36 Vignette

Maggie appears on time for her session, and falls in step with you as you walk together from the waiting room to your office. As is her custom, she sinks comfortably into the recliner, and then reaches into her large purse to retrieve her therapy workbook and three-ring binder.

“This is our second-to-last meeting,” she says. “We’re almost at the end of the workbook, and I feel sad about it.”

This comment offers two directions; you can empathize with her feelings, or point her toward awareness of emotional growth. You choose to highlight the growth. “A couple of months ago, you called yourself an emotional one trick pony, and said you experienced anxiety or nothing. Notice now how you’re able to spontaneously identify and experience a much fuller range of emotions?”

She cocks her head, considering what you’ve said, and then nods. “You’re right. I’m much better at knowing what I’m feeling, and feeling a lot of different things. It’s still not great to be sad, though.”

“Allowing yourself to experience a wider range of emotions is definitely a mixed bag,” you agree. “It’s true that, when you open yourself up to feelings other than anxiety, you risk the experience of sadness. But you also open the door to the experience of hopefulness, happiness, joyfulness, excitement, and a bunch of other feelings which can be pretty wonderful.” Maggie takes this in, nodding thoughtfully.

“I’m interested to hear about your week,” you continue. “I think you had a visit planned to Hills and Hollows, with Sarah. How did that go?”

“It was okay,” she says. “I practiced worry exposure about it several times last week. I imagined the worst possible outcome, and then imagined a happier ending.”

“And what did you find when you finished the imagining and actually made the visit?”

“I discovered that it’s a good place,” she says simply. “Listen, all long-term,

subacute pediatric facilities can be pretty rough to see. Profoundly impaired, minimally conscious little kids on prone boards, in full-support chairs, on vents… it provides an object lesson that life can be awfully unfair. Looking at so many kids with hurt brains and bodies isn’t easy. But as for the facility, it was clean and well-kept. The kids looked

cared-for, and Joey’s nurses seemed to genuinely like him. While Sarah visited with him, I took a facility tour and got some information.” She took a deep breath. “Actually, I put Theo on the waiting list.”

“That’s a big step.” You try to keep the surprise out of your voice.

“It turns out that their waiting list is very long. Sarah waited about eight months for Joey’s spot, but after he was admitted, the next closest pediatric subacute, which was on the other coast, converted to adult care. So now, most of the severely disabled kids in the northern half of the state who need placement are waiting for a Hills and Hollows bed. It could be as long as three years before they have an opening. The admissions director encouraged me to get his name on the list. I can always decline the placement if I’m not ready when his turn comes up.”

“How did you feel about doing that?”

She shrugs. “Sad. Frustrated. Regretful. I wished for the millionth time that he was a healthy, typically developing little kid whose biggest concerns were video games and fourth grade spelling tests. But he’s not a healthy, typically developing little kid, and in three years, he’ll be twelve, almost a teenager. If he’s anywhere close to Naldo’s size by then, I simply won’t be able to take care of him at home, even with home health support. Putting him on the list was the right thing to do. It doesn’t commit me to anything; it just keeps my options open.”

“Of course,” you agree. And then, “anything else you want to talk about from the week?”

“I don’t think so,” she says. “I’m ready to review my homework and get to the lesson for today. I looked over my old thoughts records and read the preview for the session about core beliefs and did the core beliefs self-assessment.” She opens her workbook and finds the page. Reading from it, she says, “‘My old feelings of vulnerability are too entrenched to change.’ That certainly resonated.”

“What core beliefs did you find as you looked through all your thought records?” “Oh, I have a bunch of them rattling around in my head. ‘I’m not good enough,’

and ‘I can’t do it,’ and ‘it’s my fault.’ Especially that one.”

“How would you like to let those core beliefs go, and change them in a healthier direction?”

“I would,” she says. “I definitely would.”

You provide your psychoeducation instruction on the practice of revising negative core beliefs. Essentially, this requires the identification of the beliefs, which Maggie has already done, and then running a series of experiments to test their validity. Core beliefs are often structured as ‘if/then’ statements. One of Maggie’s most potent core beliefs, for example is, ‘if I had done a better job protecting Theo in utero, then he would not have been born with a disability,’ which she simplifies and generalizes to, ‘it’s my fault.’

“I remember we talked about your fear that you caused Theo’s disabilities because of your grief over your dad’s death when you were pregnant.”

“Yeah,” she says softly. “That’s always felt like my fault. Even though I know that millions of babies have been born whose mothers were grieving, and they were perfectly fine. Even though I didn’t do any drugs when I was pregnant. Even though his birth was uncomplicated. There’s still that belief which says it was my fault. The same belief I have about my dad’s death, even though it’s just as illogical. Neither of them were my fault, and I still feel responsible.”

“Why do you think that’s so?”

“No idea,” she says tiredly. “I know it doesn’t make logical sense. I know I’m not responsible for my dad’s death. He’d be horrified if he knew I blamed myself for that; it’s the last thing he would have wanted. But still, the idea is stuck in my head that it’s my fault, and that what happened to Theo is my fault, too.”

“Let’s run a little experiment for just a moment, and examine these,” you say. “If you hold tight to the belief that you’re personally responsible for the painful things that happen around you, if you can somehow make everything your fault, what might that protect you from?”

She squints at you quizzically. “I’m not sure I’m following.”

You try again. “If you live in a world where random things happen, where people get so desperate that they decide suicide is their best option, where little kids are beset with terrible disabilities through no fault of anyone, that’s pretty scary, right?”

“Yeah,” she says.

“So then, what if you’re able to personally take responsibility for those things? What if, through some kind of dark magic, you’re able to make everything your fault?”

“Why would I want to do that?” she asks. “Why would anyone want to have control over a bunch of terrible…” her voice dies away and her gaze shifts sharply to the side as she falls into thought. For the next several seconds, her eyes track to the left and right as if she’s reading text on some imaginary page. These are the visible signs of an invisible thought process. You remain silent and still as she works it through.

“Why would I want to have control?” she asks again, slowly. And then she answers her own question. “If I can make it my fault, then I have control. And if I have control, then I protect myself from anxiety.” There is another long pause as she makes the arduous connection between thoughts and feelings. Almost all the work of therapy can be distilled into these small, powerful moments. And, in the height of irony, the therapist’s most important job at these times is to stay quiet and out of the way.

Finally, she looks at you. “This is what I’ve been doing?” she asks. “All this time I’ve been trying to protect myself from anxiety by giving myself the illusion of control over bad things that happen? Except it all backfired, because instead of feeling anxious, I’ve made myself feel guilty and ashamed.” She sits with this for another few moments. “Wow,” she says at last. “It would be helpful for you to examine your other core beliefs between now and our next session. Challenge yourself to test the core beliefs and see if they hold up.” “I’m not sure how to do that.”

“For example, you might test the validity of the core belief which tells you, ‘I’m not good enough. What ‘if/then’ statement comes to mind for that core belief?”

She ponders for a moment. “If I set stronger boundaries with Naldo, then I’m likely to alienate him and he’ll resent me and I’ll feel like a terrible mother.”

“Okay. How could you test that belief? What would let you know whether it was true or not?”

“I could establish a boundary around something like his TV time, which is way too excessive, and see how he reacts. I’m sure he won’t be happy about it, but I’ll see whether setting the limit makes me feel like a terrible mother, or like a better mother.”

“That sounds good,” you agree. “After you run that experiment, give some thought to it. What did you think and feel after you set the limit? How did setting the limit impact your core belief? When you practice this regularly, you’ll probably find that you’ve punctured so many holes in those negative core beliefs that they no longer feel true.”
“I’m sure that’ll take a lot of practice,” she says.

“It probably will. But imagine freeing yourself from those beliefs which have been interfering you for so long. Wouldn’t that be an incredible payoff?”

“It would,” she says. “I can see it changing not just what I think about myself, but how I act in all my relationships. At work, with my kids, with my mom… I’ve functioned in an unbalanced, anxious, insecure way in so many of my relationships, and this opens the door to changing that. To changing me, really.”

You talk together for a few more minutes about how adjusting her core beliefs is likely to impact her relationships. “All systems seek homeostasis,” you warn, “so you might bump into some resistance as people around you notice that you’re beginning to make changes. Naldo, for example, might resist a mom who holds more strongly to her parenting limits, and your mom might react unexpectedly to a daughter who behaves with more assertiveness and confidence.”

“It’s possible,” she says. “But the reward will be worth the risk, if I end up being that more assertive and confident person. The only way to know will be to give it a try.”

You schedule the next appointment. “Will it really be our last one?” she asks. “If you don’t feel ready, we’ll schedule another. And you’re always welcome to