TRANSCRIPT OF AUDIO FILE:

BEGIN TRANSCRIPT:

THERAPIST: So I understand from the message you left yesterday that you are feeling [both higher intensity anxiety] (ph) so you went in for a urgent care appointment with a psychiatrist yesterday.

CLIENT: Yeah. I individually had, like I don't know why they didn't I guess because I had other things like, starting I changed my medicines my (ph) last appointment before yesterday was day before Halloween to instead of 75 milligrams of Seroquel at night to 50 milligrams. So I tried that and then, like, possibly completely coincidentally and then, like, started getting some, like, really intense panic attacks and then also I, you know, I was like, what is this? I don't know. And then I was spotting and I was like, "Oh, maybe it's PMS," even though then I look it up and I'm like, "Wait, no. The birth control pill makes it so I shouldn't be getting PMS at all." And, like, then I tried going back up to the 75 milligrams of Seroquel and it was, like, OK for a while and then, like, a couple of weeks or then, like, last weekend the panic attacks started coming back and, like, really intense Saturday night and really intense Sunday night.

THERAPIST: Did it have an identifiable trigger?

CLIENT: No, it was just coming out of nowhere. And, like, it would last for a good maybe anxiety attack could be a better term. I'm not even sure but, like, it was...

THERAPIST: For you, how are you defining them differently?

CLIENT: I guess I'm defining them differently in that panic attack, like, seems to be more of a term that I've been using incorrectly and it's really for, like, acute panic when you can't do anything instead of, like, really uncomfortable feeling of anxiety. Well I guess, like, this weekend it got to a point of what would actually be a panic attack. [00:02:02]

THERAPIST: How long were they lasting?

CLIENT: Several hours. Like, you know, it was panicking. Like, Sunday I was panicking before I got to rehearsal. I got to rehearsal and actually it was, like, fine during rehearsal. I come back from rehearsal and panicking again. And, like, I have nothing rational that I could be panicking (inaudible at 02:24). I don't have to clean anything. I don't have to write any e-mails. I don't have to do any work. Like, there is nothing that I should be panicking about right now. And it, like, wouldn't go away. And then, like, at a certain point actually, like, you know, Sydney was, like, holding me. Like, eventually I did calm down and then a few minutes later it came back.

THERAPIST: What did it feel like?

CLIENT: It felt like this uncomfortableness but, like, I got really irrational and, like, the part you know, there's some part of my brain that knew this is a panic attack. It's going to go away eventually. But, like, I was feeling like I wanted to hurt myself and then I was feeling suicidal because that was, like, the only way I could get this to stop is to kill myself, you know. Not to the point that I needed to go to the ER because, like, no I'm not actually going to do anything but, like, maybe I should. Like, the fact that I went there was bad. So that is why I had the appointment yesterday. [00:03:23]

THERAPIST: And what came out of the appointment? What did the psychiatrist think?

CLIENT: Well, she was, like, yeah, you definitely need to do something about it. So we're doing because I would take a what, it's five milligrams (inaudible at 03:38). Whatever (inaudible at 03:39). But Klonopin, I take one at night and a quarter, like, as needed. So now it's going to be one at night and one in the morning (inaudible at 03:52) I'm starting off with half in the morning because, like, it makes you tired.

THERAPIST: So having Klonopin more regularly?

CLIENT: Yeah. And stay under 75 milligrams of Seroquel. So I'm going to try that for a week and then if that isn't enough then the next step is to try going down to the 300 milligrams of Wellbutrin instead of 450. And then, like, in another week or so I'll see her and a week or so after that.

THERAPIST: So you're keeping your Wellbutrin as is for now...

CLIENT: For now.

THERAPIST: ...and just adding the additional Klonopin?

CLIENT: Yeah, we're trying these things one at a time.

THERAPIST: That makes sense.

CLIENT: And then possibly there's, like, this other drug and I forget the name of it that she was telling me about. It's, like, an older one that, like, works like Wellbutrin and, like (inaudible at 04:43) epinephrine (ph). And, like, I guess it sometimes it could lead to not that it would lead to heart problems. But if you had heart problems then you could not take this medication. But for most people it was, like, OK. But it actually also manages panic for some reason, even though it doesn't do anything with the serotonin. So I might switch to that if these other things don't work.

THERAPIST: [That's hopeful then] (ph). I mean, there's plan A, plan B, plan C already all planned out. And it might be that plan A works well and that we can figure out a way to control the panic. And it sounds like one of the things that scares you so much is where your thoughts go when you're panicking. So having those suicidal thoughts. Even though it sounds like you trust yourself that you're not going to follow through on it, it's the idea of having such an intense thought.

CLIENT: And, like, I was even trying to, like, figure it out with Sydney. I'm like, "What if I, like you know, what if I hurt myself in a way that, like, wasn't permanently damaging? Would that be OK?" And he's like, "No, that would not be OK." You know, if I figured out how to cut myself into, you know. Like, you know, not even hurting myself to, like just to, like, get the pain to go away and, like, I knew that I shouldn't be doing that but I was, like, strongly contemplating doing that. But I have a phobia of, like, cutting so...

THERAPIST: That's a pretty good barrier. [00:06:09]

CLIENT: It's a pretty good barrier and I was a little too panicky to try and think of, like, other ways that I could hurt myself without hurting myself without, you know, making Sydney upset. But, like, it seemed that doing anything would upset him.

THERAPIST: How would you feel if the situation were reversed?

CLIENT: Probably similarly. I mean, I guess if I, you know, knew that, like, you know, he was doing things in a way that he wasn't going to damage himself and, like, the fact that I guess the times that he's been trying, which hasn't happened in a really long time. But when he, like, got so upset that he wanted to hurt myself and be, like, while we were fighting with each other. And it'd be like, OK, this is all my fault whereas, like, the entire time I was panicking, like, this is nothing you've done. You have done nothing wrong. This had absolutely nothing to do with you. So I guess if he were saying the same thing I might be more OK with it but probably not OK with it. So I guess I understand where he's coming from.

THERAPIST: I mean, it sounds almost like an oxymoron to come up with a way that would hurt yourself that wouldn't be damaging, because hurting yourself is damaging. [00:07:20]

CLIENT: Momentary pain. That would take my mind off of feeling the uncomfortable feeling inside. Like, [I guess it would be] (ph) something like digging my fingernails into my skin but not, like, deep enough to puncture anything might be something I could do and could probably do without Sydney noticing and therefore without upsetting him.

THERAPIST: I wonder how that would work to stop the panic. Are there other thoughts that are going on when you're panicking? Are there worried thoughts?

CLIENT: Mostly I'm just worried about the panic (ph). Like, you know, there was a certain point where I was worried about, like, you know, what if I can't get the meds to fix this. But, like, most of the time it was just panic, panic, panic, panic and that was really what was going through my mind thinking that and, you know. Yesterday I went home for a house meeting and Sydney was still at his place and I was, like, (inaudible at 08:22) and I was just, like, panic, panic, panic. I was still feeling all the panic ever (ph). So...

THERAPIST: Can you describe that to me? What is panic? When you're thinking panic?

CLIENT: I guess I'm just thinking, like, it is this uncomfortable feeling. I want this feeling to go away and I want it to go away. Make it stop, make it stop.

THERAPIST: Can you describe the feeling to me?

CLIENT: Well, it's like this I mean, I guess...

THERAPIST: Was it a physical feeling?

CLIENT: Yeah, it's a physical feeling and it's really hard to explain. It's sort of, like, this tightness in my chest that, like, you know, it doesn't hurt but it's uncomfortable. And, like, you know, to the point where I'm like I rather be in pain than having this discomfort (inaudible at 09:08) I know where that pain is and stuff, whereas this is (pause) and because pain wouldn't have any emotional consequences where this is, like, a physical manifestation of my emotions.

THERAPIST: What's the connection for you? What emotions are connected to that tightness in your chest?

CLIENT: Anxiety. Like, I know this is really circular but I can't...

THERAPIST: That's OK. That's why I want to go through it with you, because I want to find a way. The reason I'm asking you and kind of nagging you for more details is that we need to find a way to kind of unloop these chains.

CLIENT: Because the interesting (ph) thing was also when it was happening at night, like, I was, like, you know, what's the point of taking a quarter Klonopin if I'm going to take (inaudible at 09:59). OK, I'll take my Klonopin that I need to take to go to bed, which (pause) I think I even took my meds and still was, like, on Sunday, I was still panicking for a good while afterward and I couldn't sleep. And I actually woke up, like, a bunch of times that night and (ph) eventually. Because I didn't get to bed till, like, 2:30 or something and, you know, woke up at, like, before like, at 8:00 in the morning. And at that point I'm like, OK, whatever, I'm not even going to bother anymore. But, like, sort of like I guess adrenaline rushing through me and...

THERAPIST: Exactly.

CLIENT: And having no outlet for it.

THERAPIST: It's hard to calm your body from that.

CLIENT: Yeah.

THERAPIST: One of the things that sometimes can be helpful is keeping your thoughts very concrete. So one of the things that sounds like happens for you, which is pretty common, is that you start to feel these physical sensations that are really uncomfortable and then they get connected to this feeling of anxiety. That feeling of anxiety exacerbates some of those physical sensations. So the tightness in your chest could very well be muscular tension and feeling it's constricted here and you can't get a full deep breath. [00:11:27]

CLIENT: I mean, I could breath just fine though. So, like, I don't know if my chest is, like, grabbed (ph). Like, it's, like, in that region but, like, it didn't have any impact on my brain.

THERAPIST: You didn't feel like you were having shortness of breath.

CLIENT: No.

THERAPIST: So when human beings breathe, I think we use about 20 percent of our lung capacity on a normal. Like, sitting there just now having normal breathing. So you can have a lot of constriction and muscle tension and still feel like you're getting plenty of oxygen. Because you don't need to take full diaphragmatic breaths and using up lots more of your lung capacity in order to feel perfectly well, you know, sated with oxygen. So it might be that you're feeling some muscle tension but it's not enough to so constrict your breathing. It's not, you know, you're not having an asthmatic problem where you're not able to breathe fully. But it can feel like you said, it's not painful but if feels uncomfortable enough to make you feel somehow worried or anxious. You don't use the word worried you use the word anxious to describe it and I want to use your words.

CLIENT: Because at one point I was trying to do the concrete thought (ph) thing. I was, like, in the bathroom. I'm like, OK. I'm in the bathroom. There is a heater in front of me. This is the roll of toilet paper. There is nothing in the bathroom that can hurt me. I am sitting here and everything is fine, except the panic feeling didn't go away. Maybe I was doing it for long enough but...

THERAPIST: Well, it sounds like you made a good effort to try to be really grounded in the present moment. A step further might be doing the concrete thing with the environment but also adding that to yourself. "What's happening right now is my chest feels really uncomfortable," rather than reinforcing, "I'm panicking, I'm panicking, I'm panicking." Which is sounds like you started to do. As you noticed that you started to feel panicky, you reinforced the panic. And it might help, even though that's going on for you, to say, "OK, my chest feels really tight. It's uncomfortable. But I'm OK. That's not going to harm me." Rather than reinforcing that feeling of panic, panic, panic, panic. I mean, that's enough just to make you feel anxious in the moment when nothing's going on. So that might help to shorten it for you, because it sounds like it's going on for a pretty long time.

If we were to classify it, you know, the DSM way, panic attacks in that definition are pretty acute, pretty short. And something going on for hours would fall out of the realm of what the DSM would call a panic attack. As long as I know what you mean by your language, we don't need to go by DSM language in here. [00:14:18]

CLIENT: What would the DSM call it then if it goes -

THERAPIST: And anxiety episode, like, similar to what I think your psychiatrist might have differentiated for you.

CLIENT: I mean, I don't even know if she was we weren't really going into the nitty gritty of, like, what it was. It was more just, like so, yeah.

THERAPIST: It would be more kind of sort of we tend to think of anxiety as being something that's a little bit more long lasting, a little bit more continuous. And panic attacks is very discrete episodes with a beginning and an end.

CLIENT: I mean, it was a discrete episode with a beginning and an end. It just lasted longer than what the DSM would call a panic attack.

THERAPIST: And that's somewhat subjective, you know.

CLIENT: Yeah. It's not like your body has, like, an internal clock that says, "OK, it's been 15 minutes. That's the end of the panic attack." Like, I'm sure there is a range in there and an average but... [00:15:11]

THERAPIST: Regardless, it sounds like it's really scary and really uncomfortable for you.

CLIENT: Yeah.

THERAPIST: The particular name doesn't change your experience of feeling like this is out of control.

CLIENT: Yeah. And I had there was nothing I could, you know. At one point Sydney was holding me and that was, like, helping but, like, when he stopped it came.

THERAPIST: Do you know what it is about his physical touch that helps?

CLIENT: I like being held. Like, the pressure on me and stuff helped. And I mean, then we were talking. He was, like, able to distract me for a little bit but then it, like, came back. That's weird. Like, you know, the fact that I had it before rehearsal I was I actually had it before rehearsal yesterday too and I, like, warned Thomas. I was like, "I've been panicking. This is why I got no sleep last night." (laughter) "I have no clue what this is going to be for rehearsal but if I have to bolt then I might have to bolt." And then I ended up being fine during rehearsal. [00:16:15]

THERAPIST: So the rehearsal went OK in terms of anxiety.

CLIENT: Like, the anxiety went away because I was thinking about rehearsal. But, like...

THERAPIST: How were you feeling about rehearsal before it started, before the anxiety happened? Were you annoyed by rehearsal, looking forward to it, not wanting to go, wanting to go? What...

CLIENT: (inaudible at 16:38) I mean, at this point it's Tech Week and it's actually, like, exciting because, like, we have, like, our theme for our skits and it's all happy and positive and stuff. And, like, I had, you know, [worked out and stuff] (ph) then I performed. I was, like, really happy with what we had and we're in a good place. So it isn't like, "Oh the horror of Tech Week." And also, most of the Tech Week rehearsals are only two hours long. Like, Sunday was three hours long and then we got out a half hour late but most of them are only two hours, so it's not nearly as bad as it has been in previous years. So I didn't mind, but...

And I mean, like, last night was, like, you know, I had a house meeting and then I had rehearsal and I was a little bit panicky during the house meeting. Even though, like, it wasn't anything I needed to panic about in the house meeting. Like, I was I figured things were going to be most of it was, like because we usually do a (inaudible at 17:43), "Oh, so-and-so. Like, I did this and this and this and I left off doing this or whatever." And this time it was, like, we had all been ill with the norovirus. No one got stuff done. And so the meeting was, like, figuring out this is how we have to decontaminate things and stuff. So, like, the content of the meeting was fine but I was still panicking before it and during it and after it.

THERAPIST: But it didn't feel like you were panicking about the meeting.

CLIENT: Yeah.

THERAPIST: So the being engaged was something, seems to really help. So it doesn't seem like the attacks were triggered by something that was going on. I'm wondering, what about the things that aren't going on?

CLIENT: Meaning?

THERAPIST: Are there things that aren't happening that you feel like you want to be happening?

CLIENT: Maybe Sydney and I have been too sick to, like or were, like, for the last week too sick to want to be doing anything sexual. So, you know. And also because I had been so sick it wasn't like I was thinking about, "Oh, I didn't accomplish anything on this list of job stuff," because I had a really good excuse. You know, like, I went to the emergency room on Tuesday night. [00:18:59]

THERAPIST: Oh wow.

CLIENT: Yeah. Well, Wednesday morning at that point. It was 6:00 am.

THERAPIST: So that sounds important.

CLIENT: It does, and I don't know. Because then at a certain point, yeah, like, I also had lack of food and that sort of maybe could have contributed to the panic, except I also had it, like, you know, a couple weeks earlier without lack of food. So I don't think the norovirus had anything to do with the panic, though maybe it did. But I don't think so. But yeah, like, it's a really and I even, like, called the temp agency again yesterday. So, like, I don't think I'm panicking about, you know, and because I have rehearsal and I, like, have yarny (ph) stuff I have to do. I'm at least, like, doing things during the day. So, like, it's not like I'm feeling like, "Oh, I'm sitting around. I am so bored. I have nothing to do." Like, I actually have things I need to get done. So I don't think...

THERAPIST: And you feel like you're accomplishing those things.

CLIENT: I'm accomplishing those things even, yeah. I did do, like, you know, after we had our session last week, looking online for sweaters. And then everything I saw online at, like, Old Navy and Gap and Macy's was hideous and I was like, "This isn't going to work." So (inaudible at 20:23) avoid going shopping because I need to go somewhere where I can try things on in order to find things that aren't hideous. So I don't think it was really, like, panicking about things that weren't going on. Like, I wasn't thinking like, "Oh, I need a job." Like, you know, because other times I will have anxiety and be like, "Oh no, I need to get a job, you know, for X, Y, Z reason. I can't deal with my parents, et cetera." And I wasn't thinking any of that when I was panicking.

THERAPIST: Well sometimes anxiety attacks are free floating and we can't connect them to something necessarily that's going on or a worry that's in your head. It can be one of the reasons that they feel so upsetting, is that they really do out of the blue and unpredictable. You know, sometimes people are woken up my panic attack when they're sleeping. It's very hard to pin that on something specific in the environment. So, you know, it's not I think it's useful to look around and see, "Is there something here that set this chain of events into motion?" But we are, you know, and sometimes you're not going to be able to figure out what that is because you can't figure it out. And sometimes you can't figure it out because there isn't anything there to figure. It was a spontaneous anxiety attack or panic attack, you know, whichever we want to label it. [00:21:55]

CLIENT: I think these have been spontaneous because, like, I know what it feels like to panic about something and it wasn't panicking about something. Like, you know, if I wanted to panic about my job or lack of job, I totally could have done that.

THERAPIST: You have proven that you can do that.

CLIENT: Yeah. Like, this was not that. It was just...

THERAPIST: Well, I'm glad that you were very proactive. You took the step to get a sooner appointment. You were able to get in. There's a good it sounds like the psychiatrist is really working with you to kind of figure out if there's a good combination of meds or amount of meds that can help put this back into a manageable place for you.

CLIENT: Yeah, and I'm feeling OK today, because I took, like, the half Klonopin. And I also had a massage because I hadn't had one in a really long time. So that helped. But...

THERAPIST: And how are you feeling virus wise? I didn't know that you had landed (ph) yourself in the ER. [00:22:56]

CLIENT: Yeah, because I found out after when I got home from therapy with you last week Lee had gone to the emergency room and then it spread to the whole house from there. So I think so the worst was Tuesday night where I was, like, vomiting and diarrhea and, like, all out of control. I was like, I know that I'm getting severely dehydrated but I can't keep anything down. And I tried to go to sleep. Woke up, like, at 2:00 am. Tried to go to sleep. Woke up at, like, 6:00 am and was like, I'm vomiting again. OK, I'm going to the ER. So then, like, they gave me the bag of saline solution and then they, like, had it on antimetic and then I got a prescription for more antimetics but never ended up filling it because I was like, "I have no way to get to the pharmacy." Like, I could have waited forever in line at the hospital pharmacy but I was like, "I want to get home." So... [00:23:55]

THERAPIST: You feel more comfortable at home.

CLIENT: Yeah. I didn't end up needing it though because after that I didn't throw up. So, like, Wednesday was mostly just, like, trying to keep things in my body. And, like, I was able to, like, drink [a little bit] (ph) but still couldn't eat any food.

THERAPIST: Sounds really uncomfortable.

CLIENT: Yeah. I might have had, like, a couple of water (ph) crackers or something. But Thursday I was able to eat food. Like, I didn't have nearly as much as I normally would but I do go home for Thanksgiving. My dad picked us up since Sydney was also sick, though not as sick as I was. But neither of us could drive. So we actually stayed over Thursday night.

THERAPIST: The rule has been broken. (laughter)

CLIENT: The rule was broken because we were like, "Oh, parents need to take care of us because neither of us could take care of ourselves." Sydney was actually panicking Thursday night, Friday morning, and we ended up going back Friday morning. He (ph) was like, "I'm better now (ph) to take care of you." And I was like, "OK." When we realized it, it was like, you know, "You have to let us sleep in the same room. We're both sick. We need real beds and stuff." And also I ended up avoiding Cullen and Doreen by being upstairs in quarantine most of the time. So, like... [00:25:17]

THERAPIST: So it seems like you and Sydney traded being sick and also traded anxiety.

CLIENT: Yeah.

THERAPIST: You took turns.

CLIENT: Yeah. I mean, there was, like, very specific (inaudible at 25:28). Like, lack of privacy that my parents' house has is really, yeah, made him panic. And I guess I'm more used to it, having gone, you know, slept over there before. And I mean, I'm never thrilled by it but I'm used to it. But then by Friday I was able to, like, eat food again and since then have been fine. I guess the other thing is Sunday I didn't eat. I had a frap in the morning for breakfast and then didn't eat anything all day because I, like, went home and dyed a ton of yarn for a customer order and then I had rehearsal. But the panic was also happening on Saturday night and Saturday I did eat food. So I don't think the panic was connected to the not eating food. Like, not being able to stand up for the second half of rehearsal and falling over and having to stop singing was connected to not eating food but the panic was not connected to that. And, like, yesterday I had three meals and I was still panicking. So, yeah. [00:26:44]

THERAPIST: So that doesn't seem to be a likely or reliable cause.

CLIENT: Yeah, because I know sometimes, like, Oh, I'm hungry, you know. I'm panicking because I'm hungry.

THERAPIST: Yeah. Sometimes that shaky feeling that you sometimes get when you're hungry can mimic anxiety closely enough that it spurs you to start that spiral.

CLIENT: And I can, like, tell. At least I know, like, "Oh wait, hey. [I haven't eaten] (ph)." But, like, in this case it just...

THERAPIST: In that case it wasn't true.

CLIENT: Yeah. So, it's not hunger. It's random spontaneously generated anxiety coming from nowhere (ph).

THERAPIST: So you can't prevent it if it's random but you still can manage the symptoms when they occur. I'd like you to give a try to sort of instead of labeling it panic and anxiety labeling it by the specific feelings that are going on and then reassuring yourself that those physical feelings, as uncomfortable as they are, are not dangerous and they will end. They always end. So that, you know, they're temporary. They're not dangerous. And, you know, it's just a matter of time and not allowing yourself to wonder more about it than that. You know, the goal is to get out of that spiral. You don't have to have long conversations with yourself about when it might end or how bad it is, but just this is it. This is what's going on. It's going to be over. And see if you can get yourself to move on with it and hopefully therefore kind of short-circuiting the process a little bit rather than fueling it. [00:28:39]

CLIENT: Yeah, which I don't know. I still feel like I'm kind of lying to myself if I do I mean, I'm (ph) fine not saying it's panic when it is. I mean, I guess if I'm not saying it's not panic either I'm just saying it's...

THERAPIST: It's not that you're trying to convince yourself of something that's not true. It's choosing what pieces are you going to pay attention of what's going on. Which pieces help you to deal with what's going on and some pieces don't. So it's not that you're saying, "Well, I'm not panicking. Everything's cool." Not cool and you are panicking but focusing on the panic and repeating to yourself that you're in the midst of panic doesn't help you end the panic. But labeling it by what's going on physically is also true. Your chest you were saying when you push yourself what is that uncomfortable feeling. "That uncomfortable feeling feels like a tightness in my chest." That's very true and it's also true that that's not harmful. Nobody has ever gotten hurt from that tense feeling in their chest that's induced by anxiety. [00:29:57]

CLIENT: I don't know that no one I mean, I'm just thinking that it could theoretically. Like, if you had that feeling and you were driving or something get hurt by the distraction it causes.

THERAPIST: But you were sitting in a bathroom. You're looking for ways to freak yourself out here.

CLIENT: Well, yeah. I mean, I did have (inaudible at 30:14) feeling panicky too. So...

THERAPIST: So if you're in a dangerous situation, if you're driving a car, then you get yourself to a safe situation so that it's true. But the anxiety itself is not harmful in the moment. Sure, you know, if you're driving a car, can driving a car be dangerous? Yes. But the actual tension in your chest, that discomfort, is not dangerous or harmful to you. It's uncomfortable but in some ways it's just anxiety, it's just panic and that's not actually in itself harmful in the moment and it will go away. It always goes away. Those are the pieces that you want to pay attention to. You don't need to lie to yourself. You want to pay attention to the pieces that help you through it rather than paying attention to the pieces that can intensify it and make it longer or more intense. You can do that. You showed that you have enough awareness by being able to do that other (inaudible at 31:18) stuff to be able to use that to help yourself.

CLIENT: The other stuff didn't work so...

THERAPIST: It didn't work but it's the same skill and now we just need to apply that skill in a way that makes it more useful for you.

CLIENT: Yeah, it's just a little bit harder when it's, like, focus (inaudible at 31:36). Like, because it's one thing to focus on it [can seem like] (ph), you know, choosing what aspects of the panic to focus on where I am, you know, ignoring these other things as opposed to just being like, "The wall is white. The door is brown." Where at least there I'm completely ignoring the issue and therefore don't feel like I'm trying to convince myself of something that's not entirely true or isn't the full truth, which I always have a harder time doing because I feel like I'm trying to convince myself of something rather than refocus on something. So I can try it. I'm just not convinced that I will be able to do it in the same way that I can do other things. It's really hard when, like, you know, you try to do or especially when I did do things and it went away and then it came back. Because, you know, like, you can't, like -

THERAPIST: That feels frustrating. [00:32:37]

CLIENT: You know, if you want to keep on doing the focus thing, like, once it goes away then it's like, OK, I can't spend the rest of the day saying, "Oh, I don't have this feeling in my chest," you know. Things like that. Like, you know, you have to get, you know. But at some point you let down your guard and then it comes back. And that's also, like, when I was sleeping. Like, a lot of those nights, like, I was having all these crazy nightmares and waking up.

THERAPIST: Oh, you've had intense nightmares?

CLIENT: Yeah.

THERAPIST: Do you remember them?

CLIENT: Some of them. Like, last night I don't know if it's what were they? Like, I've had some nightmares that I'm trying to remember which are the ones that I had while I was panicking. But, like, you know, one where, like, Jonas came back and he, like, asked, you know, if I wanted to get back together with him. And for some reason I said yes. And I'm like, you know, in the back of my mind in that dream I was like, "Oh well. I know, like, you know, it isn't going to work out again. He's totally just going to flake out and leave me again." And then this other part of me was like, "Wait. Didn't I have a boyfriend?" You know, like, these other people [in the dream] (ph). Like (inaudible at 33:57) boyfriend, you know. And then I woke up and then there was Sydney and I'm like, "Oh." (laughter)

Sydney didn't exist in my dream and it was, like, this sort of nervousness (ph). I mean, like something is wrong. Something is wrong. And I was really relieved when I woke up and he was next to me. So, like, I think that was one of the ones that at least made is the most coherent sense (ph). Like, the one last night involved being (inaudible at 34:24) spaceship and randomly having my cat (inaudible at 34:32) on the ship and weird things happening. I don't even know why it was a nightmare but it just was not pleasant, so, yeah. Like, they weren't nightmares of things that were necessarily objectively scary just like...

THERAPIST: But you felt scared in your dream.

CLIENT: Yeah, I felt scared [and woke up] (ph) feeling comfortable.

THERAPIST: And like something was missing, it sounds like.

CLIENT: Yeah.

THERAPIST: Or something felt like it was missing in the dream and then that relief when you woke up and [you made sense of it] (ph).

CLIENT: I mean, that time it was a relief. Other times, like, there wasn't. you know, it might be a relief I'm not in that situation anymore, but not like something is missing, something is wrong. Like, that was the only one where I was like, you know, (inaudible at 35:12) relief. Other times I'm like, "Oh, wait. I need to go back to sleep. OK, I really hope I don't go back into this dream." So...

THERAPIST: That's interesting to imagine what the spaceship was.

CLIENT: Yeah, it just didn't make sense. It's like yeah, I can't make any sense of it. Maybe it was a nightmare because I didn't want be in space. I don't know. And all of a sudden having to take care of this cat on the spaceship that it was not meant for it and I guess they were going have to do something, like drop it off on a planet and I don't know. I don't know. It didn't make sense at the time.

THERAPIST: Dreams (ph) often don't make objective sense. (laughter)

CLIENT: Like, sometimes they do and this one didn't. So I just...

THERAPIST: it's striking to me that the same fear that you're feeling during the day during these anxiety attacks is also being felt and expressed at night in the form of dreams where you feel uncomfortable, even if it doesn't necessarily make sense. Kind of like having a panic attack out of the blue. There's nothing apparently scary about the spaceship but you felt fearful.

CLIENT: Because usually when I go to sleep, like, often I'll have good dreams and then I want to go back to sleep because I, like, actually like the dream and want to go back to it and believe [it has even happened] (ph). Because, like, it poisons my sleep. That's how much the anxiety was leaking over. And I'm sort of (inaudible at 36:47) like a little bit. Like, not actual panic but, like, this panic, like this feeling like this panic would be here if I hadn't taken that Klonopin this morning. It is trying to break through. So...

THERAPIST: Well it seems to me...

CLIENT: (inaudible at 37:02)

THERAPIST: ...that you've felt uncomfortable in your life for quite a while now and you've been in this place that you don't really want to be. Looking for a job, feeling dependent on your parents, not feeling secure financially. You've been uncomfortable in your life for a while, a long while, and that can really wear on you. And you're just kind of carrying around that burden of that anxiety, the uncertainty of when the situation will be different.

CLIENT: And so now I'm having a nervous breakdown and having this anxiety so I can focus on the anxiety instead of on the actual issue, because I'm not thinking about the actual issues?

THERAPIST: Well, that was a mouthful. (laughter) What do you think?

CLIENT: I'm just thinking because, like, when I have the thoughts and, like, you know, in a uncomfortable situation or something or, like, you know, when I broke up with Jonas or something and then (inaudible at 37:54). You know, I was or whatever was going wrong. I was, like, (inaudible at 37:58) that I have these thoughts that were being uncomfortable and wasn't thinking about any other, like, actual issues in my life. And I'm like, maybe the anxiety could be the same thing.

THERAPIST: So that the panic attacks give you something specific to focus on instead of these other things that you don't have as much control?

CLIENT: I guess. [It's not that] (ph) it wasn't, like, during the day before the panic attack I was like, "Oh, I need to get a job." Like, especially when I was coming off of being sick and I was just like, "I'm sick. I can't do anything productive anyways," you know.

THERAPIST: I guess I'm a believer that something doesn't need to be conscious for it to be affecting us. That sometimes you're consciously aware of these pressures and sometimes they're not as conscious, not as on your mind. But I don't think that when they're not on your mind that they don't have an effect on you necessarily.

CLIENT: Maybe. It was like I was starting to make forward progress and stuff.

THERAPIST: You are.

CLIENT: You know, and, like, Sydney, his insurance, like, offers a discount for seeing a personal trainer and there's one that's, like, right near my house and they, like, do small classes of two to four people. So we're, like, looking into seeing a personal trainer. (inaudible at 39:26)

THERAPIST: These are great forward steps. I don't think this negates that.

CLIENT: But, yeah.

THERAPIST: So those sound like really good active steps for you. And having had the panic attacks doesn't mean that those aren't great steps and that you don't continue to push forward with those.

CLIENT: All progress on the actual looking for job that doesn't involve calling the temp agency every other day has been halted.

THERAPIST: Well, it sounds like that can get restarted, now that you're no longer unable to keep food down.

CLIENT: Yeah. I don't know. I guess maybe the anxiety is, like, making me not focusing on the things that would otherwise make me anxious.

THERAPIST: Well, it could be kind of a focused expression of those kind of more free-floating on undifferentiated anxieties. All types of anxiety are linked, whether we call it anxiety or whether we call it a panic attack or whether we call it an obsessive-compulsive thought. These are all in the same family and, you know, sometimes they can kind of shift from primarily being expressed one way to being expressed in another way. And that may have been part of what was going on for you. You can still work, I think, combating it and working forward in what your goals are are the same thing. Your goals are still the same thing. Your goals are still to get more active so that you feel better about yourself and better about your body. To get more active in pursuing work so that you can have the independence that comes along with that and the structure that would come with a job. Your goals are the same and moving toward the goals is following the same steps.

CLIENT: Yeah. I just, like I don't know. I'm like now it's I guess (inaudible at 41:40) I'm like, oh, if Sydney and I are, like, together, like, you know, in a year or so, like, when his lease ends next September, you know, maybe we'll get a place together. Which I would only do if I had a job and therefore could justify spending more, you know, going to a place that has an increased rent cost, you know. And then we'd be able to get cats and chinchillas and, like, things like that.

THERAPIST: (inaudible at 42:05) things to think about.

CLIENT: You know, it's not like, "Oh, well I have until next August." No, I want to find a job now so I can start saving money for things like that. Like, if I want to have a future not just, like, living, you know.

THERAPIST: Yeah, and so you can earn that trip that you want to make.

CLIENT: Yeah, which I still haven't even set up the system for that yet.

THERAPIST: Let's pick one thing that you want to work on and have checked off by next session.

CLIENT: Write a cover letter and send it. And the application, if it has an application too.

THERAPIST: OK, so I will make sure to check in on that by next time. I did want to take a couple minutes to do some insurance related stuff. I don't think I have do you have a card with a number?

CLIENT: I have a card with a number.

THERAPIST: OK, I don't think I have a copy of that information. But I did get the referral that you sent.

CLIENT: I couldn't find it for a while and then I found it and sent it.

THERAPIST: Well, I did get that in the mail. And I assume a copy of that has been sent to oh [I don't have any more insurance forms] (ph). I can fix that. (inaudible at 43:26)

CLIENT: I haven't done the whole calling them again and being like, "Hey, I have a referral now." Like, I'm not sure if it automatically goes through the insurance. Like, they might not, do you think because I guess if the doctor sent a referral to an insurance every time, you know, especially if you don't have an appointment set up for the doctor you're going to see and then you never see that doctor then the insurance wouldn't pay attention to it. But, yeah, there's a card and everything and so many things are covered by my insurance that it would have been cheaper like, I took a five dollar cab ride to the ER. If I had taken an ambulance, it would have been free.

THERAPIST: Well, that seems strange.

CLIENT: They cover all there's no copay for ambulances. I mean, I wasn't going to do that because it would have been a waste but (laughter)... You said that there was a second bill that you still haven't given me that I have to get.

THERAPIST: Let me see if I got around to actually printing that out.

CLIENT: OK. I thought you could, like, e-mail the (inaudible at 44:53) amount.

THERAPIST: If I haven't printed it out I'll just give it to you next time. I'd rather not use e-mail for billing related things. It's just a risk to your privacy.

CLIENT: True, OK.

THERAPIST: Protecting your privacy is more important than me getting a check a week earlier. All right, so I think... the customer service number. Have that. Mental health is separate. No, they just wrote it twice. It's the same number.

CLIENT: It's really exciting to have a card, to be able to hand it to people.

THERAPIST: I do notice that the referral that your PCP sent...

CLIENT: Only three sessions?

THERAPIST: Only three sessions, yes.

CLIENT: That's a default. Because I noticed it when she gave it to me. And, like, she can't actually adjust the number in the system, so...

THERAPIST: I'm not sure we're still I guess a little unsure exactly what is going to be covered and how much, because I'm not in network.

CLIENT: But even three sessions, it would be three sessions less then to pay for.

THERAPIST: Right, absolutely. So we're going to pursue it. I will contact them and find out exactly what I do with the referral.

CLIENT: Yeah, because I have no clue what to do with it. All they told me was get a referral and I got a referral.

THERAPIST: Right, and you got a referral. I will see you next week.

CLIENT: Yeah.

END TRANSCRIPT