She had lived in a major city for years and felt confident and secure in her ability to negotiate public transportation. During the pandemic, she worked from home, like a large portion of the global population. Emerging from that dark time, as people returned to work, so did she. Barely a month back on the job, she was pushed against the wall by a man in the subway, had her purse snatched by a man outside a drugstore, was physically assaulted by a man in a pedestrian walkway that connected her neighborhood to public transportation, and intimidated by a man standing behind her at the pharmacy.
All these events occurred within her neighborhood, an upscale complex near an inner-city transportation hub. The final straw was a shooting incident in a public area she had to negotiate to connect with public transportation to work. Paralyzed with fear she withdrew to the safety of her home behind an iron gate and security cameras. If she ventured from the home, it was with Uber or her husband. She had lost her sense of safety and security. Working from home during the pandemic was safe for her, and returning to the office was not initially a problem. But in the shadow of these frightening events, she began experiencing obsessive thoughts, sleep disturbance, hypervigilance, flashbacks, difficulties concentrating, depression, and anxiety. She reached out for help via telehealth and with the devoted support of her husband, treatment began. In a short period of 11 months working with her, she was able to reclaim her sense of safety and security, and her confidence in negotiating her environment. She was to call that 11-month period, “The journey.” Her name was Sarah.
My first step was to remove the pressure of traveling to work so we could begin to address her anxiety as we began to focus on treatment. Fortunately, her employers were very supportive, only asking for documentation to process her request. She was the driver on this journey, so I sent her the document for approval before sending it to her employer. Sarah said when she saw the document, she cried because someone finally understood what she was experiencing. Her anxiety and mood instability diminished with the approval of her medical exemption to work from home.
I typically conceptualize symptom management and coping skills as “tools in the toolbox.” If they are willing, I ask clients to draw a picture of their toolbox and to put their tools inside it. This activity makes an internal process feel more real. I suggest that they add tools as we go along.
At the onset of treatment, Sarah preferred not to use medication. She already had many skills, resources and supports in place. These included her friends, work environment, pets, cooking, reading magazines, gardening, music, exercise, walking, yoga, and art. She and her husband were taking a self-defense program, and he had already purchased a handheld pepper spray for her, which she never left home without. Her husband was her strongest support, ally, and partner in the treatment process, working the plan with her from beginning to end.
During treatment, Sarah was able to share the trauma narrative by describing each incident that occurred. The first step in her desensitization was to describe the walk between her home and the transportation link. Next steps were to have her husband video record the walk for them to watch together which they did, several times.
One month after her first appointment, we discussed using behavior modification and progressive desensitization. Her homework was to develop the plan. She was to work the plan at her own pace, which she did eagerly, logging the steps as she took them, her physiological responses, feelings, and thoughts. We would discuss her journal entries in treatment, and she would modify the plan as needed, especially when barriers and roadblocks seemed insurmountable.
Initially, and each time one of these events occurred, Sarah’s symptoms would briefly re-emerge. During those times, we explored the incident in detail, and how she and her husband responded. We were able to reframe her responses as correct and resourceful choices. She began to recognize that different environments and events required their own unique, rather than blanket responses.
When Sarah did encounter either internal or external obstacles, she would modify her response accordingly, an example of which occurred around her visit to the local drugstore, which was frequented by vagrants. Everything in the store was under lock and key, and customers had to ask for help. During this particular instance, Sarah implemented what we called the “fire drills.” This involved visiting a same-named drugstore in a “safe” neighborhood, and recognizing that it was not the store, but the neighborhood that elicited fear and anxiety. Sarah and her husband concluded the environment they were living in was changing and no longer safe, and that it was time to make a change. Sarah was soon able to apply a related strategy to coping with her fears associated with the tunnel where one of her earlier traumatic experiences had occurred. We successfully added EMDR to her treatment plan.
We had been preparing for termination and scheduled our final appointment. When she came on-line for that session, she excitedly proclaimed, “You are not going to believe this.” She then detailed how she and her husband decided to take the subway home one night after leaving the theater, in front of which there was a protest.
Realizing that while many of her initial fears were justified, Sarah had re-gained control of her life and put her traumas behind her. She had completed her journey both literally and figuratively! She shared her final art project with me, which was a graphic reflection of her healing journey. A masterpiece in every sense of the word; it was being framed as we concluded our work, and was to hang in her new home, as a trailhead of sorts for the next phase of her journey.
File under: The Art of Psychotherapy
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All these events occurred within her neighborhood, an upscale complex near an inner-city transportation hub. The final straw was a shooting incident in a public area she had to negotiate to connect with public transportation to work. Paralyzed with fear she withdrew to the safety of her home behind an iron gate and security cameras. If she ventured from the home, it was with Uber or her husband. She had lost her sense of safety and security. Working from home during the pandemic was safe for her, and returning to the office was not initially a problem. But in the shadow of these frightening events, she began experiencing obsessive thoughts, sleep disturbance, hypervigilance, flashbacks, difficulties concentrating, depression, and anxiety. She reached out for help via telehealth and with the devoted support of her husband, treatment began. In a short period of 11 months working with her, she was able to reclaim her sense of safety and security, and her confidence in negotiating her environment. She was to call that 11-month period, “The journey.” Her name was Sarah.
Preparing for The Healing Journey
Upon initial assessment, my strategic plan was to stabilize Sarah in the face of this crisis, reduce her symptomatic behaviors, evaluate her coping strategies, develop a de-sensitization plan, and incorporate EMDR into the process.My first step was to remove the pressure of traveling to work so we could begin to address her anxiety as we began to focus on treatment. Fortunately, her employers were very supportive, only asking for documentation to process her request. She was the driver on this journey, so I sent her the document for approval before sending it to her employer. Sarah said when she saw the document, she cried because someone finally understood what she was experiencing. Her anxiety and mood instability diminished with the approval of her medical exemption to work from home.
I typically conceptualize symptom management and coping skills as “tools in the toolbox.” If they are willing, I ask clients to draw a picture of their toolbox and to put their tools inside it. This activity makes an internal process feel more real. I suggest that they add tools as we go along.
At the onset of treatment, Sarah preferred not to use medication. She already had many skills, resources and supports in place. These included her friends, work environment, pets, cooking, reading magazines, gardening, music, exercise, walking, yoga, and art. She and her husband were taking a self-defense program, and he had already purchased a handheld pepper spray for her, which she never left home without. Her husband was her strongest support, ally, and partner in the treatment process, working the plan with her from beginning to end.
During treatment, Sarah was able to share the trauma narrative by describing each incident that occurred. The first step in her desensitization was to describe the walk between her home and the transportation link. Next steps were to have her husband video record the walk for them to watch together which they did, several times.
One month after her first appointment, we discussed using behavior modification and progressive desensitization. Her homework was to develop the plan. She was to work the plan at her own pace, which she did eagerly, logging the steps as she took them, her physiological responses, feelings, and thoughts. We would discuss her journal entries in treatment, and she would modify the plan as needed, especially when barriers and roadblocks seemed insurmountable.
Addressing the Clinical Obstacles
Sarah’s environment provided unanticipated challenges that put her coping skills to the test. Multiple such incidents occurred in their neighborhood; a man fleeing from the police jumping into their backyard while they watched, a shooting in the lobby of a theater before they arrived, teenagers rioting over the weekend, and a man riding a bike in the neighborhood being attacked.Initially, and each time one of these events occurred, Sarah’s symptoms would briefly re-emerge. During those times, we explored the incident in detail, and how she and her husband responded. We were able to reframe her responses as correct and resourceful choices. She began to recognize that different environments and events required their own unique, rather than blanket responses.
When Sarah did encounter either internal or external obstacles, she would modify her response accordingly, an example of which occurred around her visit to the local drugstore, which was frequented by vagrants. Everything in the store was under lock and key, and customers had to ask for help. During this particular instance, Sarah implemented what we called the “fire drills.” This involved visiting a same-named drugstore in a “safe” neighborhood, and recognizing that it was not the store, but the neighborhood that elicited fear and anxiety. Sarah and her husband concluded the environment they were living in was changing and no longer safe, and that it was time to make a change. Sarah was soon able to apply a related strategy to coping with her fears associated with the tunnel where one of her earlier traumatic experiences had occurred. We successfully added EMDR to her treatment plan.
We had been preparing for termination and scheduled our final appointment. When she came on-line for that session, she excitedly proclaimed, “You are not going to believe this.” She then detailed how she and her husband decided to take the subway home one night after leaving the theater, in front of which there was a protest.
Realizing that while many of her initial fears were justified, Sarah had re-gained control of her life and put her traumas behind her. She had completed her journey both literally and figuratively! She shared her final art project with me, which was a graphic reflection of her healing journey. A masterpiece in every sense of the word; it was being framed as we concluded our work, and was to hang in her new home, as a trailhead of sorts for the next phase of her journey.
File under: The Art of Psychotherapy