12 Vignette
The following day, you usher Maggie Perez into your office. She is a pretty, petite, well-groomed woman who appears to be in her early thirties. She’s dressed in maroon scrubs which are embroidered with her first name and the name of a local outpatient surgery center. Her dark hair is pulled into a bun, and she wears stylish glasses which accentuate her brown eyes. Her skin is clear and olive-toned. Her body posture is stiff and her shoulders are updrawn. Most especially, you notice fatigue and tension in her face.
After explaining her rights and responsibilities as a client of the counseling agency and providing her with the informed consent form to review and sign, you set about the work of gathering psychosocial information; this will help you understand her situation and decide whether she needs ongoing mental health services. “Tell me a bit about what’s been going on for you,” you invite, setting back into your chair and putting a clipboard with an assessment form in your lap. Later, you will transfer your handwritten notes to the EMR. For now, you plan to jot brief notes as she talks, which will enable you to give her your undivided attention.
“Dr. Munson said I should come,” Maggie begins. “Do you know her?” “I do. I work with her quite a bit.” “Yeah, I think she’s a good doc. She’s taken care of me for six or seven years. I went to her earlier this week because I thought there was something wrong with my heart, but she said my heart is okay and I just need to talk to someone.”
“What made you think there was something wrong with your heart?”
Maggie pauses. “It’s a little embarrassing, actually. I’m an RN, a surgical nurse, so you’d think I’d know better. But a couple of months ago, I started having these weird episodes. I’d wake up from a sound sleep with my heart galloping in my chest, and then I started noticing my heart skipping beats, especially when I was stressed out. Then last week I had a total meltdown at work. I don’t really know what happened. It was just a normal day, and then, all of a sudden, I was diaphoretic and hyperventilating and tachycardic… I thought I was having a heart attack. But they gave me an EKG right there and my rhythm was normal. I tried to calm myself down but I just couldn’t, and then my boss said I should go home. It was so mortifying, you know?”
You nod slightly, silently encouraging her to continue. Sweating, panting, and a rapid heartbeat, along with feelings of impending doom, are classic symptoms of a panic attack, the results of which can not only be mortifying, but downright dangerous, depending on where they occur. Just yesterday you saw a client who passed out during a panic attack while driving and rear-ended another car.
“We’re leanly staffed at the surgery center already, and every procedure has a particular staffing protocol, so it’s really inconvenient to the entire team when anyone has to leave early. My manager was the one who said I should go home, and she was nice about it, and everyone else was understanding too, but I know there’ll be problems later, especially with the doctors. I heard through the grapevine that one of the doctors doesn’t want to work with me because he thinks I’m unreliable. And… it’s terrible to say but I guess he’s right. I’ve been distracted, and I’ve dropped instruments a couple of times during procedures. You can get written up for that, so I’m really worried about it. I feel like I used to be really good at my job, but I’m not anymore, and now my job’s in danger. I’m just… I feel like I’m falling apart.”
You’ve been diligently taking notes, and now, having heard what sounds like a cognitive distortion, you look up from your clipboard. “May I ask you to clarify something? You said that your manager was understanding when you got panicky at work and left early, and you also said that your job is in danger. I’m wondering whether those things are related in your mind, and whether your supervisor has told you that you might lose your job?”
She shakes her head from side to side. “She didn’t say that. Bonnie – that’s my nurse manager – she understands my situation with my son, and actually she’s given me MVP awards twice in the last six months. Those are just little commendations, you know, with a twenty-dollar gift card attached. You get them for good documentation or making special effort to help out, or for exceptional patient care. They’re not a big thing, really, except she only gives out one a month, and if you get more than two of them in a year, then you earn an extra percentage in your annual raise.”
You’re less than ten minutes into the consultation and already recognize a self- deprecating bias in Maggie’s thinking. She catastrophizes the negatives (her boss tells her to go home early and it means to her that her job is in danger) and disqualifies the positives (the award her boss gives out only once a month, which is tied to a salary bonus, which she has earned twice in six months, is “not a big thing”). Interesting.
“Okay,” you say. “So, you’ve recently gotten two commendations from your supervisor, and she didn’t say your job was in jeopardy for needing to leave early last week, but you’re still worried that you might lose your job.”
“Yeah.” She gives a shaky laugh. “Kind of nuts, huh? But that’s me… just call me Queen of the Worriers.”
“Sounds like worrying is something you’re pretty familiar with. I wonder… does it seem to you that your worry is excessive, or that you worry more than other people?” This language is almost exactly quoted from the anxiety disorders section of the DSM. Already – and without even being consciously aware of it – you’re beginning to sift through diagnoses which match Maggie’s symptoms. After so many years in practice, this process is second-nature to you now.
“I don’t know,” she says, shrugging a little. “Sometimes I think I’m just a neurotic mess and I worry way more than most people. But then sometimes I think that I’ve got a lot of real-life stuff to worry about, so worrying is just… normal.”
“Thank you for clarifying,” you say. Then, “you mentioned a situation with your son?”
She blinks and looks away and her shoulders rise slightly; she appears to be bracing against a blow. Note to self, you think. What’s that about? Then she says, “I’ve got two sons, twelve and nine.” She pauses, makes eye contact again. “You have any kids?”
For just a moment, you flash back to the earliest days of your practice, and even before that, during your practicum experiences in graduate school, when you had long and earnest conversations with fellow students and your supervisors about how to respond to personal questions posed by clients. You’d decided back then that you’d never tell clients anything about yourself, ever, in order to avoid deflection, transference, countertransference, oversharing, ‘me-too-ing,’ and the other clinical entanglements you learned about in school. In the beginning of your practice, when clients asked personal questions (“Are you married?” “Do you have kids?” “Were you raised in the church?”), you responded with awkward avoidance (“We’re not here to talk about me” or – even worse – “why do you want to know?”) which generally had a chilling effect on your clients’ ability to relax into a working relationship with you. Over the years since then, you’ve become more sophisticated in your understanding of the clinical relationship, and you know now that when clients ask these personal questions, what they’re really asking is “can you understand me?” “Do you recognize my world view?” “Have you had experiences likes these?” “Can I trust you to know what I’m talking about?”
It’s a terrifically delicate balancing act, to be sure, the self-disclosure dilemma. Talk too much about yourself and the client is likely to develop a full-blown fascination with you, seizing the opportunity to focus on you in order to avoid doing her own work. But sharing too little of yourself is risky as well; the therapist who won’t answer even the most basic personal questions comes across as haughty and remote, which certainly doesn’t help the development of the all-important therapeutic alliance. Even in your style of brief therapy, a positive and trusting professional relationship is necessary if the client is to make meaningful progress. These thoughts skip across your mind in a split-second, like a stone cartwheeling on the surface of a pond. “I have a grown-up daughter,” you respond. “I’d love to hear about your sons. What are their names?”
“The oldest is Naldo. He’s named after my father. My father was Reynaldo, and he was called Rey. So, when Naldo was born…” she shrugs. “The name just seemed right. Naldo’s twelve. The little one is Theo” – she pronounces it ‘TAY-oh’ – “and he’s nine. He has CP. Do you know what that is?”
“Cerebral palsy,” you answer. People with CP can have a raft of disabilities: motor, intellectual, communication, neurological and sensory, just to name a few, and the degree of impairment can range from quite mild to devastatingly severe.
“That’s right,” she says. “He’s pretty involved. He’s hypotonic – very floppy – and he doesn’t hear or speak very well, and developmentally he’s slow. He didn’t learn to crawl ‘til he was five. He can stand with a walker for a minute or two at a time, but mostly we have him in a chair.”
“It can be really stressful to care for a child with special needs,” you say. “What kind of help do you have at home?”
“My mom lives with me,” she says. “She tries to help, but sometimes I feel like I have a third kid in the house, instead of a second adult.” She pauses. “I’m a single parent, did I tell you that?”
You shake your head, make a note.
“Well, the less said about the boys’ father, the better. They have the same dad, but he dropped out of the picture when Theo was just a baby. Theo had all kinds of feeding problems back then, because he couldn’t coordinate the muscles in his mouth well enough to suck or swallow, so he had to have a feeding tube put in. Mike, my ex, took one look at that tube and was out the door. He couldn’t cope with it.” She laughs somewhat bitterly. “It’s ironic. You know, I always thought he was weak because he couldn’t cope with real life, and now here I am, barely coping myself. What does that say about me?”
You recognize that question as an invitation to explore Maggie’s most fundamental thoughts about herself. “What do you think it says about you?”
She shrugs. “That I’m weak, just like Mike was? That I can’t solve my own problems? That I’m a pathological mess who needs medication and counseling?”
And there they are, pulled into the open and laid bare, Maggie’s negative core beliefs. “I’m not good enough…” “I can’t do it…” “I’m not capable…” These are the distorted cognitions which keep her stuck in a pattern of unrealistic pessimism about herself and her ability to cope with her life.
No time like the present to begin enumerating strengths, you decide. The sooner those core beliefs are challenged, the better. “I have an alternate perspective,” you say calmly. “The fact that you’re here in my office says some good and important things about you. For one thing, you’re open-minded enough to follow reasonable recommendations from your physician. Also, you’re willing to get some help and learn a few new skills in order to cope better with all the stuff you’ve got going on in your life.”
She pauses, considering this. “Hmm,” she says finally. And then, “It doesn’t sound so bad when you put it that way. Because I am willing to follow Dr. Munson’s recommendations. I think she’s really smart, and I trust her. After I had the meltdown at work, I made the appointment with her to check out my heart, and she said my heart is fine but she thinks that all the stress and worry is getting to me. She gave me a script for .25 Xanax PRN and asked me to make an appointment for counseling. Specifically, she asked me to make an appointment with you, because she said you work a lot with women who have anxiety. So here I am.”
“Got it,” you say, making another quick note. “So, you’ve been prescribed a quarter milligram of Xanax to take as needed. Are you prescribed any other medication, or do you take anything that’s over the counter?”
“Nope, just the Xanax. I don’t like to take meds, and I’m especially cautious of the benzos. They’re so addictive, you know? But Dr. Munson said I should take it if I need it, so I filled the script just in case.”
More than a few times, you’ve referred clients to the addiction counselor in the practice because they’ve begun to overuse their anti-anxiety medication. Xanax, Klonopin, Valium… they’re velvet hammers which subdue anxious distress in just a few minutes, replacing it with dreamy insouciance. This makes them famously attractive as drugs of abuse. Unfortunately, they’re also wickedly difficult – even dangerous – to withdraw from without medical supervision.
“You’re wise to be alert to the addictive potential of benzodiazepines,” you tell Maggie. “That’s a great strength. It’s also helpful that you’re a nurse and so you’re knowledgeable about medication risks and benefits. While we’re on the subject of meds, let me ask whether you use or abuse any drugs which aren’t prescribed, or use any illegal substances?”
Maggie shakes her head resolutely. ‘I experimented a little when I was a kid, the way I guess most kids do, but that’s not my life anymore. Like I said, I’m a single working mom, and my teenage partying days are long behind me. I might have a wine cooler or a glass of wine once a month or so. Most nights I’m in bed by nine-thirty. Not very exciting, huh?”
“Sounds like you’re doing the best you can to take care of business like a responsible mom,” you say. “Now… you told me earlier that you felt like you were falling apart. Are you referring specifically to the panic symptoms you had, or is something else causing those feelings?”
Maggie, who until now has been perched on the edge of her chair, leans back for the first time. It’s a good sign; the body language suggests that she’s beginning to relax. “It’s just… I worry about everything, especially in the last year or so,” she says. “I’ve got two kids, and one of them is disabled, and I’m a single mom, so that’s a lot to handle right there. I worry about money, even though I make a good salary, because Mike isn’t reliable with child support and my mom has very little money of her own. Don’t misunderstand, I love my mom a lot and would do anything for her, but she can be a handful. You already know about my job. I have a lot of responsibility; it’s not a place where anyone can afford to have a bad day. I worry if I get sick, what will happen to my family, because they’re all completely dependent on me. I worry about sending my kids to school and whether there’ll be a crazed school shooter roaming the halls. If that happened in Theo’s school, he’d be completely helpless; he couldn’t even hide himself. It’s terrible, the things you have to think about these days… I worry about decades from now, when the boys get older and I’m gone, whether Naldo will be resentful that Theo will need help and guardianship for the whole rest of his life. It’s just everything, you know?”
You nod. Maggie had opened the session by recounting the experience of having a panic attack at work, so initially, you’d let your mind ramble toward a diagnosis of panic disorder. Now, though, you’re triangulating on another possibility: generalized anxiety disorder, in which patients manifest uncontrolled worry about many different life events or circumstances. You remind yourself to stay open to all diagnostic options and comorbidities, but already, you’re moving closer to identifying the disorder with which Maggie is grappling, and considering the treatment strategies which might be deployed to eradicate it. If GAD is the problem, it’s good news for her; GAD is one of the most common and one of the most readily treatable disorders in the DSM.
“I feel like I’ve got about a thousand responsibilities everywhere I go,” Maggie continues, “and everything’s important, and everything competes for my attention all the time. I feel completely stressed about all the things I need to do, and then, even though I keep a lot of lists, I’m petrified that I’ll forget something important and someone will get hurt because of it. I’ve got lists for everything. My mind is continually going, all the time. Even when I sleep, I’m making lists in my head. I wake myself up thinking about things I need to do, and I have nightmares about what I’ve forgotten to do. I have this one repeating nightmare that I’m at home helping Theo with dinner, and my phone is nonstop ringing and blowing up with text alerts but I’ve left it in the living room and I can’t step away from Theo because he’s so choke-y when he swallows. Finally, I’m able to get to the phone, and I see that I have about a hundred messages from Naldo saying he’s on a class trip in Washington and I’ve forgotten to pick him up at the Pentagon!” She shakes her head. “I know how crazy it sounds, but I have that nightmare at least once a week. Then I wake up worried that my dreams are telling me I don’t give Naldo enough attention, and then I can’t go back to sleep.”
“How many hours of sleep would you say you get each night, on average?”
“I don’t know. Five? Maybe six. I keep waking myself up with these worries and nightmares, so in the mornings, I’m tired and cranky and distracted, but I still need to get the kids ready and wake up my mom and get myself out the door to be to work on time. I’m running, running, running, all the time. And I feel like… I feel…” she pauses, searching for the words. “I live my whole life feeling like I’m being chased by tigers,” she says finally. “And I feel like, if I stop running, the tiger will catch me and I’ll get eaten alive.”
No wonder she’s anxious, you think. Out loud, you say, “That sounds exhausting.”
“It is,” she agrees. “And because I’m exhausted all the time, I worry that it affects my reputation. Like, everyone thinks I’m always in a bad mood. I know I get crabby or freaked out sometimes at work, and my kids have told me they think I’m mean. Naldo says that, anyway. He wants to do fun things, or buy a bunch of expensive stuff, and I’m always telling him I don’t have the time or we don’t have the money, and then I feel so guilty, because he’s already twelve and in a couple of years he won’t want to do anything with me because he’ll be all tied up with his friends, and a couple of years after that he’ll be gone, and then I’ll have missed my chance to spend time with him and make him happy. But I’m torn, because Theo needs so much help with everything, and the older and bigger he gets, the harder it is to take care of him. My mom tries to help, but she’s in her own world half the time. She gets up in the morning to put the kids on the bus, but then I know she goes back to bed. She sleeps most of the day away. She’s been depressed for a long time.”
“You see Naldo growing up, and you worry that time with him will get away from you,” you reflect. “And your mom tries to help with the kids, but she’s depressed, so sometimes it seems that having her in the house is like having a third child.”
Maggie nods. “I’m awful to feel that way, because my life has been a breeze compared to hers. She’s been through so much crap in her life. She was one of the Pedro Pan kids – both my parents were – so she grew up separated from her parents and raised by strangers, always feeling like an outsider, and then she finally finds some happiness and a good life with my dad, and that turned out to be a totally heartbreaking disaster.”
You make a quick series of notes, trying to keep up with this family information. “The Pedro Pan kids…?” You tilt your head quizzically. “I don’t think I know what you mean.”
“Hardly anyone knows about it, but it’s actually pretty interesting,” Maggie says. “And even more interesting to me because it’s the history of my family. I don’t know, maybe it explains why I’m so screwed up. It was kind of a state secret when it was happening, but it’s all out in the open now. What happened was, back around 1960, Cuba had just been taken over by Communism, and a lot of people were afraid that their kids would be sent to Russian work camps after Castro took power. It sounds crazy, but they were really worried about it then.”
You nod, noting that even in Maggie’s stories about others, she focuses on the experience of worry and distress.
“So, a bunch of business leaders and some priests got together,” she continues, “and arranged for thousands of little Cuban kids to be sent to the US. Literally thousands of them came over. Some went to live with their families who were already here, but a lot went to foster homes or boarding schools. My dad came over when he was twelve, and he was one of the ones who didn’t have family here, so he went to a foster home for a while, and then to a boy’s school. His brother came too, but they lost track of each other almost immediately, and they didn’t get reconnected until their thirties. My mother came over a year later. She was only ten. She also didn’t have family here, so she went to a foster home. She says it was brutal. The couple who took her in didn’t speak Spanish, and she didn’t speak English, so she had a hard go of it for a while. Can you imagine being such a little kid, sent to a different country completely on your own, and no one can understand what you’re saying? I get panicky just thinking about it.”
“Definitely sounds rough,” you agree, making a margin note to do some research on Operation Pedro Pan. You’re also thinking about generational patterns of anxiety, and how her parents’ migration to a new country alone, as children, might have impacted their daughter decades later.
“Well,” Maggie continues, “by the late 1960’s, so many Cubans were trying to get across the Florida Straits that the Cuban and US governments arranged for these freedom flights, to get people safety to the US so they wouldn’t risk their lives crossing the Straits on rickety boats. Most of the Pedro Pan kids were reunited with their families then. My dad wasn’t, though. By then, eight or nine years had gone by. He was twenty and had already been on his own for a while when he found out during the freedom flights that both his parents had died. My mother’s parents came over when she was seventeen, but by then they were pretty much strangers to her. She’d grown up in the suburbs outside Fort Lauderdale and had become completely Americanized, and they were from rural Cuba. They were so different from her that she had trouble relating to them, and I’m sure they had trouble relating to her, as well. The end result was that they had a lot of trouble getting along, and she moved out on her own after living with them for less than a year. Then she met my dad and they fell in love and got married when she was barely twenty.”
“That’s quite a family history. Lots of loss. You mentioned that your mom has been depressed. Is there any other history of mental illness in the family? Sometimes there’s a genetic predisposition.”
Maggie hesitates. “Yeah,” she says finally. “I guess you could say that. I mean, we don’t know too much about the extended family because they were both separated from their families when they were young, like I said. But there was trouble with my dad.” She pauses, looks away. The silence lengthens between you, stretching for a minute or more, as she debates with herself whether or not to tell you something. Something important to her, you judge, based on the distress of her expression. You watch her, and you wait. Another thirty or forty seconds go by before she makes her decision and breaks the silence.
“It’s probably important for you to know that my dad killed himself,” she says. “I’m pretty much over it. I mean, it happened a long time ago. Ten years. I was 26 when he did it.” Her voice is even; the tone is flat. Suspiciously little affect for someone recounting such a profound loss.
“I’m sorry,” you tell her. “That’s such a hard way to lose someone you love.”
She nods slowly. “Yeah, it was. I was really blindsided by it, too. See, I always thought of him as such as successful guy. When he and my mom got together, they were just kids, you know? He worked as a taxi driver. Day and night, he worked. I barely remember seeing him at home when I was really little, because he worked so much. But then he switched to driving for a limo company, and then slowly he worked his way up. Took some business courses, helped the owner on the office side as well as doing car service. When I was in middle school, the owner made him a full partner. He did really well. By the time I got to high school, I thought we were rich.” She laughs. “We weren’t really rich, you know, by millionaire standards. But we had a big house with a fancy pool in the back, and I went to the best Catholic school in the city. My mom didn’t have to work, just stayed home and took care of the two of us. It was a good life.”
You nod slightly. Wait. The silence stretches out for three beats, maybe four, as Maggie reminisces. Eventually, she continues. “I should say that it felt like a good life to me, because I was a kid and it was important to both of them to protect me. Because life was so hard for them when they were kids, you know? But it turns out things weren’t really going so well after all. What my mom and I didn’t know is that my dad got into trouble with gambling. Big gambling, like five- and ten-thousand-dollar wagers at a time. My mom knew that he liked going to the casinos, but she had no idea what he was doing.”
She trails off, and you nod again, and wait again. “Apparently,” she says after a time, “he was losing a lot of money with the gambling, and then he started taking money out of the business to cover his debts. Eventually his partner found out and said he was embezzling – which I guess he was – and sued him. The first thing my mom knew about it was when someone came to the house to serve him papers. He told her what happened, and that night he hung himself in the garage.” She grimaces, looking down. “I never know how to say that properly. He hung himself? Hanged himself? I don’t know which one’s right.”
You’ve seen this dodge before. Maggie is focusing on a grammatical irrelevancy in order to separate herself from the emotional pain of her father’s final act. In future weeks, when she’s more comfortable with you and with the therapy process, you’ll probably spend some time talking about her father’s suicide and the effect it’s had on her. For right now, though, you let it go; it’s much too early in your relationship to be poking around in these tender corners of her history.
“Anyway, he left my mother with nothing but debt, which was terrible for her. She only has a high school education and she hadn’t worked for the ten years before he died. There was no way she could support herself, so she moved in with Mike and me. Naldo was two when all this happened, and I was pregnant with Theo. Then, when Theo was born, he had trouble right away. He couldn’t feed and he was completely floppy, and he was diagnosed with CP. The obstetrician said it wasn’t my fault, but I still think it was. Mike blamed me, too. I’m sure that’s another reason why he bailed, because he was mad at me for making Theo sick.”
You spot another logic error. “You think it’s your fault that Theo has CP?”
“Yeah.” She rubs her forehead absently. “I was about four months pregnant when my dad died, and I was so, so upset. I cried for weeks. Can you imagine what that must have been like for poor Theo, to be trapped inside a mom who was losing her mind with grief? No wonder his brain development got all screwed up… poor kid.”
First session, you think. Go slow. But you confront the distortion anyway. “I’m wondering if you ever addressed those concerns with Theo’s neurologist or pediatrician?”
She ducks her head. “Yep. They said it’s not my fault, that my grief or whatever couldn’t have caused his problems. But it still feels like my fault, you know?”
“Sometimes,” you say thoughtfully, “there’s a lot of territory between something feeling true and something being true. Kind of like the panic attack at work. You thought you were having a heart attack, but your belief about what was happening was faulty. You were having a panic attack, not a heart attack. It’s likely that your belief that you caused Theo’s CP is similarly faulty, and the guilt you feel is based on something that’s simply untrue.”
“So, you’re saying it’s irrational for me to think that I caused Theo’s problems,” she concludes. “I guess I know that, kind of. I’m a nurse, remember, so I understand more than most people about fetal development and CP. I’ve even read medical studies about whether maternal stress and bereavement during pregnancy can cause CP. But whether it’s irrational or not, I still feel guilty about what happened with Theo, because I was so upset about my dad’s death when I was pregnant. It was my job to protect Theo, and I failed him.”
You move on from this, knowing that it will take time and practice before Maggie is able to correct her cognitive distortions and experience relief from her painful feelings. “After your dad died, did you get any counseling?”
She nods. “My mom and I both went to a yellow ribbon group. Suicide support. You know about those?”
“Yes.” You’ve been a guest speaker at many yellow ribbon suicide-survivor support groups over the years.
“It helped some,” Maggie says. “Mom went for longer than I did. She was afraid for his immortal soul, you know, because he killed himself in a state of sin. Bad sin, too, the mortal kind. But eventually she talked to our priest about it and he was comforting to her, told her that God could forgive anything. I believe that, too.”
You nod. “Other than the support group, did you have any other counseling?” “No,” she says. “This is the first time I’ve ever been to a counselor.”
You grin, intentionally lightening the somber mood in the room. “How’s it going so far?”
She laughs unexpectedly, following your emotional lead. “Not so bad,” she says. “Dr. Munson promised that you’re good, and God knows I could use some help, because I really can’t keep going on like this.”
“It sounds like a great time in your life to learn some new skills,” you agree. “And that’s really what cognitive-behavioral therapy, or CBT, is about. It suggests that thoughts drive feelings, and feelings drive behavior. What that means is that when you change the way you think, and correct your faulty beliefs, you’ll get relief from many painful emotions, and gain control of your anxiety. Then, because you feel less anxious, you’ll be able to sleep better, perform better at work and at home, and enjoy a generally higher quality of life.”
Maggie nods slightly as she takes this in. Then, “it sounds pretty straightforward. I assume you have techniques and stuff to help me?”
“I do.”
“And people can actually get better from worry? Can change the way they think?”
“People can and do, all the time. As with learning any new skill, it takes a bit of time and practice to master, but most people are able to get the hang of it within ten sessions or so.”
Maggie brightens. “That sounds fantastic,” she says. “I thought it would take years! What do we have to do to get started?”
“This first evaluation visit gives us a good foundation,” you explain. “Learning about your history and some of the symptoms you’ve been having gives me the information I need to understand what’s wrong, and to work with you to develop a plan which is likely to be helpful.” You look down at your assessment form. “I have just a couple more questions.” “Shoot,” she says.
You ask about Maggie’s appetite, weight and eating history (she’s height-weight proportional and denies history of eating disturbance or disorder), her mood (stable), her motor activity (restless), and inquire for any history of intense fears or phobias, hallucinations or delusions.
“I definitely don’t see or hear things that other people don’t,” she says. “I don’t think I have any intense fears. I don’t like snakes or rodents or bugs, but I wouldn’t say I’m phobic about them.”
“Good,” you say, making a note. You ask about obsessive thoughts or compulsive behaviors, which she denies. “Except for the worries I’ve already told you about,” she says. “I can get pretty stuck on my worries, but I don’t count cracks in the sidewalk or check a thousand times a day that my doors are locked, or anything like that.”
You spend a little time exploring Maggie’s cultural identity, which she describes as “confused.” You invite her to tell you more about that, and she hesitates. “Back in high school, we read a short story called ‘The Man Without a Country.” It’s about a guy who’s convicted of treason and is sentenced to live at sea for the rest of his life and never set foot on land, ever again. That story always reminded me of my parents’ relationship with Cuba. They were young kids when they came here, remember; my dad was twelve and my mom was ten. My dad had a little English when he came over; my mom had none. Neither wanted to come here, and neither was given the choice. They were just plopped into an airplane and sent to the new world.” She smiles. “That’s what my dad called America when he got here, el nuevo Mundo, the new world. But soon – really soon – they got assimilated. This culture became their culture. Cuba was lost to them, in a way, like the guy in that short story; they were told to go, and they never set foot on Cuban soil ever again. They learned to speak perfect English. My dad had a tiny accent, but my mom sounds just as American as I do, and if you ask her, she’ll tell you that she knows English much better than Spanish. She says she thinks in English, too. She and my dad spoke Spanish together at home sometimes, and I learned a little that way, but I wouldn’t call myself fluent by any means. I can speak enough to get by with patients at work, asking about pain or whatever: ‘dónde está el dolor?’ But my grasp of the language is pretty basic. The only other piece of Cuban culture that they kept was the food. My mom learned to make Cuban food from her mother, but she didn’t serve it a lot, except for maduros, which are very sweet, pan-fried plantains. It was one of my favorite things to eat when I was a kid.”
She lingers with that memory for a moment, and then visibly shakes it off. “Anyway,” she says, “that was a long answer to a short question. I guess I’m not really sure what to say about my culture. My heritage is Cuban, and like many Cuban people I have light brown skin which tans easily, but if you’re asking whether I feel Cuban or Hispanic, the answer is no. I feel American. My parents grew up here, and I grew up here, and I’ve never even visited Cuba. I knew my mother’s parents, but they both died by the time I was seven or eight, so I don’t remember much about them. I always worry about what little box to check on those forms which ask about racial identity. Should I identify as Hispanic? I guess I should, because that’s my heritage, but I feel like a poser whenever I check that box.”
Moving on in response to your assessment questions, Maggie reports that she has a few good friends, mostly from nursing school and from the CP family group in which she participates once a month with her boys. “It’s good,” she says. “There’s a sib group which Naldo belongs to, so he gets to spend time with other kids who have a disabled brother or sister, and the parent group has been really helpful for me.”
She denies any history of suicide attempts or suicidal ideations. “I would never – never – do that to my kids,” she says. “Or to my mom. My mom wouldn’t be able to handle another loss like that, ever again in her life. She’d go completely nuts. They’d have to lock her away.” She also denies homicidal ideations or thoughts of aggression toward others, or destructiveness toward property. “I’m more of a – what do you call it? – more of an internalizer than a really angry person.”
Other than the death of her father, she denies any significant loss or trauma history, and denies any history of physical, sexual or emotional abuse. She had no learning problems, graduated on time from high school, and went immediately to nursing school. She has worked as an RN for sixteen years. She has never served in the military. Other than a few traffic tickets for speeding, she has never been in trouble with the law. She reports that she has safe and stable housing, having bought her home two years after her divorce. “It’s not super-fancy,” she says, “but the boys each have their own room, and I have my room, and there’s a little mother-in-law suite in the back for my mom.” She denies financial problems or food insecurity. Sources of income include her salary, disability benefits for her younger son, and sporadic child support from her ex-husband.
“Let me switch gears now and ask about the goals you have for treatment,” you say. “At the end of our work together, what would you like to be different in your life?”
She hesitates. “Do you mean what would I like to see happen, or what do I think will actually be possible? Because even though I’m willing to do what you say to get better, I don’t know that it’s realistic to expect that I’ll just change my thinking like magic.”
“You’re right,” you agree. “Change doesn’t happen like magic, and it’s not realistic to expect that after you have therapy, you’re never going to worry about anything ever again. But it is realistic for you to expect freedom from the persistent worry which gets in the way of your life satisfaction.”
“Well, that’s my goal, I guess,” she says. “If we can accomplish that, then therapy will definitely have been worth my time and money.”
“Sounds good,” you say, making a note. “Any other goals?”
She thinks for a moment. “I guess… I feel a lot of worry about what happened to Theo with his CP, and also about my dad’s death. That I just didn’t see it coming, you know? He was in so much trouble, and I had no idea. I think I must have been a terrible daughter that I had no idea he was so desperate and in so much pain. I’ve felt bad about that, and about Theo’s CP, for years.”
“Understood,” you say, making another note. “Any other goals?”
She shakes her head. “I think if we could accomplish those things, I’d be really happy.”
“Okay. Now another question. What resources do you have that we can use as we work together?”
“Resources? You mean, what can help me?”
“I’m thinking about all the resources which you might be able to use in order to help with the change process. For instance, the work that we’re going to do will take practice, and practice takes time. We’ll have to meet together once a week or once every two weeks for the next few months, and I’ll give you daily homework to do in between sessions.”
“I can do that,” she says at once. “I don’t have tons of free time, but getting better is important to me. I’m sick of living like this.”
“Good,” you say. “That’s a great attitude. Your willingness to invest time is a resource. What others can you think of?”
“I don’t know,” she says. “I have good insurance and can afford my copay? We see a lot of people at work who really stress about how to pay for their medical care.
That’s a worry I don’t have, thank God.”
“That’s excellent,” you agree. “Now, thinking of other resources, what about people who can give you emotional support?”
“My mom,” she says immediately. “Also, my best friend Sarah knows I made this appointment, and I’m sure she’ll do whatever she can to help.”
“That’s great. Now, what about your own emotional resources? What strengths do you have that will help us in this work together, especially when we deal with things that may be painful or difficult?”
“Strengths,” she ponders. “I guess I don’t have too many of those.” She shrugs. “I don’t know.”
“What about perseverance?” you ask. “The ability to stick with it, even when the going gets tough?”
“Good point,” she laughs. “I always say that if I could get through nursing school, I can get through anything.”
“Bingo!” You point at her. “Perseverance is an amazing resource. What else?”
“Well… I guess you could say I’m pretty hard-working. I’m a single, working mom with an almost-teenager and a high-need CP kid, and getting through my days takes a lot of energy and juggling and multi-tasking, let me tell you.”
“Being hard-working is a terrific resource which we’ll definitely be able to use.
What else can you think of?”
“Well…” she pauses. “This is hard. I’m not used to thinking of my resources. But… could we say I have a strong will to change? I’m really, really sick of feeling all emotionally twisted up like a pretzel, and I really want to change myself so that I feel better.”
“Your strong will is probably the best resource of all,” you say. “With your persistence, hard-working nature and strong will, we should be in great shape to tackle the change process.” You jot down the identified resources, then say, “now let’s think about barriers. What might interfere with your progress in therapy?”
Maggie takes a deep breath, then exhales in a sigh. “I can think of a million barriers. Time, for one. I’m crazy stressed for time, but as I said, I’m willing to do what it takes to get better. Another potential barrier is Theo’s health. He’s pretty fragile, and he’s in the hospital at least a couple of times a year with aspiration pneumonia. When that happens, all other priorities get rescinded. I take family medical leave from work and I’m with him around the clock at the hospital. So, if that happens when I’m working with you, we’ll have to take a break until he’s better.”
“Completely understandable,” you agree. “Any other barriers you can think of?”
She hesitates. “I can think of a lot of things that could get in the way if I let them, but mostly I think this will just be a matter of setting priorities, and making this a priority for the next couple of months. You’re sure it will just take ten sessions or so?”
You shrug. “Sometimes a little less, sometimes a little more. I won’t kick you out at the tenth session if you don’t feel ready, but most people are able to get the skills they need by then.” You look down at the assessment form, now covered with your handwritten notes. “That almost wraps up the assessment. Do you have any questions for me?”
“Yeah,” she says. “This is uncomfortable to ask, but… Is it just anxiety that’s wrong with me, or is there a specific diagnosis, or…?”
“Well, that’s a great question. I’d like to read you something.” You pull your iPad from the magazine basket beside your chair and tap the blue “DSM-5 Criteria Sets” app on the home screen. You swipe to the anxiety disorders tab. “Let me know whether or not you’d say this is true for you. ‘Excessive anxiety and worry for more days than not, for at least six months.’”
“Absolutely,” she says. “Only it’s been going on for way longer than six months.”
“Okay. Next, ‘the individual finds it difficult to control the worry.’”
She rolls her eyes. “Absolutely true.”
“Okay. And how many of these have you experienced for more days than not in the last six months? ‘Restlessness or feeling keyed up or on edge.’”
“Yes.”
“’Easily fatigued.’” “Yes.”
“’Difficulty concentrating or mind going blank.’” “YES,” she exclaims. “Absolutely yes.
“’Irritability.’” “Unfortunately, yes.” “’Muscle tension.’” “All the time.”
“’Sleep disturbance.’”
“Yeah, like I said, my sleep is very messed up.”
“Okay. Would you agree it’s true that ‘those symptoms cause clinically significant distress or impairment’ in your functioning?”
She nods. “Definitely true.”
“All right. The other criteria relate to the fact that these symptoms aren’t caused by any medical illnesses, which Dr. Munson has already ruled out, and aren’t caused by other mental conditions, which we’ve ruled out by the responses you gave to the questions I’ve already asked you.”
“So, what is it?” she asks. “What’s the diagnosis?”
“The symptoms you describe meet the criteria for what’s called Generalized Anxiety Disorder, or GAD. It’s a common anxiety disorder which is well-understood and is readily treatable by the cognitive-behavioral therapy which we’ve talked about.”
“So, you’re saying there’s help for me?” She’s teasing; there’s actually a twinkle in her eye.
“Most certainly,” you say, grinning back. This is ‘installation of hope,’ the lightbulb moment when a client first understands and believes that change is possible. It’s a key component of client buy-in, and provides motivation for the work which lies ahead. “Let me show you something.” You swivel in your chair to the low bookcase against the wall, and reach for a thin workbook with a gray, salmon and teal cover. Handing it to her, you say, “this is one of the best resources we can use together as we challenge your symptoms.”
“‘Overcoming Generalized Anxiety Disorder,’” she reads. “‘A Relaxation, Cognitive Restructuring and Exposure-Based Protocol for the Treatment of GAD.’ Wow.” She thumbs through the pages, pausing periodically to read a sentence or study a form. “This really works?”
“It’s a well-validated treatment method,” you affirm. “Most people who engage in this protocol get significant relief within just a couple of months.”
“This looks great,” she says. “What do I need to do to get started?”
“Between now and our next visit, read the section called ‘Session One,’ and the ‘Preview to Session Two.’ For homework, please take the State-Trait Anxiety Inventory, or STAI, which you’ll find in the back of the book, in the appendix. At about the midpoint of treatment, you’ll take that same test again. Then I’ll ask you to do it one more time at the end of treatment.”
“To measure change,” she says. “Like taking a patient’s vitals.”
“Exactly like that,” you agree. “The STAI will show us how you’re progressing as we work through the protocol.”
“It’s funny,” she says, “but this actually sounds really similar to what we do at the surgery center. “I was expecting therapy to be sort of – ” she laughs – “no offense, but I was expecting therapy to be sort of woo-woo. You know? Not very structured or scientific. But this – ” she taps the book – “this looks good to me. An organized protocol that I can work through, a week at a time.” She smiles broadly now, obviously and evidently relieved. “Wow,” she says again. “Just a day ago I was on the phone, crying to you and feeling totally messed up and totally hopeless. And now… now I think I can actually do this. I can actually get better from this thing.”
You stand, and so does she, and you shake her hand. “You can actually do this,” you say, matching her smile. “You can actually get better from this thing.”
Before Maggie leaves, you make an appointment for a week from today. She promises to read the assigned sections in the workbook and complete the STAI before returning for the next visit. You see her out of your office, and then, still grinning, you go to your desk to write up her psychosocial and diagnostic assessment.
Vocabulary
