TRANSCRIPT OF AUDIO FILE:

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THERAPIST: Okay.

CLIENT: So otherwise it means going to (unclear) to get it.

THERAPIST: So it's pastrami sandwiches for a while for lunch.

CLIENT: For a while at least until we run out of pastrami.

THERAPIST: What else do you eat if you can remember your last workday? And I know I didn't get a workday on this.

CLIENT: The workdays I only went to work on Wednesdays because Tuesday I was still exhausted from the flight on Thursday and Friday. It was snowing so on Tuesday I made two pastrami sandwiches and between the two I had a package of pastrami and a package is about a quarter of a pound.

THERAPIST: And then four pieces of bread because you had two sandwiches.

CLIENT: Yeah, four pieces of bread because I made two sandwiches.

THERAPIST: Anything else on the sandwich or did you just –

CLIENT: A little bit of mustard and honey.

THERAPIST: The mustard is free?

CLIENT: Okay.

THERAPIST: Okay for work tomorrow, working?

CLIENT: Yeah.

THERAPIST: Let's plan out a slight change to that that would be a little bit less calorically but still keep you full.

CLIENT: Okay. I'm still planning on bringing the pizza and I can probably just eat two out of three because I got the older one – the older one I only did have two slices left so then I'll have two like medium slices. Yeah, a slice is a 12" diameter so a sixth of a 12" diameter pizza, so two of those.

THERAPIST: Now that probably won't keep you full the whole daylong. Like two pieces of pizza might be enough at lunchtime but you're going to be hungry either you know sometime during the rest of that day. So what else can you bring with you to keep you from feeling really hungry that's not going to add too many more calories? CLIENT: I guess if I can do the whole going to the grocery store beforehand thing I can like tonight, sort of after dinner anyways, I think, I can get a new thing a lot of nights yeah –

THERAPIST: Then bring a few.

CLIENT: Yeah. I still have to figure out what I'll do for breakfast though. I guess I can buy Crispix for my place because those ones are at Sydney's place. We're staying at my place tonight.

THERAPIST: Okay. Yeah, that's it. And what about like a fruit at breakfast as well to give you or to have like in the car because I know you're driving and you were getting hungry on the long ride.

CLIENT: I guess if I peeled the Clementines ahead of time and put them in a zip lock bag that would probably be, but then I think I can safely eat them while I'm driving?

THERAPIST: Would you feel comfortable eating a banana? It's less work.

CLIENT: Yeah. I like Clementines better but I could eat a banana.

THERAPIST: Or grapes are pretty much low maintenance.

CLIENT: Yeah. I really like grapes so I guess I can eat grapes.

THERAPIST: So those are – I'm just kind of trying to brainstorm with you things that are low maintenance so that you won't have to spend a lot of time chopping or peeling or whatever that are pretty easy to kind of pick up and pop in your mouth and are not distracting. I don't want you eating a bowl of cereal in the car.

CLIENT: Yeah that would be really dangerous.

THERAPIST: What do you drink during the day at work?

CLIENT: Sometimes I have a power-ade and like I only have one power-ade with me but it's like 32 oz. and I'll drink it during the day. Otherwise it's water. What I really need to do is start drinking more water. The thing is, you know, a library or like a special library you can't have it next to you. But there is like an area in front of the stairwell, there's a water fountain so –

THERAPIST: Making sure you drink lots of water throughout the day.

CLIENT: Yeah like I'll take a glass like because they have little kitchen area so I fill up on those glasses of water and have that. It's just not being able to drink water while I'm working. But I can ask if they allow closed bottles because I don't actually know if they do and they might. So I'll ask them. If not –

THERAPIST: But regardless you need to drink at some point during the day whether it's leaving the area to go drink and water or like seltzers or something like that is really going to be your safest bet because there's actually a lot of sugar in power-ade, Gatorade, vitamin waters, things like that. So it's not really filling you up that much but it is really adding, especially a big bottle like 32 oz. or 20 oz., that's like four or five servings. So you're getting probably at least 300 calories.

CLIENT: Yeah, it says on the bottle two servings – each serving is 180 calories.

THERAPIST: So that's 360 calories.

CLIENT: Or was it 180 calories total for the bottle. I don't remember. The number 180 – or maybe it was 100 calories and I was like almost two servings – 180 calories total.

THERAPIST: Either way if you're getting 180 calories of sugar that's not filling you up that much, you would feel more full by eating 200 calories of something else. Because 200 calories could be like four pretzel sticks which would be a much more filling snack and would carry you longer then something like the Gatorade. CLIENT: Okay.

THERAPIST: And the other place in just the days you gave me where I saw maybe a potential to cut a lot of calories and not feel necessarily deprived is switching from whole milk to 2 percent or 1 percent.

CLIENT: Okay.

THERAPIST: I don't know if that's possible the way you share food.

CLIENT: Yeah. Like at my place that's possible because we have skim milk and 2 percent milk and also whole milk but yeah, that (inaudible) drinking milk so sometimes if we have all the different milks around, sometimes the milk will go bad or whatever, getting to choose what's available so I you know so I can't get that so if at home I can drink skim milk but Sydney likes whole milk so – I mean I can ask him if we could switch to 2 percent and if – he probably would be okay with that but I don't think we could switch to skim milk.

THERAPIST: Yeah, that might be too much of a departure for him. So yeah, if you could do that, if you can choose, if it's available at your house or if he would be willing to go down to 2 percent that's a way to save, make a big difference but not eliminate any food from your diet that you're eating.

CLIENT: Yeah, because like he also wants to lose weight so he probably would be okay with that and we have to finish up the whole milk today but after that we probably can.

THERAPIST: So yeah, what we discussed are a few changes to think about making for this week, see how you feel with them and we can do the same thing again next week. Kind of look at where some little things we can do to try to keep you full but get the calories down a little bit so you can see some of the changes you want. How do you feel about what we talked about today?

CLIENT: Well, it feels like it should be pretty manageable. I like the idea of actually being able to snack. I figured that there was probably you know, if I'm just having two or three big meals a day and not like in my like brain I can do without that (unclear). [00:07:53] I don't know if they're still good but as of last week they were. Like Aimee bought a bunch of like green bell peppers for me to sort of snack on specifically.

THERAPIST: Oh, that's nice.

CLIENT: Yeah.

THERAPIST: The other thing, since you like peppers – they have those, I've seen them in the grocery store, bags of little –

CLIENT: Oh the like red, yellow, oranges ones.

THERAPIST: That you can just kind of take a bite out of and have that. I wonder if that would entice you.

CLIENT: Yeah, I could bring those with me and that would be a lot easier probably. I love those things.

THERAPIST: Those are great. My kids will eat those. And they think it's fun because they can hold on to them, dip them in hummus and take a bite – fun food. It's also enticing for grown-ups and delicious and no work. I think the idea of not creating extra work would allow you to get more creative and variety would be powerful.

CLIENT: This is something I have to figure out like what will fill me up for breakfast that isn't doughnuts?

THERAPIST: Also, one day here you have the Crispix. What else – what other – and you did the crepes.

CLIENT: I had Crispix, I actually on the Wednesday I went to work so that morning I had a bowl of Crispix and then I got hungry on the way there. I had to pull over to the rest stop anyways because I wanted to sleep and I still had an hour, I still was really, really tired so I ended up having to get coffee so with the coffee I got a doughnut too.

THERAPIST: What do you put in your coffee?

CLIENT: I get it with extra cream and extra sugar. I mean I could put in Equal or something but –

THERAPIST: I'd rather didn't see you switch from sugar to Equal. I'd rather see you switch from cream to milk and not extra cream but regular cream. Those are little changes that –

CLIENT: Does Dunkin Donuts have skim milk when you ask for milk?

THERAPIST: Okay. CLIENT: I wasn't sure, so.

THERAPIST: That will even give you a choice of skim or regular. Or just take away the extra. Little changes at a time.

CLIENT: It tastes good. I rather switch it to milk then have to take away the extra.

THERAPIST: So pick one something to change and that way it won't feel like it's that big of a difference. Your palate will adjust.

CLIENT: Okay.

THERAPIST: So if you make one change and get used to that then we can figure out whether or not you need to make another one.

CLIENT: But it's only a small coffee, so. But yeah, like I don't usually need caffeine to wake up but like since it's so early in the morning even if I'm going to bed at 10 like – THERAPIST: It's just really different for you.

CLIENT: Yeah. So I mean at least it's not like caramel cappuccino or something –

THERAPIST: That's true.

CLIENT: And I don't know if eating a doughnut like later in the day –

THERAPIST: It's hard when you're around a place like that it's hard. None of the choices that you're going to make there are going to give you a lot of bang for the buck kind of choices but thinking about what could you bring, trying to plan ahead so that you don't find yourself really hungry without a lot of options or you know, trying to plan ahead. And you're going to have days where you can't plan perfectly and that's okay but I think the idea of having (unclear) with you, having a banana or something like that so that you don't find yourself at Dunkin Donuts with not a lot of good options for you.

CLIENT: I'll probably still need to get that coffee.

THERAPIST: That's okay. And you're making the one change of going from the cream to the milk there will be a step for you.

CLIENT: I just don't like the fact that I have to rely on coffee.

THERAPIST: Do you like, I know we were trying to think of breakfast options that would be filling. Do you at eggs?

CLIENT: I do.

THERAPIST:

Would you eat a hard-boiled egg that you can make the night before?

CLIENT: Yeah.

THERAPIST: That way it doesn't take up time in the morning.

CLIENT: I could do that. I mean would I add that to cereal so it would be enough?

THERAPIST: Egg whites are – I mean you can eat the whole egg. Egg whites particularly have protein and are pretty low in calories. It's like I think – I have my book over there and just try to refamiliarize myself with this – but I think it's 60 or 80 or so calories for an egg white which is not very many calories at all but because it's protein you're going to find that it fills you up longer. Proteins have more staying power than carbs and so your bagel, your pasta, your cereals – those are all carbs so they don't stay with you that long which is why you feel you need to eat a lot of them and we could add in some protein choices so you're going to feel fuller longer. CLIENT: Yeah. I could do that. So I could hard boil (cross talk) (unclear). [00:13:00]

THERAPIST: They stay good in the fridge for a long time so if you do that, like if you can send time one night hard boiling, just taking 12 minutes to boil the water and hard boil some eggs and keep a stash of them, that's something that's easy to pick up in the morning and eat quick and feel satisfied.

CLIENT: Yeah, I could definitely do that.

THERAPIST: I feel like I could give you a lot of things but I don't want to overwhelm you.

CLIENT: Okay.

THERAPIST: And then I know we also talked about actually working with a nutritionist because while I can give you some direction I'm not a nutritionist, just a psychologist with a history of working with eating disorders that's where my eating and food and nutrition knowledge comes from.

CLIENT: Yeah, so I have, I sort of can leave you with one medical thing at a time. I'm dealing now with seeing hand doctors in my insurance because my wrist brace broke and I can't just like go in and have them make a new one. I have to like the specialist look at my hand and stuff and put in the order even though I have a brace and like (unclear) that it broke in the same place that the other one broke too. So –

THERAPIST: When did that happen? I didn't know that was going on with you.

CLIENT: That happened the Saturday night, like not this past Saturday night, but the Saturday night before while I was in Kentucky so.

THERAPIST: Has your hand been hurting?

CLIENT: Like I could still wear it with it broken. It's just annoying because, okay so the brace goes like – you know how there's the part where you stick your thumb through the top of (unclear) that's the part that's broken. So for the most part it's still working for me and I'm like so –

THERAPIST: And you're using it at work?

CLIENT: I'm using it at work sometimes. I'm using it every night when I go to sleep and I might go back to wearing it while I drive because sometimes my hand has been hurting from driving. So I really need a new one, so right now I'm going to deal with making that appointment. At least –

THERAPIST: I can understand when you have a lot of things to deal with at a time –

CLIENT: And the specialist like she works at the same place that they make the wrist braces so I at least can get that all done (unclear).

THERAPIST: Great.

CLIENT: Yeah.

THERAPIST: I'm going to make a start with what I can help with while you deal with that and then if you do need to contemplate the nutritionist then we'll add that on later.

CLIENT: Yeah. I'm wondering if I can like call my insurance and get one rather than having going through PCP and get a referral on stuff because I don't – you know if I can eliminate steps they would be more likely to do it.

THERAPIST: Well let's get through the wrist brace piece first.

CLIENT: Yeah. I'm just glad I don't have to like try to figure out how to get my insurance to cover like the doctor and stuff which I'm afraid that they'll probably say no to, so like there's no way I can get a new wrist brace. It's going to cost me thousands of dollars which I don't have insurance for and stuff. So it won't cost me thousands of dollars.

THERAPIST: I'm glad to hear about that. Anything else we should catch up on? We haven't – we've focused so much on the food and the weight that we didn't catch up on other stuff and I just want to make sure I check in about that.

CLIENT: Did I tell you that when I saw my psychiatrist two weeks ago like she put me on the Lamictal?

THERAPIST: Oh, I didn't know about that change. CLIENT: She put me on the Lamictal so only like I don't know how many milligrams the pills are but whatever the smallest one is like I think the dosage is going to go up to – like now it's one every other day and then it will go one every day and then it will go two every day and I think two every day is the most you can get it. THERAPIST: And is that instead of or in addition to?

CLIENT: It's in addition to. You have to go up slowly because there's the possibility of developing a rash on it and so it's like two weeks for each stage but it takes over a month for know whether or not it actually works. So yeah, because she couldn't really think of like anything else I could do about my period like I still have to have it but you know.

THERAPIST: So this is in hopes that that will help with some of those really deep mood swings, dips.

CLIENT: Yeah.

THERAPIST: Okay. And you expect your period again in about two months, right? It's been about a month since you had it last?

CLIENT: Yeah. Two months are as long as I can put it off for. I can't put it off for longer.

THERAPIST: Well it sounds like even if it's been two months hopefully the Lamictal will have kicked in by then and gives you time to see if that's going to be helpful.

CLIENT: Yeah, this is like my second week on Lamictal.

THERAPIST: And how do you – no rash so far.

CLIENT: No rash. The rash you get like the most – either you get it when you first start or like when you go up on the dose.

THERAPIST: I see.

CLIENT: So yeah, no rash so far.

THERAPIST: And have you noticed any changes in mood? How has your mood been?

CLIENT: It must have been okay like there's still have been times I've gotten uptight. I think part of the being upset is just feeling like you don't have as much free time and just the whole stress of like having to go back and forth between my place and Sydney's place and work. Like the commute part is fine. I need to find time to stop by my place but then I have to go sleep at Sydney's place and then I have to work the next day and so that's been –

THERAPIST: And you guys always sleep together regardless of which place you're at?

CLIENT: Yeah. So yeah it would be a really big change to be like okay with sleeping in my place at night instead.

THERAPIST: A big change that you would be okay with or not okay with?

CLIENT: I would only, I would rather avoid it like I think it's worth the annoyance of commuting from his place but yeah. It's a good thing tonight he's going to sleep at my place because I have to make dinner but yeah, it's definitely not ideal.

THERAPIST: Yeah. It is more stressful to have to live between two households. CLIENT: And especially –

THERAPIST: It takes more time and thought and preparing –

CLIENT: And having clean clothes and all that is yeah, really a lot to deal with sometimes. So yeah it would be a lot easier if he was just always at my place. He likes to be at his place during the day which makes sense but the question is whether or not he'll like if he, once he gets better if he could like take the (unclear) head's place or like – no eventually I'm going to buy the car from him and he's going to buy a new car and then I think that will be easier because I want more like independence and stuff (unclear). [00:20:24] And if things go well and when his lease is up we might live together and then I won't have to do that anymore but until then. So at least until September if not longer I have to deal with the whole two places, having less time and getting used to having things done. And he says also I can do (unclear) and he says no he can't and then I'm like trying to figure out how to get everything done without his help.

THERAPIST: It sounds frustrating.

CLIENT: Yeah, it can be. So his leg is better. And at least I like my job. And it is only three days a week so I have like the other half of the week to not be worrying about it.

THERAPIST: And right now it's still new so it's a big transition to have more constraints on your time. And to have more planning to do about where you're commuting from but I think that you will probably get adjusted to it after a few more weeks. It won't feel so – you'll have developed maybe a new routine and it won't feel as tiring.

CLIENT: Like if I have some time, that's the main thing. Like on Tuesday night I had rehearsal and I left. Sydney has the car because he was going to go to the grocery store and then he couldn't go to the grocery store and I mean he ended up actually later because he couldn't sleep without going in like one or 3 o'clock in the morning like while I was asleep because there was like no way to get. I can't go to the grocery store, I need to go to bed.

CLIENT: Well if you can plan, maybe plan time for groceries. You mentioned maybe being able to go tonight. Like tonight I can do it.

THERAPIST: So go with a list in hand. Have some of those fruits and vegetables that you can easily add in. Maybe be thinking about things that don't need to be refrigerated makes it easier then you can just stash a bunch at work.

CLIENT: Would adding nuts be a good idea or like I know they have lots of protein. I know they're also high in calories.

THERAPIST: Yeah, so if you can be really careful about serving size, then nuts can be a healthy addition of protein because protein is definitely lacking from the days that you recorded.

CLIENT: And what if I put them in with like crasins. Would that be better or worse?

THERAPIST: Crasins are mostly sugar. Delicious. So if you'll eat a salad and sprinkle some nuts and crasins on the salad and then eat it, that's great. You're not going to want to eat crasins as a snack because you're not going to get that much filled up that much for the amount of sugar and calories that you're getting. But if it's something that will entice you or that you can add into something else then yes.

CLIENT: Crasins in salad and then I have to make the salad.

THERAPIST: You have to make the salad.

CLIENT: And it's easier to deal with like one vegetable at a time.

THERAPIST: So you might be better off getting like prepackaged individual – not bags. You know they ones set up to be snacks. It might be something that you can bring to work with you and that way you're limited because enough can add up the calories from that pretty quickly because they have a lot of – it's a healthy fat and they're a good source of protein but they're pretty but they're pretty calorie dense. So you want to make sure that's really a small snack. You know like when you said, well Clementines are not going to fill me up. Well but maybe two Clementines and a handful of nuts would. Like definitely protein is missing from that list you gave me from those days.

CLIENT: Yeah, I could probably add that in, maybe get a big bag that I could like keep at work or something.

THERAPIST: Just be careful with big bag because it's hard if you don't portion it ahead of time, sometimes it's hard to stop. Especially because you're used to using fullness as your guide and that's been off.

CLIENT: I mean it would be like the way I would stop is just grab a handful so I can quickly eat it and go back to work. So I think I can manage it.

THERAPIST: Yeah. I mean the other thing you can do if you want to be – I know it's more economical to buy a big bag, prepackaged things. Buy a big bag and buy a package of snack size zip locks and prepackage for yourself. Just so you can keep track of it and then you can figure – if you're just putting nuts in them all the time you can reuse them so it's not a big expense. So the things on your list are going to be grapes, Clementines, eggs so you can make hard-boiled eggs for the morning. Green peppers or maybe the bag of the little peppers and cucumbers which you said you liked. I think that's a good plan for this week.

CLIENT: Okay.

THERAPIST: And then – are we normal next week? And then on the 25th I'm actually not going to be in. I could do a phone session that day though or we could meet on another day that works with your work schedule. I think you work on Tuesdays right?

CLIENT: Yeah. Well that Tuesday will be the middle of Passover. So I could stop in because I could walk over or something because I would be working.

THERAPIST: So I could meet with you at 11:30 Tuesday, I'll be in. CLIENT: Okay, yeah, I could do that.

THERAPIST: Oh I also have a 2:30 that day that I could be here for so you have a choice of 11:30 or 2:30 on the 26th.

CLIENT: Okay, I'll do 2:30 then.

THERAPIST: Okay.

(Pause): [00:26:14 00:26:51]

THERAPIST: And then we can be back to normal. Your 2:30 next week which is the 1st.

CLIENT: Okay. It will still be Passover but I can still come over because I wanted Sunday night, Monday, Tuesday, but yeah.

THERAPIST: Okay. We'll tackle the Passover eating challenges before –

CLIENT: Sometimes I end up eating healthier on Passover.

THERAPIST: Lots of veggies are still appropriate.

CLIENT: Yeah.

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