21 Vignette

Maggie smiles and waves when she sees you appear in the waiting room to pick her up for her fourth session, and she follows you down the hall toward your office. You can see from the way she moves and in the relaxed expression of her face that she’s feeling better.

Ahead of you in the hallway, you observe Jill, your play therapist colleague, walking toward her office with one of her little patients, a tiny girl with a halo of frizzy blonde hair and an exaggeratedly bouncy walk. Suddenly, the child giggles delightedly and pivots away from Jill, with arms outstretched like an airplane. “I’m flying away,” she squeals. “Come catch me!” She zooms toward you, bumps indecorously into Maggie, and splats onto the carpeted floor, still laughing. Rolling her eyes heavenward, Jill trots over to collect the little girl.

In your office, Maggie curls comfortably into the large recliner. “When I graduate from therapy, can I take this chair with me?”

“Well, I don’t know about that, but I’d be happy to tell you where I bought it.”

“Maybe you should. It’s cozier than anything I’ve got in my house. I want one just like it in my living room. It would be terrific for me when I practice my relaxation exercises.”

You grin. “You had success with your homework, I take it?”

“Yep. I practiced every night and almost every morning. I missed one session in the morning on Wednesday because I overslept my alarm, but otherwise, my practice record is perfect.” She reaches into her large purse and brings forth her therapy workbook and the three-ring binder she’s been using for her worry record and journal.

“How was the week?”

“Pretty good. Naldo made the soccer team at school and was really happy about that, and Theo’s holding his own.”

“And how about you? How are you doing?”

“I’m okay,” she says. “This PMR skill is good for me. I think I’ve spent so much time being all tense and clenched up that it’s been helpful to learn what it feels like to make my muscles relax. On Tuesday, I practiced before I went to bed, and then I took a bath, instead of a shower, so the relaxation followed by the warm bath felt great. It even made me sleep better!” She laughs. “Which is a good news/bad news kind of deal, because I overslept the next morning.”

“It’s terrific that you’re finding PMR so helpful. I’d like you to keep practicing twice a day for another week, and then you can reduce the practice to once a day. How does that sound?”

“No problem.”

“Okay, then, let’s get down to work. Our agenda for today will follow the pattern of the other sessions we’ve had. First, we’ll look at your homework, then I’ll teach you a new skill, called risk assessment, which we’ll practice together. After that, I’ll give you some homework to practice on your own between now and next time. Then, at the end of our time today, we’ll talk about how you assess risks in the context of your personal

relationships.”

“Sounds like a plan.” She opens her notebook. “So, as I said, I think the PMR was helpful because I’m learning what physical relaxation feels like in my body. I’ve noticed that when my body is relaxed, my mind is more relaxed too, and I worry less. There’s definitely a connection between a relaxed body and a relaxed mind, isn’t there?”

“Seems to be,” you agree. “How does that sense of relaxation and relief from anxiety feel to you?”

“It feels really empowering. Instead of just caving in to anxiety and tension, I’m making myself more relaxed and making myself worry less. I’m still practicing my worry time and that’s going well. Not to say that I don’t worry at other times, but I’m getting better at deciding when I’ll worry and when I won’t. I really like feeling in control of that.”

“Great work! When you’re practicing relaxation, where do you especially notice it in your body?”

“I think especially in my neck and shoulders and jaw,” she says. “That’s where I’m usually very tense, so I’ve been paying particular attention to relaxing up here.” She gestures from her breastbone to the top of her head.

“Well done,” you say. “And what about your worry record?”

She flips to a different section of her notebook. “My lowest average level of anxiety was a six, which is better than last week, when my lowest was a seven. And my peak was a nine, which is better than last week, when my peak was a ten.”

“Fantastic! You’re seeing measurable change from one week to the next. Notice how you’re taking control of your symptoms, and seeing clear progress as a result. That’s your hard work and commitment paying off in terms of symptom reduction. So far, you’ve learned to contain your worries and to relax your body. The next step we’ll take is to examine your automatic thoughts, and see if you’re overreacting to perceived threats in your environment.”

She nods. “I did the risk assessment quiz in my workbook and I really relate to some of it.” Opening the workbook, she finds the page and studies it. “For instance, if I feel unsafe, I have a hard time figuring out what to do to make myself feel better. Also, I tend to expect negative outcomes even when things will probably turn out okay. So, a lot of it described me pretty accurately.” She looks at you knowingly. “That means my thinking is all screwed up, doesn’t it?”

You segue into a brief lesson on automatic thinking and over-reactivity, explaining that her assessment of stressful situations may happen so quickly that she’s not even consciously aware that she’s assigning risk inaccurately. Learning to consciously and intentionally evaluate risk, using a step-by-step procedure, you tell her, can slow the process down so that she’s able to think about her thinking, improve the accuracy of her risk assessments, and reduce her overall level of anxiety.

What you know, but choose not to say at this point, is that the risk assessment process you’re about to practice together is likely to mobilize her anxiety to a significant degree. The point of the exercise isn’t to distress her pointlessly, but to provide a demonstration; by exploring a triggering situation in detail, she’ll see how inaccurate assessment of risk leads to catastrophic thinking, which feeds her intense anxiety. Early in your career, you used to issue a pre-emptive warning about this activity to clients, like the contraindication notices in television pharmaceutical ads: ‘may cause acute escalation of anxiety; panic attacks may result.’ You don’t offer the disclaimer anymore, though, because you found that it amplified resistance to an unhelpful degree. Better just to jump right in, you’ve learned, and deal with whatever happens. This has been the great gift of your long experience as a counselor; you have unflinching trust in your ability to shepherd your clients through whatever difficulties might arise in the clinical hour. Come what may, you think to yourself. Let’s get to it.

“Doing a risk assessment is a multi-stage process,” you tell Maggie. “Let’s run one in session, so you can see how it works. It begins with naming a triggering situation, something which makes you feel anxious. Can you think of a triggering situation we might be able to use?”

“Yeah,” she says. “The preview to this session in my workbook got me thinking about triggering situations. It’s one of the things I really like about using the workbook; I always know what’s coming up in the next session and what we’re going to be working on. But there is something, actually…” She pauses, tilts her head. “It’s the anniversary of my dad’s death in a couple of weeks. It’s a hard time every year, both for my mom and for me. I kind of dread it, to tell you the truth. Every year when the date comes up, my mom gets depressed and I get stressed out. Even more stressed out than usual, which, as you know, is really saying something.”

“That sounds like a triggering situation, all right,” you agree. “So, on a scale of zero to 100, where zero is the most relaxed you’ve ever been, and 100 is the most stressed and anxious you’ve ever been, how anxious are you right now when you think about the anniversary of your dad’s death?”

“I guess… around an 80?” she says, considering. “It’s not the most anxiety I’ve ever felt in my life, but it’s not the least, either.”

“Okay. Other than the anxiety, what feelings come up for you about the anniversary of your dad’s death?”

“I don’t know.” She pauses. “I don’t think I feel anything else. Just anxious.”

“Linger there for just a moment.” Maggie’s anxiety is the 800-pound gorilla in her emotional universe; it shoves her other emotions out of the way and demands her full attention. Now, it’s time to draw those other emotions out. “You said you feel anxious and have a sense of dread about the anniversary of your dad’s death. What other feelings might be hiding in there, along with the anxiety and dread?”

“I don’t know,” she says again. And then, doubtfully, “maybe… sadness?”

Okay, sadness. Sure. Anything else?”

“Mmm, I don’t think so.” Pause. “Maybe a little… I don’t know. Maybe I feel a little … spooked. Or… I don’t know… apprehensive. Like something bad will happen.” And then you feel it; tension rising in the room like the temperature on a scorching day.

“Spooked,” you repeat. “Apprehensive.” Your voice is gentle and steady. Easy does it, you tell yourself, but you’re right on the brink of something big; you can feel it. “All right. So, you’re feeling anxious and sad and maybe a little spooked and apprehensive about the anniversary of your dad’s death.”

“Feeling spooked doesn’t really make sense,” Maggie says. “There’s nothing scary about the day my dad died. Like I told you before, he’s been gone ten years now and I’m pretty much over it. I mean, I miss him, but I’ve adjusted.” She’s gazing fixedly at a point on the carpet, and the easy energy with which she entered the office has completely worn away. She’s feeling the escalated tension too.

“So, that’s interesting,” you say. “It doesn’t really make sense to you, but still you’re feeling spooked, like something bad might happen.”

A long pause as she continues studying the carpet. When she speaks again, her voice is low and pained. “It’s always hard for my mom, this time of year. She was the one who found him, did I ever tell you that?”

You shake your head slightly, say nothing.

“She found him – found his body – in the garage. She about went crazy. If it wasn’t for me, I think she might have…” another pause. “She’s been so depressed since he died. Depressed for ten years straight. I don’t know how she keeps going.” She hesitates. “I don’t think she’d ever commit suicide herself. Definitely not.” Then she adds contemplatively, “But of course, I didn’t think he’d do it, either.”

She is stock-still, barely breathing, appearing transfixed by that spot on the carpet. The atmosphere in the room is palpable, thick with tension.

“Let’s notice the automatic thoughts now,” you say quietly. “What pops into your head?”

She breaks the statue pose by immediately and vigorously shaking her head. “This is dumb,” she says. “Nothing is in my head. I don’t have any automatic thoughts.”

“Just the first thoughts which come up for you.” “Nothing comes up.”

You wait silently. Thirty or forty seconds pass until she speaks again. When she does, her tone is reluctant. “Maybe… I don’t know. Maybe I’m scared on some level that she might do something like that one day too? God, what an awful thought. What would make me think that? I can’t even… I can’t even go there.” She pushes out of her chair and begins to pace back and forth in your office. You can see that she’s trembling as she walks.

You remain physically very still in your chair, counterbalancing her escalated energy. “What other thoughts do you notice?”

She continues to pace, clearly distressed. “That everyone I love leaves me?” “Okay. What else?”

“That I’m not safe? That loving people isn’t safe?”

“Okay. What else?”

“I don’t know. I don’t know!” She bolts back to her chair and sits with her knees drawn up to her chest and her arms wrapped around them. “I don’t like this. It’s making me feel bad.”

“I understand,” you say calmly. “When we look at triggering situations, it’s natural to feel triggered by them.” She nods tightly. “Now, I’ll ask you to go even one step further, and imagine the worst possible outcome that could arise from the anniversary of your dad’s death.”

She barks out a disbelieving laugh. “You’re kidding me, right?”

“I’m not.”

“Why do I have to think about this? I don’t want to think about it!”

“I know it’s hard. Stay with it.”

She shakes her head and closes her eyes. “The worst outcome. The worst… possible… outcome. Okay, here goes. The worst possible outcome is that my mom decides to jump off a bridge on the anniversary of my dad’s suicide, and then I go crazy so they have to put me away in a rubber room, and then Naldo and Theo are put into foster care, and then Naldo becomes a delinquent and spends the rest of his life in prison, and Theo chokes to death before his tenth birthday! How’s that for a worst possible outcome?” She’s almost snarling now.

“That’s a very vividly imagined worst possible outcome, the worst you can think of when you’re feeling highly anxious,” you say. “Now, let’s switch gears. Imagine thinking about the anniversary of your dad’s death when you’re feeling less anxious. For instance, after you’ve completed PMR and you’ve had a warm bath.”

“I don’t know,” she says. “I can’t just switch gears like that.”

“Stay with it for just another minute. Take a deep breath.” She does.

Good. Now another. A little slower, this time.” She does. “Good. Now, picture yourself at home. It’s night time. The boys are safely in bed, your mom is in her room, you’re close to the end of your day. You’ve finished your PMR session, so your body feels loose and relaxed. And you took a warm bath, so you’re feeling even more loose and relaxed and comfortable than usual. Do you remember that feeling?”

She nods.

“Good. So there, in that moment, when you turn your mind to the anniversary of your dad’s death, what’s the worst outcome you can imagine?”

There’s a long pause while Maggie draws in another deep breath and closes her eyes. Her self-calming effort is visible, and you watch as her muscles gradually relax and she leans back into her chair. As she does this, the tension melts from the room. “I guess… when I’m relaxed… the worst outcome I might think of then is… my mom will cry a lot on the anniversary, which is on a Sunday this year, and then she’ll isolate herself in her room. And I’ll feel stressed out. But I’ll still have to get myself through a normal day because the boys will still need care and the laundry will still need to be done and the meals will still need to be made.”

“Good,” you say promptly. “Notice the difference? When your anxiety is very high, your worst possible outcome is catastrophic. You imagine that you go crazy, your mom and Theo die, and Naldo spends his life in prison. When your anxiety is lower, your worst possible outcome is much more realistic. You imagine that you and your mom will both have uncomfortable feelings on the anniversary, and then you’ll get through the day. The point of this activity is to show you how anxiety distorts your thought process. When the anxiety is high, you’re much more susceptible to unrealistic, catastrophic ideas which interfere with your ability to accurately assess the risks involved in any given situation.”

She nods. “Not really a fan of that activity, though,” she says shakily. “My anxiety spiked up really a lot.”

“It did,” you agree, “and then you were able to bring yourself back down again, to rescue yourself from the hijack situation, and to think more realistically. Let’s end this activity by having you rate your anxiety about possible emotional threats on the anniversary of your dad’s death. On that same zero to 100 scale, how anxious are you about it now?”

“I think about the same,” she says. “A 75, maybe? Maybe a little less, because it’ll probably be a day like I talked about, with my mom in her room feeling bad, and me spending time doing chores and taking care of the boys. So… maybe a little less anxiety about that now. Maybe closer to sixty-five.”

“Good,” you say. “Ready to move on from this?”

She nods, and you explain the thought record to her, in which, as triggering situations arise, she’ll identify what happened, what she felt about it, her automatic thoughts, her imagined worst possible outcomes, and then a re-rate of her thoughts and feelings. “You don’t have to invent triggering situations just to write something down in the log,” you clarify. “But, when triggering events occur which result in an anxiety state of 50 or higher, write them down. So, sometimes you might have several triggering events in a day, and on another day, you might have one or none. Just jot them down as they happen, so we can look at them together next time. Make sense?” She nods again.

“Excellent. Now, let’s look at your personal relationships through your view of the world as an unstable place, where catastrophe can happen at any minute, and where the people who love you are bound to leave you.

What insights do you have about that?”

She shrugs. “That seems to be the way it is,” she says. “My dad died, and obviously his love for me wasn’t enough to make him want to keep living. And Mike left, because he was freaked out by Theo’s disabilities, and his love for me wasn’t enough to make him want to stay. I can’t imagine for a minute that my mom would choose to leave me, too. I literally just can’t even imagine losing her that way. But, it could happen, right? I mean, she’s mortal, so one way or another, she’s going to die. And I hate that so much. I hate knowing nothing is forever. You love people and then you lose them, and that’s just the way life is. I think that’s why I keep my circle really small. I don’t want to have to deal with any more loss.”

You talk for a few more minutes about her perception of her vulnerability in relationships, and the discomfort she feels in that, and then move to summarize the session. You also explain her homework for next session, which includes completing at least one risk assessment each day and completing a thought record entry whenever her anxiety about a triggering event is above a 50 on a zero to 100 scale. You also ask her to continue her PMR relaxation twice a day, to continue her worry record, and to continue working in her therapy journal.

“That’s a lot of homework,” she says, “but I’ll make sure to get it done. I’m a little worried, though. What if I get freaked out doing those risk assessments like I did in here? What if my anxiety spikes up?”

“What if it does?”

“Then… I’ll freak out and feel bad.”

“That’s certainly an option,” you say. “What else could you do?”

She thinks for a moment. “I guess… I could practice my PMR to make my body relax, and then my anxiety level would drop down. That would probably work.”

“Sounds like an excellent strategy,” you agree. “Same time next week?”

Okay,” she says. “Wish me luck.”

“You’ve got it.” You open your office door to show her out just in time to see Jill’s little blonde play therapy patient skip past you on her way to the waiting room.

“Looks like she had an easier session than I did today,” Maggie says ruefully.

“True fact,” you tell her. “The hardest sessions are often the most helpful in the long run.”

You say goodbye and then go to your computer to write up the progress note.