TRANSCRIPT OF AUDIO FILE:

BEGIN TRANSCRIPT:

THERAPIST: So, where are you this week?

CLIENT: It’s been a really strange week. (chuckles) Lots of good things and bad things.

THERAPIST: Which (inaudible at 00:00:15) do you want to go?

CLIENT: Well, okay. Every time something (ph) bad happened, I immediately start thinking about what I’m going to tell you. Which sometimes feels to be counter-effective. It also makes me feel a little crazy. (chuckles) And I don’t know if I’ve ever told you this before, but, I don’t know. Lately it’s been really a problem, because then, I think about—it also makes it worse in a way. (chuckles) (inaudible at 00:00:39)

THERAPIST: Yeah. What is the process? What’s going on?

CLIENT: Well, so, on Sunday, our—I decided I wanted the dogs to come home. And so, they came home on Sunday. And [then they] (ph) came home, and the couple who brought them—who was taking care of them brought them. They were really nice. And the dogs were also clearly a little different (chuckles) than when they last left. [00:01:01] And I don’t know, I just –

THERAPIST: How are they different?

CLIENT: Well, they’ve been spoiled rotten, basically. (chuckles) I don’t know. It was so overwhelming, the whole thing, that I just cried for like 20 minutes after the people left. And I wasn’t even sure if I was happy or sad or why.

THERAPIST: You were emotional.

CLIENT: (sighs) I still don’t even know.

And then, Josh did something similar. (chuckles) At the end of the week, he went and laid out—he’s still been sleeping on the couch, because he didn’t want to—doesn’t want to ruin the relationship. And he went and laid down on the bed to take a nap. And it was probably the first time he’s laid on the bed since he’s got home. And I guess it was so comfortable, he started to cry. And he couldn’t decide if he was happy or sad or whatever. It was just too—it was so comfortable.

And that was good. But it was also really sad that he hadn’t been so comfortable –

THERAPIST: Right. That he didn’t deny himself the comfort. [00:02:02]

CLIENT: So, I just don’t know what’s going on with us. (chuckles) We had a great day when the dogs came home. But then, I was also so upset or—I don’t even know if I was upset or couldn’t figure out what I was feeling. (chuckles)

THERAPIST: Right. I think you’re a little—I think you’re both overwhelmed.

CLIENT: And so, when these—a bunch of these sorts of things happen, and then I just try to figure out why. And then about what I’ll say here. Which is not (crosstalk at 00:02:27) –

THERAPIST: Mmm. Think about what you’ll see here because you feel like you need to figure it out in order to present it to me?

CLIENT: I don’t know. Maybe. I mean, just to figure out what is going on. And maybe it feels more urgent. I don’t know. I have no idea. I don’t know. I thought I was okay this week.

Okay. Last week, I was way too happy. I was so happy. And it was kind of how I felt when I first started taking Zoloft. Things were not good, but it didn’t matter. And I just felt so good. (chuckles) And I freaked out a few days after I last saw you, because I woke up in the middle of the night a few nights later going a mile a minute. [00:03:07]

And then, I think the next night, I took an Ativan before I went to sleep, which are awesome. Except that I’m not sure I had a clear conversation with Linda about how exactly I’m supposed to use it. If I’m supposed to take it every day, because that would be great. I wish I could take like ten a day. That would be great. (chuckles)

So, anyway, I freaked about taking –

THERAPIST: I think you’re not supposed to take ten a day.

CLIENT: I’m pretty (chuckles) sure.

THERAPIST: (chuckles) But I do think you should talk to—because she gave it to you to use, from what I recall, for nights when you’re having a really hard time sleeping. And for times when you anticipate that there’s going to be something that’s really difficult, like a surgery day or –

CLIENT: Right. But I know Ambien, I shouldn’t take every day, because it will become addictive. Even if I couldn’t sleep for a month. So, I’m not sure how often I can take and still not –

THERAPIST: Yeah, so I think you need to talk with her about what the limits are. [00:04:00] It’s not a thing to use, I think, in a daily way like that.

CLIENT: Yeah. And the bottle says, “Take up to one daily.” And I couldn’t remember what she’d said, so I don’t know. And of course, I worry about it.

THERAPIST: You can e-mail her. You don’t have to wait until your next appointment.

CLIENT: That’s true. I don’t know why I haven’t e-mailed her. I should just do that.

THERAPIST: Yeah. And then, you have it in writing, too, to refer back to if you get confused. So, that might be a good thing to shoot her a quick e-mail about, “Give me some clear-cut directions on how to best use this.”

CLIENT: Yeah.

THERAPIST: And she’ll respond.

CLIENT: What was I just going to say?

Oh. Because I was having weird problems—I wasn’t necessarily (ph) having problems sleeping. I just wasn’t sleeping well. Waking up in the middle of the night, or not being able to fall asleep for just longer than usual. And I freaked. (chuckles)

THERAPIST: Yeah, you got nervous.

CLIENT: So, I started taking less Zoloft again. [00:05:00] And I don’t know if that really was a good choice. So, I just have to calm down and take more [of them] (ph) as of today. But, I don’t know, I’ve been really agitated since I stopped being so happy. (chuckles) And just confused, I guess. Randomly crying. And then, we had a great day on Saturday. And we went to my parents’ house. And Josh was really making an effort. We went to a restaurant for the first time in months.

THERAPIST: That’s really exciting.

CLIENT: Had a pain-free, medical-problem-free lunch/dinner thing. Felt so happy.

THERAPIST: That sounds great. Yeah. Yeah, so your mood—I mean, your—(inaudible at 00:05:48) you have strong reactions to things that happen, whether they be good or bad. Right? You have this good day and you feel elated.

CLIENT: Yeah. And I can’t stop thinking about why. When it’s bad. [00:06:00] I don’t think I go on and on when it’s a good day.

THERAPIST: But why do you react so intensely when it’s a bad day?

CLIENT: Well, and I can’t seem to stay happy if Josh is miserable. I mean, maybe for a day. But if there’s another day and another day? (sighs) He banged his leg on something. And because he’s on blood thinners, it makes this huge hematoma, I guess. And then, it makes all his muscles freak out and it’s just really painful (ph). So, that has been the pain of the week. (chuckles)

THERAPIST: Well, how could you stay completely divorced from that? I mean, I think it’s unrealistic to expect that it’s going to have no impact on your mood, because you live with him. So, it’s hard to say, “That’s your stuff and this is my stuff,” because you see it.

CLIENT: I mean, and he’s just walking around miserable.

THERAPIST: [I mean] (ph), you care about him.

CLIENT: Freaking out. This morning, he particularly just—”What’s the point of being home?” and “This is all terrible. My life is terrible.” [00:07:02] I mean, people keep asking, “Isn’t it great that he’s home?” And it sort of is. And then, I mean, he wrote this long thing on the website. I think I told you about it. About how being home is incomplete and it will never be complete. I don’t know.

There’s not a whole lot more progress. Or the progress that we made from now on is really slow. And so, it’s less of a, “Oh, our first this. Our first that.” (chuckles) To keep us excited.

THERAPIST: Right. The milestones are harder to come by.

CLIENT: Right. The fact that the blood thinners make his body so (chuckles) –

THERAPIST: Right. So fragile.

CLIENT: fragile is really, I think, killing him, which then kills me. (sighs) So, I don’t know.

THERAPIST: It feels like your mood is really precarious. [00:08:00]

CLIENT: I don’t know. It’s up and down and up and down. I guess that’s precarious. It’s not like it’s good but on the—or I don’t know.

THERAPIST: Yeah. Well, I guess by precarious, (inaudible at 00:08:09) any little thing can really tip you one way or the other significantly.

CLIENT: Yeah. I mean, I was feeling a little I don’t want say rebellious but frustrated end of last week. So, I took my little brother out and got really drunk with my little brother. And then, the next day (crosstalk at 00:08:28) –

THERAPIST: (inaudible at 00:08:28) frustrated and rebellious.

CLIENT: But I don’t know who I’m rebelling against. The fact that I should’ve been at home with Josh. I don’t know. (chuckles) Then, I went home and I changed his dressing after having like five drinks, which is just really irresponsible. And then, I went shopping the next day with my mom and bought all this silly stuff that I didn’t need, just because I was feeling like I just wanted to make slightly bad choices. I don’t know. Not that bad, but . . .

THERAPIST: How did the buying stuff make you feel?

CLIENT: I think I bought a ridiculous pair of earrings that I then wore to the hospital on Tuesday just because. [00:09:06] I always make an effort to look nicer when I go to the hospital. Just so it doesn’t suck me into its sadness. And then, the nurses comment on my earrings.

So, I don’t know. Made me worried about money afterwards, but also (chuckles)—I don’t know. It was satisfying, I guess (crosstalk at 00:09:27) a way. But then, I wonder if that’s bad. (chuckles)

THERAPIST: Why would it be bad? What are you really worried about?

CLIENT: Oh, I mean, money is sort of a—it’s not a problem, it’s just tight with Josh. I also feel really guilty because I agreed to have the dogs come home, because he would pay to someone to daycare three days a week, which is really expensive.

And so, I’m taking the dogs out. I go drinking. Whatever. And he’s sending them to daycare so I can (crosstalk at 00:09:56). I don’t know.

THERAPIST: So, I guess you have to figure out is the money really an issue. [00:10:03] Or is that you’re being a little bit more flexible with your money than what you typically would. Because, I mean, if that’s really a problem, then we have to look at, well, are these—how impulsive are your—how risky are your decisions? How impulsive are they? Is that problematic? Or is this appropriately way to give you at a time when there’s so little that you have control over? And things are pretty sucky. And maybe a little brightness like a new pair of earrings is worth it. So, where are you on the scale?

CLIENT: Yeah. I was with my mom, and (inaudible at 00:10:39) so irresponsible. If I horrified her, she would certainly have said so.

THERAPIST: Yeah. So, she didn’t think it was too crazy, then.

CLIENT: No. She was a little bit like, “Whoa,” but –

THERAPIST: “Whoa” because of the expense or, “Whoa,” because of different taste?

CLIENT: Well, because of the way I spend (inaudible at 00:10:52). I was like, “Sure, I’ll buy this, that.” I mean, she thought the earrings were crazy and—I don’t know. [00:11:00] She’s just not super-talkative about her judgments of me, but . . . (chuckles)

THERAPIST: But she was making slight judgments, it sounds like. But not totally.

CLIENT: Yeah.

THERAPIST: Or not a strong.

CLIENT: Yeah, yeah. She didn’t intervene afterwards or anything. (chuckles)

I don’t know. I mean, I guess I feel okay about it. I just, while I was doing it, recognized that I was coming from feelings of frustration.

THERAPIST: Yeah. Well, it makes sense to me that you’re frustrated.

CLIENT: (inaudible at 00:11:43) frustrated doesn’t even feel right, exactly.

THERAPIST: Do you want a word list? Find something that resonates better?

CLIENT: (chuckles) I bought this emotions—you know, the emoticons list for Josh when he was in the hospital, because people were always coming in and completely clashing on how he was doing at the moment. [00:12:06] He was really on-edge and they would just bombard him. Or they would be really pushy. I don’t know.

So, I got him this emotions list thing. (chuckles) And every once in a while, I’ll flip through it. And, I mean, there’s like 100 things. And none of them are ever quite right. I don’t know. Maybe there’s the right word, but (inaudible at 00:12:22).

THERAPIST: [Well, let’s give it a try] (ph). Because sometimes, if hit upon the right thing, it just feels better to know what you’re actually feeling.

CLIENT: I mean, crazed, a little bit. But it’s not quite an emotion, I guess.

THERAPIST: (inaudible at 00:12:38) some of these lists.

CLIENT: (chuckles)

THERAPIST: (inaudible at 00:12:42) favorite one.

CLIENT: (laughs)

THERAPIST: So, they’re in categories. So, flip to a negative one. [00:13:00] You’re also allowed to feel one—more than one thing at a time.

CLIENT: Yeah. I mean, hostile almost feels right. If there was on occasion, I would’ve gotten into a fight with somebody like I’ve done before. (chuckles)

THERAPIST: Oh. Like over the parking spot?

CLIENT: Yeah. Worked-up? That’s good.

(pause)

CLIENT: I guess worked-up. That’s (inaudible at 00:13:50).

THERAPIST: It sounds like hostile and worked-up sound like the hit you the best. Who or what do you really want to get in a fight with? [00:14:01]

CLIENT: I don’t know. I mean, I guess not being able to fight with Josh right now kind of stinks. On Tuesday, I had to drag him out to go (inaudible at 00:14:15) check-up. And he ended (inaudible at 00:14:18) exhausted. And I had to drag him out of the house. And I was feeling sort of really frustrated just all day. Also, I had a lot of work to do. (inaudible at 00:14:27) trying to do work while we were at the hospital and—I don’t know. And he moves (ph) so slowly. And particularly. It’s very hard to slow down. And I also can’t get frustrated at him, because it’s not his fault. It just doesn’t go anywhere, I guess.

THERAPIST: Yeah. So, it’s like you want to be able to yell at him to hurry up and let’s go. And you feel like you can’t.

CLIENT: Well, he could tell that I was mad. Not mad. He could tell that I was aggravated. [00:15:01] Worked-up. And by the time he was feeling more with it, almost by the time appointments were all over, he was trying to cheer me up. Because he could tell I was not doing the best that day.

THERAPIST: So, where does that pent up sort of aggravation go?

CLIENT: (sighs) I don’t know. I mean, on Monday, I really had to work. And I really, really also need to go run or something. Because I just couldn’t finish work and run. And I usually would prioritize running or something, but I didn’t, because I really was more worried about work. And then, I got home, and Josh was like, “Please take an Ativan. I can’t watch you.”

So, it either goes—it’s either helped by (ph) drugs or running. [00:16:01] Although, at this point, I’m pretty tired. And so, I ran yesterday and it just felt awful. And I’ve been starting to feel uncomfortable when I—I’m just trying to hang out, which is not good.

THERAPIST: Uncomfortable, like, restless, keyed-up uncomfortable?

CLIENT: Yeah. Yeah. Relaxing is not relaxing. Even though I went for a run yesterday.

THERAPIST: Yeah. I mean, because I think that pent-up feeling sounds like it’s pretty on-target, because there’s all this—yeah, irritation and annoyance and frustration pent up inside you.

CLIENT: (inaudible at 00:16:44) and that leads to –

THERAPIST: And if it has no place to go. Yeah, if you could get in a (inaudible at 00:16:48) showing that to Josh. You’d feel probably like you had vented a lot of it. But I know that there are obvious reasons why that’s not exactly how you want to let go of it. [00:17:01] So, if we can find maybe another way to be able to let go of some of that pent-up hostility. You have good reasons to be mad at a lot of stuff.

CLIENT: (inaudible at 00:17:13) and this morning, when he was just freaking out about his leg and was just miserable, I just wanted to leave. And I did. Just leave him.

THERAPIST: [You had to just] (ph) escape it.

CLIENT: (chuckle) And I went to—I actually went to a yoga class that turned out to be really not a good one. I was so mad through the whole yoga class. Because I left him to go try to relax and it was –

THERAPIST: Mm-hmm, and it’s not working. So how dare it?

CLIENT: You can’t really just—I suppose you could get up and walk out of a yoga class. But then, nothing would be helped. And I’d feel bad about doing that. So, that just makes me more frustrated.

THERAPIST: Yeah, so it makes you more frustrated, because you feel like you don’t have any options at that point. The option you took didn’t work. The option of leaving doesn’t really feel like a good one. [00:18:00]

CLIENT: Yeah. I don’t know.

THERAPIST: So, when was the last time that you got (ph) to yell and scream and cry and stamp your feet?

CLIENT: I don’t know. I mean, getting really drunk with my little brother, whom I can just say anything to on Friday was really nice. It was not yelling and screaming, but it was –

THERAPIST: Well, maybe that’s not what you need. Maybe, I mean, that was sort of my inclination. (chuckles) But maybe you don’t need to yell and scream and cry. Maybe you need to be able to say anything.

CLIENT: Yeah. And, I mean, I can to Josh, sometimes. When he’s feeling okay. (crosstalk at 00:18:40)

THERAPIST: But it’s not completely free. You have to wait for the right time, which might not always match up with when you feel like you really needed it.

CLIENT: Yeah. Also, after he started crying over being so comfortable in the bed, we agreed tonight to try sleeping in the bed together, because I can’t have him crying over how comfortable the bed is and then sleeping on the couch just because of me. [00:19:05] (sighs) So, I mean, I’m not—I’m a little nervous about that. And I don’t think that I cannot sleep and yell at him and freak out, like I have before. When I wake up in the middle of the night because he’s snoring or something, I can’t freak out at him. Or maybe I will, just because I don’t care. But just could lead to more trouble.

THERAPIST: Well, what can you do to—so, if he’s going to—if you guys are going to sleep in the same bed tonight, what can you do to maybe help push it in the right direction so that it’s actually a good first night?

CLIENT: Well, that’s just really that he’s a really loud beeps and things. So, I have the best earplugs I can get, which don’t work 100 percent. And then, the fans. I’m just going to –

THERAPIST: Mmm, yeah. So, you use all that.

CLIENT: probably take some drugs and hope for the best. (chuckles)

THERAPIST: And take your Ativan. Mm-hmm.

CLIENT: (sighs) Because hopefully, if he can get a good night’s sleep and be comfortable, he’ll be better. [00:20:06] But I don’t know. I was hoping you could give me some magical way to separate my feelings from his, but . . .

THERAPIST: Mmm. Well, you love him. So, unless you were to stop caring about him, I don’t think there’s going to be a complete separation of your feelings. I don’t think you really want there to be. I think it is okay for you to have some separation of your feelings when you need. Being able to say “I need a break. I’m going to go leave for an hour for a class,” or, “I’m going to work for the morning.” It’s okay for you to escape and give yourself permission to go escape, whether it’s for work or to just go take a walk or . . .

CLIENT: Yeah. I don’t know. I have been. But it hasn’t been enough to not feel all worked up. So, I don’t know. [00:21:00] Maybe the Zoloft will help again. I don’t know. (chuckles)

THERAPIST: Yeah. Well, I think part of it is we do—I think we do need to find a way for you to be able to let go of some of that pent-up aggression that it makes sense that you have. But feeling blocked from being able to get it out and let go of it is—I think that’s—chronically, that’s a problem. Sometimes, there are things that we can’t address. But to feel like there’s so much that could happen in any given week that you can’t express, that you need to somehow subdue, whether it’s because he’s really struggling or because you don’t want to yell and scream at the nurses for screwing up. Yelling at the blood thinners doesn’t really do anything. But there are all these things that you want to be mad at.

CLIENT: (inaudible at 00:21:57) I don’t even know how to be mad at what’s happening because—yeah, I mean, it’s just this situation. [00:22:02] It’s just crappy.

THERAPIST: Right. It’s nobody’s fault, but it does suck.

CLIENT: So, yeah. I don’t know. Maybe I should do martial arts instead of yoga or something. (chuckles) (crosstalk at 00:22:13)

THERAPIST: I mean, you might want to experiment. Maybe that would help make—I mean, you’re a pretty physical person. Right? You experience things very much in your body.

CLIENT: Yeah. And (crosstalk at 00:22:24), yeah.

THERAPIST: So, maybe it would help to experiment with other ways of letting go of some that aggression. Maybe a boxing class would be awesome for you. Maybe some sort of martial arts would be an avenue to release some of that pent-up aggression. We want to search for as a constructive way to let you let go. The feelings make total sense. Getting in a fight with a random stranger or screaming at Josh is probably going to have other consequences that are just as unhelpful as the pent-up feelings and (ph) frustrations. We want to find an adaptive way of letting go of them without creating another problem. [00:23:02]

CLIENT: Yeah. I mean, I don’t know what to do when running doesn’t—when I’m too tired to run. That’s (ph) always been a problem. I don’t think I ever (crosstalk at 00:23:09).

THERAPIST: Right, because running is awesome, but when you’re not sleeping –

CLIENT: Yeah.

THERAPIST: that it’s—that it doesn’t feel satisfying or it doesn’t feel good to your body.

CLIENT: Yeah. And, I mean, I’m still entirely sure why I’m not sleeping. I had that terrible dream about bringing Josh home from the hospital. I don’t know why. Or why one night, I woke up in the middle of the night. I just (inaudible at 00:23:32) because of this frustration or if there’s something else going on. I’m drinking too much coffee. I don’t know. (chuckles)

THERAPIST: Both of things make sense. See if you can experiment with some other types of exercise, since exercise has been useful for you. Maybe that’s a realistic place to start. I mean, I know in the past, you’ve also talked about—tapping into any of your senses might help. [00:24:03] Some people find it a real release to listen to certain types of music. Or some people find a real release through art. You’ve got to match it with you. There’s no one right way. But the only way to find things that click are to maybe start experimenting with stuff you haven’t tried before.

CLIENT: I was thinking about how I wish I had a piano. I could fit one in my apartment.

THERAPIST: What about a keyboard? If you scale it down, would it work? (chuckles) Or can you go to a music store and bang away at a piano?

CLIENT: Because that’s something that’s active, but not exhausting. (chuckles)

THERAPIST: When is the last time you played? [00:25:01]

CLIENT: I don’t know. I don’t know why that—I just—that’s just is what came into my head as something I’d like to try. Also, I don’t have to schedule anything.

THERAPIST: Right. Yeah. But, I mean, so, I mean, intuition led you there. Who knows why? But it did. So, let’s trust it. (chuckles) And, yeah, maybe a keyboard is a worthwhile purchase. Or go to a music store around here and try it out. See how it feels.

CLIENT: Yeah. My mom has a keyboard. I wonder if I told her that my therapist said to borrow it (inaudible at 00:25:43).

THERAPIST: I will write you a script if you want one. (laughs)

CLIENT: Because she has a nice one that she uses for her jobs.

THERAPIST: Well, I bet you could certainly try it out. See if it gives you—see if it is a form of release for you. And if it works? [00:26:01] I’ll write you a script.

CLIENT: (inaudible at 00:26:07) this is a good idea. Because the thought of doing anything when there’s a scheduled class time –

THERAPIST: Yeah. We (ph) don’t want to add—if that –

CLIENT: just sounds annoying (ph).

THERAPIST: yeah. So, I think, paying attention to that gut reaction is—trust that. You don’t want to add another stressor. And if a scheduled class feels like a stressor, then that’s—there’s not room for more stress right now. If it’s something that you could just pick up when you felt like you had the need might fit the bill.

CLIENT: Yeah. I wish I had one (inaudible at 00:26:49). (chuckles)

THERAPIST: Well, it sounds like your parents come and visit. So, have her bring it next time on your visiting schedule. [00:27:02]

CLIENT: Yeah, they come all the time. In fact, they were here last week. And were asking me if I would ever play the violin, because I used to play (inaudible at 00:27:10). My mom’s a music teacher. And I told them absolutely not. (chuckles) I don’t have time. (chuckles) So I’ll have to (crosstalk at 00:27:20).

THERAPIST: Well, it doesn’t have to be a practiced way. Right? It’s not like you’re getting back to an instrument and you want to perfect it. It’s like (inaudible at 00:27:27) on the keys and create some sound.

CLIENT: Mm-hmm.

THERAPIST: And it might be a way to tap into some of what you’re feeling and get it out there.

CLIENT: But if I borrow, then they’ll be really excited (inaudible at 00:27:41) music and stuff. (chuckles)

THERAPIST: No, you can take it. It doesn’t mean you have to play it.

CLIENT: Mm-hmm.

THERAPIST: So, I mean, if it’s—if accepting sheets of music that comes along with getting the keyboard leant to you, accept it. Put it in a folder. If you don’t want to play any of that, keep it folded up in the folder. [00:28:03] And tell your mom you’re going to get to it when you can.

CLIENT: (chuckles)

THERAPIST: You don’t have to take on their expectations or fight them. You can just channel it.

CLIENT: Yeah, I know. I wish I could talk to them about any of this stuff, but I don’t know.

THERAPIST: Can you? Would that be an option?

CLIENT: Not in the way I would want to, I guess. (chuckles)

THERAPIST: What would you want to be able to say?

CLIENT: Well, I guess I’ve been holding in what would otherwise be spontaneous freak-outs, I guess. Which I think I probably used to do a lot with Josh and vice versa.

THERAPIST: Mmm. So, there’s nobody that’s safe to spontaneously freak out to anymore. You used to.

CLIENT: Well, my brothers. [00:29:00] They’re not always right there and available. But I would call one of them if it was something I particularly needed to talk to somebody about. I don’t know. I mean, I guess I could call my brother and complain about Josh’s leg pain, but I don’t know. It didn’t occur to me. I also just don’t know exactly why I’ve been feeling the way I’ve been feeling and stuff.

THERAPIST: Yeah. It’s okay to not know why. You don’t have to necessarily be able to explain it somebody in order to express it to somebody.

CLIENT: Well, I mean, why I spontaneously start crying. What am I letting out? I don’t know.

THERAPIST: Maybe just pressure.

(pause)

THERAPIST: You do have a lot of expectations on you from different directions. [00:30:02]

CLIENT: What do you mean?

THERAPIST: Well, I mean, there’s a—to me, it seems like there’s a lot of expectation about you being responsible for all of Josh’s daily care. I know that some of you peers at school have expectations on you to holding up some of your end of the bargain, with work. Even that’s been somewhat relieved but not entirely.

CLIENT: Yeah. I mean, that’s also gotten worse, because we’re going in a month to a meeting and there’s been a lot of pressure. And usually, school pressure is fine, but it’s just—I don’t have enough space for it.

THERAPIST: But you don’t have the same resources that –

CLIENT: Yeah.

THERAPIST: you used to have to be able to meet those demands.

CLIENT: So, I mean, it could just –

THERAPIST: You don’t have the—it used to be, you had unscheduled days where you’d put that work in. And you could put other stuff aside and put in a really long day at work. [00:31:02] Or you’d move a meeting or something. But now, there are so many more constraints on your time.

CLIENT: I mean, it could just be work that’s causing me to go over the edge of being not worked up. But I don’t know. I mean, I’m liking it. It’s not. But it is really stressful. I need to solve it in a month, so I don’t know. (sighs)

THERAPIST: Yeah. So, there’s an increased time pressure because of—there’s not unlimited time to work on this stuff.

CLIENT: Right. I don’t know. I mean, I hope it works itself out. But this past week has been a little (inaudible at 00:31:58) if I don’t sleep through the night a couple nights, I freak out. [00:32:02] Which I wish I didn’t, but it probably just makes it all worse. And I think about what I’m going to say to you, and that makes it worse. (sighs) I don’t know. (chuckles)

THERAPIST: Could you come in here without a plan of what to say? I know that used to make you nervous.

CLIENT: To come in here without a plan?

THERAPIST: Yeah. To not know what you were going to talk about at all.

CLIENT: I mean, it’s not even that I want to know what I’m going to talk about. I mean, I come in every time and I don’t know what I’m feeling. But I mean, it’s (sighs) I don’t know. I guess in the way I think about planning things, over and over and over. It always causes me anxiety to plan what I’m going to say here because it’s something to plan. I don’t know. (inaudible at 00:32:46)

THERAPIST: What if you didn’t? What if you didn’t give me the update of what happened during the week? Or haven’t looked at what your mood was like over the course of the week? And we just talked about what you were—and the plan would be the—you’d talk about whatever you were feeling at 3:30 on Wednesday. [00:33:05] And what you felt on that—on Tuesday or Monday or Saturday didn’t have to be part of the discussion.

CLIENT: So, what do I do if I don’t sleep and I can’t stop thinking about why? I don’t know. I’m sure I’ll replace it with something else. (chuckles)

THERAPIST: (chuckles) Does it seem like you think about it more because you know you’re coming in here? Or you would think about it anyway?

CLIENT: I don’t know. I guess I forgot we had put up a wall or something that I forgot about (crosstalk at 00:33:47). Maybe I just need—it’s almost—maybe it’s almost a little self-indulgent to just become more anxious. It’s an easy path. I don’t know.

THERAPIST: I certainly don’t want you to become not introspective and thoughtful. [00:34:01] Those are useful skills that you have. The “why” question is very circular. And it doesn’t always—why aren’t you sleeping? Well there’s probably a gazillion reasons. And we’re never going to know exactly which one it is. Right now, it’s not consistent. Right? I mean, it’s not like you’ve been having insomnia for days on end.

CLIENT: Mm-hmm.

THERAPIST: You had some bad nights, and that’s concerning because you have had periods of time where it is really consistently insomnia. And so, I can see why it makes you—I can understand why it makes you anxious. But asking yourself why probably doesn’t help.

CLIENT: (inaudible at 00:34:47) about something—I want to change something . . . (chuckles)

THERAPIST: To prevent it. But there might not be necessarily anything you need to change to prevent it. Until it actually becomes a problem, you don’t have to worry about changing anything. [00:35:00] And a couple of bad nights here and there is not actually a problem. Right? Are you not with me, here?

CLIENT: (chuckles) I guess it’s just hard to accept that there just be random bad nights. I must have done something wrong.

THERAPIST: Well, can we experiment and see if it is possible to have some random (inaudible at 00:35:34) nights that aren’t your fault in any way?

CLIENT: Yeah. So, I don’t know how I stop from having those thoughts, though.

THERAPIST: Well, so we do the adaptive test. Is it useful? So, when you start asking yourself questions about something that’s happened, whether it be a freak-out or a not-sleeping. Instead of answering a question, you ask a different question, which is, “Is it useful for me to be trying to figure this out?” [00:36:04] And if it’s useful, then, okay. If it’s causing you more anxiety, that’s not useful. Right? You don’t need extra anxiety. So, if it’s not useful, that’s when the wall goes up. And you say, “Okay, I’ve thought about it enough, because spending more time on it isn’t really helping me, actually.” And that was the wall thing that we had used in the past.

CLIENT: Mm-hmm.

THERAPIST: And the way we got to it was figuring out—sometimes, being thoughtful is really useful. Sometimes, being thoughtful is circular and it’s not getting you anywhere. So, if it’s not getting you anywhere, then, you put up the wall and you go down another path.

CLIENT: Yeah. I mean, there’s also that physical feeling of—it’s almost like someone’s grabbing your chest or something, which is what keeps from relaxing. [00:37:00]

THERAPIST: Yeah. I think that’s some—that physical feeling, you really is your way of experiencing anxiety. Right? Because grabbing your chest is probably—there’s probably a lot of things associated with that. Probably shortened breath. And so, if can try to expand your breath when you start to feel that, it’s a way to resist that feeling. And you can see that with the wall. As soon as the wall goes up, it protects you from further thought which is anxiety-producing. So, you can put that wall up, and on the other side of it, there’s lot of room to take nice, deep breaths. Go down another path that’s not threatening. Able to relax the muscles that surround your rib cage so that doesn’t have to feel tight.

CLIENT: Yeah. Maybe I need other paths. I don’t know what other paths (crosstalk at 00:37:50) –

THERAPIST: All right. What would you like them to look like? Where do you want to go?

CLIENT: Ugh. (sighs) I mean, I used to love watching silly romantic comedies and things like that. [00:38:00] But lately, I can’t watch them, because (chuckles) mostly because there’s too much sex (chuckles) (inaudible at 00:38:05).

THERAPIST: Yeah. So, it’s too much of a reminder of the life that you’re not living right now.

CLIENT: Or trashy beach novels. I can’t read those (inaudible at 00:38:15), so –

THERAPIST: Also too much sex?

CLIENT: Right. Haven’t found anything to fill that total silly indulgent something. I don’t know what to replace that with. Maybe something angry. I don’t know. (chuckles) Horror movies. I don’t know.

THERAPIST: Or do you not want to lose the silly romantic comedies and the trashy beach novels because you like them even though they trigger too much of the sexual stuff?

CLIENT: No. I really have no desire to watch them. (chuckles) I don’t know if that counts as another path, but . . . [00:39:00]

THERAPIST: Yeah. It does. And that was a very strong, clear feeling that you had that nope, you actually just don’t want to touch that stuff right now. (chuckles)

Would it be helpful to daydream about a better time with Josh?

CLIENT: Yeah. And we did that a lot on Saturday at our dinner. And it was nice. But it (inaudible at 00:39:29) hopeful. (sighs) I don’t know. It’s hopeful and (inaudible at 00:39:37). It’s kind of nice to do it with him and sort of sad to do it myself, because it feels a little hopeless just to daydream on my own (crosstalk at 00:39:50).

THERAPIST: Well, when you’re not some—being able to envision yourself having a path be—being able to envision yourself doing something that you really like or would feel really empowered by. [00:40:04] Being successful someplace, whether it be at work or finishing a race or planting a garden or something that you felt like maybe was more realistic right now. Those are things you can do, because they don’t involve Josh having a great day, which you have no control over. Or when the transplant will happen.

CLIENT: Yeah. I don’t know if I have any good daydreams on my own at the moment. (crosstalk at 00:40:37) (chuckles) THERAPIST: So, maybe the path is to start creating one. It might be fun to play with what you can do on your own as—and enjoy on your own that you would have more control over.

CLIENT: I did. Actually, I did daydream a little bit about—Yale was having a free trip that they sent out to visit policy institutions in Philadelphia I was like, “Oh, no, I can’t go on that,” because I’d have to arrange someone to take care of Josh. [00:41:03] And then, I was like, “Well, I’m just going to apply.” And then I did daydream about it a little bit. And then, I got rejected, because they had filled up, so . . . (chuckles) sad. But I don’t know.

THERAPIST: But maybe you could daydream about the next one.

CLIENT: Yeah. I mean, if I daydream too much about my career, then I start to feel so trapped by the current situation. Maybe I could just try not to think about. (chuckles)

THERAPIST: Well, and maybe practicing—part of a daydream is that it doesn’t have to be realistic. Right? So, when you start daydreaming about something and then you feel constrained by the current situation, it’s because you’ve started to plan instead of dream.

CLIENT: Right. Well, me, I don’t know how to separate the two. (chuckles)

THERAPIST: Mmm. And so, well, it’s just a matter of practice. It’s about dreaming about something with no limitations. [00:42:01] And when you start to plan and notice where reality might get in the way of your dream, you get to say to yourself, “I don’t have to be realistic, here. I get to have exactly what I want.” Because it’s a dream. Dreams are about having exactly what you want. I mean, if you think about the famous “I Have a Dream” speech. If Martin Luther King had looked at what the reality of the (ph) situation was in the day that he was writing his speech and what he wanted –

CLIENT: (chuckles)

THERAPIST: very hard to see a path from here, where he was, to there. Right? But he let himself dream. It was a dream. “This is what I see as being fair and equal in the world that I would create.” Didn’t have to be realistic in the moment. It was still really inspirational and important. And when you’re feeling anxious and trapped, being able to give yourself a little of your own inspiration just to have the nice dream. You don’t have to know how you’re going to get from here to there. [00:43:01] You don’t plan out the whole Civil Rights Movement. (chuckles) You can just dream about what you really want and allow yourself to feel what you’d feel if you had it. And you don’t stay in the dream forever. It’s just a pathway to get out of where you are.

CLIENT: I’ll try.

THERAPIST: Yeah. And it’s about the process. Right? This is not a goal-oriented exercise. It’s about the process. So, you try and that’s it. My belief is that if you can notice those moments where you’re starting to feel that tightness in your chest, and you notice that you’re caught in a loop of thought that’s not helping you, and you can take a little bit of time to take some deep breaths and dream about something for yourself? That’s enough to move you from one moment to the next, where you might be feeling something different. And that’s all it has to do. It doesn’t have to solve any problems. [00:44:00] It just has to move you to the next piece of your day.

CLIENT: Is it sort of a cop-out that something like Ativan makes that so much easier?

THERAPIST: It’s where you are right now.

CLIENT: Because that sounds so hard. (chuckles)

THERAPIST: Yeah. It is. It is hard. And Ativan’s not a cop out. Ativan is one of the tools in your bag. It can’t be your only tool, because you can’t use it all the time. But it’s appropriate for it to be one of the tools in your bag to use. And so, you use that sometimes. And then, you use these other techniques other times. When they work, you’ll (ph) get easier. And when you have lots of different tools to use, it’s—I think that’s a safer situation to be in, rather than only having one thing that works for you. [00:45:00] Right? Because it’s like (inaudible at 00:45:02) works. You went to yoga and class sucked and you’re stuck. (chuckles) You want to have something else to go to. (chuckles) You want to know, “Okay. If the next yoga class I walk into sucks, I am going to get up and walk out quietly and go do my other thing.”

CLIENT: Yeah. I wish I have (ph). I mean, I guess drugs, Ambien rarely works as well as it used to anymore, so (inaudible at 00:45:24) stop working.

THERAPIST: They can.

CLIENT: (chuckles)

THERAPIST: They usually don’t stop working completely. I mean, I don’t want you to fear that it’s going to be something that only works for a little bit, and then never again. But, yeah. The drugs have a downside in that they can lose some effectiveness. You can build up a tolerance to some drugs. And then, it doesn’t work as well, or you need to take more to get the same effect. And a lot of the anti-anxiety meds are habit forming. And when used correctly, you don’t have to worry about it so much. But if it’s the only thing you have to rely on, it’s really easy to—it’s easier to use it in the way that’s not going to be good for you long term. [00:46:02]

CLIENT: Well, it definitely adds to anxiety when I have—when I go up on Zoloft, it makes me feel bizarrely good and then (crosstalk at 00:46:10) stop for –

THERAPIST: You get nervous. (chuckles)

CLIENT: It almost makes me—not nervous. It’s a lot of more frustration, I guess. (inaudible at 00:46:20) “How could I have felt so good and (inaudible at 00:46:22) this was how it was going to be? And it was just drugs (crosstalk at 00:46:24).”

THERAPIST: And (inaudible at 00:46:24) disappointed.

CLIENT: Yeah, yeah. And that was really terrible, when I first started taking Zoloft, because I felt so good. And then, I had the same insomnia come back. That (ph) was really disappointing and I completely forgot about that until this whole (crosstalk at 00:46:40).

THERAPIST: Until you had that week of feeling so good.

CLIENT: Yeah, yeah. And I didn’t even realize that that was what was happening until it stopped working there. Felt really stupid.

THERAPIST: Oh. Well, I’m sorry it felt stupid.

CLIENT: Well, I mean, it’s so nice. Why can’t that just (crosstalk at 00:46:57) –

THERAPIST: Why can’t you stay like that forever?

CLIENT: Yeah. [00:47:00] Yeah.

THERAPIST: Maybe on the right dose, it would. I don’t know how much more room there is, but I know Linda said that you had been on a pretty low dose. So, there may be more room to go up. And maybe finding the right dose might be where it stays good for a lot longer.

CLIENT: Well, I have to talk to her if there is any reason that—because it definitely—it gave me more energy, if that would keep me from sleeping. Because then, I had started taking it later in the day so it didn’t hurt my stomach. (chuckles) But, I know I’m still taking a small dose. She said I could go up to like 400. I’m only on 75. I can’t imagine (inaudible at 00:47:41) taking 400 (chuckles) but . . .

THERAPIST: So, that’s a really wide range. (chuckles)

CLIENT: And I think 400 would be for the biggest person ever. (inaudible at 00:47:50) dose. I don’t know. That’s what it seemed like, but . . . THERAPIST: Well, usually, also, use them different for depression versus obsessive thought. Right? [00:48:00] For obsessions, they usually use really higher doses of those medications. So, it’s not just about weight, but also about look what are you actually targeting with the med. But, I mean, clearly, there’s lots of room. Not that you would necessarily ever go up to that high dose, but there’s a lot of room for movement. If this isn’t working, then that becomes part of the conversation that you have with her. What’s the next step for you? And that dramatic rise and fall that you feel when you have a switch. What does that mean? Does that mean that you could be on a higher dose and not have—have the risk without the fall? So, I think your first question to her is about the—how many of the—not Ambien. The other one.

CLIENT: Ativan.

THERAPIST: The Ativan. Thank you. Can you take?

CLIENT: I’m going to write this down. (chuckles) I’m going to forget the minute I leave.

THERAPIST: Do you want paper?

CLIENT: Yes. [00:49:00]

THERAPIST: Do you have a preferred color of pen that you like to write in?

CLIENT: (chuckles)

THERAPIST: I have green, purple, red. Blue.

CLIENT: Purple is good. I never write anything down anymore.

THERAPIST: Yeah. So, you had questions about the Ativan. And then, a secondary question about the Zoloft.

CLIENT: I don’t know why I never e-mail her. Because she’s told me before I can. It didn’t even occur –

THERAPIST: You want to ask your mom about the keyboard, too. I don’t know if you want to write that one down.

CLIENT: Sure. (chuckles)

THERAPIST: And that’s probably enough on your list for one week. And then, are we officially scheduled for next week? I think we are.

CLIENT: For Monday.

THERAPIST: Oh, Monday?

CLIENT: Unless you don’t have a slot (inaudible at 00:50:00). [00:50:00]

THERAPIST: Oh, yeah.

CLIENT: Okay.

THERAPIST: Yep. 12:30 Monday.

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