24 Vignette

Maggie presents as scheduled for her fifth appointment, and walks quietly beside you in the hall between the waiting room and your office. Her body posture is fairly relaxed, but you notice tension in her face.

This is not entirely unexpected, given the emotional intensity of the last session, as well as the upcoming anniversary of her father’s suicide, which, as you know, is a triggering event for her.

Once inside your office, she goes through her usual settling-in routine, placing her workbook and therapy journal on her lap before making herself comfortable on the couch. If all goes as planned in the remaining sessions, this visit will mark her halfway point in therapy.

“How was your week?” you ask. “It was okay,” she says.

“Tell me.”

“I’ve been doing a lot of thinking about our last session. It was really an eye- opener.”

“Oh? An eye-opener in what way?”

“Well, for one, because I took an honest look at why I’m always so stressed out on the anniversary of my dad’s death. I mean, I knew I was always stressed out on that day, but I never really let myself think about why.” She pauses, and you nod slightly. “It’s because I’ve been petrified for all these years that she’ll do it too,” she says. “And I’ve known that but not known it at the same time. It’s the strangest thing. What is that?”

“Denial ain’t just a river in Egypt.” It’s an old joke, but she smiles wanly anyway. “Denial,” she says. “Denial is knowing something, and simultaneously not letting yourself know it? Well, that’s exactly what’s been happening. So, I’ve been in denial about it. I haven’t been tense because it’s the day he died; I’ve been tense because I’m afraid she’ll do it too. It seems so obvious, but I just didn’t put it together before.”

“That’s a big secret you’ve been keeping from yourself. Sometimes we do that – we keep big secrets from ourselves – because letting ourselves consciously know the truth feels too threatening.”

“Well, I don’t think that’s the only secret I’ve been keeping from myself.”

No?”

“Nope. Last time, you asked about other feelings, what was I feeling besides the anxiety, remember, and I kept insisting I didn’t feel anything else?” You nod. “So, all this week, I’ve been thinking about how anxious I feel about everything, and I realized that, as long as I feel anxious all the time, I don’t have to feel sad or hurt, or hopeful, or anything. I’ve become this emotional one trick pony; I feel anxious or nothing. I’ve been in denial about having any other feelings at all.”

Inside, you’re celebrating. These are the exquisite moments in therapy, the brief flashes when clients connect to their emotional lives, develop insight, get a glimpse what’s possible for themselves in the future. “So, what would you like to do about that awareness?”

“I need to get a handle on all my feelings,” she says. “Not just the anxiety, but all my feelings. The anniversary of my dad’s death is coming up on Sunday. This year, I want to do it differently. I want to deal with my feelings directly, whatever they are. I want to be able to talk to my mother in an honest way. I want us to get through it together, instead of being isolated from each other.”

“That’s an excellent goal, as well as a great way to transition to our work for the week,” you say. “Our skill for this session is problem-solving. Just as in previous sessions, we’ll look at your homework, then we’ll talk about problem-solving, then we’ll practice it together. At the end of the session, we’ll talk about how you use problem- solving in your relationships with other people.”

She opens her workbook and her three-ring binder. “I did the self-assessment for the week,” she says. “And, for the first time, I feel pretty good about some of my answers. For instance, it’s true that I learn from my mistakes and usually don’t repeat them, and I’m pretty good at sticking to decisions once I make them, and I’m willing to try new things to help myself.”

“Fantastic,” you say. “You’re really giving yourself appropriate credit for your strengths. Well done!”

“Thank you,” she says. “I’ve also been sticking very faithfully to my homework. I still do my worry time during the washing up after dinner. Honestly, I think I’ll continue that forever, because it’s a great thinking time for me, and it helps me keep my worrying in check.”

“Keep doing what works,” you agree. “How about the PMR?”

“That’s another handy little skill,” she says. “I’m able to relax my body more automatically now, even at work when I feel myself getting tense. The practice has definitely paid off.”

“Really good job,” you say. “What about your worry record?”

“My peak worry this week was an eight, when I started thinking about the anniversary of my dad’s death. My average was a six. So, both of those are down from last week. I like being able to track from day to day and week to week, to see how I’m doing. It definitely gives me a feeling of progress.”

“Well done! How did you manage with the thought record?”

“On the thought record, I used the risk assessment procedure at least once a day, and sometimes more than once a day. Most of the triggering situations were small. For example, Theo ran a slight temp which I thought was leading to an episode of pneumonia, so of course I got anxious. My automatic thought was that I wouldn’t be able to deal with it, and my worst imagined outcome when my anxiety was all fired up was that he was going to have to go to the hospital and I’d get fired from my job. None of that happened; his temp went back to normal and nothing came of it. Another triggering situation happened when my boss told me that she’s going on extended leave because of a surgery, and she wants me to step in for her while she’s gone. Of course, I immediately felt anxious, and my automatic thought was that I wouldn’t be good enough, and my worst imagined outcome was that a patient would die and it would be my fault.”

“How did you re-rate your anxiety and other feelings after each of those triggers?” “I did a quick little PMR session after both situations, which helped my body relax, and that helped me to think more realistically about them. My automatic thoughts seem to center around my fears that I can’t do it or that I’m not good enough, somehow, but…” she shrugs. “I’ve seen Theo through many illnesses, so I know that I can take care of him, and my boss showed faith in me because I’m a good nurse. If I wasn’t, she’d have chosen someone else.”

“Really well done,” you say. “In addition to getting a better handle on your anxiety, it seems that you’re gaining confidence in yourself.”

“I think so too,” she says.

“That fits in very well with the next part of our session, which is about problem- solving. Let me explain it to you, then we’ll practice together.” You provide a brief period of psychoeducation about problem-solving, as that skill is used in cognitive behavioral therapy, using the SOLVE method. First, the client states the problem, then outlines the goals, lists alternatives, views the consequences, and evaluates results.

“Let’s practice together in session. What situation would you like to apply this to?”

“Talking to my mother about the anniversary of my dad’s death,” she says immediately. “That’s not a low anxiety situation, but I think I can handle it, and I really want to address it with her.”

“Fair enough, you say. “So, the worst possible outcome of this situation is…?”

She thinks for a moment. “The worst possible thing might be that she doesn’t want to talk about it, so she shuts down the conversation and goes to her room, and then I’ll feel anxious and upset that I brought it up to her. We have kind of an unspoken rule that we don’t talk about it, so I really don’t know how she’ll handle it if I bring it up to her.”

You walk Maggie through the SOLVE procedure. She identifies the problem as her anxiety that her mother might be angry, confused or hurt that Maggie wants to talk about her father’s suicide and her fears for her mother, related to her mother’s depression. The goals for change including reducing her anxiety and being more emotionally honest with her mother and herself. The alternatives she identifies include going for a walk with her mother during the talk, so her mother couldn’t easily retreat to her room; talking with her after dinner when the boys are in another room; and talking to her in the presence of the family priest, who is a trusted figure in her mother’s life. She explores the consequences by deciding not to invite the priest over (“I’m afraid she’ll feel like we’re ganging up on her,” she says) and inviting her mother for a walk after dinner, when Naldo can keep his eye on Theo for a short time.

“What do you see as the possible positive consequences of that plan?” you ask.

Maggie considers for a moment, then says, “she might be glad I’m paying attention to her, and noticing how depressed she is.”

“True. What about potential negative consequences?”

“She might shut me down completely and tell me she doesn’t want to talk about it.”

“How will you feel if that happens?”

She shrugs. “Upset, a little. But we’re not talking about it anyway, so I don’t see how that will leave me any worse off than I am right now.”

“That’s a healthy outlook,” you say. “The fact is, we don’t know how your mother will respond, and we don’t have any control over that. Instead it’s vital for you to pay attention to your own thoughts, feelings and behaviors after you talk with her. What will you do if the talk doesn’t go as you hope it will, and you notice your thinking becoming catastrophic?”

“Then I’ll practice my PMR,” she says at once. “I’ll bring my anxiety level down and at least give myself credit for trying.”

“That sounds terrific,” you say. “And, it fits nicely into a change you’ll notice in your thought record for next week. You’ll see that an adaptive response column has been added to the thought record, which asks you what you did to manage the triggering situations you encounter during the week. Practicing PMR is an excellent strategy, and you can use that column to identify any adaptive responses which helped you get through the triggering event.”

You spend a few minutes discussing Maggie’s problem-solving efforts in her personal relationships. She relates that she doesn’t typically use any type of problem- solving, choosing instead to retreat from conflict and internalize her feelings. The one exception she identifies is in her role as Theo’s mother and primary caregiver. “When he gets sick or has a need in school, I’m relentless,” she says. “I advocate for him ferociously, because he can’t advocate for himself.”

You close out the session by providing homework instructions. You ask Maggie to continue the work she’s doing on the thought record, the worry record, the therapy journal, and the PRM practice. You ask her also to read the preview to session 6 in her workbook, and to complete the second STAI, which marks the mid-point of her therapy.

“We’re already halfway finished,” she muses. “I remember you said that we’d do the STAI at the beginning, the middle and the end. I can’t believe we’re already halfway done.”

“How do you feel about the work you’ve accomplished so far?”

“Good,” she says at once. “I’ve gotten a lot out of it already, and I’m looking forward to seeing what’s next.”

You make an appointment for the following week, show Maggie out to the hallway, and return to your desk to write the session note.