33 Vignette

It’s been two weeks since Maggie’s last visit. She cancelled last week’s appointment because Theo was briefly admitted to the hospital due to respiratory problems. However, she presents today as scheduled, and walks companionably with you from the waiting room to the office. You note that her body posture is somewhat tense, and you can see fatigue etched in her face.

Once inside your office, she curls up on the familiar blue couch, pulls her binder and workbook from her bag and sets them on her lap. “Remember the little blonde cutie who ran into me – literally – in the hallway a couple of weeks ago?” You nod. “The kid therapist picked her up just a few minutes before you came to get me. Little Miss Thing threw a hissy-fit in the waiting room. The poor mom seemed so frazzled and embarrassed. I wanted to tell her, ‘listen, your kid can walk and talk and throw herself on the ground and zoom down the hallway like an airplane… be grateful for every single bit of that.’ But I kept my mouth shut. Everybody’s got their own stuff to deal with.”

“Everybody does,” you agree. “How are you doing with yours?”

“Mmm,” she says, tilting her head back against the couch and closing her eyes. “Tired. Been a busy few weeks. Theo had aspiration pneumonia and was admitted to

CRMC for about a week. We go through this a couple of times a year, so it’s not unusual, but it’s always exhausting. I room-in with him down there for the duration while Mom stays home and takes care of Naldo.”

CRMC is the Children’s Regional Medical Center located about an hour away from Round Rock. It’s a large, well-equipped and highly-regarded level-one pediatric

trauma hospital which provides care to children with conditions running the gamut from appendicitis to cancer. “That does sound exhausting. I’m glad Theo’s doing better now.”

“Thanks. And, I hope you’ll be pleased to know that, with a couple of unavoidable exceptions, I even managed to complete my therapy homework.” She pats the binder on her lap.

“That’s amazing,” you tell you. “You’ve demonstrated incredible commitment to your recovery. Remember all the way back at the first session, when you said your strengths were that you were persistent and hard-working? You’ve definitely proven those to be true.”

“I appreciate the credit,” she says, “but honestly, I don’t know how I’d live without the relaxation skills and worry time anymore. Being at the hospital is stressful,

for sure, but because of those two skills, I was able to contain my worry and stop my body from becoming one big clench. They’re really helpful.”

“It’s excellent that you were able to put those skills to use during such a stressful time,” you say. “I remember that part of your homework was to practice in-vivo worry exposure, and I’m guessing that the time spent you in the hospital gave you plenty of

opportunities to practice.”

“Oh yeah,” she says. “The pulmonologist stopped by to talk about the possibility of a temporary vent for Theo. Talk about in vivo worry exposure! One of the few things that Theo has been able to do in his life is breathe independently. Putting him on a vent takes that away, and it’s always been a line I never wanted to cross with him. He’s a low- functioning kid, so it’s not like we can have heart-to-heart talks about his wishes, but I’ve always had the idea that he wouldn’t want that.”

You nod slightly as she takes a pause. “It would have only been temporary, and it turns out he didn’t need a vent after all, but it gave me lots of worry-exposure practice, for sure.”

“I would imagine. How did you manage with the reduction in safety behaviors?” “Saying ‘no’ is really tough for me,” she says, “but I had a chance to practice that,

too. Theo’s class had an outing to the fire station this week. I’d agreed to chaperone last month, but then I had to back out, because I missed time from work when he was in the hospital, so I couldn’t take any extra days after he came home.”

“How did it feel to set that limit, to tell the teacher you couldn’t fulfill the commitment?”

“It was a little uncomfortable,” she admits. “but she was very understanding and said they’d work something else out.”

“Very good,” you say. “How was your anxiety level during that time?”

“It was fine.” She shrugs one shoulder. “Honestly, I think I was so tired by that point that it didn’t even really register with me as an anxiety-provoking event.”

“Anything to report in your worry record or thought record?”

She opens her binder and flips pages. “The high since last time was a nine, when the pulmonologist talked about the possibility of a vent. The low was a three.”

“Three! That’s the lowest you’ve been so far.”

“Yep,” she says. “I rated the anxiety as a three on the Sunday morning after we got home from the hospital. The kids were still asleep, and my mom and I caught up over a

cup of coffee. We hadn’t seen each other when Theo was in the hospital, so it was good to spend a little time with her. I felt so glad to be home, and it was great to relax and enjoy a peaceful morning.”

“How did you do with the thought record?”

She turns to another section in her binder. “I documented a bunch of triggering situations having to do with Theo at the hospital, but I dealt with all of them. Mostly, I used relaxation, and that worked for me.”

“Sounds like good work. Anything else you want to talk about before we get started on the agenda?”

“Don’t think so,” she says. “Except, I’m supposed to go with Sarah to visit Joey at Hills and Hollows this weekend, and I’m feeling pretty anxious about it. I’ve used worry exposure when I started ruminating about it, but as the visit gets closer, I’m finding it harder to imagine the happier alternative ending.”

“That’s a good segue to our topic for the day. Did you get a chance to read the session preview in your notebook?”

“Yeah,” she says. “Session eight is – “ she wiggles jazz-hands in the air, widens her eyes in an expression of mock-surprise – “thought-stopping!” Perfect timing, just in time for my visit to a kiddie nursing home.”

You launch into psychoeducation mode, describing thought-stopping as a behavioral technique for interrupting intrusive worries and other unwanted thoughts. You explain the process for the technique, which involves identifying a list of unwanted or intrusive thoughts, and then calling to mind a few unrelated pleasurable or pleasant thoughts. In the next step, the intrusive worry or thought is imagined in detail, and then

dramatically interrupted with a loud “stop!” thus halting the flow of distressing worry. After that interruption, the pleasurable or pleasant thoughts which were previously identified should be called to mind as a method of distraction and relaxation.

“You can make a big show of the part where you tell yourself to stop,” you say. “Really ham it up for full effect. Here, let me demonstrate.” You leap from your chair

and howl, “STOP!” like a coyote baying at the moon, feeling intensely glad, as you do so, that your friend in the office on the other side of the wall is away on vacation.

Maggie giggles at your exaggerated display. “’Make a big show of it,’” she snickers. “Like I’d ever do that in front of anyone! I’ll have to wait until there’s no one at home, which is practically never. Or practice in my car!”

“You won’t always need to make a lot of noise when you give yourself the thought-stopping instruction,” you assure her, grinning. “As you get better it, you’ll be

able to say it in a quiet tone, and eventually, you’ll get to the point where you can think it to yourself without making a sound. At the start, though, it’s best to really grab your attention with a very theatrical, noisy command.”

You work through the activity together. She is successfully able to list unwanted thoughts, including ‘it’s my fault,’ or ‘I should have known.’ Both of those particularly resonate with her, because they relate back to her old concerns that she was responsible for causing Theo’s CP, and that she somehow missed signals from her father that he was suicidal in the days before he died.

She’s readily able to identify the pleasant scenes which she should switch to after the stop command. These scenes include her early Sunday mornings when she enjoys a quiet cup of coffee before the rest of the house awakens, as well as her memory of a family vacation she took as a teenager to Redwood National Forest. “There’s some kind of magic in that place,” she says. “The trees are so ancient and undisturbed; they remind you how small you are in the grand scheme of things.”

“Those are terrific peaceful images,” you say. “Practice thought-stopping and then the switch to those pleasant memories when you notice yourself getting stuck on thoughts which are unhelpful or unwanted. I think you’ll be surprised at how quickly you’re able to derail the unwanted thoughts and switch to more pleasant ones.”

“Another skill for my toolbox,” she muses. “I wonder if I’ll like it as much as worry time and relaxation.”

“You’ll have to practice and then find out,” you say. “Do you have any questions about thought-stopping, or practicing it at home?”

She has no questions, so you shift into a discussion of her ability to set limits with other people, and her fears she associated with that. “It’s like we talked about last time,” she says. “I’ve kept my anxiety in check by being a compulsive people pleaser. So, setting limits and saying no … those are very threatening ideas. What if people get mad at me, or don’t like me, because I’m not being as nice as I once was?”

“What if they do?”

“Then I’ll feel sad and guilty and responsible because I messed up.”

These are her recurring emotional themes, the issues with which she’s been grappling since her father died and she gave birth to a profoundly disabled son. Step lightly, you remind yourself, because you know that a poorly handled intervention here is likely to result in defensiveness, denial, and emotional backsliding. “Let me ask: what

practical control do you have over other people?”

She ponders for a minute. “Like… what can I make people do?”

“What can you make them do, what can you make them think, how can you make them feel?”

“Well, other than my kids, I guess I can’t really make anyone do anything.” “Right,” you agree. “We all have agency, the ability to exert our own power and

decide for ourselves what we do, where we go, how we invest our thoughts and behaviors

and time. We decide for ourselves. We don’t get control over one another; we can only control ourselves.”

“Agreed,” she says. “And sometimes, we don’t even do too good a job controlling ourselves.”

“So, if we agree that we can only be responsible for ourselves, and we only have control over ourselves, then under what circumstances should responsible for – or guilty about – the behaviors and actions of other people?”

Her gaze drops to the carpeted floor while she mulls that over. “You’re talking about my dad,” she says finally.

“No” you say gently. “I’m talking about you.”

She scuffs the carpet with the toe of her shoe, and is silent.

This is important,” you tell her. “Your dad found himself in a desperate situation. His gambling problem resulted in financial and legal troubles which pushed him beyond the limit of his ability to cope. Then, he made a tragic and irreversible decision to escape his desperation in the only way he thought he could.”

“I think about how much pain he must have been in,” she says. “How much shame. How alone he must have felt.”

“Yeah,” you agree. “It’s painful to imagine a level of distress which is so intense that suicide is seen as the only way out.”

“I still think should have known. How could I have had absolutely no idea?” You switch tactics. “What am I thinking right now?”

She looks askance at you. “What?”

“Right now, what thoughts are in my head?”

“I don’t know.” She pauses as your words sink in, then smiles thinly. “You’re saying that I’m not a mind-reader, and there’s no way I could have known what he was going to do. But still… aren’t there suicide warning signs? There must have been signs, and I feel guilty that I missed them.”

“It’s true that there are suicide risk factors and, sometimes, warning signs which suggest that a person might be suicidal. But, like many people with compulsive gambling habits, your dad had been hiding the extent of his problem for years. You might even say he’d become an expert at hiding. Very sadly, he was successful at hiding his problem and his desperation from the people who loved him most in the world.”