxation, or PMR. By now, you know the process by heart, but in the early days of your practice, when you were less familiar with the steps, you read the instructions aloud from your Therapist Manual. You ask Maggie to practice PMR with you in session, telling her that it will take about 20 minutes, and she agrees. Following your suggestion, she presses the button to extend her recliner until she’s resting in a nearly supine position. She closes her eyes while you guide her through the PMR experience, isolating specific muscle groups in her body and then flexing, holding and relaxing them. You remind her to notice the feeling of relaxation in the muscles when they are released after the period of tension. Then you talk for a few minutes about the experience.

“My body feels pretty heavy,” she says in response to your question. “My muscles feel tired, sort of like they’re glad I’m in this comfortable chair and I don’t have to move for a little while.”

“That’s good,” you say. “So, your body is enjoying the feeling of relaxation.

That’s the physical feeling we want to connect with the reduction in your worry, so both your mind and your body are able to feel loose and comfortable at the same time, and you’re able to generate that relaxed feeling whenever you want to.”

“And I need to practice it every day for homework, right?”

“Actually, I’m going to ask you to practice it twice a day for the next two weeks, and then once a day for the two weeks after that.”

“It won’t be any problem to do it at night,” she says. “I can practice before I do my worry record and my journal. The mornings will be tough, though, because I’m so busy hustling around to get myself and the boys ready for the day.”

“Sounds like a dilemma,” you say. “How do you think you can resolve that?”

“I guess I’ll have to wake up half an hour earlier for the next couple of weeks,” she says. “No biggie. It’s not forever.”

“That’s an excellent way of looking at it,” you say. Then, you move on in the agenda to a discussion about the connection between relaxation and her relationships with others. Particularly, you ask what relationships in her life give her relief from worry.

“I’d definitely say that I feel relaxed in my friendship with Sarah,” she says. “She’s completely supportive of me, she doesn’t judge me, and I know that she really cares about me. We tell each other the truth, even when it’s hard, and we’re good supports for each other. In some ways, my relationship with my mom is like that, because I know she loves me and wants to do anything she can to help me. And she does help me in the house and with the kids, watching them after school until I get home, and doing a lot of the housework. My life would be much tougher in some ways if she wasn’t there.

But I’m not completely relaxed in that relationship because I know she’s depressed and has been ever since my dad died. She’s fragile, emotionally, so I feel like I need to take care of her, rather than being able to use her as a big support for myself.” She hesitates. “I haven’t had a boyfriend since Mike left, which is almost nine years ago. At first, I was too busy trying to adjust to Theo’s needs… there just wasn’t time for anything or anyone else. I miss that kind of relationship. I don’t mean I want to be with Mike again, but I do miss having a man in my life. When I was a kid, I remember feeling safe with my dad, and when I was with Mike, I felt safe with him, at least until Theo was born. One day, I’d like to date again, and find someone I can trust and depend on.” She shakes her head.

“That’ll be awhile. I’ve got no time for romance at this point in my life. But I do miss having a special someone.”

You nod empathetically, and then, with five minutes left to go before the session ends, move to summarizing the session. You reinforce the importance of continuing the daily worry time and adding two periods of PRM relaxation each day. You also ask her to continue writing the worry record and journal each day, and remind her to bring them with her to the next session. Finally, you ask her to read the “preview to session 4” in her workbook.

“Will do,” she says, pressing the button on the motorized recliner, so that she is brought gently back to an upright position. “This is the most comfortable chair! I need one just like it at home.”

You schedule the next session for a week from now, then you both stand.

“Thanks,” she says shyly. “I appreciate what you’re doing for me. Dr. Munson was right about you. She said she trusted you, and that I could too.”

“You’re welcome,” you say, walking Maggie to the door. “I take her trust and yours very seriously. Have a good week, and I look forward to seeing you next time.”

“You too,” she says, then heads down the hall to the waiting room. You quietly close your office door, then walk to your desk to write a progress note in the ten minutes before your next client arrives.