TRANSCRIPT OF AUDIO FILE:

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CLIENT: I'm good.

THERAPIST: You always sound a little surprised when you tell me that you're good. Are you surprised?

CLIENT: Well I mean I feel good every time I see you now. I feel...

THERAPIST: It's been a couple sessions in a row.

CLIENT: Yeah and so, I don't know I just sometimes don't know what to do.

THERAPIST: (laughs) That's okay to feel good.

CLIENT: Yeah and for a while I was feeling good and all the stressing about if I even want to bring things up in here or whatever.

THERAPIST: What allows you to feel good? I think one thing we want to do is support the things that are working to help you feel good and keep those in place.

CLIENT: Sleeping, feeling like I want to be around people again, being around people. I'm happy and successful everyday as opposed to barely making it through.

THERAPIST: Those are big differences from how you were feeling over the summer. [00:01:11]

CLIENT: Yeah and I'm not really sure why things like...Josh's procedure next week, is not causing me more stress, maybe it will next week? I don't know. I can handle things better now than I could before so...This past Sunday I was in a cooling swamp and there was another girl there from my lab and I ended up drinking a little wine just for like telling her...she was telling me all kinds of terrible things that have happened to her her second year of graduate school and I was just like "Whoa!" I just told her everything and I can do that now and I probably do that too much now (laughs).

THERAPIST: Well how would you know if it's too much?

CLIENT: Well I've been thinking a lot lately about what I was telling you I think last time about how sometimes I feel like things are still so exciting to me when I get out there and do them, like having a little wine at a cooling swamp that I wanted to go to in the middle of the weekend and I had a good time and I get overly excited so... (laughs) I'm afraid I'm overwhelming people.

THERAPIST: Did anyone seem overwhelmed?

CLIENT: I don't know. She's not...we're actually very sad when my friend Anna who I also told you about last time, who I went to dinner with and we go riding together and who is as overwhelming as me and so when we're together there's no chance. I don't feel that way because we (inaudible) way worse and leave her and then I'm suddenly exhausted. (laughs) [00:02:46] She's moving away so I'm really sad...in three weeks.

THERAPIST: Where is she moving to?

CLIENT: She's decided on a whim, not on a whim, but all the sudden to bring her startup company to Washington so...

THERAPIST: Far away.

CLIENT: I'm jealous. So that's sad.

THERAPIST: Yeah, it's a loss cause she's a good match for you.

CLIENT: Yeah. But I mean even the more things happen that are good, the less intensely I react to them so it's good.

THERAPIST: Yeah cause it's balanced out. I wonder if part of what led to feeling kind of really cautious about feeling good was that it felt like the good things were so few and far between that they really wanted to hang on to them and there is this fear that you might not hang on to the one good thing or the one good night of sleep but now as you kind of see that you can have more than one good night of sleep, you can have more than one good social interaction, that each one gets a little bit less precious. They're not so great, not so fragile.

CLIENT: Yep. (pause)

THERAPIST: What has sleep been like? You said you were sleeping?

CLIENT: Yeah...

THERAPIST: Are you falling asleep okay? Are you staying asleep? [00:04:15] Are you waking up early?

CLIENT: Yeah, depending again on the time. Sometimes I wake up extra early. I'm still so sensitive and that's probably never going to change. The heat goes on, it's really hot, I wake up, whatever. If I drink too much water I'll wake up but it's not a problem I feel like I'm out of energy even if...

THERAPIST: If you go earlier?

CLIENT: Sometimes, so...it's been good. I mean it could be better, I wish it was perfect but I don't know if that's possible.

THERAPIST: Perfection is hard to come by.

CLIENT: I keep finding out more and more, like things I thought were from my dad or from my mom, like I just had lunch with her today and I was telling her about how sometimes I just feel like I go crazy and use up all my energy because I was telling her about Anna, my friend leaving, and how sad...we just use each other up. (laughs) She's telling me how she used to be the Energizer bunny, (inaudible) she's not anymore.

THERAPIST: When did she stop being an Energizer bunny?

CLIENT: I don't know. She says she's gotten better in a year which is surprising to me. I didn't realize.

THERAPIST: You don't ever remember her being like that? [00:05:31]

CLIENT: No I have nothing to compare it to, the way she was and I didn't quite realize. I don't know. (laughs)

THERAPIST: So maybe figuring out how to sort of meter it out the way that she does give you a little bit more security? Feeling like you know how to use it up and when to use it up so that you don't feel suddenly drained?

CLIENT: Yeah I mean I don't mind that about myself necessarily. I just didn't know. More and more of my personality I find out is...she's told me she's having trouble sitting (laughs).

THERAPIST: Oh really?

CLIENT: Not, I don't think because of anxiety, who knows why? I don't know. She has trouble. She's always been a bad sleeper.

THERAPIST: Huh.

CLIENT: Bad in that if you say her name she'd wake up.

THERAPIST: So light sleeper like you?

CLIENT: Yeah.

THERAPIST: Some genetic component here?

CLIENT: Yeah combined with my father's anxiety disorder.

THERAPIST: What does she do? Does she have any tricks for getting back to sleep or staying asleep that you could learn from her?

CLIENT: No, she told me she tries to read and then can fall asleep. It doesn't sound like she's...I mean I don't know what's going on. [00:06:55] Maybe her own mother was messed up too. I don't know.

THERAPIST: It's possible.

CLIENT: (laughs) Probably.

THERAPIST: It's possible that she's went through different hormonal changes than you are.

CLIENT: I think she already did but maybe it's still going on. (laughs) Poor mom.

THERAPIST: In what other ways are you finding out that your similar to mom?

CLIENT: (pause) I've always thought I was similar to her in a lot of ways but...she doesn't talk much about her troubles like I told you before so things that trouble her...

THERAPIST: You don't know that they're necessarily...?

CLIENT: I don't necessarily know that. I'm like her in a lot of other ways, in ways that are good I think, that I like or that maybe drove me nuts and now I realize were really important. (laughter) (pause) So I mean I don't know exactly what I want try to fix or work on or do exactly.

THERAPIST: Maybe nothing needs fixing right now? That doesn't mean there aren't things that are important to talk about or that you want space to talk about but you don't always have to think of yourself as a problem to be fixed. [00:08:14]

CLIENT: (laughs) Well I always feel like and I hope you don't mind me saying this but coming here has almost become like a yoga class instead of like a doctor's appointment because I (inaudible).

THERAPIST: I'm cool with yoga.

CLIENT: Okay (laughs) Which is funny cause I have no desire to go to yoga right now.

THERAPIST: So what does it mean that coming here is like a yoga class?

CLIENT: I guess self-improvement as opposed to (pause)...I don't know what the opposite would be.

THERAPIST: When you first came in you were feeling pretty desperate and it was maybe feeling like a doctor's appointment to like fix something that's really, really wrong.

CLIENT: Yeah, yeah.

THERAPIST: Versus feeling like... you've actually been doing pretty okay for a bit now so it feels more like kind of continuing to make that better rather than feeling as desperate as you were when you were totally sleep deprived and really anxious.

CLIENT: Mm hm.

THERAPIST: Restless and tired at the same time...which is a pretty miserable feeling.

CLIENT: Yep. [00:09:24] Yeah and it doesn't even bother me as much being on the drugs. I had dark feelings about that and I do still wonder about what will happen if try to go off them but... (pause)

THERAPIST: When it's time to go off them we'll make sure we do it in a supportive way so one thing I usually like to talk about with people is...you want to stay on it a while because you want to give it a good, long trail but for me one of the ways of thinking about medicine is using it as something to take the edge off the symptoms and once some of the severity of the distress is relieved, it gives you an opportunity to put other things in place, skills, support, things like that that maybe you couldn't do before when things were so miserable and then you use those supports and those skills to kind of get you through if there's any rebound when you go off the meds, sometimes people feel a little bit of rebound anxiety when they go off medication. Part of that is being worried about what's going to happen when you go off medication and part of that is you know actually being able to feel some of the changes when the substances wear off but now you have...by that point you'll have more practice using some of the cognitive skills that we've looked at and you'll have support in place because you've reached back out to friends and you've been able to be involved in your social network again to help you weather those bumps. [00:11:08] So it doesn't need to be terrifying and you won't be sleep deprived.

CLIENT: Yeah.

THERAPIST: Because you'll have months and months of good sleeping under your belt.

CLIENT: I anticipate and I hope my life being stable for at least the next four years. I have one friend and I hope you don't mind also who I gave your number to...

THERAPIST: No, that's fine.

CLIENT: Because she's breaking up with her boyfriend but doesn't want to and is switching jobs cause she's miserable and is displaced from her family and is crying all the time and is really, really upset. I was talking to her last night and she just was...she's a usually really happy person but she's so miserable and that almost put things in perspective for me a little bit because I feel like I used to cry every day, at least once a day (laughs).

THERAPIST: And when was the last time you cried?

CLIENT: I don't remember.

THERAPIST: That's quite a difference.

CLIENT: It is, yeah, quite a difference.

THERAPIST: Are you okay with your friend seeing me if she calls?

CLIENT: Yeah.

THERAPIST: It's totally okay with me but I need to make sure you feel comfortable with the idea that I might know someone you talk about.

CLIENT: Yeah.

THERAPIST: Okay.

CLIENT: I doubt she will, I'll be shocked if she does. [00:12:26] I really, really hope she does though. She's not someone I ever thought would call me crying about all those things.

THERAPIST: You were really surprised?

CLIENT: Yeah.

THERAPIST: So it sounds like she must trust you in order to be able to do that?

CLIENT: Yeah and actually one of my other displaced friends who loves my family, in fact my father. She loves my father (laughs).

THERAPIST: What's that like for you to have people feel that way about your family when you don't necessarily feel the same?

CLIENT: Well I mean I love my father. I mean I think it's great, sometimes it gets me into trouble because she'll talk to my father...

THERAPIST: Yeah.

CLIENT: (laughs) and I'll find out about it later. It's not, actually it's good for her. So...I mean it makes me happy that people appreciate my dad cause in small doses he can be helpful.

THERAPIST: Mm hm. Yet what you find frustrating is that you see the same pattern now for a long time?

CLIENT: Yeah, well and...yeah exactly. Yeah another thing I'm trying not to do lately is...I was even afraid it would be too much to give my friend your number or say maybe cause I mean she has sort of been stuck for a while and maybe needed to go see someone but I don't want to give people advice necessarily like my father would, based on my own experiences and what worked for me and be adamant that that's the right direction to go. [00:14:01] My dad, if I asked him again he'll go on and on about his meditation tapes...he listens to those tapes over and over and over when that is not a direction I want to go you know? So I don't want to be like that.

THERAPIST: Yeah.

CLIENT: It's hard to be supportive and give advice or not give...sometimes I don't know exactly.

THERAPIST: Of what you're role should...

CLIENT: ...my friends are serious crazy lately.

THERAPIST: Well I wonder if...so when you've been opening up to people and sharing what some of your experiences have been and I wonder that frees up people to then be able to be a little bit more open with you so it might not be that all of your friends, suddenly all your friends are having all these crazies, but that you've kind of opened the door to be able to talk in this more intimate way. You shared some of what you've done or what you've been through and then they feel free to do the same thing knowing that you probably won't judge them.

CLIENT: Yeah I mean she's been...we've been talking about things for a while, she's been down for a while and that's gone really bad. She knows some of what's been going on with you but...Yeah I mean like this past Sunday was nice that I shared with this girl and she told me all kinds of terrible things that are happening to her (laughs). [00:15:17] I've told you some of that about my...people on my...

THERAPIST: Yeah sometimes you both don't feel comfortable and then you can get a sense of what friendships are good for what.

CLIENT: Yep. Did I answer your question? I forget.

THERAPIST: Yeah (laughs). I asked if you were comfortable if your friend called if it was really okay with you to have her come in.

CLIENT: Oh, yeah (laughs). I really hope she does.

THERAPIST: When I saw you last you were anticipating a Hanukah with your family and you were really annoyed that thanksgiving with your family so I'm wondering how the next holiday celebration went?

CLIENT: Oh, yeah it was fun. (inaudible)

THERAPIST: Oh no, I know you were very excited about your gift.

CLIENT: No actually I mean Josh was the problem that day. He's not super good when I drag him to events he doesn't want to go to. He loves my family but then he had to go to another family's Hanukah party that they invited us to and sometimes he just becomes frustrating, whiny, cranky, but I mean it was fine but it certainly caused me to be less relaxed than I would be otherwise when I got home because he's a little upset.

THERAPIST: How does he express his frustration, whininess and crankiness?

CLIENT: (laughs) Looking at me and telling me we need to go and complaining all the way there "Do we have to go?" and complaining all the way home about how tired he is and we talk about this all the time because this happens all the time. Maybe eventually I mean he's afraid to say no to things and sometimes he just can't say no.

THERAPIST: So he says yes but then complains? [00:17:14]

CLIENT: Well unless there's a way of getting out of...but yeah in general.

THERAPIST: Hmm.

CLIENT: Which makes me sad sometimes cause he's not very social and I wish that he was more but just being dragged all the time to my social events...or sometimes not going. If he says yes and then comes unless something amazing happens and he has a great time he's generally really frustrating.

THERAPIST: What's it like for you to be kind of in that position with him?

CLIENT: It definitely takes away from the whole experience for me. I generally wish I hadn't brought him but then that makes me sad that he won't come out and have fun with me. He's just really picky, which is good in some ways. It's cost me that he doesn't try to do too much, he tries to do as little as possible. People he doesn't necessarily, unless he absolutely loves the people, he just doesn't want to spend the time.

THERAPIST: Are there friends of yours that you guys absolutely love together?

CLIENT: Yeah, Anna, the girl who is moving away. There's a couple, for sure but it's slower to go out with friends lately. He doesn't like people often. All the mutual friends we have so far are cyclists so...[00:18:51] So it's fine he, you know, I'm sure will continue causing stress in little ways as long as it's not super catastrophic...

THERAPIST: How much is his heart impacted?

CLIENT: He's not telling me lately but he's extremely stressed lately, like he's not sleeping well.

THERAPIST: Oh.

CLIENT: Been kind of tense lately and he says its cause his grad school applications are due but I'm sure it's the procedure.

THERAPIST: You think he's worried about the procedure?

CLIENT: Or both. I'm sure it's both.

THERAPIST: Those are two really important things. It's scary to know whether the procedure's going to work. What is this one coming up?

CLIENT: It's another ablation. Its supposed to be not as bad. He's not supposed to have to stay overnight in the hospital but there's a lot of pressure on him because if it doesn't work I mean there could be a third one. That would be kind of...I don't know. I think they sometimes do up to three. I think after the second one usually it cures like 75 percent of people and the last 25 percent are just really tough cases. So I don't know.

THERAPIST: Yes, so it feels like there's a lot of pressure on this one to work and of course you can't do anything to make it work.

CLIENT: Yep. Because I have no idea what's going through his head so...

THERAPIST: He doesn't talk much about it?

CLIENT: No.

THERAPIST: What happens when you ask him about it? [00:20:26]

CLIENT: You know he'll express worry every once in a while...I don't even remember what he'll say exactly. I just tell him its going to be fine, it's going to work and it's going to be great. I'm not sure now is a good time to start discussing what if it doesn't work options.

THERAPIST: I wonder what would happen if you said "I get it that you're really worried about it."

CLIENT: (pause) Yeah I mean I don't...like I said I've never had a major procedure. I can't imagine. I'd probably lose my mind.

THERAPIST: Have you shared that with him?

CLIENT: I think so, yeah, I mean I'll tell him again, I'm pretty sure...

THERAPIST: Sometimes you don't have to say anything but just listening and reflecting back whatever he tells you. If he tells you that he's really worried while you can't understand exactly what it feels like, you know what worry is. You've certainly been worried. I think reflecting back that sometimes just feels validating. [00:21:42] You lose, I think, there's good benefit to lots of different types of responses, the cheerful, optimistic "It's going to work" is sometimes really useful at other times that feels...he might feel like that feels kind of invalidating cause he's really worried about it and you both know that neither one of you knows whether it's going to work or not. Sometimes he might want that kind of cheery lets be positive and optimistic and sometimes he might want you just to listen and kind of commiserate how hard it is to be in this position of having to wait for another week. Judging by how he responds to you, you kind of know which place he's in and what kind of response might be helpful.

CLIENT: Yeah, I think he lied to me actually because one of the reasons he tells me...says yes to things and then later decides he doesn't want to do them but then it's too late and then he complains is because he doesn't want to let me down and I tell him constantly that it's worse that way (laughs). If he says yes and then complains about it as opposed to just saying he can't go...so I mean it was even worse when we first got together and I constantly tell him...that's why he still biked last year cause he didn't want to let me down so I'm sure he's...

THERAPIST: What does he think your expectation is? [00:23:05]

CLIENT: Well I don't know if that's more about grad school or more about...sometimes he'll just go on about how he's going to be stuck working at bike shop the rest of his life, he may as well just give up.

THERAPIST: Would that be okay with you if he was working at the bike shop the rest of his life?

CLIENT: if that's what he really wanted, I don't think it really is. I mean I told him I would support that if he was really passionate about it because for a while he had this project at the bike shop he was working on constantly, redoing the entire store and all his inventory, spreadsheets and analyzing all their sales data and just basically going nuts and I asked him "Is this really what you want? You're not doing any papers for school." He's like "I don't know. It's not..." and he's really passionate about teaching. Yeah I told him that, if that's really what he loves he could start to make it into a career.

THERAPIST: But he doesn't believe you for some reason?

CLIENT: Or he truly does and...

THERAPIST: Or that's not what he wants?

CLIENT: Yeah, I don't know. (pause) He wanted to be more involved in the bike culture until he got sick. I'm not sure how painful it is to work in a bike shop...

THERAPIST: Yeah...

CLIENT: To talk about it all the time and...he told me recently he makes up, when he's selling bikes, sometimes he makes up that he's been riding, he'll tell people stories about it when he's talking to them. I don't know. [00:24:38]

THERAPIST: Yeah cause he wishes he was really part of that culture?

CLIENT: Yeah so maybe that's what holds him there because he's been sad. (pause) It feels like next week is forever away.

THERAPIST: It's really hard to wait.

CLIENT: Well and in fact we won't even know if it works for months.

THERAPIST: Wow.

CLIENT: It has to heal and then they don't declare you officially fixed or not fixed for three months or so.

THERAPIST: Will there be indications before that?

CLIENT: There could be worse or better things sure, they still won't say for sure. Last time it never kicked him back into rhythm and he was shocked back into rhythm and it didn't quite fix him. It was pretty clear at that point.

THERAPIST: You guys have been through a lot with his heart.

CLIENT: Yep. (pause) On Monday I was still sort of excited about this (inaudible). I had such a good time in Farmington, got all this stuff on...I was talking to a bunch of people in my lab and there's somebody giving a presentation next Wednesday and they have to go to the hospital and I was like "Can you show it to me before cause I really want to know about all this stuff. I have to take my boyfriend to the hospital next Wednesday." For some reason I just told them. It was... I got these like...oh my gosh, like...and I wasn't sure if it was a good idea that I told them cause it kind of made me feel better but then it was also really uncomfortable and I thought it was too much information. [00:26:27] Maybe not necessary, maybe made people feel uncomfortable. Why was I telling you this?

THERAPIST: I said you had been through a lot.

CLIENT: Yeah!

THERAPIST: Do you think it's true? What's your relationship like with people in the lab?

CLIENT: Pretty friendly, occasionally we're doing things outside of school, not close but we talk about everything all the time.

THERAPIST: This is a pretty big thing. Figuring out where the boundaries are is really personal to what your relationship is like with them. There's no reason not to tell people and yet people might have a reaction and feel concerned for you and be surprised. Most people your age don't know the kind of stuff that you're learning about heart rhythms unless they're pre-med. But this is what's going on in your life and you spend a lot of time at that lab, those are the people that know a lot about what's going on in your life.

CLIENT: Yeah actually it was really wonderful about Sunday talking to this girl is that Josh had to hear that in grad school she had some horrible gall bladder trouble, I forget if it was, what happened and she was in pain for eight months while trying to take her qualifying exams. She told me she didn't tell anyone nor did she tell our advisors even though she was really, really struggling for like four months because probably it comes from an advisor that doesn't share personal things, don't share your personal things and she went and did and it was much better. After she did...it made me feel a lot better because you're having gall bladder stomach pains that are incapacitating you basically and it's really an uncomfortable thing to talk about.

THERAPIST: Mm hm. [00:28:14] But yet it was important for her to be able to talk about it and she stayed in school and things went well.

CLIENT: Yeah but I mean it was nice to hear. I don't think anyone else in the lab really knows. (pause) It was nice to hear.

THERAPIST: Yeah, well it gives you some information to kind of in this more extreme circumstance, what are the boundaries? It's not that you're sharing every little detail of everything but this is the big deal.

CLIENT: Yeah whenever I talk to someone who's had the trouble themselves it's not been their partner. She was telling me how hard it was on her boyfriend who turned into a jerk and broke up with her... "really dude?"

THERAPIST: (laughs)

CLIENT: And how big of a strain it was...sometimes I feel badly because I'm the one complaining about my boyfriend, not complaining but, complaining basically.

THERAPIST: Clearly it impacts you both.

CLIENT: Yeah.

THERAPIST: It's really hard to be the partner of someone who's going through something.

CLIENT: Yeah I mean I'm really happy that at least I'm in a better spot for Josh. I also had incredible guilt that I was having trouble because of him, because of myself...I eventually decided it was really not his fault (laughs) but for a while I really blamed him yet I felt bad because he had been hurt before. [00:29:45] I just couldn't sleep.

THERAPIST: But not sleeping is really tiresome after a while.

CLIENT: Yeah.

THERAPIST: Sleep is a really important function. Without is so many things get impacted.

CLIENT: Yeah I mean Josh couldn't sleep last night and he probably slept half the night and this morning I could barely talk to him he was just like in a rage which used to happen to me like every day.

THERAPIST: So having one night with sleep deprivation is different than what you had which was chronic sleep deprivation.

CLIENT: It also makes me feel a little better too because he's an amazing sleeper that he'd sleep through like an earthquake. He falls asleep the minute he lays down if he's not stressed and is relaxed. It happened to him too (laughs), made me feel better.

THERAPIST: Happens to the best of them huh? (pause) [00:30:54] Anything else been on your mind today?

CLIENT: No.

THERAPIST: No racing thoughts? You don't have to make any up, I'm just checking to see if there are?

CLIENT: (laughs) No, I don't know where they went!

THERAPIST: Well I'm glad they're not in your head.

CLIENT: Actually you know what? Even the other day actually we were going to meet someone at the gym, he was late and had a lot of things to do and I was, I mean lately I'll just like plan, plan, plan, whatever in my head. I get really stressed out over how I might make it through everything today but then he finally showed up and went to the gym for an hour and afterwards I felt so much better. (laughs) So as long as I still have the energy to exercise it seems like it will be okay.

THERAPIST: Yeah. Well and I think it shows that one, exercise is really useful for you, it helps you let go of some of whatever extra energy you have and any anxiety you have, it helps you release them of that and it's also a good confirmation. If you have the energy to exercise you kind of use that as a check on yourself of how you're doing.

CLIENT: Yeah I mean...

THERAPIST: It's a good cycle. [00:32:13]

CLIENT: I do wish I could somehow do that...have that same effect on everything else as exercise. Maybe someday I'll figure out what else that could be? But yeah I mean, it was a little scary how much it helped the other day in a way. If I hadn't I probably would've had a really crappy day.

THERAPIST: What else could you have done to let yourself move on if he didn't show up?

CLIENT: I mean I was going to anyway if he didn't show up (laughs). If I couldn't go to the gym forever I would have had to do something really productive, like clean the house, I don't know, wouldn't have quite been the same. I don't know why that is.

THERAPIST: What would you have been thinking? Like if you don't have time to go to the gym what gets stuck in your head that gets in the way?

CLIENT: The planning and circles, going on and on and on. I mean it's almost a little panicky and not like it was before but...

THERAPIST: What does it sound like?

CLIENT: Almost like I'm trying to fit everything I want to do into like...puzzle pieces in a puzzle and I can't decide "should I do this, should I do that, would it be better if I did this first, or that first, should I stop on the way to school and get lunch or..." just silly things. [00:33:44] I even said it to Josh that morning, he's like "Don't worry, sometimes I do that too." Like sometimes if he's really stressed he'll wake up and be like "Oh my gosh! What should we do for dinner?" It's eight a.m.! No one cares (laughs).

THERAPIST: So maybe one way to kind of shorten is rather than trying to plan the whole day, allow yourself to plan part of the day and then acknowledge that you'll plan the rest later? So if you can just maybe plan the first three stops or the first three items and then make a plan to check in, see what you have accomplished and fill in the rest later. Similar to how we schedule sessions, we used to schedule a bunch and then "We'll check in and schedule some more," but not trying to map it all out cause it sound like that's...you're almost trying to do that fortune telling thing like figuring out exactly how it's going to go and that can set you up for failure because one little thing doesn't happen the way you expect it to and it can throw a lot off.

CLIENT: Yeah well it's much worse when there's other people involved which is why I think Josh sometimes makes things worse. I mean if I can have total control over him. It's awful. Like waiting for this guy, I can't do things I want to do because I have to wait for him and just ruins my whole plan. It sounds terrible but it's true or if I have to incorporate Josh into my plans (laughs) and how he wants to do it and it just causes (inaudible).

THERAPIST: So what I heard you say was that waiting for this guy who doesn't show up ruins the whole plan? [00:35:24] That sounds pretty all or nothing.

CLIENT: Well it doesn't ruin the whole plan, just he's wasting my time so everything else becomes more stressful and I just want to do this right now and get it over with and go on to the next thing. Well let me just say and also he's coming with us to the gym because we're helping him out because he's Josh's protégée so we're teaching him and if we just do it without him and he misses it it won't be good for him either. (laughs) I think eventually it just means I shouldn't worry about him, take care of other people.

THERAPIST: How did you get to that last part? What did you say to get yourself to that last part?

CLIENT: When I was feeling exhausted by myself? I mean I got to the last part but I'm not sure really like...

THERAPIST: You didn't fully buy into it?

CLIENT: ...one hundred percent fix everything.

THERAPIST: That's okay cause part of thinking about changing how you think is you're not necessarily going to do a one-eighty and erase all the feelings that you had but if you can take the edge of you can make it a lot more bearable. So one of the things I heard you say is that you're wasting all this time waiting for him and you know what if you had tried to limit that a little bit in your head? Like "Okay, so I've used up seven minutes waiting for him or I've used up fifteen?" but then it's a concrete number and its limited rather than thinking "I've wasted all this time" which allows you to sort of go all these places in your head about all the amazing things you could've done with all the time you have wasted. If you limit it and make it more realistic "Okay, I've been waiting for seven minutes, he's running late and I'm going to start my workout and he can join in," that would've made it more sort of middle of the road. [00:37:14]

CLIENT: Mm hm.

THERAPIST: You may have felt less frustrated, less bad that he's missing out on this great workout and a little bit less pessimistic about how the time is getting used and it might not change it, you still might be frustrated that he's running late but it would be less intense.

CLIENT: Yeah. (pause)

THERAPIST: I hear that kind of all or nothing thinking.

CLIENT: Yeah I mean luckily I had slept well.

THERAPIST: Yeah sort of let you rebound?

CLIENT: So I could have some sort of perspective that I was being a little ridiculous although it was one thing to recognize that your being extreme and then another to stop it. I'm not sure why that is.

THERAPIST: Well you have to recognize it first and then in order to change it you have to practice your alternatives. When you recognize that your being extreme rather than judge yourself which your calling yourself ridiculous sounds a little bit judgmental so refrain from judging it but see how you can temper it. "What can I say to make this a little bit less extreme?"

CLIENT: Well and it also feeds into a larger frustration with myself that I need everything to be on such a schedule, if I'm sleeping, eating, whatever it is and then I do to feel the best and I wish it didn't have to be that way. I haven't yet figured out how to not make it be that way and I feel the best when I am that way.

THERAPIST: And that's what's necessary for now.

CLIENT: Yeah. [00:38:55] You think there's hope to sort of let that go a little? I mean sometimes it works but that's the minority of the time. Not that you think that things are not the way I planned but it still works out okay.

THERAPIST: I think that you can work toward greater flexibility and part of that is letting go of some of the judgments of yourself because I think they're related in that when things don't go...you plan very specifically and when they don't go as planned it feels like a pretty big disaster and big disasters are hard to cope with but if you can allow yourself more flexibility and not have to critique the way that you do things then the disasters that happen when they don't go the way they're planned are less intense and so it takes less to be able to deal with them. So I think in some ways they go together and the more consistency you can have, the more good experiences you can have, the longer you can feel stable, the more you can challenge that rigidity that you feel like you need right now.

CLIENT: Yeah I mean it's even better than it was.

THERAPIST: Yeah and as you have success with that you'll be able to let go a little more but it happens in baby steps because it's like you got to be testing it to make sure it doesn't fall apart.

CLIENT: Yeah it is really baby steps. I thought it would happen faster since I started sleeping. [00:40:18] It didn't.

THERAPIST: Change is slow. Change is slow. But slow change tends to be more permanent and when people make wild changes and sometimes people do, that's hard to hold onto but when you make little changes at a time they stick and that's really what you want.

CLIENT: Well the worst I think was the first week or two I started taking the Zoloft, I don't know if that was in my head, probably in my head or whatever.

THERAPIST: Whether it's placebo or medication it happened so...

CLIENT: Does that happen to people?

THERAPIST: Yeah, yeah, you can give people a pill of sugar and they can feel better in a week.

CLIENT: (inaudible)

THERAPIST: Well the placebo effect happens. It doesn't mean that the medication doesn't also have an effect but you're hope and your expectation of what it's going to do also has an effect and so that's really strong right at the beginning.

CLIENT: Well I was just terrified of the medication. I certainly didn't expect it to fix me, I was really scared but really, deeply, irrationally scared. But yeah it was just magical and wonderful and then it kind of went away.

THERAPIST: And then it wasn't which was disappointing?

CLIENT: I was so sad...yeah. So I expected that. That's when I...even you had expected it to fix me.

THERAPIST: You expected that to happen in therapy too?

CLIENT: Something to happen. I don't know what I expected about therapy. I felt like it was the right thing to do if I was going to go on these drugs I was scared of. [00:41:50]

THERAPIST: It seems to be working.

CLIENT: I think so. Yeah. I think the biggest thing it's done is got me stop blaming Josh for grad school.

THERAPIST: Hm. You have more control over that?

CLIENT: Yeah. Yep.

THERAPIST: Well it's nice to be able to see you come in week after week and be surprised that you're doing well; you still seem surprised when you say that you're doing well but it has stuck around for a while.

CLIENT: Yeah I stopped writing it down. I should've...The first time I felt well and I felt like it had been forever and it had been like two weeks.

THERAPIST: I write stuff down so... (laughs) I can look back in your notes if you want to know dates.

CLIENT: You write down stuff after?

THERAPIST: Mm hm. I have to, it's the law.

CLIENT: I would forget it all. (laughs) I'm sorry?

THERAPIST: It's law, I have to write it down.

CLIENT: It is?

THERAPIST: Yeah. I have to keep notes on, you know?

CLIENT: Is that (inaudible)?

THERAPIST: I don't know. Is it law or is it...maybe it's just part of our ethical code that we keep notes so I don't know which it is but all therapists do keep notes, just like doctors keep records. It's not for insurance purposes. Insurance requires you write the date of the session, the time that you met, I don't know why it matters if you meet at 1:30 or 4 but whatever...the date and time and diagnosis and when you plan to follow up. Insurance requirements for notes are pretty low and they never check unless like...I don't know, I guess unless I was being sued for like insurance fraud or something. I'm not worried about it. [00:43:26] I guess it's probably part of our ethical code that we keep notes so that we can follow sort of whether or not treatment makes sense and what's happening with your symptoms cause it doesn't make any sense to keep doing something if it's not working. I tend to keep brief notes on content of stuff so I can look back and try to track what happened when and more of a focus on sort of how you're doing and I hardly ever go back and read them but if you wanted to know particular dates we could go back and look how long it was, what was that first day you came in and said that you felt good and it had been a couple of days.

CLIENT: No. (laughs) I hate looking back on anything.

THERAPIST: Really? That's interesting.

CLIENT: I've had some people give me journals and I've written one or two pages in them, read them and like cringed...just couldn't stand it so I just can't write journals. I still have this journal in fact I think I use it now for like a to do list of things that has a few pages of once when I was like 8 or something and I was so mad at my brothers and I wrote about what crappy brothers they were. It was awful. (laughs)

THERAPIST: Very real at the time, I'm sure.

CLIENT: (laughs)

THERAPIST: We should probably stop there for today.

CLIENT: Okay.

THERAPIST: We're on for our regular time next week?

CLIENT: You know what? I looked at my calendar and next week is Josh's appointment.

THERAPIST: Oh, that's right.

CLIENT: And I was wondering if I could meet you the Friday after and I put on my calendar that we had made an appointment for the Friday after that and I wasn't sure if that was my mistake or if that was just the time you had?

THERAPIST: I wonder if I messed up?

CLIENT: Cause next Friday is the 21st and I wrote Friday the 28th in my mine.

THERAPIST: Oh, yeah, I did too. Okay so next week is his appointment, the 18th, so we should cancel the 18th? [00:45:23]

CLIENT: Yes.

THERAPIST: Okay.

CLIENT: Yes.

THERAPIST: So I did not do that. Now I do have time on the 21st which is when you would like an appointment.

CLIENT: Yeah that would be great unless it's too close to the holidays or something?

THERAPIST: No. So on the 21st I have a 10:30, 11:30 or 12:30. Any of those work?

CLIENT: Any of those will work. Maybe 11:30?

THERAPIST: Okay. The 21st at 11:30 and I did have us for Friday the 28th at 9:30?

CLIENT: Yeah, why don't we just keep those two Fridays if that's okay and cancel the Tuesdays?

THERAPIST: Yes, well Tuesday is Christmas.

CLIENT: Oh right.

THERAPIST: It doesn't matter for you. But the whole world is closed.

CLIENT: Not even close.

THERAPIST: (laughs)

CLIENT: For displaced people.

THERAPIST: Yeah (laughs) Okay so the 21st, the 28th and then go back to your Tuesday on January 8th?

CLIENT: Sure, yeah.

THERAPIST: At 3:30.

CLIENT: Mm hm.

THERAPIST: And all the Januarys other than the first can just be normal cause your schedule doesn't really change right now. Neither is mine so I'll just put you in for those so we can start thinking about what January looks like.

CLIENT: Okay. I just gave you the check?

THERAPIST: Yes you did.

CLIENT: I did? Okay I just wanted to make sure.

THERAPIST: And I put it somewhere but I don't know where I put it.

CLIENT: (laughs) Great.

THERAPIST: So I will see you next Friday.

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