TRANSCRIPT OF AUDIO FILE:

BEGIN TRANSCRIPT:

THERAPIST: So you've been having a rough time.

CLIENT: Yeah, more panic attacks and stuff. It was really Sydney who wanted me to get the extra appointment, so I said sure because it was starting to get really rough on him because it wasn't like I wanted to hurt myself, it was me asking him like trying to convince him that it would be that he'd be better off if I were dead and stuff which I guess I like something that's really hard to listen to.

THERAPIST: Is that how you feel?

CLIENT: That's how I feel when I'm in that much panic and am trying to rationalize it because I'm just like there is no way to make it better other than to not experience anything anymore and like right now I'm not panicking, but -

THERAPIST: So what do you think now when you're not panicking what do you think about hurting yourself?

CLIENT: I don't want to hurt myself right now because I'm not panicking so I thinking normal but, yeah.

THERAPIST: So it must be pretty scary for him to listen to.

CLIENT: Yeah, I mean he knows that I'm actually not going to hurt myself, oh, what's the difference, like when he gets really crazy like he's done things like hitting his head on the floor or something. He drags himself from like trying to bash his head in on the wall, but still (unclear) I'm not like [00:01:50] -

THERAPIST: Are you sure that he knows that you're not going to do it? Are you sure you know that you're not going to do it?

CLIENT: Sure, I know that I'm not going to do it. I'm pretty sure he I mean I guess there was a point like on Tuesday night where I like went to the bathroom and was there for like a little while and Sydney was like wondering what happened to me because he because all of his shaving stuff is in the bathroom and so he thought that I might like try to hurt myself which really I was just taking a while in the bathroom and it hadn't even occurred to me that the shaving stuff was in the bathroom so like that was like the one time that he was really like (cross talk) worried. [00:02:38]

THERAPIST: He was concerned.

CLIENT: But I didn't do anything.

THERAPIST: So I guess I'm curious about him. What it does for you to talk about it because it sounds like you feel certain even when you're in those moments that although you want the panic to stop that you're not actually going to hurt yourself so I'm wondering, what does it do to talk about it? Does that make it better? Does that make it worse?

CLIENT: I don't think it makes it worse. I think it's sort of like I have this urge to talk about it so, like it's me being weak I guess and guess it's like lately I've been trying to be better about it and stuff, but -

THERAPIST: You've been weak?

CLIENT: Oh, the fact that I give in instead of just not saying anything at all. I mean not that Sydney wants me to like not tell him when I'm feeling this way but I guess I could do it in a more productive way.

THERAPIST: What would that be?

CLIENT: Not asking if I could kill myself but just be like, 'by the way I feel like I want to hurt myself right now.'

THERAPIST: What do you want him to do? What do you want his response to be?

CLIENT: I don't know. Because I feel like if he did give me permission to kill myself that would probably make him a very bad boyfriend.

THERAPIST: And it sounds like you don't actually want to.

CLIENT: At least not now, but when I feel like that like I mean I guess I would if he were to give me permission to like hurt myself like in a way that wasn't permanently damaging, if could figure that out like that would be something that would actually be productive because then I though I don't even know that hurting myself in a non-permanently destructive way would even like actually do anything to temporarily relieve the pain, it just, my brain thinks it will and but like he isn't even okay with that, so it's not like I'm going to change his mind on anything.

THERAPIST: Would it be okay with you? Do you think it's okay to hurt yourself?

CLIENT: Maybe if it wasn't permanently damaging or even like damaging at all, like just momentarily cause pain like I don't see the big problem with it. You know if it wasn't something that could become dangerous like I'm really liking the things that could do it, but like -

THERAPIST: So, there's the problem.

CLIENT: Yeah.

THERAPIST: Hurting yourself is hurtful.

CLIENT: Yeah. There are really like so many injuries that people get that they like immediately recover from. You know (chuckles) I feel like the concern with cutting yourself, not that I could do that with the whole (unclear) [00:05:47] and cutting thing is that like the concern becomes that you're going to cut yourself too much and too much blood comes out, that you're going to get an infection, that there will be scars on your body or that you'll like you know, cut the wrong way and like bleed out like.

THERAPIST: Those are all risks.

CLIENT: But if you do it correctly that way you could avoid all these risks and not actually permanently dam the scars which you can't really avoid.

THERAPIST: The other problem with you cutting or hurting yourself in any other way is that it doesn't stop the problem.

(Pause): [00:06:27 00:06:35]

THERAPIST: There isn't somebody who cuts once and never feels the panic again or the depression or the sadness again without working through whatever it is that's creating the panic. They're not effective treatments. It might, maybe somebody feels distraction or relief in the moment, but it doesn't do anything to prevent the next panic attack or to change the external situation that might be creating stress. It just adds another problem and one that's potentially difficult to manage the risks. I know you're having a lot of panic and it's really uncomfortable but I don't know how adding another issue on top of that is going to make you feel better.

CLIENT: Well, it's not like anything I'm currently doing is really effectively managing the panic.

THERAPIST: That's true. You seem to be having a lot of trouble finding something that will abate what's going on.

CLIENT: Like I've been on the reduced Wellbutrins and it's not (unclear). So this is like the sixth day of being on reduced Wellbutrin and like I can't really see much of an effect. Like it isn't making me worse so I guess that's a good thing, so it's like (unclear) I just wanted to reduce the Wellbutrin anyway, so [00:07:56]

THERAPIST: But it's not so it's not having a negative effect, but it's not having a positive effect either.

CLIENT: Like, it's sort of like I guess the panic often, it won't start until mid afternoon, perhaps earlier. But it still happens. It still happens almost every day.

THERAPIST: Almost every day?

CLIENT: If not every day.

THERAPIST: How many panic attacks are you having in a day?

CLIENT: I'm not sure because they're like at least a couple but then again maybe you could consider them like you know if I don't get a distraction then it's one panic attack, just a very long panic attack, you know, and then I guess like when I have rehearsal and stuff, okay so I have a panic right before rehearsal, go to rehearsal, feel fine for rehearsal, get out of rehearsal another panic attack.

THERAPIST: So whenever you're not occupied.

CLIENT: Yeah.

THERAPIST: Your mind or your body are panicking.

CLIENT: Yeah. Like last night yesterday I was like able to hold out for, until 4-ish or so and then even then I was still able to like, something like 'cause normally panic attacks like prevent you from going about your day to day life and mine don't. Like I can still do things. Like I still was like, okay well you know I need a lock and someone bought one for me so I am going to walk to the post office and drop off these packages.

THERAPIST: And you could do it.

CLIENT: And I could do it and -

THERAPIST: We're you panicking while you were doing that? Or did the panic sort of subside a bit while you were active?

CLIENT: I was panicking while I was doing it, you know, and still panicking when I was at the theater and like adding photos above the yarn things to put up on my store and panicking, you know -

(Pause): [00:10:14 00:10:20]

CLIENT: when I was sending e-mails and stuff and I guess I didn't do that much, I did some productive things. I guess I went grocery shopping but that was before the panic had started. And, oh, we went to the store and I was still panicking then and we drove home. Like we had to go to Sydney's house to get some packages that he had gotten and so we went to the store on the way there. Then, you know, and he was driving there to the store and then to his place but then on the way back he asked if I could drive because he's not really good with night driving and he was really, really tired and I was like 'okay, well, you're really, really tired and I'm just panicking.' And I drove home. And managed to drive home without hitting anyone or doing anything unsafe and parked the car, all while panicking.

THERAPIST: That's unusual.

CLIENT: Yeah.

THERAPIST: How did you manage to do that? How did you focus your thoughts enough to be able to make good decisions and drive safely?

CLIENT: I don't know. I guess I was sort of focusing on the road but like you know there was still that underlying uncomfortable feeling inside me that was anxiety and like it was very much still there and I was aware and like, 'okay, I'm driving this car while I'm panicking.' So I don't know how I did it, I just did things because I had to. I think that's usually the way that things happen to me so that if I can get anything productive done it's like because it has to be done.

THERAPIST: It seems like that ability you have to be able to somehow focus your thoughts on what you need to focus on can be used, because once you the more, usually the more you get engaged with something the panic subsides enough so that you're not so that it doesn't feel like a panic attack, right? When you said like your having a panic attack before rehearsal, you didn't during rehearsal. You were engaged and not focused enough in what you were doing that the anxiety was reduced enough so that it wasn't bothering you.

CLIENT: Well, that I didn't feel at all. I think the thing is like it can only, it has to be something that takes up my entire like consciousness and stuff. Driving I can still think about other things. Walking to the post office I think about other things and so there I can just do these things while panicking whereas rehearsal like once I get into it is like, you know, takes up all my -

THERAPIST: You get absorbed in it.

CLIENT: Yeah, so -

THERAPIST: It seems like you we need to find ways for you to be more absorbed more often during the day.

CLIENT: Yeah.

THERAPIST: I wonder if part of what's happening is that there's not enough of your day right now is taken up by things that feel productive, that feel engaging. I don't think you're satisfied. And that space, that empty space you have is being filled by panic.

CLIENT: Yeah. But it's like, I don't know. Like sometimes I have more control than others, but like, you know like I don't control whether or not I have rehearsal. That's like based on the semester and stuff and whether or not we have a concert coming up so you know I had a tech week last week but this week I only had rehearsal on Tuesday night because -

THERAPIST: Are there other things you can do? Can you volunteer more? Can you schedule outings with friends so that you're not staying home?

CLIENT: Maybe. I don't know whether or not there would be enough (unclear) to (unclear) because they're not like something doing productively. Today like after this I have an interview for the, like I'm actually finally interviewing at the temp agency, so -

THERAPIST: I noticed you were wearing dressier clothes than usual.

CLIENT: (Laughs) Yes. That was on purpose. So, like maybe they'll be able to start me with something as soon as Monday. If they could that would probably solve the problem at least while I'm at work and then I guess I'll have to deal with the panic in the evenings, but -

THERAPIST: If you even panicked.

CLIENT: But of course it also assumes that work is something that doesn't take, you know, would take enough of my brain, because I was just thinking like if I'm at work like especially now that I like finished the actual project I needed to finish, like if I'm just coming in to like do whatever, like I don't know, like Tara is very talkative so if I end up wasting time and talking to like Tara and stuff then like be occupied enough, so, yeah, it depends on it really depends on what I do because lots of things still take up all my brain. Like last night when I was panicking Sydney was like, 'why don't you try knitting?' I was like, 'okay, I guess,' and I like tried knitting and it did absolutely nothing which is what I figured it would because it wasn't really taking up enough of my brain. So, like I don't know if getting together 'cause like hanging out with Sydney is not enough to make it go away most of the time. Even if we're like watching a TV show or something, the panic's still there. I guess there has to be something where I'm like actually required like because of rehearsal I'm required to do things, you know, I have to sing. I can't just stand there, so -

THERAPIST: Are there thoughts that trigger the panic? I know once it starts you say you just kind of think, 'I'm panicking, I'm panicking.' But I wonder if you notice what happens just before you notice the panic.

CLIENT: I don't think so, like I really don't think there's anything that triggers like it just happens and then I just feel the physical feeling and then I'm just like, 'oh, no, not again.' Like, the feeling doesn't come, there's nothing that comes before the physical feeling as far as I can tell. Like I've never been (unclear) [00:16:38] so I'm pretty sure it's just happening and not being triggered by anything.

THERAPIST: And it feels really out of your control. I can hear that, 'oh, no, not again,' and it feels like there's nothing that you can do to direct it or moderate it at all.

CLIENT: It didn't last night, like you know I started, like whenever we got home at like you know, maybe like before midnight like I took my nighttime meds which included the Klonopin, like when I got home and then I was still up for like another hour or so panicking and the Klonopin did nothing immediately so you know which leads me to believe that if I had, you know, earlier I'd taken a quarter Klonopin the same thing would have happened where it wouldn't have done anything immediately, so -

THERAPIST: So you don't feel like the Klonopin helped at all?

CLIENT: I don't know, like I guess it doesn't. It used to help, but now like if it does it does in such a subtle way that like it doesn't immediately help as (unclear) I can see working right away. [00:17:40]

THERAPIST: Usually people feel an effect in about 20 minutes.

CLIENT: Okay. Yeah that didn't happen last night.

THERAPIST: And usually a panic attack is over with in 20 minutes. Typically.

CLIENT: Yes. Which also didn't happen last night. Or any night. So -

(Pause): [00:17:58 00:18:11]

THERAPIST: It's been a really rough couple of weeks.

CLIENT: Yeah.

THERAPIST: What's been going on with Sydney? How's he been doing the past few weeks?

CLIENT: He's been doing better other than, we've gotten into a couple of fights the last couple of days like when I've been all panicky and like taking it out on him and I feel bad about doing that and -

THERAPIST: So you've kind of flip-flopped a little bit. He's been doing a little bit better and he's been doing a little bit worse.

CLIENT: Yeah. I mean sometimes he still has problems like doing things like getting out of the house but in general, like he's been doing a lot better than he had been.

THERAPIST: Do you think there's any connection?

CLIENT: Because he's doing better and I'm doing worse? I don't think so.

THERAPIST: You know, you're often the strong one for him so I wonder if now that he's doing better you know, you're often the strong one for him so I wonder if now that he's doing better you don't have to be as strong. He relies on you a lot when he's not feeling well.

CLIENT: I guess it could be that, but the panic would have been there all along and I had just been holding it back like, you know, when you get if you're in school and you get sick right after finals because your body is like had been fighting it off like for half a semester and then all of a sudden it's like (unclear) where you've got to get sick, so -

THERAPIST: Let your guard down a bit and it takes over.

CLIENT: Yeah. So maybe, I mean that's entirely possible but I didn't make the connection or -

THERAPIST: I don't know if there's a connection but I guess you guys you spend a lot of time together. You guys are very closely connected and I wonder if it almost works as a system rather than complete independence of one another.

(Pause): [00:20:06 00:20:11]

CLIENT: Possibly.

THERAPIST: I wonder if you can find a way where you could both do really well.

CLIENT: Yeah. It's really hard on the we're hoping that fixing the other (unclear) issues you know [00:20:24] but at temp I'm making like however much, you know. They let you put a (unclear) like however much you would want and so I put my minimum at like 13 hours so if I was working 40 a week like that would be enough to support myself.

THERAPIST: Yeah, well I think that would be a big would certainly relieve one external stressor.

CLIENT: Because I wouldn't be dependent on my parents and I could buy all the things I could finally, properly yell at them for not giving their employees health insurance because they would no longer be like, 'oh, well, you're profiting from this,' and I'd be like, 'not any more.' And I wouldn't have to deal with them.

THERAPIST: That would feel nice to be able to say some of the things you've been holding back.

CLIENT: Yeah. So, that and just not feeling guilty every time I have to spend money on anything like, 'is it a necessity?'

THERAPIST: Carrying around that guilt probably does weigh on you.

CLIENT: And then also the whole getting out of the house and having something to do.

THERAPIST: So there's a lot that would change if this works out. Was there anything you could write a cover letter for this week?

CLIENT: I mean there was the thing last week. I haven't really tried this week because I've been, well there was the whole going back and forth with the temp agency and then the whole panic thing, so.

THERAPIST: So that got in the way even of being able to -

CLIENT: Write a cover letter. Yeah, I mean I used to have like you know, I get out of here and my thing is at 12:30 and it'll take like maybe 20 minutes to get down to the downtown crossing so I could theoretically like look and see if there was one thing to write a cover letter for but (unclear) the deadline would have been for (cross talk) [00:22:17]

THERAPIST: This is true. But, since I have you here today I thought I'd ask.

CLIENT: So I have not actually been looking for things, yeah, but I could in theory write one cover letter, maybe, if there's something there's probably something.

THERAPIST: Yeah, I think that the job postings will probably slow down later this month when the world shuts down for Christmas. Or at least this part of the world. So, using that while you can, you know, when people might still be putting their postings up earlier in the month, try to take advantage of that.

CLIENT: Yeah.

(Pause): [00:22:54 00:23:06]

THERAPIST: Trying to focus your mind on things that you can do rather than letting it be filled by whatever pops up which right now when it's empty, the thing that pops up is not feeling good.

CLIENT: Question. Should I be like looking into cognitive behavioral therapy group thing?

THERAPIST: We do lots of cognitive (unclear) [00:23:29]

CLIENT: Okay. So would that like be -

THERAPIST: So the behavioral piece of cognitive behavioral is some of the actions that I encourage you to take, things like scheduling in walks, creating a structure in your day and some of the breathing exercises and relaxation exercises we've tried. I know we did some last time. I'd like to try some again today. Those are some of the behaviors that often work to manage anxiety symptoms. And the cognitive piece when the people say cognitive behavioral therapy are things like when I ask you to try to come up with an alternative way to think about something, to challenge some of the beliefs and the assumptions that you make -

CLIENT: Okay, so basically all the stuff I end of fighting against. Okay.

THERAPIST: Yeah. And so cognitive behavioral therapy is what most people recommend for anxiety because it works for lots of people to manage the symptoms and you struggle against it but I keep sneaking it in there (chuckles) and I hope that at some point it will take hold for you and that you'll be able to get use out of it. But they're hard for you.

CLIENT: Yeah.

THERAPIST: What do you think it is that makes those concepts really hard for you to sort of grasp?

CLIENT: Because I feel that I'm smarter than them and -

THERAPIST: Take (unclear) [00:25:01]

CLIENT: Right and that these thoughts are like ones that we're trying to put in my head to be more useful but they're not necessarily true and therefore I'm trying to believe something that isn't true or isn't the whole truth and I can't make myself do that.

THERAPIST: Would you rather be right or comfortable if you had to pick one?

CLIENT: I would probably pick comfortable but like -

THERAPIST: But you don't.

CLIENT: But I don't have the ability to because I'm too focused on being right and I don't have the ability to I don't know if I want to be comfortable though at the expense of believing something that isn't true, if I, I don't have that sort of will power to believe something that isn't true. I'm too skeptical.

THERAPIST: But you're not skeptical of your own beliefs.

CLIENT: Well, sometimes I am, but it depends on the situation.

THERAPIST: Because for some people what's useful is not necessarily believing another thing, but believing that there are other possibilities. That's true skepticism that there isn't necessarily one right but that there are lots of ways to look at something or lots of possibilities and we're uncertain, that there's some level of uncertainty in any of the beliefs and sometimes that you're not necessarily choosing a different belief, but your just choosing to believe that there may be some wiggle room or some error in any one belief gives people freedom to just feel more comfortable. And if you want to choose comfort, sometimes that helps.

CLIENT: Yeah, maybe I'm too stubborn to choose comfort and like stubborn (cross talk)

THERAPIST: Like part of you wants to be comfortable but right now it's more important to be right.

CLIENT: Yeah. Just because I'm so stubborn you know, strongly believing that I'm right with things like therefore I have trouble believing that there might be other options when I know that I'm right. Maybe I'm wrong but I feel like I'm right. It could also be like the depression lying to me, but -

THERAPIST: What do you mean by that?

CLIENT: Well, I don't know. Just like in general, depression lies to the self so I mean it's like I know there are times when I know I'm not right, I mean like when I'm feeling like, 'oh, I would be better off if I were dead,' so I mean there's the rational part of my back in the back of my mind that's like, 'no that's not true.' That's just the depression lying to you.

THERAPIST: Does anxiety lie in the same way?

CLIENT: I guess. Sort of.

THERAPIST: How might it?

CLIENT: I'll just say, 'yes,' thinking making me think that this panic is so bad that I could die over it or telling me that if I hurt myself it will make me feel better, which probably also wasn't true.

THERAPIST: Yeah, I think I would agree with you there that those do feel like anxiety lies.

CLIENT: Yeah.

THERAPIST: So, what is your truth? So if those are anxiety lies and depression lies we'll call them, what is the truth on the other side of that?

CLIENT: That, well theoretically, this anxiety isn't actually worth killing myself over and that it will go away eventually. It just doesn't feel like it will go away eventually because here I am, you know, doing my best to be productive and trying to do all the responsible things and not getting anywhere with it like it's just so frustrating.

(Pause): [00:29:06 00:29:16]

THERAPIST: And so when you ask about cognitive behavioral therapy the next step there so one step would be is what you just did for me this is the anxiety lie and here's another way to think about it. Maybe the anxiety feels really horrible right now but it wouldn't be better to die. That's an alternative belief and you just came up with it. The next piece is to look at what you said next was doing all these things and it's not working and I'm really frustrated. Making that so that's a very kind of absolute it's not working, making that a little less absolute, doing all the responsible things that I'm supposed to be doing and they're not working and just adding right now. It doesn't make it untrue. Right? It's not working right now that's very true, but what it does do is it makes you feel a little bit like, a little bit less like it will never, ever, ever, ever work. When you say it's not working that could go on you could assume in there it's not working, it's never going to work. It's not working forever. And if you just add staying in the present it's not working right now that actually takes a little bit of the intensity off because it makes it a little bit less overwhelming to think that you're going to be stuck in this particular situation forever is unbearable. To think that you're going to be stuck I a horrible situation for a limited time is still totally uncool but it's less than bearable. We can usually bear tragedy, horror, intense discomfort for a limited time. You actually, you are doing some of the steps of the cognitive work that helps and just pushing yourself to take that next step, making it present centered rather than letting your thoughts be about the future and beyond. That's part of what makes it so overwhelming is when you think it's going to be forever.

(Pause): [00:31:22 [00:31:34]

CLIENT: But it still feels like it's you know because like I feel like I shouldn't be kept on something by now, like shouldn't a medication change (unclear) which I guess it has if there's stuff like okay now I'm not panicking every morning, I'm just you know it pushes it off until the afternoon and maybe I should call (unclear) again and ask her about levels, what if I took half in the morning and half in the afternoon and split it up more? [00:31:43]

THERAPIST: Yeah, so it's not working perfectly, you know, probably close to perfectly, but it does seem but something has changed and so letting yourself see those little pieces rather than it being all or nothing, rather than it's not working at all. Well? It does seem to be delaying the panic, making yourself recognize different shades of gray.

(Pause): [00:32:28 00:32:37]

CLIENT: I guess just like my whole understanding of the situation is (unclear) you know like how [am I going to work then?] (ph) because like you know when I take the medicine at night that I'm supposed to take at night that's supposed to help with the panic you know, and then an hour later I'm still panicking. Maybe it's not I would have been panicking even more and maybe I'm panicking less but I'm just panicking so much that I can't tell the difference.

THERAPIST: Sometimes -

CLIENT: You know like if my panic level was at 200 and now is at like 250 and so -

THERAPIST: Right. Maybe you don't notice the difference. Absolutely.

CLIENT: Yeah.

THERAPIST: And what we need to do is keep working until it's different enough.

CLIENT: Yeah.

THERAPIST: That it's more recognizable.

CLIENT: Yeah. But, yeah. I guess the other question is also like, 'did I ever do the whole like signing the waiver for you to talk to Dr. [Barnes] (ph) [00:33:23] about the medicines.

THERAPIST: Um hmm?

CLIENT: Okay. I thought I did. I was just double -

THERAPIST: I believe that's in your file.

CLIENT: checking. Okay.

(Pause): [00:33:32 00:33:36]

CLIENT: I assume I signed it on her end too.

THERAPIST: The one you signed here is a two-way release so she may want you to have one for her records, but you're technically covered.

CLIENT: Okay.

THERAPIST: And, you know I'm happy that I talked more with her but you'd I think you do an excellent job staying on communication with both of us. A lot of times people are unsure about what they're supposed to take or how much, but you're very careful about that. It's good to have the release so we can communicate if needed, but with you doing good follow up with her it's not as necessary for me to hear her say the exact same thing.

CLIENT: Okay, that makes sense. I guess I should call her this afternoon.

THERAPIST: Yeah, give her an update of what's happening. You've followed the steps that she's outlined thus far and let her know how it's affecting you, that it seems to be pushing them off a little bit, delaying them maybe, but that you're still really suffering.

CLIENT: It's like I don't have an appointment with her until the 19th which is like another almost two weeks.

THERAPIST: Oh, no?

CLIENT: So, I therefore like, that's still another two weeks of -

THERAPIST: Yeah, what's the plan from now 'til then? Is it that your time will help more on a lower dose of Wellbutrin?

CLIENT: Not really. Like it was just step one, step two and then wait 'til then -

THERAPIST: Well, then that's why you're checking with her to see what -

CLIENT: Yeah, it was just a week you know, okay so I did the, you know, switching to a lower Wellbutrin like a day or two early, but now it's been almost two weeks since the appointment with the week of the Klonopin, the week of the lower Wellbutrin. It's not like lowering the Wellbbutrin stops the taking more Klonopin. It's one at a time so, yeah, I guess I could call her and ask about the intermediate stuff of spreading out the Klonopin more and whether or not it would work because like, I think it's like you know low enough that it doesn't like cause me to be too tired during the day. I have been, I mean I've gotten tired lately but not in the morning when I take the Klonopin. I think it's more just like all the panic is making me tired.

THERAPIST: Panic is exhausting. Your body goes through a lot to get to that intense feeling.

CLIENT: Like last night. The other thing was when I took a Klonopin at like midnight, whatever, and I ended up going to bed at like 12:30 or something, and then I was able to fall asleep just fine and then I woke up at 2:30 and was like completely and totally awake and panicking.

THERAPIST: It's really disruptive when you think of panicking.

CLIENT: And I was able to get back to sleep again after that. And that's how I slept through the rest of the night, (unclear) kept on waking up in the middle of the night is really frustrating. [00:36:39]

THERAPIST: How long does it take you to get back to sleep?

CLIENT: I don't think it took me too long. You know I got up to like go to the bathroom and was talking to Sydney a little bit because he had also woken up but I don't think he woke me up and then I had him go downstairs and get me a challah roll because also I had been feeling like a little bit of stomach acid trying to reduce all that and so he went downstairs and got me a challah roll that we split it and so I ate my half and then I was able to go to sleep. But there's no way to prevent myself from waking up in the middle of the night really.

THERAPIST: You don't have a lot of control when you're sleeping and it's very disruptive to be woken with that anxiety.

CLIENT: Maybe I guess I could ask if I could take some sort of, like Sydney takes Ambien but I there was one time I took one of his Ambiens and that was like the night I was trying to go to sleep when I was like super duper sick and throwing up and stuff and I ended up throwing up the Ambien but like -

THERAPIST: And you don't generally have trouble falling asleep.

CLIENT: No, but I'm having trouble staying asleep, so I don't know if sometimes in general I don't but with the panic it also has made it harder to fall asleep too.

THERAPIST: Well let's see if we can't find other ways to kind of lower the general anxiety baseline. Your baseline of anxiety right now is really high. Your panic attacks are lasting longer than typical panic attacks so it's really high generalized anxiety and I think if we can lower that your sleep will return to what your typical sleep is like.

CLIENT: Will sleeping more help in general with things?

THERAPIST: It's a cycle. Absolutely. Being sleep deprived makes you more prone to anxiety, but you do have the ability if you wake up at night to sleep longer during the day to kind of catch up from that. And rather than adding another medication to the mix we're already making a lot of med changes.

CLIENT: Yeah, though that's one I'd like I could take as needed. It wouldn't be like take it every night.

THERAPIST: Well, you can certainly ask your psychiatrist about it and see what her thoughts are.

CLIENT: Okay.

THERAPIST: She would know best how it fits into the overall plan. Let's take a few minutes to practice that deep breathing and muscle relaxation again and see if we can't get that working for you. And then regular appointment on Monday?

CLIENT: (Unclear) [00:39:14]

THERAPIST: Okay. So close your eyes so you can tune in to what your body's feeling and let yourself just follow a natural rhythm with your breathing, scanning your body mentally and just taking notice of what your body feels like, noticing any places that feel tight and tense, anything that feels uncomfortable. Let yourself shift however you need to to relax those spaces.

(Pause): [00:39:47 00:39:57]

THERAPIST: And then as you let yourself get more comfortable let yourself extend your breath so that you're taking slightly longer, fuller inhales and exhales.

(Pause): [00:40:07 00:40:24]

THERAPIST: Today I want to try something called timed breathing. You're going to work to your own time. What you're going to do is as you inhale do a regular inhale and just count to four as you do it. And then after you've taken a full inhale to four you're going to hold your breath for four and then you're going to exhale for four. So work at your own pace to get into that rhythm.

(Pause): [00:40:50 00:40:56]

THERAPIST: Inhaling for four then holding for four. And then exhaling for four.

(Pause): [00:41:01 00:41:05]

THERAPIST: Repeat that cycle a few times.

(Pause): [00:41:06 00:41:11]

THERAPIST: Inhaling for four, holding for four, exhaling for four.

(Pause): [00:41:17 00:41:28]

THERAPIST: As you're comfortable doing that you can scan your body again noticing any places where it might feel different than it felt before. No need to judge the feelings. No need to judge if it's the same or different. Just noticing it.

(Pause): [00:41:48 00:42:01]

THERAPIST: And now just let yourself return to normal breath, inhales and exhales at whatever pace feels natural to you.

(Pause): [00:42:08 00:42:20]

THERAPIST: And then let yourself return to the room, let go of your focus. That was different than what we've done before. What was that like for you?

CLIENT: Holding my breath for four was a little bit dizzying though, it shouldn't have been.

THERAPIST: Don't judge it. It is what it is.

CLIENT: Yeah, but like I sing. I've had to do holding, you know, using my air for a lot longer than that. It's from sitting down and stuff that -

THERAPIST: Well, so it's probably not right its probably because you've done, with singing you do breath work whether you're focusing on breath work or not. Right?

CLIENT: Yeah.

THERAPIST: It just happens to be singing. So it's probably the, the dizzy feeling is probably not about the air. But you felt it, so it means something.

CLIENT: I guess.

THERAPIST: So maybe it's just uncomfortable for you. So it's not dangerous. You know you can breath for a count of four. You've held a note longer than that so it's not about whether you really have enough air but something about focusing on it felt different, felt dizzy. That doesn't have to be a bad feeling.

CLIENT: Okay. Yeah I like to breathe in and out before I get that extra four for holding it because, yeah, I guess I'm used to breathing (unclear) you know, not just holding but like letting out over a long period of time.

THERAPIST: A long period of time.

CLIENT: But like there's no -

THERAPIST: Something about stopping and holding that felt different.

CLIENT: Yeah.

THERAPIST: And part of doing an exercise like that is that you want to feel something different so when you're in the middle of a panic attack where you may be breathing in lots and lots and lots of oxygen, doing something different can be enough to shift it so it's not necessarily that you're looking to feel something particular, when you're panicking you just want to feel something different, so you might so now I've introduced you to two different types of relaxation exercises. The last time we did a little bit of deep breathing and then a very muscle focused one and today just chose something different because I want to give you options and you know try it out. You can try it when you're not panicking, but when you are panicking and know that you're safe. You know if you're sitting in a chair and start to feel a little bit dizzy, it's a different feeling but it's not a dangerous feeling to you. And sometimes people feel dizzy because they're paying so much attention to their breath in a way that they're not used to paying attention to it, and that's why I only had you do it for a few minutes. You don't want to do it for an hour because then it would feel overwhelming. So do a few breaths like I think I had you count four or five cycles maybe and then let yourself return to normal and it might be just enough to move you out of where you are to a different place. Okay? So I will see you on Monday.

CLIENT: (inaudible)

THERAPIST: Yeah, regular time.

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