TRANSCRIPT OF AUDIO FILE:

BEGIN TRANSCRIPT:

THERAPIST: I don’t know where you want to start.

CLIENT: I guess Sydney and I have been fighting a lot lately.

THERAPIST: Does that feel different to you than usual?

CLIENT: I guess over the past few days it’s just sort of intensified.

THERAPIST: I’m sorry to hear that. Sounds like it’s really been rough for you guys.

CLIENT: I feel like I keep on being a jerk and the fights still come up in my face. And I thought we had made progress on… it was either Friday or Saturday night where… because one of the problems is that if I bring up anything… even if he’s in an okay mood ahead of time, as soon as I bring up something, our lack of sex life, he immediately starts being really upset, and then he can’t discuss things rationally when he’s upset. We tried a work around, which was to stop talking about it and cuddle and get him to calm down. [1:10] And then we were able to talk a little bit. But after some point he wasn’t…

THERAPIST: If it’s something important to talk about because that’s been an area where you have been very frustrated for years.

CLIENT: Yeah. And he keeps on saying he’ll work out and he’s working on it, but I see no evidence of that and…

THERAPIST: So it doesn’t feel like anything’s changed.

CLIENT: Yeah, like nothing changes. And I’ve tried… I don’t know. I don’t want to break up with him. I don’t know how to get my sex life back. [crying] We discussed the possibility of maybe me seeing… going to other people for sexual things so that way he doesn’t… I don’t have to bother him about it.

THERAPIST: Is that what it feels like to him? Sex feels like a bother? Or any intimacy? What is he comfortable with?

CLIENT: He’s comfortable with cuddling, but only for a little while because then he gets uncomfortable. Not emotionally, but physically. And I guess it’s just hard because I guess in previous relationships he’s had a twin bed and so then you’re like automatically closer so… well it’s like if you… he’ll… if your head is between the… my pillow and your pillow you can move your pillow over. This should not be something that’s insurmountable but that’s it. Maybe a little bit of kissing but not even making out, just a couple of kisses or something. [2:45] That’s it. That’s all he feels comfortable with.

THERAPIST: Do you understand what is his discomfort? Is it that he does not feel any sexual urges? Is it something that he’s uncomfortable with the idea of sex?

CLIENT: It’s every time it comes up, he panics.

THERAPIST: What’s the panic? What’s he afraid of?

CLIENT: I don’t know.

THERAPIST: Do you understand that?

CLIENT: I don’t understand that. It happens every single time, sometimes even when he’s into it. Yeah, so it’s not that he has no sexual urges, it’s that any sort of action induces panic.

THERAPIST: So it’s almost like he has a phobia.

CLIENT: Yeah.

THERAPIST: And when he says it’ll work out, he’s working on it, do you know what that… what does he’s working on it mean?

CLIENT: I mean I guess he sometimes brings it up in therapy. But…

THERAPIST: But he’s not seeing a specific sex therapist.

CLIENT: No, he isn’t. [3:51]

THERAPIST: Is that something he’d be open to? It’s a pretty unique specialty and that…

CLIENT: I don’t know if it’s something he’d be open to.

THERAPIST: Is that something that would… when you… I mean you mentioned kind of breaking up. Would some… that changing or him specifically addressing that, is that something that you feel like you need in order to stay in the relationship?

CLIENT: I think so. I mean right now I think a lot of me staying is inertia, feeling like I can’t do everything on my own and being afraid of being alone. And…

THERAPIST: So being afraid of being alone is not a great reason to be with somebody.

CLIENT: No, it isn’t. [4:36] (pause)

THERAPIST: It’s scary, though, to think about such a big change. You’ve been together for a long time.

CLIENT: And I don’t want to give up after I’ve been waiting and waiting and waiting, trying to be as patient as possible. [crying] And it just also… I’m starting to think that okay, maybe if you get out, the relationship will instantly get better and he’ll be fine having sex with someone else is

THERAPIST: That would be really hurtful.

CLIENT: I’ve given up two years of having no sex life to stay with him.

THERAPIST: There’s no guarantee.

CLIENT: I mean what kind of work… what would going to a sex therapist be like?

THERAPIST: Well I’m not a sex therapist so I don’t know exactly what the treatment plan would be. One of the reasons that I ask about it is because if that was specifically an issue that somebody were struggling with and coming to see me, I don’t think that I... I don’t feel competent to treat that. So I’m not sure the position that his current therapist is in because it’s not… that’s not the specialty, from what I understand, with his current therapist. It wasn’t the original reason he sought therapy. So there actually is an Institute for Sexual Intimacy in… it’s either New Haven or Wallingford, somewhere close, and Doctor Kyra Johnson is the person that runs that agency. And she’s pretty well known. But that whole practice is geared towards people who have various issues with sexual intimacy, whether it be recovering from physiological trauma or more emotional issues like sex phobia or pain upon intercourse or inability to have intercourse for either emotional or physical reasons. [6:36] So I don’t know exactly what the treatment would look like but what I do know is that I’m not experienced enough in that field to adequately treat somebody who’s struggling with that particular issue. And I… what I would do if that was a main issue of therapy is certainly refer to someone who does have that specialty. And I can certainly provide you with information. I don’t… this isn’t your issue; this is Sydney’ issue. And obviously it has significant impact on you. And expecting and wanting to have a satisfying sexual relationship with your boyfriend is perfectly appropriate. That’s something that you need in a relationship. It’s okay for you to need that.

CLIENT: [crying] And yeah, I don’t know. I mean I think it comes up in therapy but I don’t think it’s ever… it doesn’t really get addressed head on or I don’t think they’re doing anything specific about it. And just if I do end up by myself I don’t think I’m going to find anyone else. I’ve gained all this weight and I’m depressed and I can’t have vaginal intercourse, so I thought who would want to date me. I’m just never going to have a satisfying sex life. I don’t even think I could find someone to… if Sydney was okay with me going and seeing someone else while still dating him, I don’t think that would ever happen either at this point because I’m just so fat and ugly. [8:35] No one would want me like this. I don’t know why Sydney still thinks I’m attractive. And I’m pretty sure he’d be the only one that thinks that. He says that. If he met me the way I’m looking now without knowing my personality he would’ve asked me out, but I don’t know that that’s really actually true.

THERAPIST: Why don’t you believe him?

CLIENT: Because I’m fat.

THERAPIST: And that means you’re not attractive to anybody? [9:10]

CLIENT: Yes.

THERAPIST: I don’t know that that’s necessarily the case. It certainly doesn’t seem like it’s the case to Sydney. You’ve gained weight but he doesn’t feel that you’re unattractive.

CLIENT: It’s not like other guys ever hit on me or anything. Even when I was thin it didn’t really happen and…

THERAPIST: It’s two separate issues, right. So whether I think staying with Sydney because you’re afraid you won’t find somebody else is not a good reason to stay with Sydney. I can understand your fears of being alone, but not wanting to be alone does not mean you stay with someone that you’re unhappy with. So I think what you need to determine is do you want to be with Sydney. If you do, that’s okay. And you have to find ways for you to feel comfortable and satisfied in your relationship. If you don’t want to be with him anymore, then you need to break up with him and we confront the next piece, which is your fear of being alone and not finding somebody, as a separate issue. But staying with somebody because you’re afraid that you’re not going to find somebody else doesn’t lead to a happy relationship with that person.

CLIENT: I know.

THERAPIST: I’m not telling you anything you don’t know. [10:43]

CLIENT: I don’t know, I want to be happy with him. I do. It’s really hard to get past the fact that we have no sex life and then we fight and it’s usually my fault that we fight and he doesn’t… he says he’ll do something in a second and then he ignores it and continues to not do it.

THERAPIST: And that’s your fault?

CLIENT: No, but me bringing it up is my fault, and getting annoyed at it and telling him that I’m annoyed at him and getting annoyed at him is my fault. And but all the trash and recycling in the house has just piled up and I can’t conquer it by myself. And he says that he’d help me and he never does and [inaudible]

THERAPIST: And that’s a really uncomfortable situation to live in.

CLIENT: I don’t know how I’m going to get out of this mess by myself.

THERAPIST: Mess, what’s the mess?

CLIENT: Well the boxes for takeout and stuff, and the trash, which is probably too heavy to… the fact that there are things that are too high for me to reach and…

THERAPIST: Makes you feel really dependent upon somebody that’s not dependable. It’s a precarious situation to be in.

CLIENT: I don’t want to move back in with my parents but maybe I should. [crying]

THERAPIST: How would things be different if you were on your own?

CLIENT: I mean I’d probably make myself do the dishes more and eat takeout less because I couldn’t afford it. I don’t know. I don’t know how I’d do groceries without a car because otherwise I’d have to carry heavy things back. And it would mean having to go to the grocery store more often, and I don’t know if I’m going to be able to be that responsible, or if I’m too depressed for that. And just the way the apartment is set up, it’s not good for someone my height. [13:07] Which I should have thought about more when I got it.

THERAPIST: You were looking at other requirements so it may be hard to see details like that.

CLIENT: And it’s just a problem. Everything is not good for people my height. They don’t build apartments for people my height. And I feel so boxed in and trapped.

THERAPIST: So let’s think about ways you can overcome some of the hurdles. Are there accommodations you can make, stepstools, things that help you extend your reach? Do you have any of those kinds of tools?

CLIENT: Well I have a stepstool. The problem is, the… even the... so there are these four shelves that are above the sink. But first of all you have the sink coming out so you’re already further away from it, and then I can reach the first shelf and that’s it. And I have a three step step stool and I think that will get me up to the second shelf, possibly the third, but it’s really…

THERAPIST: And you have things stored on there that you need access to, out of reach.

CLIENT: The second shelf has the Tupperwares for me to put in leftovers, so I need that.

THERAPIST: And do you have one of those grabber thingys?

CLIENT: No but I don’t… they’re hard to operate. I’ve used them before. They’re not very good at actually… it’s like one of those claws in the machine with toys and stuff like that. It feels like that. [14:50] And definitely not anything delicate.

THERAPIST: No, but Tupperware, I was thinking, might… depending on what you put on those shelves, something like a Tupperware that’s light and if it drops won’t break. So I mean there’s little… there’s situational problems like this that we might be able to find workarounds for. But the bigger thing is really if you are afraid of being independent, how much you trust yourself to take care of yourself.

CLIENT: [crying] I really wish I could move back into the house and… or… I can’t. And I don’t know if I can find another group of people to live with and who aren’t crazy.

THERAPIST: What felt easier about being in a house?

CLIENT: Well for one there were people around me who were taller, who could reach the top things that I couldn’t. And I didn’t have to get groceries, I just had to put in money and circle items on the list that I wanted. And I wouldn’t necessarily get them as soon as I wanted them but somebody with a car or a big bicycle would… big bags would do the grocery shopping and…

THERAPIST: So what about a delivery service? If what you want to do is pay money and circle items…

CLIENT: Because it’ll cost too much. I can’t afford it.

THERAPIST: Does it cost more than ordering out?

CLIENT: I don’t know but Sydney [inaudible] pay for the ordering out, so I can’t be afford to be on my own. It costs more than going to the grocery store. [16:45] And I have to be there to accept the delivery and I don’t know if they deliver within a certain window or anything. Can you specify brands and stuff when you’re…

THERAPIST: Mm-hm. (pause)

CLIENT: And then I have to give up contra dancing because you need to really… and it’s difficult to get out to Norfolk without a car.

THERAPIST: The question is, do you want to be in a relationship with Sydney. If you…

CLIENT: If he… if we could get our sex life, yes… back, yes. But it just seems less and less likely as time goes by because he’s not doing anything about it. He says he is but I want to believe him but I don’t see any change. And [crying] why hasn’t his therapist referred him to a specialist? Why isn’t he… his therapist thinks that we shouldn’t break up, and he knows that we haven’t done anything sexual for over a year and he knows that we… that this makes me upset but he still thinks that we should stay together. [18:44] And he hasn’t told Sydney to see a therapist… a specialist and hasn’t done anything about it.

THERAPIST: How do you know what his therapist thinks?

CLIENT: Because Sydney told me.

THERAPIST: It’s interesting that his therapist is putting in a vote because I’m not voting one way or the other.

CLIENT: I guess it was like Sydney was talking about how hypothetically people thought maybe that we should break up, and then his therapist was all like oh no, if that’s what you think I say, that’s not what I think. So…

THERAPIST: Well I think you and Sydney need to decide what’s best for both of you. Your job is really to think about what’s best for you.

CLIENT: It all seems so insurmountable that I just want to kill myself but I mean I have to… I can’t until my parents get back from Israel, at least, because then they’d miss… they’d come back from Israel early, and I have to go tomorrow and take care of the kittens. And they don’t want the kittens to not get fed and die or anything.

THERAPIST: No, I don’t think they want the kittens to die, or for you to die.

CLIENT: If I die it doesn’t matter. If the kittens die it does matter.

THERAPIST: I think it would matter a great deal to your parents. And to me. [20:16] And to Sydney. And I imagine you could think of a few other people who it would matter to.

CLIENT: They’d get over it.

THERAPIST: Family members don’t really get over the death of a loved one. They may live on and continue on but they would not get over you.

CLIENT: It just seems that no matter what option I choose nothing is going to actually end up making me happy. And I’m never going to get a job and I might as well just die because it’s never going to be good. And my life sucks a lot [crying] and…

THERAPIST: Yeah, things are really hard.

CLIENT: There’s nothing worth living for. I don’t want to live anymore. I don’t. I really don’t.

THERAPIST: What would make life worth living for?

CLIENT: If I was less… maybe if I had a job and I had a relationship with a sex life and I had friends. [crying] If I wasn’t so fat. I feel like I’ve gotten to the point of no return with my body and I’ll never get not fat and it’s just too much weight to lose. [22:07] And I haven’t really been able to do that much change over the past week. I was in Rhode Island for most of it and didn’t go dancing because I haven’t really been… I mean I guess I walked a lot this weekend for vericon because we were going back and forth between lots of different buildings and I took the T [inaudible] in the car but it didn’t really feel like I was doing that much. And my pants don’t fit anymore and… these ones do but they’re corduroy, so it’s starting to get warmer so I don’t even have pants that I can wear in this weather. And I have to wear skirts and I just feel humiliated that my pants don’t fit. [22:52]

THERAPIST: That must’ve been really hard to discover [sp?].

CLIENT: And I can’t even… I mean I guess it’s more like what happens is that they start coming unzipped and... after a while of wearing them and I don’t know what to do because I don’t even know that there are stores that… the problem is, even if I buy a pair of pants that are big enough, they’ll be too long and then I have to get them hemmed and I can’t… and then it will take a few days.

THERAPIST: It’s not going to be instantaneous.

CLIENT: I can’t just get instantaneous pants like a normal person can. Normal people don’t have to always get their pants hemmed. And I don’t even know if any stores sell things for people as large as me, or if I have to get everything online and then I have to wait for it to be delivered and just… it’ll take even longer. And I’m just so humiliated by my state that I’ve become and…

THERAPIST: Is this the heaviest you’ve ever been?

CLIENT: Yes, it is the heaviest I’ve ever been. I’m so horrible and disgusting. [crying] Of course the world would be better off without me.

THERAPIST: That’s not the case Georgia.

CLIENT: Well…

THERAPIST: Your worth is not determined by your size.

CLIENT: And I can’t get a job and everyone hates me and…

THERAPIST: You’re stating a lot of things as fact that are simply not fact. [24:30]

CLIENT: Okay, it is a fact that I’m severely overweight.

THERAPIST: You are overweight but that does not equal worthless or unlovable or unemployable. Your weight is weight. It’s the size of your body. It does not determine your worth. And it does not determine whether or not your parents love you or whether you can perform a job that’s useful to society.

CLIENT: But it determines whether or not they will hire me for that job.

THERAPIST: No, it does not.

CLIENT: Well it factors in.

THERAPIST: Yes, unfairly it does factor in. You’re right. There’s absolutely research to show that there is size [inaudible] but it’s not the only determining factor. And it certainly does not determine your worth as a person or your value as a human being. It’s an obstacle. It does make buying clothes harder; it, in many cases, does make getting employed harder, but it’s not your worth.

CLIENT: I was having such a difficult time getting employed even before I gained all the weight and now I’m just like it’s impossible.

THERAPIST: It’s going… it is challenging, mostly because of the job market, not impossible. You don’t know what’s possible or impossible.

CLIENT: I’m having trouble even motivating myself to write the cover letters at this point so…

THERAPIST: Yeah, that means…

CLIENT: And I just got another two rejections from Yale.

THERAPIST: That’s disappointing. I’m sorry to hear that.

CLIENT: And I’m not even getting any interviews for jobs in my field.

THERAPIST: That’s really hard. [26:19] So that’s what’s making it feel impossible.

CLIENT: And just not knowing anyone and not being able to network because there’s no one I could go to. [crying] They haven’t even gotten the volunteering thing started because they had to go through some logistical hoops with HR or something and it’s taking a while and she submitted the forms in the beginning of March and in almost a month and nothing. And so maybe I won’t even be able to volunteer and then I...

THERAPIST: Well let’s not [inaudible], right? The present is hard enough to be in. Stop yourself from predicting what’s going to happen in the future because you’re not making very promising predictions.

CLIENT: Well I don’t think my future is very promising.

THERAPIST: But you don’t know.

CLIENT: I don’t want to live through it. I don’t want to have to be sad all the time. I don’t want to be crying every day. I don’t want to have to deal with fights. I don’t want to have to deal with being alone. I don’t want to have to deal with it. I’ve done it too much. I’ve been alone for the majority of my life and I don’t like it. And [crying] now I’m just so removed from my friends I don’t live with anyone or near anyone. At least when I was living on my own I was half a block from the dorm where most of the people lived. [27:59]

THERAPIST: Where have your friends moved to, and how far away are you from them?

CLIENT: I mean they’re in Belmont and…

THERAPIST: And your apartment’s where?

CLIENT: A different part of Belmont than where people are. And…

THERAPIST: Belmont’s not that big Georgia. It’s not… you can get from one side of Belmont to the other.

CLIENT: Well outskirts then.

THERAPIST: You’re talking in the same town.

CLIENT: [inaudible]

THERAPIST: You need to step back for a minute and get take some perspective. When you say you’re not living near anybody and that you can’t see your friends…

CLIENT: But we’re really close [inaudible] Colorado and Florida.

THERAPIST: Yes, those people you can’t see on a regular basis. People that live on the other side of town are not removed from you. You can get access to those people. And I think…

CLIENT: It’s not like they ever ask to hang out with me.

THERAPIST: Have you called them?

CLIENT: I made a night [sp?] to take out [sp?] with Mary the other week and knit then, but…

THERAPIST: So being isolated is a real problem.

CLIENT: They never make plans with me or invite me to anything. [29:18]

THERAPIST: You need to keep reaching out because when you called somebody and set up a date to knit together, you got to see a friend and you got to spend time together.

CLIENT: But they don’t really… if my friends really wanted to hang out with me wouldn’t they ever make those plans instead of being like… I’ve always been the one making plans with my friends. Always, always, always.

THERAPIST: If you want to spend time with people…

CLIENT: My whole life.

THERAPIST: If you want to spend time with people and they take you up on offers then that’s the way it goes. But don’t deny yourself the comfort and friendship of people you like because it feels unbalanced. If we’re solving an immediate problem, if the… there maybe absolutely be a longer term pattern that we need to look at at some point, but this is not the time to do it. You’re feeling isolated. If there are people in your town that you like then you have to do the work of getting into the habit of setting up dates with them. [30:25] And it will be great if they can reciprocate and do some of the initiation but it doesn’t seem worth it to cut yourself off from that because you’re feeling resentful. And to cut yourself off from friends that live in the same town or even a town over seems like a real loss that doesn’t have to be there. There are some losses that you can’t do much about, people that move to Colorado or Florida or live really far away. You don’t… it’s really hard to make plans with those people, and they’re going to be people that you only see once in a while. But people that live in New Haven or Wallingford, that’s not so far away. Yeah, I mean it’s not as convenient as the same neighborhood or same house, but reality is that most people don’t live with all of their friends in the same neighborhood.

CLIENT: I mean the other thing is that most of my friends are employed and so…

THERAPIST: Yeah, so the schedules… their schedule is more limited, but you have nights and weekends.

CLIENT: I know. I guess.

THERAPIST: If you could spend more time with your friends would that be a reason to live?

CLIENT: I don’t know. Maybe. It doesn’t really seem like enough of a reason. [32:10]

THERAPIST: So what’s keeping you alive today?

CLIENT: Inertia and [inaudible] not wanting to make my parents miss the rest of their trip to Israel.

THERAPIST: Well I guess that’s enough for this week. I’d like it to be more, but if that’s what keeps you here this week then that’s, I guess, what we’re going to have to take.

CLIENT: That’s really pathetic that that’s the only thing keeping me alive, is wanting to not make [inaudible]

THERAPIST: Like I said, I’d like it to be more but your care for them, the value you place on their life, it’s really important right now.

CLIENT: [inaudible] probably could… I think Sydney would tell my parents and my parents would at least either come home or they’d probably call the cat sitter that they had for… while I’ve been in New Haven for the past few days, so actually I just don’t even really matter.

THERAPIST: How do you think Sydney would feel?

CLIENT: He’d feel bad but I don’t know that I care because I feel like I care worse though than he would feel if I were dead, and that he’s not doing his part to make me happy, and we have no sex life and I’m miserable. And so if he’s miserable because I die he deserves it.

THERAPIST: So would killing yourself be revenge? You said he deserves it? So it sounds like it would be revenge.

CLIENT: Partially, but mostly it would be to stop all the pain that I’m feeling and just make it go away. It just feels like I’m trapped and it’s never going to get better.

THERAPIST: It sounds like you’re pretty serious.

CLIENT: I mean I also can’t really make myself do it every time I try. I never can make myself.

THERAPIST: What do you mean try?

CLIENT: Well I’ve not actually… I mean I might be holding the pill bottle but I don’t ever open it up and take the pills or anything.

THERAPIST: When was the last time you stood there holding the pill bottle, thinking about taking more than you’re prescribed?

CLIENT: Oh, a couple of weeks ago. [34:49]

THERAPIST: Does your psychiatrist know that?

CLIENT: No.

THERAPIST: If you are seriously thinking about taking more than you’re prescribed it’s important for her to know because it’s not safe for her to prescribe you as many as she does if that’s the case.

CLIENT: But it’s like five days’ worth that would… there’s no way to write that. Then I’d have to go to CVS every day.

THERAPIST: That would be a pain in the ass. But if you can’t keep…

CLIENT: I don’t want to go to CVS every day.

THERAPIST: If you can’t keep yourself safe then you can’t have those things around that are dangerous to you. As your providers it’s up to her and I to make sure that you’re safe. That trumps your convenience. It’s up to you to determine whether or not you’re safe at home with your meds. If you’re not safe at home with your meds, then either you can’t be at home or they can’t be there in that amount. (pause)

CLIENT: I’m probably not going to ever do anything. [36:22] There’s always something holding me back.

THERAPIST: Probably doesn’t feel very safe. Do you feel safe with yourself?

CLIENT: Yeah.

THERAPIST: You do.

CLIENT: I do. (pause) I mean I also feel like the alternative… it isn’t just a convenience thing, I’m thinking that I won’t actually go to CVS all the time and then I’m going to be unmedicated and then that’s also really dangerous too.

THERAPIST: That… so that would be your responsibility.

CLIENT: And I don’t know that I’m responsible enough to…

THERAPIST: Well so then there’s two ways… there’s two things we need to think about. This… your psychiatrist’s job and my job is to make sure that you are safe, that we’re providing safe treatment, and if that’s not possible in an outpatient setting then to get you into an inpatient setting. Your job is to follow through in your treatment recommendations that both she and I make. So if it’s not safe for you to have more than five days’ worth of meds at home then it’s important for your psychiatrist to know that and to prescribe accordingly. If you can’t follow through on it, that’s… it’s not her responsibility to make sure that you pick up your meds. It is part of her responsibility to make sure that she’s not prescribing medication to you in ways that’s dangerous. [38:11] Obviously you need those meds. So you either have to get… be safe with them yourself or be in a place that’s going to monitor for you and not give you access to more than what you need at a time. When you report that you’re suicidal it’s important for me to know exactly what that means. If you’re saying that you’re suicidal but you don’t actually really think that you’re going to do it, then maybe we need to change the language of what you’re saying so that it’s more accurate.

CLIENT: Okay.

THERAPIST: So I’m just trying to get a sense of what’s really accurate. I get that you’re miserable. I mean I think that’s what you’re really saying, is that you’re miserable. Am I getting it? Do I understand you? I want to understand.

CLIENT: I think so. I’m just so miserable. [crying] Nothing seems worth it. I hate myself so much. I think I deserve to die even though no one else does.

THERAPIST: Who else deserves to die? Are there other people that you feel like deserve to die?

CLIENT: I mean no one that I personally know. Maybe people who are mass murderers and stuff. [40:05]

THERAPIST: So you and a mass murderer are the same?

CLIENT: We deserve to die in different ways.

THERAPIST: Okay, tell me more about that.

CLIENT: A mass murderer would be like someone who is… especially one who’s unrepentant or something like that, is a danger to society. I mean even then I guess they could just go to prison. Yeah…

THERAPIST: And you deserve to die in what way?

CLIENT: Because I’m not contributing anything to society and I’m taking up valuable resources and wasting them.

THERAPIST: If I asked your parents if you were contributing in any way, what would they say?

CLIENT: Maybe they wouldn’t want to see me die but I don’t think that they think I’m contributing to society. I’m not. I’d say they value me but that’s not the same as being useful. (pause)

THERAPIST: Did you feel useful when you were working?

CLIENT: A little bit. I mean my job didn’t feel like the most useful thing in the world, and I wasn’t earning enough to support myself, so I didn’t feel that useful. I didn’t feel… I feel more useful than I do now.

THERAPIST: And this week your use is in taking care of your parent’s cats.

CLIENT: Yeah, but they could hire…

THERAPIST: You’re doing an important thing for them.

CLIENT: …someone else to do that.

THERAPIST: They could but they didn’t. [41:54]

CLIENT: I mean they I guess there’s a somewhat small added value of socializing the kittens. That’s the only reason why they needed me and not the cat sitter. If they hadn’t been fostering the kittens then they wouldn’t have needed me at all. I think a bunch of kittens on the whole is not that much added value.

THERAPIST: You’re also effectively house sitting too, right?

CLIENT: Yeah.

THERAPIST: You’re doing them a favor.

CLIENT: I guess. I mean I don’t really know how much house sitting is actually… I mean they’re not in an especially crime filled neighborhood. I think their house probably would’ve been fine on its own for two weeks. [43:03] (pause) I mean compared to the amount of money that I’m spending on rent and stuff like that, it’s nothing in comparison. And I just make people miserable all the time like I’m making Sydney miserable. Otherwise we wouldn’t fight so much.

THERAPIST: You can’t take responsibility for Sydney’ depression.

CLIENT: No, but I can take responsibility for, in general, making the world a more miserable place.

THERAPIST: It seems like an awful lot of responsibility [inaudible] control.

CLIENT: [inaudible] only a little bit more miserable but I’m not making the world a better place. I’m making it a worse place.

THERAPIST: I respectfully disagree. I don’t think you’re making the world a worse place. I do think that you’re really unhappy. I hear how unhappy you are. I don’t think the world is negatively influenced by it. I’m sure Sydney feels sad for you and clearly you guys are having a lot of problems in your relationship because you’re both dealing with so much sadness. Seem to be reinforcing each other’s unhappiness in some ways while at other times you guys bring each other happiness. It seems that the past couple of days have been especially hard. [44:50]

CLIENT: Would you still be able to get to report me and stuff if ever I do any non-lethal self… or non-permanent self-harm?

THERAPIST: Would I report you to anybody?

CLIENT: Get me into a mental hospital or whatever.

THERAPIST: After talking with you today I’m concerned about you but I feel secure that you’re not going to harm yourself between today and our next appointment. You do have the responsibility of caring for the cats, which seems important to you. And you’ve also said that while you’ve in the past couple of weeks maybe stood there and held the bottles and thought about taking the pills, you haven’t actually ever taken off the cap and taken more than you’re supposed to. So I feel secure that you’re not in imminent risk of harming yourself. It’s my job to continue to assess it every time you say it and I will. I do have permission to talk with your psychiatrist. You signed a release. I trust that you’re honest with her, too.

CLIENT: I just haven’t been this bad since I’ve had the appointment.

THERAPIST: Right, so I know you don’t see her as often, which is why when you come in every week and express this much distress that I ask questions, because I know I’m the person who sees you the most. So I see you… the intricacies with the ups and downs. I know that today is clearly a down place but it’s not where you are all the time. And I take that into account when I think about whether or not I need to ask you whether or not you feel like you need to be in a higher level of care at a hospital. [46:33] I would never call anybody without you knowing. If at the end of a session I feel like you’re not going to be safe until the next session, I would ask you to call the ER. But I want you to be in control as much as possible. You need to be honest with yourself, and that’s part of what you’re struggling with, is am I a capable adult? Am I taking care of myself? I want to continue to support you being as adult and capable as possible, which is why if I felt like you needed to be in a hospital I would ask you to call. I would ask you to be the adult. I’m not a parent. Yes, I… it’s my… it is my job to assess your safety but I hand the responsibility to you as much as possible to keep yourself safe because you’re a grown up and you are competent. If you feel like that’s too much responsibility then we can talk about that. But does that feel like too much?

CLIENT: I don’t think so.

THERAPIST: Because if it does you let me know.

CLIENT: Okay.

THERAPIST: And that would be a sign that you need to be in a hospital. If you can’t make… if you can’t do those basic things then together we need to decide that a hospital is the place for you and not outpatient care.

CLIENT: I don’t know how being in a hospital would help if it just made me even more…

THERAPIST: It just keeps you safe.

CLIENT: So it’s basically just okay, [sp?] looking at down the road.

THERAPIST: It keeps you safe until such time you can do so yourself. I believe in the inherent value of your life.

CLIENT: But what if I never… like if they’re not really treating me or anything…

THERAPIST: They would be treating you. [48:38] You would be getting your meds, you’d be getting therapies, and it would be more intense. When you’re in the hospital you’ll get their… you have a session every day. And there’s also other… I mean there’s levels of care in between inpatient unit and outpatient therapy. So the level in between would be intensive outpatient, a day program, where you’d be doing group and individual therapy in a daily way. So what we know is therapy works for depression and anxiety. Your…

CLIENT: Then why am I not getting any better?

THERAPIST: You certainly have had points where you’re better.

CLIENT: But not recently.

THERAPIST: Well, last week you… if you listen to the recording from last week you were at a different place then than you are today. So… and one of the things about feeling very depressed is that it’s often very hard to remember what things were like three days ago if you’re feeling really bad today. And you project it forward. You’re imagining that you’re going to feel the exact same way forever that you are right now. Sitting over here, I know that’s not true because I’ve seen you have ups and downs. Being in a down does not mean that there will never be an up. It’s hard to trust that right now. It’s much easier for me to say, but if you can step back and think about other weeks, other days, they’re not all the same. [50:13] Now we can stop there for today. If there’s a time where you don’t feel safe you call me, or you immediately call the ER.

CLIENT: Okay.

THERAPIST: And I think…

CLIENT: Are we scheduled for [inaudible] I know we’re on schedule [inaudible]

THERAPIST: We’re not scheduled next week because you’re going to be away.

CLIENT: Yeah, should we do a phone session?

THERAPIST: We certainly can.

CLIENT: If you have time or…

THERAPIST: I can do one on Tuesday. Is there a time of day that would be better for you? It would be Tuesday the first.

CLIENT: Yeah. What times do you have? [51:03]

THERAPIST: I could do from 2:30 to 3:30. I could do one in the evening if you… if that would be better for you, from 8:00 to 9:00.

CLIENT: [inaudible] might even be back. So let me check one thing. I’ll [inaudible] They get in on Tuesday morning so I should be back by Tuesday night, so we could do the Tuesday 8:00 to 9:00.

THERAPIST: Okay, that would still be phone.

CLIENT: Oh, it would still be phone?

THERAPIST: Yeah, because I’m not going to be in the office at that time.

CLIENT: Although probably… maybe the 2:30 one. The 2:30 one… okay, do the 8:00 to 9:00 phone session anyways because that way I’m not going to be driving at the same time and stuff.

THERAPIST: Yeah, that’s probably safer.

CLIENT: Yeah. (pause) Okay…

THERAPIST: And then…

CLIENT: Would I be calling you or would you be calling me?

THERAPIST: Why don’t I call you just in case my schedule is not quite as… it’s not quite as structured out of the office so I will call you as close to 8:00 as possible. I’m not to the minute the way I am in the office. And then the following week we had scheduled for Tuesday at 2:30, for some reason, instead of Monday. Is that because of me or you?

CLIENT: Probably because of me, probably because of Passover, but let me just…

THERAPIST: Passover’s the next week.

CLIENT: Oh, no, it’s because of me, because I’m getting back from a wedding.

THERAPIST: And then the following week is Passover. And I won’t… I can’t do our typical Monday because I’ll need to leave early. I am going to be working Tuesday morning. I don’t know if you can come in or if that conflicts with your observance.

CLIENT: I could come in on Tuesday morning.

THERAPIST: Is 10:30 okay for you on the 15th?

CLIENT: Do you have anything later than that? Otherwise I can do it but I’ll…

THERAPIST: I can do the 11:30, or it even… I actually can do it 2:30 in the afternoon if that would be preferable.

CLIENT: Probably… I think the 11:30 would probably be preferable in case I’m doing anything related to a seder.

THERAPIST: Okay, so we’ll do the 15th at 11:30. Then I’m away the week of the 21st and we’re back on for our normal time Monday at 2:30 on the 22nd… on the 28th.

CLIENT: Okay, yeah.

END TRANSCRIPT