30 Vignette

Maggie appears as scheduled for her seventh session, and walks amiably with you from the waiting room to your office. You notice ease in her face and relaxation in her posture, the looseness in her limbs as she walks. Before the session even starts, her body language communicates her progress.

It never fails to amaze how quickly most people are able to free themselves from troubling symptoms once they make the commitment to do the work of change.

Sometimes, new patients arrive at your office and solemnly proclaim that they have untreatable, intractable anxiety. They’ve been in therapy before, they tell you, but have never been helped by any of the interventions which were offered. Experience has taught you that, in general, those ‘untreatable, intractable’ symptoms only flourish when patients aren’t exposed to an organized, validated treatment protocol which is competently carried out by a qualified provider, or when a patient’s personal identity has become so wrapped up in her disorders and disabilities that she’s become accustomed to thinking about herself as fundamentally sick or fragile, which makes it challenging for her to surrender her symptoms and develop a new and healthier self-concept. More rarely, you meet a person who is frankly unwilling to work on achieving recovery due to the financial benefit obtained from being declared ‘totally disabled’ by the government.

Not long ago, a woman presented to your office for a routine Continuing Disability Review (CDR) through Social Security. She was on disability due to agoraphobia, and arrived with form in hand, requesting an evaluation which would substantiate her need for continuing financial benefits. She had not received any counseling or pharmacologic intervention in many years. “I’m a hopeless case,” she said gravely. “Treatment doesn’t work on me.” You advised her that agoraphobia is a readily treatable condition, and that most patients respond positively to CBT and exposure-based protocols. The woman demurred. “I can’t get better, or I’ll lose my benefits,” she said. After (correctly) ascertaining that you would not sign off on her CDR, the woman departed your office in a huff, presumably on her way to find a provider who would substantiate the “hopelessness” of her condition and enable her to remain on disability, undisturbed by any prospect of recovery.

Maggie, thankfully, is a typical representative of the legions of patients who successfully engage in CBT, most of whom are willing to invest time and effort across the span of a couple of months in order to gain some skills and lose some symptoms. It’s a better-than-fair trade in which you’re delighted to play your part. What could be more satisfying than to help a patient shift from pain to relief? There is little joy more significant to a psychotherapist than watching this transformation unfold, one small step at a time.

Maggie beelines for the couch and places her therapy workbook and binder on her lap. “Go ahead,” she says. “Ask me about my week!” Her tone is playful.

“So, Maggie,” you say, joining the game, “how was your week?”

“It was good! I can’t believe I’m saying this, but I had fun with the worry exposure practice. I mean, imagining the bad outcomes made me feel anxious, but I loved the next part, imagining the happier outcome. It made me realize that I’m much more likely to scare myself to death by imagining disaster than by thinking that things might turn out okay. I can come up with ten thousand terrible disaster scenarios in about a minute, but for some reason, it’s never occurred to me to flip to the other side of the coin and imagine a happier ending.”

“That’s a great insight,” you tell her. “What happens to your anxiety when you switch from imagining disaster to considering the possibility of happier outcomes?”

“It just… evaporates,” she says, with near-wonder in her voice. “Really, it’s the damnedest thing. “During the worst possible outcome part of worry exposure, my body got all tight, my jaw clenched up, I went the whole nine yards in my anxiety response. But then, when I flipped to the positive outcome, the anxiety just sort of fizzled away.”

“What are the implications of that for the future?”

She considers for a moment. “Well, when something happens that I’m stressing about, instead of imagining all the terrible possibilities that might happen, I could picture a happy ending instead. Then, even if the happy ending doesn’t happen just like I imagined it, at least I’m able to get through the stressful time without drowning in anxiety which makes it hard for me to function.”

“That sounds great.”

“I’m supposed to go with Sarah this weekend to visit Joey at Hills and Hollows, so I used worry exposure to imagine that visit. You know how worked up I’ve been about going there, thinking about it as a place for Theo when I can’t keep him at home anymore?”

You nod. “Well, I imagined going there and talking to the admissions counselor, saying, ‘I’ve got a son with severe CP who needs placement.’ I pictured myself saying those words out loud, and I imagined that the admissions counselor looked just like the witch in Hansel and Gretel who eats little kids. I imagined that the place was terrible, all dirty and nasty, and the kids weren’t well taken care of. I know that’s not true in real life, but I just imagined it to really make myself stare the anxiety in the face.”

You give a low whistle. “You really challenged the anxiety, stood up to it nose-to-nose.”

“I did! I dared it, almost. And, no kidding, I felt really anxious, like a ten out of ten. But then, after a while, I changed the scenario. I imagined the place like I’ve seen it in Sarah’s pictures. I imagined that it was a good, protective place, and that the people who worked there cared about the kids and wanted to do well by them. And that Theo would feel safe there, and would understand why I had to leave him.”

Suddenly she is weeping.

“God, I hate to think about that day when I send him away from home. I know it’s inevitable. It is so hard to take care of a severely disabled child. No one who hasn’t done it could possibly understand.”

“No doubt true,” you murmur, silently thanking God for your own sturdy, bright, easygoing daughter, who is quick with a laugh and has a gentle, generous spirit. She lives in the Midwest and is happily raising a family of her own.

Maggie takes a deep breath, brushes away her tears, and takes a moment to collect herself. Then she opens her binder and begins to leaf through it. “The rest of my homework was pretty routine,” she says. “I practiced my relaxation and my worry time. The workbook says I can stop those now, but I’m going to continue with them.” She shrugs. “They help, and I don’t want to mess with what’s working. I also did my thought record and worry record. My lowest daily worry was a four, and my peak was a ten. That ten was when I did the worry exposure activity, though, so I’m not sure it counts. I also did the safety behavior self-assessment. I had no idea what safety behavior was when I started the preview, but I realize now that I do a lot of it.” She opens her workbook and flips through it until she finds self-assessment page. Studying it, she says, “I double- check a lot, and I over-prepare almost everything, and I tend not to trust my first instincts.”

“It sounds like working on reducing safety behavior will be well worth our time, then,” you say. You launch into your explanation of safety behaviors, those deeply ingrained, superstitious activities which offer anxiety relief through illusory comfort or reassurance. You explain the origin of most safety behaviors, which are generally developed as an adaptive response to overwhelming stress. “You created them because they were the only strategies you had, at the time, to reduce your anxiety. But now, you have skills in place which make them unnecessary, so let’s look at them together and see if there are any which you might be ready to set aside.”

You explain the skill-building activity you’ll both work on today, which includes making a list of the safety behaviors, ranking them in terms of relative ease at cessation, and predicting the consequences of stopping them. You’ll then ask her imagine what it would be like to stop them, rating her anxiety both before and after the imaginal activity.

You work together to create her list.

“I have a lot of safety behaviors, I think,” she says. “I call my mom from work at least once a day just to check up on her. There’s no real reason to do that, except I want to make sure she’s still okay. Like we talked about last week, I’ve been harboring this secret fear that I’ll come home and find her hanging in the garage, like she found my dad. Calling her every day has been my hedge against that anxiety, I think.”

You nod, pleased that Maggie is able to make this connection between a long- established safety behavior and her worry for her mother’s well-being.

“That’s not the only one, either. I don’t assert myself nearly enough with Naldo. Don’t get me wrong; he’s a good kid. He does his school work, and he helps out with Theo. But I feel bad that so much of my attention is on Theo all the time, so I let him get away with too much. He watches way too much TV, plays video games for way too many hours… I know that it’s not good for him, but I don’t set firm limits because I feel

guilty.”

“Okay, good awareness. Are there any others?”

“Oh yeah,” she says. “I take on too much, almost everywhere. I volunteer for special projects and to be a preceptor at work, I’m responsible for completing the pain monitor report every month, I stock the recovery rooms… I never stop moving from the time I arrive to the time I leave. I always thought that I did those things just to be nice, or to make everyone like me, but the truth is, if I don’t do them, I get anxious.”

“Again, that’s a really good awareness. Did you come up with any others?”

She thinks for a moment. “I take on more than I should at Theo’s school,” she says. “There are eight kids in the class. Half of them have been surrendered to the state and are in medical foster care, because, as I’ve told you, they’re really high need kids who are tough to care for. The other four are living at home. Of those, Theo and Cara – I think I told you about her, the little girl who nearly drowned? – those are the only two whose parents are involved. Cara’s parents are great, but they have a couple of other kids who are younger than her, so they’ve really got their hands full. Because of that, I’m the first one the teachers call if they need help with a special project, or if they’re running a bake sale, or if they need a chaperone for an outing. I mean, I want to help out when I can; I think that’s any parent’s responsibility. But now that I really drill down and think about it… I guess I’ve always jumped in to help because I’ve been worried on some level that they’ll take it out on Theo if I don’t.” She shakes her head. “That makes no sense.

The teachers are good, kind, professional people. I have no reason whatsoever to think they’d hurt Theo in any way, for any reason. It’s silly to believe that they’d retaliate against him if I refused to make a double batch of brownies for the bake sake. But still… I don’t say no, even when I should, because I feel anxious if I set a limit.”

She identifies a few other safety behaviors, and then you work through the skill- building activity. She imagines setting a limit on Naldo’s video game time, and she describes the imagined scenario in detail. She describes him blowing up at her, blaming her for not letting him have any fun, blaming her for giving him a disabled sibling who can’t play with him and who will be a burden for the whole rest of this life. She rates her anxiety as a rising eight when she imagines setting a limit rather than engaging in the safety behavior of permissive, conflict-avoidant parenting.

“You’re going to ask me to practice giving up the safety behaviors in real life, aren’t you?” she asks.

“I am,” you say. “Start with the easiest ones and see how you do.” “I’m going to be anxious,” she warns.

“Yeah, you probably will,” you agree. “And what will you do when you feel anxious?”

“I’ll use my skills,” she says, as if reciting her catechism. “You have no idea how good it feels to have some skills to use when the anxiety starts ratcheting up. I don’t feel like anxiety’s victim, anymore. I’m not powerless against it. I still don’t like feeling anxious, but I’m beginning to trust my ability to bring it down to a manageable level when it spikes up.”

You’re closing in on the end of the hour, so you take a few minutes and talk about how Maggie’s safety behaviors are linked to her personal relationships. She recognizes that she employs safety behaviors most often with the people who are closest to her, or who are involved most actively in the lives of her sons.

“I think I’m afraid that, if I stop doing everything for everyone, they’ll like me less, which is a scary idea,” she admits. “But I see the rationale for making a change. I want people to like me for who I am, not because I do their work for them or buy ten boxes of their kid’s girl scout cookies, or whatever. My mother knows I love her without me calling her at work every day, and it doesn’t help Naldo any if I’m a pushover mother.”

You review her upcoming homework assignments, which includes reading the preview to session 8, practicing the reduction of safety behaviors, practicing in vivo worry exposure, and completing her thought record and worry record. Then you schedule an appointment for the following week.

She stands. “All right then,” she says. “The homework will be extra challenging this time, I can already tell, because it’s directly aimed at changing behavior which will make me anxious.”

You stand too, and walk her to the door. “Can you handle it?” You smile with your eyes as you open the door.

“Yeah,” she says. “I can handle it.” She walks out of the office and you close the door gently behind her.

“She can handle it,” you say to the empty room, grinning. Then you walk to your desk and begin to write the session note.