TRANSCRIPT OF AUDIO FILE:

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THERAPIST: How are you?

CLIENT: Um, similar I guess.

THERAPIST: I'm just curious where you were when you called. It was right after our session.

CLIENT: Yeah.

THERAPIST: Like ten minutes later or something.

CLIENT: So I guess sometimes I'm finding myself in these situations where I feel like completely overwhelmed. And immediately like I don't-it feels like really intensely isolated, or alone, or like-like I'm not okay, that's the way I would put it. I'm really not okay and I feel like I should-like I need something, somebody, okay, I don't feel okay. And that happens sometimes. And it's not always-like it's not necessarily just after a session, it's sometimesAnd I don't really know what to do in those moments. It feels like I've just got to pull through it. Which I do, and I did.

THERAPIST: Yeah.

CLIENT: It happens. But I guess I don't feel like I have maybe-I'm not sure what skills I should be using or what I should be doing in those moments.

THERAPIST: Yeah, yeah. Does it feel like having a panic attack?

CLIENT: No.

THERAPIST: Or is it something different? It's something different for you.

CLIENT: It's different.

THERAPIST: So what does it feel like in your body, for example? What is the-

CLIENT: It feels-this is a poor way to describe it maybe, but it feels almost like shaky inside. I'm not physically shaking. Sometimes I am, but I'm not in those moments. And I feel like so insecure, almost like I've got something wrapped around me, almost like IWhich is-it's an awkward way to describe it, but that's-

THERAPIST: No, it's so helpful, it's so helpful.

CLIENT: I think that's why I put the word 'insecure' to it, because I feel-I don't know. Because it feels-so. And I think last week I-I would definitely put that onI don't know. I guess I was thinkingWe talked a little bit about everyday things, but then we also spent some time talking about like some historical stuff, as it were, with my dad. And when I left I felt like I didn't get to-I didn't chose to talk enough about some everyday things that were going on that were feeling really intense I guess. [2:20]

THERAPIST: Yeah.

CLIENT: So I didn't deal with them. And even some things from the two weeks before.

THERAPIST: Okay.

CLIENT: Or however many weeks at that point. So it was like-and I understand.

THERAPIST: So part of it sounds like there's almost a kind of urgency feeling-

CLIENT: Mm hm.

THERAPIST: -of you didn't get enough, or we didn't get there, and now, oh my goodness, a whole other week and you're left alone with all this stuff that's still kind of pilling up inside. That's so important, I'm glad-I'm really glad to hear that description of it, because it helps me understand a little bit better. One of the things I then think we should really start to shift in doing here is allowing you to set the agenda more.

CLIENT: I think-I hear you saying that, and I feel like that's a good idea, but I don't always know how. Because I feel like there's-I don't even know what it would look like to talk about me, or have it focused on me. Because it already feels like it is. I mean, that's what a therapy session is.

THERAPIST: Yeah, yeah.

CLIENT: But I feel like there's all this-there's Ivan, there's all this stuff with my parents, and there's all this stuff with me and my-like, what's the point of my life, and there's like-I don't even know what's the most important or how to juggle it all.

THERAPIST: Yeah, yeah.

CLIENT: So I think when I do do the journaling that helps. It's really hard for me to make myself do it sometimes, but it does help. Because then I like-from the day I get whatever it is out. And that helps me to sort of, I don't know, digest it, or process it, or deal with it, as opposed to a week has gone by and I have no idea how to focus my thoughts in 45 minutes. [4:00]

THERAPIST: Yeah, yeah. I also, just for the record, when I see you, I really, really think you could benefit from being here twice a weeks.

CLIENT: So I think that's very true, but I don't know what to do at this point, because Dr. Farrow has been trying to see us twice a week.

THERAPIST: Yeah.

CLIENT: And if I'm here twice a week-and I've been having a couple dental appointments-I'm like-

THERAPIST: You're flooded with doctors-

CLIENT: The appointments might be like-

THERAPIST: Yeah.

CLIENT: So I don't know. I will say next week she's on vacation, so maybe that would be an opportunity.

THERAPIST: Yeah. I guess I feel like I just wanted to make sure you know that I feel very clear that that would be helpful to you.

CLIENT: Okay.

THERAPIST: I totally understand that we have to balance that with the logistics of your life. There's so much, Ivan, going on inside you. Just even if you weren't in the relationship I think there's a lot going on inside you-

CLIENT: Yeah.

THERAPIST: -that we could be helpful to you with. Now, add Ivan into this, add your sort of history, add even your transition coming up from school into potentially a job, and all the anxiety and stress with that transition alone, there's so much. A longer session, if we could ever find, that might help, but there's something about having the container of two-like two check-in points, rather than then the whole week passing that sometimes can feel even more holding. I know you live far away and this is not the most convenient thing.

CLIENT: It's not, but honestly it's the easiest appointment to get to. So, I mean, it takes a little over an hour, but it's still one trip.

THERAPIST: It's long though. I hope you can study on the train.

CLIENT: Sometimes I can read. It's really not that-it really takes me an hour to get to school, so-but-

THERAPIST: So here's another point about our agenda for what are we going to do in 45 minutes to make this the most useful. I feel from you sometimes like you're looking for me to set the agenda. Like you will sit down and say, "So tell me what to talk about," essentially in your eyes. You're not saying that with words but your eyes say that. And I think there's a part of you that feels like that, feels like being taken care of. Like you feel in some ways that would be my, you know, the metaphorical arms holding you with saying, "Let's talk about this, and let's talk about this," and guiding you and sort of just being that person who knows what to do. And I think there's some relief in that for you. The only problem with that is that sometimes I won't know exactly what's in your mind. [6:40]

CLIENT: Mm hm, mm hm.

THERAPIST: And while I might have some good ideas that might at some point be relevant and important, that week it really could not be where you are. So if we follow my agenda that day you're going to leave feeling deprived, overwhelmed, urgent, and like next week is an eternity away. So to the degree that I can help you start trusting you a little bit to be kind of an informant here about what we need to work on, to the degree that you can trust that when I am looking for you to inform me it's not because I'm not trying to be helpful or like I'm taking the backseat, it's more that I'm really focusing in on, okay, where is she this week and what's the strand that's the hottest inside, because we want to help that strand. Even though there could be ten strands that I'm aware of, any one of which could be really important to do this week. So does that-

CLIENT: Mm hm.

THERAPIST: To the degree that we could help you find you, like what's prominent in you, and then I come in and help you with that piece, I think it's going to feel better.

CLIENT: So I tried-in light of that, I tried to think about what I could think about or talk about in this space this week that would be me.

THERAPIST: Yes.

CLIENT: Which is so weird, because I'm like, no, I really want to talk aboutSo I guess to that end I'd like to talk just a little bit about how I've been feeling, or how the anxiety/depression has been playing out. [8:00]

THERAPIST: Yeah.

CLIENT: So going back to something I mentioned a couple sessions ago, you had said that you thought that I was-it's transference? My feelings towards my mom at least towards you.

THERAPIST: Yeah.

CLIENT: And I'd like to say, in the moment it didn't feel very good to hear. But I feel like it's very accurate. Especially when you called and said, "How would you feel about a pharmaceutical consultation?"

THERAPIST: Yeah.

CLIENT: It was so me reacting to my mom. Because so many times she has told me, like, "I can't help you, you need to go see someone. You should be on anti-depressants." Or, "Have they evaluated you for pharma-maybe that's what you need." And it really feels-I'm sure she means well on some level, like I'm sure she really-but it really feels like I can't help you, I'm not interested, I'm overwhelmed, I don't have time, I don't care. Like it's too complicated, you have-like, what's going on with you is way too much for me to handle and I just can't even-you have so many issues, you've got to go work them out and then we'll talk. It feels like. I'm not saying my mom says these things. And that's how it feels. And especially with the pharmaceuticals it always feels-especially considering the experience I had when I was on them, literally being forced to take them. At first, not the whole year.

THERAPIST: Yeah, yeah, yeah.

CLIENT: But it really feels like take this medicine and fix what's going on, like get it together.

THERAPIST: It's so interesting.

CLIENT: And I'm not saying-like, I know that's not anything you're saying, but in that moment I thought, "Oh, maybe there is something to this idea of transference." Which I feel like-I don't always maybe feel like I'm reacting that way, but-

THERAPIST: But you could see how maybe there might be some moments where something-it's not that there's nothing happening, there could be something subtle that is like that, but it feels like it's really exactly like that. [10:00]

CLIENT: Yeah.

THERAPIST: Yeah. That makes sense. One of the things you're saying is that the idea of a pharmaceutical, or as something else maybe brought in, feels like a rejection almost. It's kind of like she was saying to you, "I can't help you, I don't want hear anymore, bring this to somebody else."

CLIENT: Yeah. Yeah. It alwaysSo many times she's said like, "You've got problems and you need to work on them." And it really doesn't feel the same as, you know, like, "I see you're struggling and I want to help you." Or, "I'm here to listen and I will do everything I-" Like, not that she hasn't said that at some points, but it really mostly always distantly feels like-and even like, "Are you telling them this and this when you go to your session?" Like, "Are you being honest about what you're doing?" Like, I mean-

THERAPIST: Really?

CLIENT: Yeah.

THERAPIST: She would say things like that?

CLIENT: Yeah.

THERAPIST: Oh my goodness.

CLIENT: Yeah.

THERAPIST: Oh.

CLIENT: And she even-she had a little bit of I think-I don't know. Because when I was going through that when I was at home and about 16 I was really, you know, turning to the psychologist once a week, and was turning to her for trust and help and for all these like-dealing with my, you know, very personal problems instead of turning to my mom. And I can understand that that would feelAnd I can also understand-I mean, clearly I was upset about some things going on at home, so I could understand that I wouldn't feel very good to know that I was talking about that with someone. But she, you know, very much made sure you're responsible for your part in it. So-

THERAPIST: So what a fertile ground then for feeling like there's some repetition happening here of exactly that, where it could feel like I'm saying, "Wait, are you talking about your part?" You know, "Why are you blaming Ivan?" It could be like your mother saying, "Don't blame me. Make sure you're telling them everything that you're doing wrong too." But she really was doing that from a place of feeling herself kind of jealous and insecure and critical of you, rather than from, for example, a psycho-pharm recommendation could happen from a loving, like really interested in helping you kind of place, and thinking about what the options are. But it wasn't coming from there. [12:20]

CLIENT: I think it's really hard, because I know like-I know my parents wanted me to get help, and I know that they wanted me to take the medication to help me, but at the same time I have memories of my dad like holding my arms and my mom pilling me like you would pill a cat. It's not a good memory. You know? It's just not a good memory. On top of dealing with the depression and all the other stuff in there, their stuff. It's just not a good-

THERAPIST: This is when you were 18?

CLIENT: Yeah. No, I mean, I was essentially an adult and they-I did not want to-

THERAPIST: You didn't want to take it at all.

CLIENT: No. No. And I-I mean, at first I didn't want to go to counseling either, but I grew to be the advocate for that and I even-

THERAPIST: Yeah, yeah.

CLIENT: So-

THERAPIST: How did the idea of medication come about even in that treatment? Was it only from your parents?

CLIENT: No, no. I saw one counselor for a couple of months, and then I saw another one. And it was the female I saw that I then had a relationship with for year, and I even saw her a couple times the following summers, like once in a while I would see her. And she connected me with a psychiatrist, and then I would go see them, I don't know, was it once a month tops. But-

THERAPIST: So it came up over the course of the therapy.

CLIENT: Yeah, yeah. No, she-like there was an actual recommendation and actual appointments and the whole thing. So-

THERAPIST: Yeah, yeah.

CLIENT: -it wasn't all them. But it's still like a trigger for me I think.

THERAPIST: Oh, my goodness.

CLIENT: And it's really hard-

THERAPIST: Of course.

CLIENT: -because I'm turning to Ivan and saying, like, there's no shame with it. But I'm the person who like changed the name-like wrote the generic and like crossed out "Prozac" on all of my permission slips because I didn't-you know, that's not easy to tell your friends when you're a senior in high school. [14:10]

THERAPIST: Yeah.

CLIENT: So anyway, it's okay. But I definitely-especially I was really upset because I-that one session where you said like I was really depressive and really-you saw it was agitated depression, I was so I guess embarrassed or humiliated, and I even felt like I didn't want to come back because I didn't want to-like, I didn't want to be that way, and I didn't want to expose you to that essentially. Like, I didn't want to be that person, or that patient, or whatever.

THERAPIST: And yet what's so hard is it's like it pulls you totally back to this childhood place of your parents telling you it's you, it's your fault, it's not us or something, there's something wrong with you, go get it fixed out there. And why would you want to come back to that if that's what this feels like? You know what I mean? Like, how understandable if you're triggered in that place.

CLIENT: I think it almost feels-I'm not sure. It almost feels a little bit like-like looking back, I was, I was so aggressive and so upset, and just so angry in that time. And so upset too. I mean, I really was sobbing when I left here, which is a little embarrassing. But I really had those times obviously where I've expressed that anger and hurt to my parents, and it-that's also not very productive, but I also feel like it's gotta--there's got to be some way to get it out somehow. So anyway, that-

THERAPIST: You're-that's so thoughtful, Ivan, what you're putting together. I'm floored by what-the pieces that you're connecting and understanding. It feels like there's something you're really getting about what's happening, both here, I also think with Ivan. And I don't want to bring him in in a profound way at the moment, but I think-I think the fact that you can connect even-like, you could almost feel frustrated with him for not being interested in medication, and yet you are finding right now that you resonate really deep inside you with his feeling of shame. You've known yourself what that feels like to have someone be trying to push medication on you, to have it feel like they're trying to have this that this is going to confirm some diagnosis that tells us that you're the problem, you know. You know that's not all you're feeling towards Ivan, right. You know it's in part coming from a very loving place of wanting to help him and really wanting to help this get better for him and for you as a couple. But you know also what it feels like if you're in a place of feeling like it's only coming as a kind of pejorative label. [16:45]

CLIENT: Mm hm.

THERAPIST: And that if that's what his experience is, it's like-that's what I think is so cool about this, you can find there's some way, there's something you guys are sharing. Even though I think in your corners it looks like they're opposite, I think underneath you're more comfortable being angry, but just underneath that. That's what I'm saying, in your writing, just underneath that is all this vulnerable feeling about yourself that I think is very similar to his, that you're, you know, realizing you're starting to feel with me too. How do you feel about medication now that we're talking about it and you're kind of-like it feels like maybe there's a little space for it not just to be about labeling you pejoratively?

CLIENT: Mm hm. I... I don't want to, obviously. I don't think anyone wants to.

THERAPIST: Yeah.

CLIENT: But I guess I'm-

THERAPIST: Well, people feel-by the way, people feel really differently about it. Some people, no problem and it's really helpful to them. I hear that you feel a stigma.

CLIENT: I do, I do. Quite frankly in like eighth grade one of my teachers saw how I got obsessed with grades and how like anxious andAnd she had-like, she made a joke, and she's like, "You're going to be on Prozac by the time you're eighteen. Like, you've got to-" And I was. And like, you knowAnd it was like a horrible, horrible, hellish ordeal. But in the end it really helped I guess. [18:20]

THERAPIST: Yeah.

CLIENT: I feel-I don't know, it's really hard to separate the two, but I feel like the really, really hard work I've put in, and all the CBT sessions, and like all the exercises and all the-like, I really put in the time. So I felt-in the end I felt like I feel pretty proud. Even though I can't really tell anyone about it, I don't tell anyone about that so much, I feel really proud of all the hard-like I really feel like I dug myself out of that hole.

THERAPIST: Yeah. From your sense of the course of the work and the medication-I guess this is-when I asked you how do you-what do you think about medication, really wanting to know what your sense has been in the past of whether you attribute things improving to the medication. Does it feel clearly like that was a helpful piece, or was it the therapy?

CLIENT: I feel it was mostly the therapy.

THERAPIST: Okay.

CLIENT: Because of course what I remember most was putting in all the work and all the-

THERAPIST: Yeah.

CLIENT: -like exercises. And even like the thought process that she would kind of train me to go through.

THERAPIST: Yup.

CLIENT: But just because, you know, taking a pill isn't as memorable doesn't mean-I really do recognize, you know, raising the serotonin levels and the whole-the actual chemistry of it, that that was helpful. And considering how severe my depression was I don't know if I could have done it without that. Or if I would have been able to do the work as well if I hadn't had that boost.

THERAPIST: It's really hard to tell.

CLIENT: Yeah. At the same time, I don't feel anywhere-sometimes I feel a little close, just one of those moments these days, but it's not the same situation. So I guess I feel like-and it has nothing to do with you-I feel like it's maybe not enough all the time, what I'm doing now. [20:00]

THERAPIST: Yeah.

CLIENT: I'm not sure that I feel that that's so necessary yet. But again, I would trust if you feel that I'm like really ready for a consultation, or that that's got exhausted, I would take that seriously.

THERAPIST: Yeah, no. And that's actually not how I'm feeling. This is-when I raised it it wasn't as a recommendation. As a thought about pieces of a pie that sometimes can be helpful to some people. Even if you were someone whose body chemistry would really benefit from it right now, but you are morally or emotionally in a place where you're just dead set against it, guess what, it's not going to be helpful to you.

CLIENT: Mm hm.

THERAPIST: So for different reasons people feel differently about medication. That's only what I was trying to feel out, kind of was it something you were sitting there hoping and praying I would bring up and just waiting for me to bring up?

CLIENT: Right.

THERAPIST: Or did it feel uncaring that I hadn't brought it up yet? I'm always interested in people's experience of it. By and large I don't find medication ever a magic bullet for nearly anyone, with the exception of schizophrenia, okay. You're not schizophrenic, nor is Ivan, so it's just-it's not something that I recommend very readily in a very firm and clear way. You probably will never hear that from me unless you are so, so desperate for a very long period of time that it would be something that to me could be part of the picture.

I also think when you've had the history you've had, Ivan, there's so much that feels clear contributing to how you feel right now. It's not as though it's a rosy picture, and why you feel this way, and it must be your brain chemistry. Do you know what I mean?

CLIENT: Yeah. I guess I also just want to add, II don't know how toSo with the CBT it felt like a very aggressive, active approach. [22:00]

THERAPIST: Yes. Yeah.

CLIENT: And literally like she would give me exercises, like, "When you are feeling this-like when it gets so overwhelming I want you to take this spreadsheet and like write out all the hot feelings, and then go through and actually-"

THERAPIST: Yeah.

CLIENT: Like literally.

THERAPIST: Yeah.

CLIENT: And that-so that feels very different from this. I'm not saying one's more helpful than the other.

THERAPIST: Yeah.

CLIENT: But one-the way I deal is to like do and do and do, and like obsess. And I'm not saying that's a good thing, I'm saying it felt very aggressive.

THERAPIST: Maybe you're saying right now that would be helpful.

CLIENT: Maybe it would.

THERAPIST: Mm hm.

CLIENT: But then on top of medication-I don't know, it was just very different. I also-it's kind of-it's silly, it's kind of silly, but I-so taking the medication it shows up obviously on your medical records and stuff, and I-so for my senior project for high school I decided I wanted to get a pilot's license, so I took lessons and lessons. I couldn't qualify for the because I had taken [unclear 23:03]. Because there was a history of having anti-depressants and they don't like to give out licenses to people who have been on anti-depressants. And I under-you know, there has to be a few regulations. But I just feel-when I say to Ivan like, "I would think no less of you and I would have no issue with you taking the medication," I really honest to goodness mean that. I would not secretly think any less of him. But I guess I'm saying I'm not ready.

THERAPIST: Yeah. No, I hear you, I hear you. So maybe it would be helpful then for us to try to get a little bit more concrete about just skill building right now, given where things are, in dealing with the periods of emotional overwhelm that feels so out of your control. And once some of that we get to rein in a little bit there might feel like there's some space to open up more of the history that relates to the emotional dysregulation, more with Ivan that relates to that, but that we pace ourselves in getting there, kind of trying to get to a little bit more of a stabler baseline. Does that make sense? [24:15]

CLIENT: I think so. Really honestly I really want to know what's going on. Because I feel like we've now spent a significant amount of time with you, with Dr. Farrow, and I feel like I still don't-I feel like nobody's really sat me down and said like, "This is what's going on." So I guess I want to know that, and like where I can go with it, and what I can expect. And like will you be sitting here for the next five years? Or am I going to develop skills a little more quickly than that. I know there are no guarantees and you can't put deadlines to things, but I just kind of want a big picture.

THERAPIST: And the big picture would do what do you think? You think that that would feel-is that kind of how it would feel like I care somehow?

CLIENT: No, I think I just want to know-so you've told me at some points like it's severe depression, or it's agitated depression, or-I mean, obviously there's some anxiety, that's always been clear. Or chronic stress, you've described it as that way. So I just like-you've told me that Ivan's struggling with depression but also an attachment disorder of some kind.

THERAPIST: Yeah, yeah.

CLIENT: Which he tells me Dr. [Bourd?] says there's no-like that's not going on. And I guess I really am waiting for somebody to say like, "This is really what's going on with you," this is really happening or not happening.

THERAPIST: I'm still-I guess so my-I'm trying to understand what that would do. So let's say I gave you a DSM-4 set of diagnoses, what does that do then? Does it feel like it's somehow-like does that settle your anxiety to know just what it is? [26:00]

CLIENT: I think so. I think I'd like to know what I'm dealing with so I have some expectations.

THERAPIST: Yeah.

CLIENT: So if you said I had mild depression I would think that's more mild than severe depression and I'd have like a better grasp of what's going on.

THERAPIST: Yeah.

CLIENT: So it's probably just about being in control.

THERAPIST: That's what I wondered.

CLIENT: Because I do.

THERAPIST: Because I feel like I've told you some things that I think it is, but it doesn't feel like it ever feels like it's enough, like it's somehow not-there's some things still you're wanting to get under your control, and that somehow maybe even a diagnosis. And then it's the same thing for Ivan, like somehow that would control it more if you knew exactly what it was.

CLIENT: I think in my mind too it's like how do I know, how can I even adjust these problems if I can't even put a label to the-

THERAPIST: Understand what you have.

CLIENT: Like yes, that's really.

THERAPIST: Yeah, yeah. So I'm going to give you-I'll give you my best description of what I think is happening, knowing full well that I'm partly entering into the system of giving you some false sense of control over it just by having an intellectual understanding. But I also think you're asking me genuinely, I don't think it's only a defense. You know what I mean? I think you're interested what is this, to the degree that it can help you understand and put into perspective even some timeframe stuff around it and how you're going to get from point A to point B. That said, it's also not going to be as black and white as I think you are wishing for it to be. I think when I don't make it black and white it feels less caring to you. I think there's something that feels like it's almost like I'm giving you those arms if I give you a diagnosis that you can just hold on to almost like a security blanket or something. It gives you something to hold on to rather than this amorphous shifting vague, you know, what is happening here. I'll give it a quick shot, and I'm curious what your reaction is when you hear what I have to say. [28:00]

CLIENT: Okay.

THERAPIST: I don't think it's going to be anything new or rocket science either.

CLIENT: Okay.

THERAPIST: But I will summarize the threads that I think I brought up at various points and maybe introduce a new piece. I think based on your family history and a number of things you've described to me, Ivan, that there is an element of what you are suffering from that has a PTSD-like quality. Would I diagnose you with formal PTSD, the diagnosis on an insurance billing quote? I probably would not because you don't meet all the criteria. So I don't hear, for example, you're not talking about having intrusive thoughts about your family all the time, having nightmares all the time about your childhood, avoiding lots of different things that remind you of your childhood. The intrusion, avoidance and night intrusion, that's often the total package for that formal diagnosis. I think what you have is suffering from a pretty severe anxiety disorder that has-so we call it anxiety disorder NOS, not otherwise specified.

CLIENT: Okay.

THERAPIST: And that's pieces of generalized anxiety disorder, which means constant worrying about everything. You might even meet [fault? 29:26] criteria for GAD, and I can go back and look at all the criteria. I think you probably would. You have elements of panic disorder, which is another separate anxiety disorder. You have elements of even obsessional OCD. You have elements of PTSD. So there is a lot of anxiety that I feel is rooted in a pretty profound history of neglect and emotional abuse in your family. And it's pretty blunt to say to you.

CLIENT: No, but I appreciate it. [30:00]

THERAPIST: That's the reason why the leading edge of PTSD within the anxiety disorder NOS to me is a piece of work that in my perspective would be helpful for you to do over time. It's long-term work though. And you may or may not ever be interested in doing that piece of work that involves going back and continuously trying to understand how the anxiety you're experiencing in the present is actually much more about your childhood. It will mean processing that anxiety, it would mean also mourning once you get to know how you are damaged more in a kind of-just in a more obvious way that you are now safely an adult to get to know how this is damaged. Even has influenced your choice of who you were going to marry at some unconscious level, is influencing your experience of Ivan right now, is making some of the things that are really happening feel that much more exaggerated. I think you would benefit in your adjustment to your life, in your experience of parenting your own children one day if that's what you want to do, kind of allowing some of the anxiety to settle down and realize how not to repeat some of the same things that were done with you. I think that would be enormously helpful to you.

The short-run work is managing the symptoms of profound acute anxiety. So when you left here for example and you were having that state happen, I might also think of that as a kind of flashback kind of state. So you're in a place that for our 45 minutes last week in some ways repeated for you, actually repeated for you something of your childhood, where you went in supposedly to be helped, but we end up talking about something that doesn't have to do with what's actually important to you as-you know, in your family as a child, here as a client. And you're left to your own devices, abandoned to your week, and no one's going to help you and you just have to figure it out and do it all on your own. And I think you are totally overwhelmed and flooded with anxiety, like probably what you felt on a daily basis to greater and lesser degrees in your own family growing up. [32:15]

So I call that a kind of flashback emotionally. Helping you in the concrete way with those flashback experiences, with the acute anxiety experiences, I think we can also do in addition to the [unclear 32:27] if you want to do that. What do you do to ground yourself more, what do you do to pull yourself out of that, how do you recognize even when it's happening what's happening so that you can find adult reality and kind of have that mind coexist alongside the child mind that's getting really triggered by something. That's the skills-based work that if you want to work on that for a little while we can just do that.

CLIENT: Okay. May I ask-

THERAPIST: Yes.

CLIENT: What about the depression?

THERAPIST: That's what I'm getting to, yes. I think you have had periods of pretty serious depression. I don't think you're always at a severe level of depression, so I think since I've known you you've probably had a full depressive episode. I don't think for example today you were as depressed as I've seen you been in the past. So even your history of depression before I've ever met you, depression feels like a very clear diagnosis. One of the things I would guess about your depression is that your anxiety about feeling like you're in control, like as long as you do this and do this and do this and do this. That feeling of having to do in order to stay on top of controlling the world, as long as that's sort of functioning-which is funny, because it's a symptom in itself-but if that's working for you it stays at a level anxiety. If you start feeling like there's so much that I can't keep on top of it, there's nothing I can do. Like Ivan right now, out of control, I can't control him. When you start feeling like your doing doesn't even help you anymore you start feeling helpless, that's when the switch happens and it pulls you into a depression. Depression is kind of like when anxiety, the stuff that anxiety-feeling on the top of anxiety, when the scale gets tipped and you no longer feel like you can be on top of it you know-you've probably learned learned helplessness. I don't know if you know that expression of what-

CLIENT: Yeah. [34:30]

THERAPIST: They've done animal studies, models of anxiety and depression for example, where feeling on top of staying alive, or staying on top of getting school, that you can literally watch an animal start to get frenetically anxious. But the moment it starts to feel like it's out of their control they just stop, they go into the corner, they sit, they just stop trying. It's a model of depression. So I think when you feel like that's it, there's nothing I can do, and you feel helplessly overwhelmed then you get depressed. I think then, because of who you are, with this strength of yours, you eventually find your way out of that by re-finding what are the things that I can do for myself. I think those are not just defenses, the skills building in depression is partly doing exactly that. How do we help reactivate a depressive helplessness, get on top of the things that you can do, get on top of good-for example, going to bed at a good time, taking medication if you need to to help yourself sleep, to just get good rhythms going. Eating well. You know, this type of skill building to get you back up. But guess what, we get you back up into your anxious state. Which to me is better than the depressed state-

CLIENT: Yeah.

THERAPIST: -in terms of the progression.

CLIENT: I would agree.

THERAPIST: It sounds like you agree with your psychic experience of that. And then we can start working more on the anxiety piece.

CLIENT: That's very helpful.

THERAPIST: So does that make sense?

CLIENT: No, I really, really appreciate that, that's really helpful. Can I-I don't know if I have anymore time but I-

THERAPIST: Go for it, yeah.

CLIENT: Okay. So I just-it's not a huge deal, but I am-so I'm aware of some of the symptoms lately. [36:00]

THERAPIST: Yeah, yeah.

CLIENT: I feel like I'm pretty-the therapist I saw before helped me pick out some of them and really label them.

THERAPIST: Yes, yes.

CLIENT: But anyway, so it's not only just doing sometimes, it has to be finished. I feel so good when something is finished and it's like this really big deal. But until it's finished, even if I've spent hours and hours on it, like, it's not as big of a deal. So it's like that feels a little obsessive.

THERAPIST: Yup. Yup.

CLIENT: The cleaning thing, I mean, is-it really doesn't happen all the time, but when I do then it needs to be perfect. Or I can look at the apartment and like, "Oh, it needs vacuumed." And so I don't look at it and say that it's clean, I say it needs to be vacuumed. I am exhausted lately. And I'm young and healthy and there's no reason, but I'm literally-lately I don't even understand. I've gone to bed as early as like 9:30 and been asleep by like 10:30. The one night, I swear, I went to bed at 8:30 and didn't get up until 8:30 the next morning. And this is not-and I'm still that kinda tired sometimes when I wake up in the morning. Which is probably because I slept way too long. But it's like not normal for me at all. Even in my most depressed times like I don't sleep the day. And I'm not napping during the day at all even if I'm tired, but I'm just like exhausted. And I try and do the gym thing sometimes because that's-I even catch myself on the elliptical, like I'm so angry and I'm going to fast. But I'm like getting it out a little bit and getting the energy out.

THERAPIST: Yeah, yeah.

CLIENT: Which is good. But I tried to do it the other day and I was just like wiped like a few minutes in. I mean, I finished, but I was just like exhausted. And I'm like, "What is going on here?" Because this is not-

THERAPIST: This isn't typical for you.

CLIENT: No, not at all.

THERAPIST: Yeah.

CLIENT: Then I need to talk about the job graduation thing at some point.

THERAPIST: Yes.

CLIENT: Because I'm freaking out and that's on my mind all the time. [38:00]

THERAPIST: Constantly I'm sure. So one thing I would say right off the bat is before we judge your sleeping a lot too harshly I might try to say just give yourself a little bit of room for forgiveness right now. Because my immediate response is, Ivan, you have a lot going on. I mean, so of course you're tired. You have a tremendous amount-well, even just of your appointments, okay, on top of school-

CLIENT: And it's really like-

THERAPIST: Working on a marriage for example and really getting into the stuff you guys are getting into with each other. I don't think you're giving yourself enough credit. That's hard work.

CLIENT: I feel like it is, but I just-I don't know. I'm not upset, because I'm like not, you know, missing class or any-like nothing like that is going on.

THERAPIST: Yeah.

CLIENT: And clearly as late as 10:00 at night like I'm not looking to those hours for [keep? 38:50] productivity. But it's still a little weird to me. I never go to bed that early. So it's like-and I can't sleep past 9:00 no matter-like even if I'm still exhausted I can't. Which is good probably.

THERAPIST: Yeah, yeah.

CLIENT: But yeah. So-and I'm obsessively thinking like every spare minute I have, even if it's during class when it's not experiment I'm thinking about all this stuff all the time. And it feels like when I journal that's good, when I go to the gym that's good, but I still think about it the rest of the time.

THERAPIST: Yeah, yeah. So again, just to reality check a little bit of-it's of course not-you don't want to be sleeping 12 hours a day. I get that that's not typical for you, it is a symptoms of something. On the other hand you sound like you are exhausting your brain, right. You are thinking constantly about things. And that's where I said just starting off with that look at what you have, even what's upcoming in this transition. It makes sense to me that your brain is getting really tired throughout the day and that you're just wiped. In other words, I think the way in to helping you with sleeping 12 hours a day might be to figure out ways to help you with your over-thinking anxiety during the day. I think your brain thinks that if you think about things enough you will solve the problem. [40:20]

CLIENT: Yeah. Well, and it's not even-it feels like there's no option. Like I can't not think about it, I can't avoid it.

THERAPIST: Right. That's what I would want to start trying to help you a little bit with, is just beginning to tell yourself-so that's the GAD component of the anxiety is a worried brain. Worry is different than anxiety. You've probably-I don't know if you've reviewed this in past CBT, but anxiety itself is the feeling, worry is the cognitive-it's thinking. So it's thinking about the things that make you anxious. People spend a lot of time telling themselves that if you just think about it enough it will feel better. The problem is that if it's productive thinking that's no problem. But if all it is incessant obsessive worrying it actually doesn't solve the problem at all, and it might even make it worse. But people with formal GAD, where that's what you do all day long is worry, worry, worry, worry, worry, worry, think, think, think, think, think, think, think just trying to figure it out, figure it out, figure it out, again, if it goes somewhere and it moves something, productive thought, but if all it is, is kind of thinking in circles, thinking in circles, thinking in circles, right, like this and it just sort of circles, it's not productive and it exhausts you and you're going to go to bed at 8:30.

So I might just starting, one of the things to start to try to tell yourself is thinking about all these things right now doesn't get me any further along in this process. Your brain will actually be furthered along by having a break from thinking about it. If you could just start to say to yourself this week try to thought catch. So the more as you're going on, just to begin to mindfully aware, "Oh, I'm totally obsessing about what to say at the session today with Ivan." Or, "I cannot stop thinking right now, this hour, about what jobs I'm going to apply for." If that hour's better spent studying you want to really notice those other intrusive thoughts. This can also happen in trauma, right, you have intrusive thinking come in as a way of feeling like it gets something more under your control, but it's a fantasy, it doesn't really, it's just an overactive brain and it's interfering in your life. So the more you can just notice the worry thoughts happening. Try to stop them for a second and try to mindfully redirect your focus back on the thing that you're trying to do instead. This is where we said maybe putting worry thoughts in a box in your mind on the shelf. [43:00]

CLIENT: Yeah.

THERAPIST: It sounds like alone doesn't cut it for you.

CLIENT: No.

THERAPIST: But journaling, if you could start to write, okay, this is what I'm worrying about, these are all the things. Just get it out so that you know it's there. That's the other thing that feel like, "Oh, if I don't keep thinking about this I'm going to lose this important thought." So if that's the distortion write it down, you won't lose it, you can have it there with you. I would go back to journaling as much as you can when you notice that thought process getting out of the control.

CLIENT: Okay. I mean, this is happening all-like, I go to the gym to try to do something, I'm listening to music, I'm working out, there are other people, I'm still thinking about it the whole time. Taking a shower, or I tried to take a bath the other day because that's like the ultimate relaxation. I couldn't do it. It's just I don't know how to shut it off. And I can be aware, and I've like tried the cloud thing-

THERAPIST: Yup, yup.

CLIENT: -and it's just like it's gone for like a minute and then I'm right back and I'mSo I can try to do the journaling more. [44:00]

THERAPIST: Try to do the journaling more. If you could while you're journaling this week notice if there's a particular time where it's driving you nuts and tell me a little bit more about it. Like actually write a little bit more about where you are, what's happening, what are the intrusive thoughts. Like I'm interested specifically what are the things that are getting you really obsessional about it. You sound flooded all the time with all different thoughts, so the more we can identify which are the ones that are particularly bothersome, and then set aside more periods of times of day where you're going to think about X, Y and Z.

CLIENT: I don't know, it's just like really-I'm not doing a very good-like I got this cavity filled last week and the whole time I'm thinking about what's going on in my marriage and what's going on in the sessions and what's on my to do list. And every day I'm obsessing over his to do list. Because not only am I like responsible for helping to make it, then I have to-if there are things that are really just his job then I obsess over if they happened, and what if they don't happen and how I'm going to deal with it when it doesn't. And like it's just-

THERAPIST: The other set of skills then that we're going to work on-we've got to stop in just a sec-but allowing some space. I'm going to ask you I guess if this week you could try to pick one thing that you are going to let go, and just let it be [untouched? 45:34]. So for example, you want to clean the apartment, you're running out of time and you really don't have time to do the whole thing. Just say, "I'm going to vacuum this room, and I'm going to stop right here."

CLIENT: Okay.

THERAPIST: And just as a practice, just an exercise for yourself. Take a deep breath and say, "I'm going to act now."

CLIENT: Okay.

THERAPIST: And even if you do it tomorrow that's fine.

CLIENT: Okay.

THERAPIST: Just have a grown up saying, "I'm going to practice here to let certain things go and [unclear, distortion]. Okay, I didn't vacuum in the [unclear] room, just I didn't." Let it pass and find out what are the thoughts that start to come up then. I'm a terrible person, if that isn't clean my [unclear]." Whatever are the immediate thoughts write it down, because we really want to know what are the distortions around [unclear] communication. [46:20]

CLIENT: But is that a thing? I mean, I [unclear] the vacuum, but [unclear] of not finishing, like is that as thing that I'm so-everything has to be finished and then-

THERAPIST: I do, I think that's a symptom.

CLIENT: Okay.

THERAPIST: I think that's a symptom.

CLIENT: Okay.

THERAPIST: And we'll have a-I think we can do that for example, what I would want to start doing is start [unclear]. You say even, okay, vacuum the kitchen and you don't have time to do that, how is allowing yourself to break it down into smaller pieces so that you check off the small piece, right, and have that be enough. There's a way-it sounds like the big thing that has to get accomplished, and if you can get the whole thing finished you don't [unclear].

CLIENT: Or I'd be exhausted. [47:00]

THERAPIST: That can be-say, okay, I did that piece and I finished this piece of the big thing. It allowed me to have some [unclear]. But work on it. For the time being, just for this week-

CLIENT: Okay, okay.

THERAPIST: -keep journaling-

CLIENT: Okay.

THERAPIST: -just to see what's coming up, when there's a particularly bad moment I want to know everything about it. Like pick one that's really bad and we'll come in and talk about that one specifically, if you could bring that in right at the beginning next time.

CLIENT: Sure.

THERAPIST: And practice one time of finding something you're going to say no to.

CLIENT: Okay.

THERAPIST: And just letting go of a piece of it and see what happens, see if you can do it.

CLIENT: Okay.

THERAPIST: Okay?

CLIENT: Okay. Thank you.

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