27 Vignette

Maggie arrives on time and as scheduled for her next session. As usual, you study her body language as you walk together from the waiting room to the office. Today, she appears relaxed, almost peaceful. It’s a good sign.

You settle into your chair, and she puts her workbook and her therapy binder on her lap as she gets comfortable on the couch. “I’m eager to hear about your week,” you say. “You were going to practice some problem-solving with your mother, as I recall.”

“I was, and I did,” she says. “I have to tell you it wasn’t the most comfortable thing I’ve ever done in my life – we both ended up crying – but I’m glad we talked.”

Maggie recounts the conversation she had with her mother on the evening of the anniversary of her father’s suicide. She left Naldo in charge of Theo at home for a few minutes, and asked her mother to go with her on a walk around the block. Her mother agreed, reluctantly. “I told her I wanted to talk to her about Daddy dying, and she said ‘no, no,’ and she didn’t want to talk about it. But I told her, ‘Mom, he didn’t talk about what was going on for him and he died because of it. We’re doing the same thing!’ Then she cried, then I cried. So, we walked through our neighborhood crying together.”

“Sounds intense.”

“It was. But I came out and told her that I feel more scared than sad on the anniversary. Not so much sad that my dad died, but scared that she’d eventually get so depressed that she’d kill herself, too.”

“What did she say?”

“She said she wouldn’t do that. But I told her again, we didn’t think my dad would do that, either. Those bad feelings, the stress, the depression, the shame… they have a way of creeping on you, taking you over, killing your soul, trying to kill you, if you’re not careful.”

True that, you think. “And what was her response?”

Maggie laughs a little disbelievingly. “She said she was proud of me.” “Yeah? How so?”

“She said she was proud because she can see that I’ve made changes since coming to therapy. That I’m less snappy and irritable, that I laugh more and have more fun times with the boys, that I’m willing to talk about feelings. ‘I couldn’t do what you’ve done,’ she said. I told her, ‘that’s not true! You’re alive, there’s still breath in you. Get some help before the depression kills you! Enough already with wasting good years of your life. Enough!’”

“How did you feel when she said she was proud of you?”

Maggie considers for a moment. “Mmm, happy, I guess? Satisfied?” “Say that in a full sentence, like you mean it.”

She laughs. “I feel happy and satisfied that my mom said she was proud of me!” “Good. Do you feel proud of yourself, too?” She nods. “Then say it, kiddo.”

She laughs again. “I feel proud of myself for talking to my mom about a hard thing. It was scary and I did it anyway.”

“Well done,” you tell her. “Good work.”

“I really want her to come to therapy,” Maggie says. “I think it could help her. If she says yes, will you see her?”

You shake your head. “It’s best for family members not to share therapists,” you say. “There are enough therapists in the world that you can each have your own. I’ll be glad to give you some names, though, in case she decides she wants to see someone.”

“I haven’t convinced her yet, but I’m going to keep working on her. And I’m going to keep talking about feelings, too.”

“That sounds like a plan,” you say. “Is there anything else we should talk about from the week?”

“I don’t think so,” she says, opening her notebook. “I did my homework. My average worry was about a five, and my peak was an eight, when I talked to my mom. And on my thought record, I wrote down a few triggering situations and added the adaptive response, which for me is usually doing relaxation or taking a bath. Both of those work well for me. I also did the worry exposure self-assessment. I see changes in myself when I read these questions. Like, I would have said before that it’s true that I avoid situations that make me anxious, but I didn’t avoid the situation with my mom this week, so I see that I’m getting better at dealing with things instead of avoiding them. Oh, and I took the second STAI.”

She hands over her workbook and you score the instrument. This time around, Maggie’s S-anxiety raw score is 38, which puts her in the moderately severe range at the 68th percentile. Her T-anxiety raw score is 52, which puts her in the severe range at the 93rd percentile. Both are significant improvements from her STAI scores at session one, when her S-anxiety raw score was 46 (82nd percentile) and her T-anxiety raw score was sixty-two (100th percentile). You share the results with her.

She looks crestfallen. “So, the scores are still pretty high,” she says. “I was hoping for better.”

“What’s the automatic thought happening right now?”

She thinks for a moment. “I’m not good enough.”

“Okay,” you say. “Is that accurate?”

“No,” she says at once. “I’m working on it; I’m a work in progress. My scores have gotten better in just a couple of weeks, and they’re going to keep getting better the more I work on myself.”

“Well done,” you say. “Notice those underlying automatic thoughts and correct them when they undermine you, or when they try to tell you something that isn’t the truth.”

She nods.

“Now, let’s turn our attention to the topic for the day, which is worry exposure.” You present the worry exposure lesson, emphasizing the link between anxiety and avoidance.

“That’s exactly right,” she says. “Just like my mom and I have avoided talking about feelings since my dad died.”

“Yes. Except this week, instead of avoiding the issue, you confronted it head on, and that’s the main objective of the worry exposure activity.”

“I wrote my worry list and ranked it,” she says. “More homework from the workbook.”

“Good,” you say. “That’ll be helpful. What are some items on the list?”

She studies her binder. “I have about fifteen things listed,” she says. The least anxiety-provoking situation is my annual performance review which is coming up next month. Around the middle of the list is my plan to go with Sarah in a couple of weeks to visit Joey at Hills and Hollows, and taking a tour while I’m there to check it out for Theo. The most anxiety-provoking things on the list are my worry that I caused Theo’s CP because I was so upset when my dad died during the pregnancy, and also my guilt that I didn’t know my dad was suicidal.”

“That sounds like a very comprehensive list,” you say. “Thank you for taking such care with it.”

You outline the steps for the worry exposure procedure, which include choosing a low-anxiety item, then practicing relaxation while imagining the worry in detail. This anxiety-meets-relaxation activity is called reciprocal inhibition. It’s very useful as a strategy for deconditioning the anxiety response; you use it most often with generally anxious people, like Maggie, and also with people who are diagnosed with specific phobia.

“After you imagine the worst possible outcome of your worry in vivid detail,” you tell her, “you’ll rate the level of anxiety. Then, you’ll use your imagination to develop a different outcome, one that generates a sense of satisfaction or safety. After that, you’ll rate your anxiety again.”

“So, instead of just imagining the worst possible outcome, I get to imagine a happy ending,” she says. “I like it!”

“Ready to practice?” you ask as she shifts to the recliner and readies herself.

“Let’s do it,” she says. She pushes the button on the recliner until she’s in a supine position, then closes her eyes. She relaxes while you encourage her to allow stress and tension to leave her body, then imagines aloud a scene in which she receives a devastatingly poor job performance evaluation from her boss, after which she’s immediately fired and then endures the public humiliation of being escorted out of the building while she is shamed by her gawking co-workers. She stays with this exposure for twenty minutes or so, while you draw her repeatedly to the worst imagined moment, when she imagines herself being summarily dismissed from her job then ordered off the property while all the other employees watch and snicker. She reports that her peak anxiety during this activity is about seventy-five. Next, you ask her to imagine a different outcome with a happier ending which results in satisfaction, and she creates a scenario in which her performance evaluation is so spectacularly successful that she wins an employee of the year award and earns a 25% annual salary increase. She stays with that imaginal activity for about five minutes, and then you ask her to rate her anxiety again.

She laughs. “Anxiety? What anxiety? It’s maybe around a ten!”

“Good work,” you say. “I’d like you to practice this worry exposure activity every day for the next two to four weeks, each day choosing an increasingly anxiety-provoking item on your list. Really take your time when exposing yourself to the worry, and then create a different, happier ending. This pushes against the anxiety avoidance you’ve been using, and, in time, will be a critical skill in keeping your anxiety reduced.”

“More homework!” she groans. And then, “I’ll do it; you know I’ll do it. God knows how I find time for it. But I just tell myself, if I can find time for the anxiety, then I can find time for recovery.”

Next, you discuss avoidance of anxiety in her relationships with others.

My relationship with my mother is a perfect example of that,” she says. “Instead of talking about our feelings, we’ve somehow made a pact that we should never talk about them. I see now that that hasn’t been good for either one of us. That same screwy idea, that we should avoid talking about feelings and problems, is exactly the thing that killed my

father. If he’d talked about his gambling and had gotten help for it, then he wouldn’t have embezzled money, and if he hadn’t gotten caught doing that, then I’m sure he wouldn’t have felt desperate enough to kill himself. Avoidance of feelings and problems is behind that whole mess.”

You nod; it’s an important awareness.

“I don’t want to avoid myself to death,” she says. “I want to do better for myself, and I want to be a better role model to my kids.”

“That’s a great goal,” she says. “This work you’re doing will help you achieve it.”

With just a few minutes remaining in the session, you turn to Maggie’s homework assignments for the week. You ask her to read the preview to session 7 in her workbook; to practice her worry exposure, problem-solving and relaxation each day; and to complete her thought record, her worry record and her therapy journal. Then you schedule her appointment for the following week.

“Got it,” she says. “Any questions?”

“No questions,” she says, standing. “Just another thank you. You’re really helping me get better. Back at the beginning, you said you could, but I had my doubts. Now, I see it happening. I’m grateful to you.”

“Thank you for the kind words,” you say, as you walk together to your office door. “But redirect the gratitude to yourself. You’re the one doing the work. You’re the one demonstrating the courage. You’re the one taking the emotional risks. This is working only because you’re making it work.”

“Yay me,” she says, smiling, as you open the door.

“Yay you,” you echo, grinning. Then Maggie makes her way down the hall to the waiting room, and you close your office door and walk to your desk. Swiveling your chair to the window, you observe the field, the scrub pines and the sky as you think about the session. After a minute or two, you turn back to your desk and begin to write.