TRANSCRIPT OF AUDIO FILE:

BEGIN TRANSCRIPT:

CLIENT: I know that you don't prescribe drugs, but I want to try and go off Zoloft.

THERAPIST: Okay, let's talk about it. I'm certainly willing to try to talk about it.

CLIENT: Friday I went with my mom to the pond in the afternoon. It was lovely. Then we went out and I called my friend who just had a baby and who is afraid to talk to you. I had a very long conversation with her. She [...] (inaudible at 00:00:28) and everything and she's had a horrible year, way worse than my year. Apparently she hated being pregnant and was afraid she'd hate her child, stuff that would cause me not to sleep for years and years. She's all fine now and she told me how it's been four weeks since she had an emergency C-section and she feels like she's finally bouncing back. Four weeks! [00:00:53]

THERAPIST: That seems like a long time to you or not a long time?

CLIENT: Not a long time. She had told me that she didn't want to see anyone while she was pregnant nine months. She didn't want to get pregnant; she hated being pregnant; she told me she felt like she wanted to be alone and was freaking out about it in general. Then she had the kid and she's bouncing back four weeks later. It was making me feel, first of all, bad about myself for being I don't know if I've been thinking about myself too much instead of just doing it. It's actually is a newborn so I would think that she'd give herself a break anyway, I was inspired and motivated to bounce back. Then I went out with my mom for dinner and I had owed her a drink for her birthday so I bought her a drink for her birthday and then we were in a rush so I helped her with her drink. I was so sick the next day. (sniggers) And this has happened to me a few times. The only think I can think of to blame is the Zoloft. [00:02:08]

THERAPIST: Because normally one drink wouldn't make you feel that way?

CLIENT: I mean it could, I guess. I was pretty upset that I was so happy and was having such a great day and talked to my friend and everything and had a great night with my mom.

THERAPIST: When did you start to feel bad?

CLIENT: In the middle of the night I woke up feeling like I was going to throw up; and then there was like 24 hours of it. It just seems wrong. (chuckles) I feel like I blame the Zoloft. I've always felt a little bit nauseous after taking it. [00:03:04] Linda had said that after a year it should have some permanent affect or have the maximum effect. I don't fully understand exactly how it has helped me, so that's a little worrying because I don't know what will happen if I go off it. I'm actually going to go meet her; next week is our next appointment, so maybe she'll tell me. We have less time and I just want you to know.

THERAPIST: I definitely think you should talk with Linda about it because she knows much, much more about how medication works and can compare benefits and side effects and tell you whether or not your side effects are typical more so than I can. I have some knowledge just from working with people and talking with prescribers and the stomach upset issue you talk about I've heard other patients talk about that, too. That' s not crazy necessarily on a medication like Zoloft. [00:03:59] Generally what people experience with mixing alcohol and their meds is that there tends to be an intensification, so having one drink on Zoloft is like having two not on Zoloft. You're a very petite woman so you're not going to have a lot of tolerance for alcohol. One drink for you is like two for someone else.

CLIENT: I've never had a lot of tolerance for alcohol.

THERAPIST: There's just not much body mass there to metabolize the alcohol.

CLIENT: My friend who just bounced back is smaller than me and she can drink like crazy.

THERAPIST: People develop tolerance if they're more frequent drinkers. You're not a frequent drinker. Some people do have a more difficult time metabolizing alcohol than others. Some people have an alcohol allergy. That wouldn't change on Zoloft versus not on Zoloft for you, so I don't know how this compares to your experience with alcohol, if you remember, before you ever took meds. [00:05:03]

CLIENT: I don't know. I've had this happen to me twice the past year. Never before. Sure, I've been hung over, but usually that hits and you just eat some food and drink some water and it's fine. I exercise and it will help. This was just everything felt so nauseating. My brother is allergic to beer. My dad has some problems. There are too many problems in my family like crazy.

THERAPIST: It's hard to tease apart all the variables, but you've expressed some ambivalence about your medication in the past, too. It seems to work miraculously and then stops working.

CLIENT: Once I got up to this dose, which is still a tiny dose...

THERAPIST: What are you taking now? [00:05:55]

CLIENT: [15.] (ph?) Today is the smallest dose that's supposed to help. It hasn't really been too up and down. Occasionally I do have issues. I'm also sick of this week/two-week change in emotions and I don't know if that's because of the pill plus the Zoloft or the pill or what. I'm just sick of it.

THERAPIST: I think we would anticipate that there should be less emotional fluctuation on Zoloft than off. That shouldn't increase the variability in your mood. Some people complain about feeling their affect, their range is flattened when they're taking any kind of antidepressant. That's not the goal; we don't want to flatten people out, but usually people do experience a decrease in the range, not an increase. If you're feeling like it's something different from that, it's not impossible. People have opposite reactions to medication than what you would anticipate. There's always a small minority that that happens to. [00:07:05]

CLIENT: Until this happened I've never paid such close attention.

THERAPIST: Right. That's also true.

CLIENT: I'm a little sick of paying such close attention and thinking about things too much. (chuckles) I did used to a lot more just do things without wondering and thinking about it for so long. I want to do more of that. A lot of the stuff that happened with Josh was I had wished I'd thought about it more, so I don't know how to go back to not overthinking everything, yet making good decisions still.

THERAPIST: How to figure out what you should be paying attention to. There are some things that are worth paying a lot of attention to, thinking a lot about, being careful about what behaviors or choices you make; and then there are other things you don't necessarily need to pay attention to.

CLIENT: I guess I form pretty strong habits. Sometimes I feel like it's all or nothing, but I could never go and actually not ever thinking about anything. Obviously something like moving across the country with a boyfriend is considered a big thing. [00:08:08]

THERAPIST: What do you feel like you're thinking too much about? You're not allowed to say everything. (laughs)

CLIENT: No, not everything. I guess being too careful with what I do. For example, tonight I actually told my friend that we'd go on a bike ride. She wanted me to do a bike ride with other people and her. It's at 6:00 which is a different time of the day for me, so I'm worried that I won't be able to do it and I'll be too tired or feel nauseous. I would ignore it if I didn't feel perfect before because I'd get excited. I was sure it would be fine. This is just silly, but last night I actually took a sleeping pill because I spent the entire evening helping Pat decide if she wanted this apartment around the corner and then making plans with this friend of mine. I probably should have just not and just dealt with it one thing at a time, but I was trying to go for it, I guess. (laughs) [00:09:12]

THERAPIST: But they're different things.

CLIENT: But I was so stressed out about Pat; and also so excited that she might take this place. And then I was worrying that it's too expensive, but it's a two-bedroom so she would rent out one bedroom. She put a lot on me yesterday. She was like, "Will you come see it with me? What do you think? Do you think I should do it? Can you help me find a roommate? Can you write up an ad for me?" Yes, but I don't want to be completely responsible. I've never found anyone a roommate; but still, it put a lot on me.

THERAPIST: She asked you to do a lot.

CLIENT: Yes. So I got a little bit worked up. And I was worried about my friend tonight and not being able to do it, so I just decided to take the sleeping pill. I don't know if that's a good decision or a silly decision. [00:10:00]

THERAPIST: Did it help you sleep?

CLIENT: Yes, it was great.

THERAPIST: Yeah, that's what they're prescribed for. On nights when you really do need to get a good night's sleep or something is getting in the way of sleeping, you have a prescription for this medication.

CLIENT: Yeah, and poor Josh. After 9:00 or so he just starts to fade. I can just go on and on sometimes. Especially if it's something with his mom; we're all kind of wrapped up in it. He just starts to fall asleep and I kind of get frustrated and then even more worked up.

THERAPIST: That's a hard feeling to settle down from, feeling frustrated and angry if he's falling asleep on you.

CLIENT: Yeah, it's not like I know he's doing it on purpose.

THERAPIST: You know he's not doing it on purpose, but that doesn't mean it doesn't affect you.

CLIENT: Before I'd be worrying about something else and knowing I wouldn't be able to sleep and he'd be falling asleep on me and I would just get so mad; really, really mad because he can fall asleep in a second anywhere anytime. [00:11:08]

THERAPIST: It must be hard to see when sleep can be so elusive for you.

CLIENT: It's not as hard anymore. [...] (inaudible at 00:11:18) other problems, but it sure used to be. (pause) So, yeah, I don't know about the Zoloft. I'm worried [...] (inaudible at 00:11:31) making things a little harder. I don't know how much easier it's still making things.

THERAPIST: Right.

CLIENT: But why not just try it? Should I just give it a break? I don't know. I don't know how people do that.

THERAPIST: Well you certainly can take a break from it. I think these are the questions that you want you said you have a meeting with Linda next week?

CLIENT: Yes.

THERAPIST: Has it been a year? How long have you been on it? [00:11:59]

CLIENT: It's about a year.

THERAPIST: There's no magic number to that. The idea is that you want to give it a full trial to see how it's going and to see what it can do for you. A year is considered definitely a full trial.

CLIENT: I would prefer to wait until September because I'm going on this field trip with my school and I'm used to it. I just don't want anything weird to happen.

THERAPIST: You don't want to change things before then. So maybe you can make a plan with her about how to taper off and give it a try without medication or without that medication in the fall and see. Kind of follow yourself.

CLIENT: Yeah, we have so little time. I have so little time when I see her once every month or so. I just want to go in there saying that this is what I want to do, I think, and see what she thinks right off the bat. Otherwise we'll just not make a decision and put it off.

THERAPIST: Is that what you want to do taper off in September? [00:12:56]

CLIENT: If it seems reasonable to you. I figured you would know. (chuckles)

THERAPIST: It also needs to seem reasonable to her. She's absolutely a better judge of whether or not that's reasonable. In my perspective, it seems reasonable to me to try without because you're functioning pretty well. If you weren't able to get to school, if you weren't able to do your work, if you were having lots of nights where you were so anxious that you couldn't sleep it doesn't actually seem like you want to take away medication. But none of that's happening. Clearly you feel like you're ruminating on things too much. There was one night last week where it sounded like you had a really hard time falling asleep, but you did okay on other nights. You felt like you needed to take a pill last night, but that's not happening night after night and you're getting to school. You're doing your work. You are going out with friends. It seems to me like you're doing well enough that it's reasonable to try tapering off the meds and seeing how that goes. You can always go back on them. [00:14:03] You just need to get from her whether she feels like that's reasonable as well and have a plan. She can sort of make a plan with you for how you taper off because you don't want to just stop.

CLIENT: I think I read it takes a while.

THERAPIST: Well you're on a pretty low dosage so I don't think it will take too long. They generally cut it in half for a week or two and then cut it in half some more; go back and forth. She'll work out the details with you.

CLIENT: I was in such a panic when I went on it way back when. If you google going off it you hear a lot of horrible things could happen. (laughs)

THERAPIST: Most people go off without incident. Some people experience some rebound anxiety. Some people do have some discomfort, but not everybody.

CLIENT: The only thing that I worry about, the anxiety I guess, is just getting my life organized and on track. I don't know what's keeping me from just getting there. [00:15:12]

THERAPIST: What feels off track?

CLIENT: I don't know. I said this last week I just need a routine or a schedule or something.

THERAPIST: Your friend said she feels like she's bouncing back and you want to bounce back. What do you envision that is for you? What is having bounced back?

CLIENT: For her that's getting back to doing the things that she was doing before, so that's easier in a way. I still don't have something that's I think we were talking about that last week super satisfying for me. I was inspired. I tried to find a Smith book club thing to join. There is one. I e-mailed them and I got no response.

THERAPIST: That's hard.

CLIENT: It's probably a bad time. At least my book club is always on vacation in July, so I don't know.

THERAPIST: So maybe put it on your list to write again in a few weeks and see if you get a response. [00:16:05]

CLIENT: Yes. I still need to find something. Maybe this is my group this afternoon. I don't know. I just want to have the energy to try and not keep myself from trying because... I don't know. I let other things get in the way. (laughs)

THERAPIST: How much energy do you feel like you have?

CLIENT: Josh still takes a lot of energy. I don't know. I have [...] (inaudible at 00:16:38) amount and it still just goes up and down every week. Sometimes I don't know if it's real or not if I can push through it or not.

THERAPIST: What happens when you try to push through?

CLIENT: There were weeks when it just felt horrible, but that's hasn't happened in a while.

THERAPIST: When were those weeks? [00:16:58]

CLIENT: When I was really on something. I guess I more don't do things if I really just don't want to because, again, I used to and each one was this anxiety. I just feel this need to either go out with friends and be with people or go bike or whatever it was. I would just feel uncomfortable if I didn't. And my friend who I talked to in Washington just feels so out of sorts, too, if she doesn't. That's probably why we're really good friends. (sniggers) I guess she didn't run in the morning she would just be grumpy, almost like she didn't have coffee or something. Of course she has no problem sleeping. I don't have that feeling much ever anymore.

THERAPIST: That you need to go do it?

CLIENT: Yeah. I think we talked about this before. I still feel better if I do, but it's just getting the motivation to do things. [00:18:00]

THERAPIST: So don't have the need or don't have the desire or don't have the energy? What does it feel like?

CLIENT: It was such a need before, even just to go hang out with people. Like this past weekend I was like, "Maybe I should call up a friend and go meet them for lunch or something." But I was like, "Ugh. I'm just too tired." I just didn't need to get out of the house.

THERAPIST: Do you remember what your mood was like?

CLIENT: Also I was also feeling pretty bummed out about Saturday, feeling super sick all day. I was like, "Maybe I'll just play it safe and just putz around," so I did. (sniggers) It was nice.

THERAPIST: Did it feel sad that day or did you feel comfortable that way?

CLIENT: I had a nice enough day hanging out with myself, I guess, (chuckles) doing useful things as opposed to the day before where I just watched TV all day. It's still not as nice as being with people. [00:19:02]

THERAPIST: It sounds also like you were scared to do that. It's almost like you were hesitant to try to plan something because you didn't know how it was going to go.

CLIENT: Sometimes I feel like I've become so much more introverted than I used to be. I don't know if that's really my personality and I should go with it or try to be like who I used to be. (laughs) It sounds silly but...

THERAPIST: It sounds like you don't really know what you want; and if it's different from what you used to want, is that okay?

CLIENT: Yeah. What I used to want it really felt like just what I should do. I didn't really think about it. Like, obviously, it's a Sunday, I'll call up my friend and do these things. My friend and I had what we called slow day, which was a joke because it was already relaxing and we would go to yoga class and we would go to lunch at our favorite place and then we would go to the beach and swim and then we would go to [...] (inaudible at 00:20:07). [00:20:08] We had this whole list of things. I told Josh about it one time and he said, "That sounds horrible." I was like, "That's the most fun day ever." But now it sounds exhausting to me, too. Again, I don't know if I should just...

THERAPIST: You don't have to recreate that if it's not what you would actually like now.

CLIENT: I don't know if what I feel like now is wrong or bad or not really healthy. I don't know.

THERAPIST: What would make it wrong or bad or unhealthy?

CLIENT: I don't know. If it's drug induced, I guess.

THERAPIST: So you don't know if it's you?

CLIENT: Yeah.

THERAPIST: If it was you, would it be okay?

CLIENT: I guess. It would be confusing.

THERAPIST: Because it feels so different from who you were two years ago? [00:21:04]

CLIENT: Yep. (pause) I guess I don't expect to be the same exact person forever every single day.

THERAPIST: But it seems like a big departure from someone who wanted to have yoga and lunch and the beach and whatever was next on the list to questioning whether or not you should call your friend for a bike ride? It does feel like a big departure?

CLIENT: Yeah, I mean I even used to love when I was at work going outside, walking outside and calling a friend or something. I don't even do that anymore.

THERAPIST: It sounds like you miss who you used to be.

CLIENT: Yeah. Absolutely. A lot of this is why I'm so angry at Josh. I stopped when I I don't know what happened. I lost my mind. (sniggers) Because I came to school with grand plans, goals and ideas. [00:22:10]

THERAPIST: What were your ideas?

CLIENT: I was just excited. I had a lot of energy. I was really ripped. I was excited to just try everything. (chuckles)

THERAPIST: What do you get excited about now?

CLIENT: What do I get excited about now? I get excited about my work most of the time, sometimes. (chuckles) I get excited about hanging out with my family, because they're probably the most comfortable people I hang out with. I don't know. I'm trying to find something else to get really excited about, something that I definitely want to go to and do, that doesn't feel like a chore. I don't know. I guess I get excited about my dogs. That's about it. [00:23:06]

THERAPIST: So what stops you from being excited about this bike ride tonight?

CLIENT: I don't know, feeling like I have to push myself to go. I need to get out there and be outside and run around.

THERAPIST: So when you think back to those days of yoga with your friend, did you have to push yourself to go to that?

CLIENT: No.

THERAPIST: So what makes it different?

CLIENT: I don't know. It's so physical. (chuckles) I don't know. I don't know what that was.

THERAPIST: What do you mean it's so physical? What does it feel like?

CLIENT: I just wanted to go and do those things.

THERAPIST: And what does your body want now? When you think about that, what is your body saying? [00:23:59]

CLIENT: It's not exhausted; it just doesn't care, I guess. I would get so energized from whatever I was going to go and do and pumped up from it. It doesn't always happen now.

THERAPIST: I wonder if maybe that is the Zoloft that "I don't care". Some people describe that as sort of feeling numb, which is what I've heard from some people who take any of the Zoloft, Prozac any of those. I wonder if, for you, you often do experience things very somatically in your body. When you're anxious, your stomach is in knots. You feel it in your body. I wonder if that feeling of your body doesn't have that care maybe it's your version of feeling a little bit flat.

CLIENT: I guess that would make sense why that didn't help me sleep, because I was so tense all the time. [00:25:02]

THERAPIST: I don't know for sure. I don't know if there's any way to know for sure, but I think maybe these are the ideas to explore about what you'd be looking for if you stopped taking it this fall. What would you notice? What would you be looking to see if it's different?

CLIENT: Yeah, Josh tells me I'm more ambivalent about sex, but I'm not really sure, I guess. It's been so long since I really wanted to.

THERAPIST: It's hard to know what to attribute that to.

CLIENT: It's like a year of not [...] (inaudible at 00:25:37) a year of Zoloft, so I don't know. That's supposed to happen, right?

THERAPIST: Some people have decreased libido. Some people have difficulty coming to orgasm. If you have sex, can you orgasm?

CLIENT: No.

THERAPIST: Could you before?

CLIENT: On occasion. I mean I can, but not with sex. (chuckles) [00:26:01]

THERAPIST: Not with him, or not with sex?

CLIENT: Not with sex. Well, kind of not with him, either, actually. (laughs)

THERAPIST: No, go ahead. This is important.

CLIENT: It has to be very precise.

THERAPIST: And he doesn't know the things that work for you?

CLIENT: He does. It does seem harder for sure, but I don't know. I guess I wish I'd been paying more attention. I don't know if it's really changed.

THERAPIST: Right. If it's really the medication or if that's just a "how you guys work together" type of thing. Most women don't orgasm through intercourse, so that's not a Zoloft concern. That's just actually how bodies work. Being able to come to orgasm with your partner versus not being able to orgasm at all is sort of a different story. [00:27:04]

CLIENT: Yeah.

THERAPIST: Is your interest in sex different because it's not pleasurable, or because you're just not interested in it at all?

CLIENT: No, it's pleasurable; but, again, once a month maybe I really do want to really have sex. The rest of the time I could care less if we do or don't. But if we do, it's pleasurable for sure.

THERAPIST: What is his level of interested? How well matched are you guys?

CLIENT: His is so tied to medication and to whether his thyroid drugs are working. For a little bit he was on a new form of a water pill because he keeps retaining too much water. It has female hormones in it. I don't know. Every time he changes his medication something weird happens. It's tough to say. (chuckles)

THERAPIST: Yeah. That makes sense. It's a big piece of a relationship and it sounds like you guys have a number of barriers. [00:28:07]

CLIENT: Yeah, and then his mother lives with us. (sniggers) [...] (inaudible at 00:28:11)

THERAPIST: What happened with that apartment that you guys were talking about on Saturday?

CLIENT: That was last night. She should have dropped off...

THERAPIST: I don't know how I made that Saturday. I'm sorry.

CLIENT: She should have dropped off the form this morning, but who knows. I think I told you before she has horrible credit. I just hope that they want her to move there. She met the guy on the bus six months ago and they've been friends, so maybe they'll give her a break. I don't know. (chuckles)

THERAPIST: I hope it works out for you guys.

CLIENT: I hope so, too. I hope I don't regret encouraging her because it's around the corner.

THERAPIST: Yeah, that's pretty close. (laughs)

CLIENT: Yeah. I would probably have had guilt that she was so far away and lonely and whatever else is wrong. [...] (inaudible at 00:29:07)

THERAPIST: It's a tough situation to be in. [00:29:12]

CLIENT: I wish she would answer why she cares so much not so much about what Josh thinks, but what I think. Why does she care about what I think at all.

THERAPIST: What do you think? What do you think makes your opinion of her is it your opinion of her or your decision?

CLIENT: My opinions of her decisions. I don't know. I don't think I understand her. She talks about regrets. She's lost most of her family. I'm pretty sure she just doesn't want to create, as she says, bad feelings.

THERAPIST: So doing something that you approve of? [00:30:00]

CLIENT: Yeah, except that she doesn't understand that a lot of what she does makes (sniggers) bad feelings anyway.

THERAPIST: I wonder if she sees you as someone who has been really successful. Here you are, managing a house and managing your money so well, able to go to grad school and you maintained a relationship with your family a lot of things she hasn't been able to do. I wonder if she sees you as someone who's made pretty good decisions and been pretty successful in ways she wasn't able to do or doesn't feel capable of doing for herself.

CLIENT: I don't know why I have such a hard time with older people like her and my father, who feel they should compare themselves to my life. My dad has so many insecurities over the fact that I'm getting a PhD. [00:31:00] He'll go on and on about how he wants to get one one day. When I talk about school, he loves to talk about school. Sometimes I get really uncomfortable because he has a great career in life and somehow he still needs to compare. (chuckles) I want to look up to these older people, I guess.

THERAPIST: And you feel like you can't?

CLIENT: Yeah, I guess, or the way that they relate to me is not it's not competitive it's sort of like they are not happy with what they're doing, I guess.

THERAPIST: They somehow feel less than?

CLIENT: Yeah. And my mom, who is a piano teacher and works part time, is amazing what she does and she loves it. She never talks about her regrets or how she wishes she had also done what I'm doing or anything. That's how I can always look up to her. She's confident. She's confident. [00:32:10]

THERAPIST: You admire her confidence in what she does.

CLIENT: That's exactly it. My dad is not confident and neither is Pat.

THERAPIST: And that's really uncomfortable for you.

CLIENT: Really uncomfortable. Really, really uncomfortable. (sniggers) I don't know why. Because if I didn't have a lot of confidence I wouldn't be doing what I'm doing because then I'd just be terrified; and my dad is terrified a lot. He once told me he thought I was braver than him. I almost ran out of the house. Again, we were talking about school. I was like, "I need you to be brave and want you to be brave so that I can be brave, too." (laughs)

THERAPIST: What makes it hard for you to continue to be brave when people aren't being brave around you?

CLIENT: I don't know. (pause) I don't know why. (pause) I guess I want to be able to want to be like my dad. (chuckles) [00:33:09]

THERAPIST: You want to look up to him.

CLIENT: I do. I don't know why. A lot of kids don't care.

THERAPIST: Was there a time that you did?

CLIENT: Look up to my dad? I don't know. We've always had a really tough time relating. I don't know if I looked up to him when I was little, but I was really frustrated with him all the time so it's hard to remember.

THERAPIST: It's hard to hold both. The wish to feel that way about your dad is certainly understandable and very often was portrayed as to be expected in a relationship, you to think of your dad as a super hero, a sort of ideal. [00:33:59]

CLIENT: A few weeks ago I was at a dinner at this computer workshop I might have mentioned and we had a long talk about women and why women are not more present in technology. A lot of it was about whose fault was it; is it the woman's fault for not asking for it and going for it or men judging them for not being as skilled or what. There was a whole discussion over why. Is it's just cultural conditioning, I guess, as Josh would say, that women just need to have all this emotional support and talk about their emotions all the time? I don't know. It kind of left me wondering if a lot of what I think I need I've been told I need.

THERAPIST: In terms of what? What needs are you referring to?

CLIENT: Even just needing very close friends around to tell everything all the time. There was a discussion that got a lot of people upset at the dinner. It was kind of blunt how a discussion about women and tech amongst just women created a lot of problems (sniggers) about how nice it was to have other women on your team because then you could do stuff like talk about your frustrations. I know when I had my girlfriend lab mate and a guy I would sometimes go talk to my advisor and say stupid things and would come back and have to let it out to my lab mate and how that's cultural [...] (inaudible at 00:35:29) that women feel that they need to do that totally and men don't; or maybe we should teach men to do that, too. I don't know. I guess I never mentioned this, but it left me feeling like everything I'm doing is maybe just silly and I should just... I don't know. [00:35:53]

THERAPIST: So the two questions I heard you ask is are these just culturally conditions expectations that I've been told I need and are they silly? If they are sort of things that are conditions, things you've learned to need based upon what our culture says, does that make them not real?

CLIENT: No.

THERAPIST: I don't think there are necessarily right or wrong answers here.

CLIENT: This is another reason. I hate thinking about this kind of stuff. Another reason I do plain, old science.

THERAPIST: It's nice when there are right or wrong answers.

CLIENT: Yeah. Sometimes I just can't handle it. There's no answer. And again, I should just stop thinking about it because it gets me nowhere. With Josh's anthropology stuff, sometimes I just can't hear about it anymore. What's the point, people? There isn't it one. It just keeps going and going and I can't take it.

THERAPIST: It's exploration.

CLIENT: Well maybe that's why I'm not good at it. It causes me stress. [00:37:02]

THERAPIST: The uncertainty and the unknown is really hard for you. My bias I don't know if it's right or wrong but my bias is that it's beneficial to challenge yourself to be able to tolerate a certain level of distress and there becomes a point at which it's no longer good for you to challenge that level and it's okay to retreat. It's like in yoga. A certain level of discomfort you want to push against, right? Because that's how you get better. But there's a point and you have to recognize it in yourself where that discomfort becomes pain and you're injuring yourself and it's not really a good idea to push any further. It might be a good idea to back off at that point.

CLIENT: If it's yoga I know exactly where that point is. I have no problems.

THERAPIST: You've had a lot of practice with yoga.

CLIENT: Running is physical. I know exactly where that point is. [00:37:57]

THERAPIST: I think that, whether it's in therapy or whether it's your own self-growth, the idea of being able to tolerate emotional discomfort is the same kinds of ideas. It's practice knowing where that point is, where a certain level of discomfort or anxiety is. It's useful to practice pushing up against it, maybe asking these questions that don't have clear answers, tolerating the discomfort that comes with creating your own answer for yourself not necessarily a right or wrong answer, but the answer that works for you. Then there's a point where it makes sense to back off and stop thinking about that and go back into the black and white world of a hard science because there's a point where too much anxiety is harmful and there's also a point where a little bit of anxiety is actually good for you. It motivates you to do stuff.

CLIENT: That's what I'm missing. I guess I don't know where that point is. I like that, actually. [00:38:55]

THERAPIST: I do think it's sort of practice at knowing what your limits are and you can't know your limits until you screw up a few times and go beyond them and don't push hard enough and don't have that kind of growth. I don't know how many yoga classes it took you to get where you are in terms of knowing your physical body and how many therapy sessions that translates to or how many dinners like this where you have those conversations.

CLIENT: Yeah. I feel like people do this earlier in life.

THERAPIST: It's all what you're exposed to. And your life changes. You got good at handling the things you needed to handle in your life and your life changed as you grew up and met Josh and chose to come to grad school. Those are all different experiences. You couldn't have had those before. [00:39:58]

CLIENT: I wish I'd been emotionally challenged (laughs) before the decisions were so much more [...] (inaudible at 00:40:04).

THERAPIST: It would have been easier to practice on a high-school boyfriend.

CLIENT: Yeah, but I had braces.

THERAPIST: (laughing) As did probably many of your classmates. So the bike ride tonight is kind of an opportunity to practice. Clearly you're a little bit uncomfortable with the idea because it's not at your normal bike-riding time, it's not your normal group, and so if you were to label that anxiety one to ten ten being panic attack anxiety and zero totally chilled what's the level of discomfort?

CLIENT: I don't know. What would it be if I really don't care if it gets canceled but I'll probably make it through? (both laugh)

THERAPIST: You get to pick your number. [00:40:56]

CLIENT: I don't know. Four?

THERAPIST: So now you remember that that's what four is. I don't care if it gets canceled and I hope I make it through. That's four. This is going to be your own scale and I'm going to ask you, as you go through the week, try to give things a number and whatever you pick for your number, it's not wrong because it doesn't have to compare to anybody else's scale. It only has to be yours. Then you can get a sense of like "that's a four." There's a difference between "I don't care if it gets canceled" to "I am hoping and praying that it gets canceled." That would be probably higher up on the scale. If you can do that enough times that you kind of get comfortable assigning things a number, how intense the anxiety is, then we can use that to figure out like when it's a four, you push. When it's an eight, you step back. That's too much. We'll kind of figure out what different things bring and what works. When it's useful to challenge it and when it's not. [00:41:56]

CLIENT: Okay. That's something I can do.

THERAPIST: We put numbers on it, it feels better. (laughs) I will try to remember to have you practice that in session and you try to remember to practice it outside of session. Anything that you encounter. Tomorrow, whatever happens, pick something and try to get used to assigning it a number and we'll see how that goes.

CLIENT: Next week I was wondering, because I'm seeing Linda at 3:00 on Tuesday, is there any chance that you have an appointment open?

THERAPIST: Let me see what I have.

CLIENT: I don't think we had canceled next week, but we canceled the week after break.

THERAPIST: Next week I have you at 4:30. That's a lot of mental health in one day. I do have times on Friday, the 19th. On the 19th I have a 10:30, a 3:30 or a 1:30.

CLIENT: How about 10:30?

THERAPIST: Sounds good. So that's the 19th at 10:30. I don't have you the week of the 29th, so do you want to meet the week of the 22nd, two weeks in a row?

CLIENT: I'm going to be away.

THERAPIST: Oh. That makes sense why we didn't schedule for then. Then we miss two weeks. Did we schedule for August?

CLIENT: Then I'm going to be here, but getting ready to go away; and then away. Can we wait and see what Linda says about going off Zoloft and then maybe just leave August and start September?

THERAPIST: Sure.

CLIENT: Or maybe the last week of August?

THERAPIST: We can do any of those things. Why don't you call me after you meet with Linda? I see you after you meet with Linda, so we'll plan for all of this next Friday. So I will see you then.

CLIENT: Do you have a lot of things? Are you booked up?

THERAPIST: I just got my calendar for the new academic year, so I wasn't scheduling August anyway.

CLIENT: I have a blank check here.

THERAPIST: Oh, great. I'll just fill it in. (laughs)

CLIENT: I wasn't sure if I needed to start paying more or not.

THERAPIST: Nope. Not yet, anyway. I think you're covered for all the ones that we scheduled.

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