TRANSCRIPT OF AUDIO FILE:

BEGIN TRANSCRIPT:

THERAPIST: So I'm clear. You have new insurance but you don't have any information yet. When you get it you'll give it to me and I will give it a whirl billing it and we'll see how that goes.

CLIENT: Yes. I need to catch my breath. The post office downstairs is awfully cranky.

THERAPIST: Oh, really?

CLIENT: I got here early.

THERAPIST: This is the Kinko's?

CLIENT: No, the U.S. Post Office. I got here a little bit early because I had a package to mail to a friend in the U.K. One was ridiculously long and the forms were all mixed up and not labeled with the name of the form. I finally found the form that said Customs Declaration. I spent time filling it out while people behind me skipped me in line to go ahead while I was writing. I finally get to the table and the guy is like, "This is the wrong form." I was like, "Okay. What form do I need?" "Go back and get the Customs form." It says "Customs Form". " Well that's the customs form for packages over 16 ounces." "Well, it doesn't say that on the form and I didn't know," and then he made me go get back in the back of the line. [00:01:16]

THERAPIST: Ugh.

CLIENT: Yeah. (snickers) Yeah.

THERAPIST: A lot of times they just let people, if they make you go get something, they just say, "

Come back up to the front." Not today.

CLIENT: Yeah. (pause) I don't know. (pause)

THERAPIST: What's on your mind?

CLIENT: I don't know. I'm tired and cranky and not feeling well. (pause) [00:02:20]

THERAPIST: Like emotionally?

CLIENT: And physically.

THERAPIST: All around?

CLIENT: Yeah. I've had a headache all day, but it's been resistant to pain killers, both over the counter and prescription. (pause) [00:03:46] Dave and I have been fighting a lot the last couple of days. I've been feeling really low. My mood has been lower the past week and a half to two weeks than it has been in quite a while. (sighs) I told him I was feeling low and that I was just really upset about a lot of things and I've been having these meltdowns at the end of the day where, almost like a little kid having a meltdown. It's just that they're too tired and they need to go to sleep but they refuse to. It's the same sort of completely losing all grip on reality and feeling like everything is overwhelming and I can't do anything. I know those are really stressful for Dave to witness. I really try to keep them bottled up and not expose him to it but I don't know. I've been kind of having this shaky edge on my self-control the last week or so. Anyway, I told him I was feeling really bad and I was really upset about the whole insomnia situation and that it's not getting any better. I have so much trouble getting to sleep, staying asleep... [00:05:14]

THERAPIST: I know you mentioned it, but we hardly talked about it. Can you tell me a little more about what happens?

CLIENT: It's just I can't sleep ever. I'll be completely exhausted at work at my desk falling asleep or sitting at home in my home study or on the couch, nodding off. As soon as I get to bed I'm wide awake and I can't get to sleep. It's really frustrating.

THERAPIST: And how long do you usually lie there?

CLIENT: Until two or three in the morning.

THERAPIST: When are you first in bed?

CLIENT: Usually between eleven and midnight.

THERAPIST: Okay. And then do you usually get up at two or three or do you eventually conk out or...?

CLIENT: I eventually conk out.

THERAPIST: And then do you sleep through until sometime in the morning?

CLIENT: No. I usually wake up two or three times a night.

THERAPIST: And then you get up at...?

CLIENT: Depending on how much sleep I've gotten and how much willpower I have, between seven and eight.

THERAPIST: You're sleeping about five hours or so, with two or three interruptions, in an ongoing way.

CLIENT: Yep. [00:06:21]

THERAPIST: I assume you've got some good drugs for this, but clearly not good enough?

CLIENT: Ambien doesn't work. I was trying Ambien, but it just doesn't knock me out. I've tried trazodone, which is an antidepressant, not a hypnotic, but it does...

THERAPIST: It's used often for sleep.

CLIENT: Yes. And the problem with that is, even at the smallest does 1/4 of the smallest tab that is manufactured it will knock me out; but then I'll sleep for ten hours and feel hung over when I wake up. I have the same problem with Benadryl. [00:06:59]

THERAPIST: Do you reset? Oftentimes when people have an ongoing sleep difficulty like that, if they get one night or a couple of nights of decent sleep, it then makes it easier after that. Does that happen with you?

CLIENT: No.

THERAPIST: Okay. So if you took Benadryl for a couple of nights, took it early, planned to go in late, did that over the weekend, there would be no difference on the next night? Okay. And how long has it been like this?

CLIENT: Years.

THERAPIST: You've been getting five hours an night with two to three interruptions for years?

CLIENT: Yep. On weekends, like generally Saturday mornings, I'll just not turn on the alarm and I'll sleep and get ten or twelve hours wake up at 10:30 or 11:00. [00:08:04]

THERAPIST: Okay. So if you could go to sleep every night at two or three and wake up at ten or eleven which I know you can't in real life but to understand, that would be better?

CLIENT: Yeah. I don't know how I could get my sleep cycle to move earlier. It should be a simple thing because I'm waking up between seven and eight. You would think I would just fall asleep after sixteen hours of being awake, but no.

THERAPIST: Who prescribes for you?

CLIENT: I don't have a name. I saw a Dr. Morgan (sp?) but I didn't like him at all. Then I missed an appointment because I screwed up my calendar and I was too embarrassed to call and tell him that I recorded it wrong. Then time went by and I got increasingly too embarrassed to call and ask to reschedule. Yeah. That was in October. [00:09:09]

THERAPIST: What had he prescribed?

CLIENT: He prescribed nothing. He said that, based on the notes that he got from my previous psychiatrist and my self-reported symptoms, he didn't think I needed anti-depressants any more. He wrote me a script for Ativan to use on an as-needed basis; and I haven't run out that script yet because I haven't actually felt the need for it. He said he wanted to check in again in six weeks, so we did. Then he said, "Sounds good. Nothing has changed. Let's check in again in six weeks," and that's the appointment I missed. [00:09:49]

THERAPIST: Right, right. This is a psychiatrist, right?

CLIENT: Yes.

THERAPIST: Was she pretty aggressive about the sleep stuff? Did she try other things besides Ambien and trazodone?

CLIENT: She was the one who told me to do Benadryl.

THERAPIST: Right, which has the same stuff as [...] (inaudible at 00:10:09).

CLIENT: She got really aggressive about monitoring my sleep hygiene and telling me I had terrible sleep hygiene; and to do better and these sleep problems would just go away if I followed the rules better.

THERAPIST: She did nothing?

CLIENT: Nope.

THERAPIST: Have you ever tried [...] (inaudible at 00:10:23)

CLIENT: I had not.

THERAPIST: I guess I'm thinking it might be good to get you a new prescriber.

CLIENT: I haven't tried Lunesta either. That's an option.

THERAPIST: Yeah. Okay, look, I don't mean to derail us in actually talking about what's going on, nor am I convinced that this will solve your sleep problems or that my guy giving you anti-depressants right now is even possible, but I think some of this stuff might help. We should probably get the ball rolling on that. I can think of a lot of things. One, if you e-mail me, do you want to use your insurance for it? [00:11:36]

CLIENT: Yes.

THERAPIST: Okay. If you e-mail me the list of people in your insurance who are in the area, I can look through it and see if there is someone I know, unless you think you might know somebody already. It will probably mean a bunch of calls [...]. (inaudible at 00:11:49)

CLIENT: Yep.

THERAPIST: Okay. All right. We can stop with that for now. It just seems like that's a good ball to get moving. You've probably tried about a million things for sleep, so I'm not going to try and suggest anything for sleep because you've probably already tried it a few times and it doesn't work.

CLIENT: Yeah. But, yeah. I was telling Dave I was really frustrated that I couldn't get to sleep because this is so stupid. He woke me up less than an hour after I finally dropped off to ask me to move over because I was taking up too much space in the bed; and then I did not get back to sleep at all that night. He woke me up at five and then I was just up. I couldn't get back to bed. When he finally rolled out of bed at 8:30, I was like, "That was totally unfair. Don't ever do that again. I know it's not fair to you if I take up more space on the bed and maybe you have to go sleep on the couch, and that's not fair; but I need to be able to sleep and I have so much trouble sleeping." He just went off at me and yelled at me about how I wasn't doing anything about my sleep problems and he had told me to try vitamin D because that would fix my sleep problems and why wasn't I better? [00:13:17]

THERAPIST: You've tried a whole lot of things. If you actually hadn't tried anything I would take his point, but there are doctors that have prescribed you three different medications and made a huge fuss. You've tried all of them and it hasn't helped at all.

CLIENT: His vitamin D suggestion is something that he pulled off the fucking Internet. It's not something that came from a doctor and the number of bullshit snake oil, fix-your-life remedies that Dave has tried because some of the quantified self people did it on themselves are you familiar with this phenomenon the quantified self? There is this trend among a certain type of techy people. The medical industrial complex is bullshit and doesn't know anything and you can't trust doctors or medical professionals. The only thing you can trust is yourself because no one knows your body as well as you do. So they do experiments on themselves untested, uncontrolled unscientific experiments and then write blog posts about it and then they try each other's ideas for how to lose weight and build muscle and develop chest hair and sleep well and lower your cholesterol by taking 6,000 I.U. of vitamin E. To an extent, I agree with some of the underlying arguments that the medical industrial complex is way too industrialized and big pharma kind of sucks. Doctors who are overscheduled and will only see you for ten minutes really don't know as much about your body as you do because... [00:15:03]

THERAPIST: It does not necessarily mean the answers are on some blog on the Internet.

CLIENT: Right. So Dave started yelling that I didn't want to try this vitamin D thing and I was like, "Well, you're suggesting that I take something like 12 times the FDA recommended allowance of vitamin D." A lot of these things I just read a study about a month ago about how vitamin C and the doses that people take to fight off winter colds, like 10,000 I.U., is actually toxic to your liver, so I really don't want to take twelve times the FDA recommended vitamin without medical supervision. He got really mad at me about that. Then a few days later I told him that I was feeling bad enough that I was worried for my safety. I was afraid I would hurt myself. He just started yelling at me again. He told me I was selfish and I wasn't thinking about his feelings and he wished that he could believe that I loved him, but he can't because if I did I wouldn't be thinking about suicide and it would destroy his world. What if I attempted suicide and failed? Then I would be mentally disabled like his brother and, "Do you really want to be like my brother? Do you really want to have that level of mental reasoning?" [00:16:19]

THERAPIST: You're feeling extremely sympathetic with him, I'm sure, at that point.

CLIENT: Yeah. Things have been rough with me and Dave and I don't know what to do about it (sighs) because I know living with me isn't easy. I'm a pain in the ass to live with. (chuckles) In some regards he kind of has a point.

THERAPIST: About what?

CLIENT: About it's selfish with me to kind of dump all my internal chaos on him and not provide better buffering and to rely on him as much as I do. It's not sustainable and not fair to him.

THERAPIST: I see. I don't question it, but I take your point. It's your view that you're kind of doing it too much to him. I don't know how to evaluate that in a sense because, on the one hand, I know you're having a very hard time and there's been tough stuff at work, you're sleeping five hours a night. Maybe we haven't talked much about that because I don't remember some of that; or maybe it was a while ago and I forgot who knows. Anyway, whatever. The point is, clearly you're having a very shitty time and it certainly makes sense to me that that could lead one to dump more on their spouse. On the other hand, you get so angry at yourself for dumping anything on anybody, I could kind of see it going on. Whatever. I take your point that it's putting strain on the relationship. [00:18:24]

CLIENT: Maybe this is the sort of thing that we should just see a couples' counselor together about.

THERAPIST: You could. You could do that.

CLIENT: It drives me crazy. He won't tell me what he's feeling. I'll ask him, "Can we talk about how you're feeling?" "I don't want to talk right now." "Okay. Can we set a time to talk?" "I don't want to schedule it." "Well, when can we talk?" "You asked me on the spur of the moment. I haven't had time to put my thoughts together." "I can ask you now and I'm going to come back in an hour. Can you put your thoughts together by then?" And then he won't. He claims that he doesn't need to see his therapist, too. He's had a relationship with his doctor since 2005. He sees him once every three months and it's mostly just to prescribe meds. [00:19:35]

THERAPIST: What does he take?

CLIENT: He has ADHD, so he takes Concerta, which is one of those drugs where you kind of have to go see a physician in person every three months because of FDA regulations. He also does psychoanalysis/therapy sort of stuff. He's not just a prescriber; but Dave refuses to go in for therapy to talk about some of this stuff. He won't tell me how he's feeling until he blows up at me and accuses me of not loving him. (pause) It's really frustrating. [00:20:28]

THERAPIST: Yep. (pause) You're utterly overwhelmed.

CLIENT: Yeah.

THERAPIST: And at your wits end.

CLIENT: Yep.

THERAPIST: And how suicidal?

CLIENT: Not close enough to actually be contemplating making plans.

THERAPIST: That part's good.

CLIENT: Yeah.

THERAPIST: But close enough to be thinking about it?

CLIENT: Yeah. (pause) I'm really tired of this particular song and dance. [00:22:27]

THERAPIST: What's that?

CLIENT: Fighting off suicidal urges.

THERAPIST: Tell me about how you're really sick of it.

CLIENT: The first time I wanted to kill myself I was eleven. I ate a pack of my parents' cigarettes. It was not a very pleasant plan.

THERAPIST: What did they do?

CLIENT: They made me throw up.

THERAPIST: That's it? No shrink?

CLIENT: Nope.

THERAPIST: [...] (inaudible at [00:23:16]) eleven year old to a shrink when they eat a bunch of cigarettes. Crazy. I mean crazy of your parents you were a super-depressed eleven year old. It's pretty unusual for that age to do something like that. I mean fifteen, okay. Eleven, not so much. I've seen certainly girls who want to jump out a window or something; but kids just don't usually try stuff. [...] (inaudible at 00:23:45)

CLIENT: I was really isolated throughout my entire childhood. I had no friends at all. I was tormented at school, tormented at home, but (sighs) even at my happiest in the last ten years or so, there's always been the thought in the back of my head that things are good now, but don't expect them to stay good. You can always kill yourself tomorrow if they stop being good. What's that scene from The Princess Bride? "I'll kill you tomorrow."

THERAPIST: Yeah. Or Scheherazade. The Arabian Nights?

CLIENT: Oh. I'll kill you in the morning?

THERAPIST: Is that right.

CLIENT: Yeah. I mean sometimes it's been the kind of downer "this is your dirt cloud on a sunny day" thought and sometimes it's been literally the only thing that's kept me from doing something right now, but... [00:25:08]

THERAPIST: You'll still have the option.

CLIENT: Right. I can always change my mind about living tomorrow. (pause) (sighs) I'm kind of sick of having that thought always in my head. (pause)

THERAPIST: [...] (inaudible at 00:25:40) (pause) What's amazing is you're having a really, really hard time.

CLIENT: Yeah, but I feel like it's always a really, really hard time. There's no bounding to that. It's an endless hard time. [00:27:11]

THERAPIST: You might be right about that, but I'm not sure. On one hand, clearly there's some of the stuff that we don't talk about that much and maybe we should more and I don't know how much is that I just haven't known about the ongoing way in which some of these things are just completely awful. It has not come across so loud and clear to me as today. Last spring when you were in school there was a time when it was really bad. There have been some times when you started working where I don't think of it as "bad", but I guess they didn't seem to me that they had been this bad. Again, I don't know if that's just sort of my not knowing about it or your feeling like things are going that way now and something has happened. The question is, "Which is it?" [00:28:44]

CLIENT: I'm not sure.

THERAPIST: Okay. (pause) There was the time, I think it was last spring, when you were pretty close to taking some pills, right?

CLIENT: Yes. It was actually last winter. It was why I fired my previous therapist.

THERAPIST: There was another time since we had been meeting where you'd opened a cabinet. Was it before we met?

CLIENT: Yeah. I probably told you all about it. [00:29:33]

THERAPIST: Right. (pause) I'm confused because I thought you had fired her because of how she was about some of the stuff you were talking about.

CLIENT: (sighs) There was a lot that I didn't like about the treatment plan that she had; but the straw that broke the camel's back was that I had been wanting to kill myself, to the point where I was hording pills and I got scared enough to ask Dave to come and take them and hide them. She completely blew that off and redirected the conversation to talking about my dad and why he is the way he is kind of arm-chair diagnosing him from a distance, which I certainly don't have enough insight into what's going on to provide enough symptoms for... [00:30:53]

THERAPIST: That's certainly not useful or a shrink's style to diagnose anybody that you haven't met with.

CLIENT: Right. Maybe he does have PTSD. That's quite likely given his history, but there is nothing I can do about that.

THERAPIST: Yeah. It certainly wasn't relevant at that moment. (pause) Okay, let me be very clear when I'm going to say, "I am not blaming you." I'm waiving my arms saying that I'm not blaming you; but I think it can be hard sometimes but I'm glad you're doing it now for you to say how awful or dire things are and what all is contributing to that. I think there are [...] (inaudible at 00:33:06) hard for you and that's why I'm saying I'm not blaming you. Also I'm glad you're letting me know now. You already told me last week things were worse. You don't hide things exactly. [00:33:19]

CLIENT: I have a strongly developed instinct to mask.

THERAPIST: I think so. I think you're worried about talking about it. With some people when they don't it feels more aggressive, like they're kind of angrily keeping things back. I think you're more frightened. I could be wrong, but you probably feel pretty ashamed about it and worried that it's going to make you look like an asshole and that whoever isn't really going to want much more to do with you. Is that about right? [00:34:02]

CLIENT: Yep. I'm also worried that if I let other people know just how bad things are, they will use that to take advantage of me.

THERAPIST: I see. (pause) I know that there is a lot that we haven't touched on about how things are awful, a lot to do with how sleeping affects you, work, which is what we were talking about last time, I think, and some of the suicidal thinking. I know I've asked a lot of questions. I guess I sort of felt like I want to get the lay of the land a little bit and worry about missing other things. Are there other things at the moment that we are missing? Are there other things that are feeling as bad as well? [00:35:43]

CLIENT: There's the chronic never-ending stress of my parents, which waxes and wanes. There is that; again, waxing and waning, but never fully going away. I have anxiety around friendships and do people actually want me around and what is my value and all of that. (pause)

THERAPIST: When is the trip with your family?

CLIENT: Mid-May. May 15th to 27th.

THERAPIST: I thought it was March or May. It's May. (pause) What's on your mind at the moment? [00:37:03]

CLIENT: (sighs) We have to get visas for this trip to China and my dad won't make up his mind whether he wants to deal with getting visas for everyone or whether he wants me and Dave to get our own. I e-mailed him to say, "The trip is in four months. We need to get our visas. Do you want me to mail you our passports and visa applications so you can get everyone's visas?" He replied with vague, incoherent rambling. I replied back and said, "Just tell me either way, but we need to know." I cc'ed my sister because my sister has been pretty much the only person in my family and I include myself in this criticism who is capable of dealing with logistics and keeping track of things and staying organized. She sent me this really nasty e-mail back saying, "I don't know why this is such a big deal for you, whether you send them to the travel agent or whether dad sends them. Why do you care? Stop bugging dad. Stop using e-mail. You should call and talk to him." I was like, a) I hate using the phone, having [...] (inaudible at 00:38:17) argues on the phone in the best of cases; b) I have a hard time understanding my dad because he mumbles; c) in e-mail at least there's a record of what is said; d) dad has a hard time understanding me because I don't know he says my English isn't clear enough for him, that I talk too fast and use too many big words, even though I make every effort when I'm talking to him to speak slowly and clearly. [00:38:45]

THERAPIST: I don't find you particularly difficult to understand.

CLIENT: My dad makes a big deal of his not being a native English speaker, even though he learned English when he was eight years old and has been speaking it since then and speaks fluently. I think he just uses it as an excuse, but with the written word, you can reread it if you don't understand and there's a wall. Also, it matters because I don't want to just send a passport to this travel agent. I need a booking code or something so that the travel agent knows who these passports are for. I ended up reading the whole log of items and e-mails between my family and myself about this stupid fucking trip and I didn't realize until I read them all together in every single regard about this trip planning, they've been disrespectful and dishonest with me. It's not just about booking dates that I didn't want to go, it was also (sighs) dad e-mailed me and said, "The travel agency offers flights to China from L.A., Boston or Chicago. The default is L.A. and you have to pay more to go from Chicago or Boston." What did Dave and I want? He gave us the table of prices. I said, "Why don't you book us straight from Boston because the surcharge from the travel agency is less than the cost of a plane ticket from Boston to L.A. In summary, please book us from Boston." He replies and says, "We booked you from L.A. You can call the travel agent if you want to go from Boston." I said, "But you asked me and I said, ‘Book from Boston.'" He was like, "We don't know your schedule." You're booking this trip. The schedule is determined by the flight from L.A. I was like, "Okay, fine. We'll book the fucking flight from Boston to L.A. Give me the contact info for the travel agent." He didn't send it. There were three e-mails in a row from me to dad saying, "Give me the info for the travel agent so I can book us from Boston to L.A." Finally he said it's such-and-such travel agency. Don't something I don't remember now. He gave me the name of the travel agency. I was like okay, fine. Then he said, "No, no. We'll do the add-on since you don't want to pay for it." I was like, "It's not the money. It's not being able to have the name and the information to call." He was like, "You don't have to go through the travel agency. Why don't you just book a ticket on the Internet from Boston to L.A." I was like, "Okay. What time does our flight from L.A. depart?" "I don't know. Why do you want to know that?" [00:41:53]

THERAPIST: We should stop.

CLIENT: Sorry. I got going.

THERAPIST: No, no. It's okay. Go ahead.

CLIENT: I hate my parents. That's all.

THERAPIST: This is another can of worms, but I have three things quickly. One is, do you want to talk more about the trip? I know you haven't been hot about whether to go or not. Maybe it's worth thinking about a little more. I don't want to put something out that's stressful on you. If it's going to feel stressful to think about, we will wait a while. Second, I wonder if it would be helpful to have another time here. I would have to check. I'm pretty wacked at the moment, but I would do what I could to do that if that might help. I don't want to sort of promise or dangle, I just don't know if I have that. I will look.

CLIENT: It would have to be a morning because of scheduling with work and leaving early.

THERAPIST: Well I'll look. And third, I hope I mumbled something about this when you first brought it up, but certainly if you have been suicidal and scared you can call me. I get calls I don't want to say all the time, but certainly sometimes like that. Have I mumbled something about that before? Okay. Good enough. All right.

END TRANSCRIPT