Mr. D: A Psychotherapy Story
Updated: Nov 6, 2020
By Terry M. Pace, PhD (2020)
One of my most memorable and rewarding patients to work with over the years was a man I will call Mr. D. As always with a story based on a real case, much information has been left out or obscured, but the essence of the story is as true as my memory allows. I have shared versions of his story with countless students and even other patients over the years (in full confidence of course).
Mr. D was a WWII veteran in his 60’s at the time I saw him many years ago. He was referred to me by an ER physician who saw Mr. D many times for acute exacerbations of Chronic Obstructive Pulmonary Disease (COPD). Mr. D. had been making many ER visits through 911 calls from his home. His physicians believed his ER visits were likely due to anxiety and panic that did have real exacerbating effects on his breathing such that he felt he was suffocating, reported chest pain and felt like he was dying. Typically he only needed oxygen in the ER with time to calm down and be reassured that his lungs were actually stable. Usually in the ER he did receive a dose of anti-anxiety medication as well. But both the misery this caused for him and the expense to him and the health care system were substantial and he did have real risks that untreated, his exacerbations could cause him to pass out and fall or trigger other problems he was at risk for such as a heart attack. He further voiced suicidal thoughts some of the times when these events happened.
Initially I addressed Mr. D’s risk for suicide and found it to be low, but real, so we did immediate suicide prevention counseling as a precaution. After I reviewed his extensive medical records and consulted with his physicians, I held a few visits with him to further assess his needs and get to know him so we could try and figure out what might help him the most. I also had him complete some psychological testing to get a broader view of his distress and personal inclinations for dealing with his emotions. In this process, I diagnosed him with Major Depressive Disorder, Complicated Bereavement, and Generalized Anxiety Disorder with Panic, along with a diagnosis of psychological factors affecting other physical health conditions (COPD).
I found Mr. D to be a good natured, friendly, no non-sense sort of fellow. As is found to be most important in psychotherapy research, I initially focused on supportive, active listening and working to build an emotional interpersonal connection based on trust and openness with Mr. D. In essence we built what psychotherapy researchers call a “working therapeutic relationship.”
He shared his history and concerns openly as I sought to be sure to understand life from Mr. D’s experiences and point of view. He had some traumatic war experiences but did not suffer from PTSD. He had married and had a family after WWII and had worked in the construction field for over 30 years. He had been retired several years and his wife had been deceased from cancer for about two years when I saw him. He had two sons, both whom had grown up and moved to other states for work and their own families; they were supportive but distant and Mr. D did not like calling on them. So, Mr. D now spent almost all his time alone. He reported his days passed by quickly with reading and watching western movies. But the nights were very long for him and usually it was late at night when his worst anxiety came and with being alone and short of breath, on the worst of those nights, he did what he could by calling 911 for help. His willingness to reach for help I took as a hopeful sign that he was motivated to make changes needed to feel better, so I relabeled this as a strength rather than a weakness for him.
After collaborative exploration of all of this we discussed various options for help. First, with his permission, I further consulted with his physicians and he did begin an anti-depressant that can also be helpful for anxiety. We spent the next few weeks focusing on coping skills for anxiety and shortness of breath. Mainly this consisted of a better understanding of his own feelings and thoughts that might be escalating his depression, then his anxiety at night. With this better understanding (thoughts were mainly about being helpless, missing his wife and family and dying alone; feelings of mainly sadness, then fear) we also explored the early warning signs these thoughts and feelings were related to, in order for him to be able to recognize these moods early before his tension levels were too high to manage. One of those early warnings of building anxiety for Mr. D (and for many folks) was a mild tightness in the chest and throat and that sinking, emptying, shaky feeling in the stomach (the body almost always tells on the brain, since they are fully connected and sustain each other and these are common normal symptoms of an over activated sympathetic nervous system). Once he had developed this new understanding to use as a cue to use the new coping skills we were building, we discussed options for responding to reduce and manage these cognitive – emotional – physiological symptoms.
He was interested in “fast” progress which can be ironic for many folks with anxiety as in general, slowing things down and allowing calm and rest will lower anxiety. However this impatience and tendency to action was consistent with his life history and instead of trying to seek personality changes (his personality was just fine), we proceeded to help him use a breathing-relaxation-imagery coping method to lower anxiety (a common behavioral treatment). He shared details of an engaging and happy place from his memory that he could use as a mental distraction method of relaxation. His behavioral training sessions then consisted of deep regulated breathing, followed by total body progressive muscle relaxation (tensing and relaxing each main muscle group in the body progressively with regulated breathing), followed by guided imagery to enhance situational relaxation (all designed to re-balance the sympathetic nervous system, regulating breathing, improving oxygenation and blood flow and cutting anxiety off at the pass, thus improving his quality of life and reducing excessive ER/911 services).
All seemed to be going well as we worked though the first behavioral treatment session. Mr. D reported to have felt calm and relaxed though the progressive muscle relaxation stage. His biofeedback indicators (which can be helpful when available but are not necessary in most cases) supported his self -report and indeed his blood pressure, heart rate, GSR and EMG readings all indicated he was activating his parasympathetic nervous system over the sympathetic nervous system, thus gaining in relaxation. This all continued until about half way through the guided imagery when Mr. D suddenly yelled at me to stop and he let me know it was not working for him (all shown as well in his bio measurements and I had already started to observe more labored breathing and some restless movement). He inclined his chair, sat forward and proceeded to educate me. During any psychotherapy, I always work to inform and encourage autonomy and self-determination for every patient, thus we proceed or stop, recover and reevaluate his treatment experience.
As we discussed what he was experiencing, he shared that the breathing exercises alone had calmed him, but agreed the progressive muscle relaxation was also helpful and he could see using that if breath consciousness alone did not help enough. He shared that the first part of his guided image was also nice but he grew restless, impatient then almost panic (like he gets at home) when I reached a certain place in the image. In rough form, shortened, here is the image we had agreed to use:
Imagine you are planning a weekend trip to your lake cabin. Remember what those days were like, getting ready to be in your woods and away from many stressors. Remember who was with you on the best of those days. How did you pack? Remember what you usually wore as you made the 3- hour drive. Who drove? What vehicle? What weather do you see as you travel? Do you stop along the way? Remember this trip, how you went so many times, through both good and bad, mostly with your family, but sometimes alone just for the peace.
Now what do you see as the trip to the cabin draws near the end? Where do you park? How do you unpack? Where do you go first? Who is with you? What do you like to do the most? Now you notice how beautiful the lake is and the way light gleams and dances over the lake, so you sit down and relax in full, let go of any other worries, see the beauty in the lake, let happiness wash over you with the lapping of the lake on the shore. So taking a little time a couple of extra minutes to let good memories and feelings wash over you and lift your spirits, allowing you calm breaths and peace.
In real life this relaxation imagery script would often be much longer and more detailed but in the end should be tailored to each person’s needs. Any healthcare treatment is based on the probability of it being helpful and that the pros outweigh the cons. More often than not, effective treatments need adjustment to the uniqueness of each person and situation and so we proceeded to make these adjustments for Mr. D.
I asked Mr. D to tell me what about the lake imagery seemed to cause tension for him. He said that he had always been a man of action (consistent with my initial assessment of his proclivities). That he enjoyed the imagery and felt at ease until I guided him to sit down and reflect on the beauty of the lake. He explained he had always preferred working to watching and working was how he coped best with other troubles, forgetting them in the work. We discussed the types of work he did at the lake and he talked about there always being repairs to make to an old cabin and dock, but that his simple favorite was chopping fire wood. We then agreed to try the relaxation plan again but that he would be engaged in imagery of chopping wood this time, from which he could also enjoy the beauty of the lake! It worked like a charm. He was able to obtain deep relaxation and calm. We practiced and reviewed this approach for a couple more sessions and he was having much better evenings at home, using one or all aspects of the coping skills as needed when his loneliness and anxiety showed their faces to him.
What works for one person may not work for another and in fact may even exacerbate their problems if misapplied. Most people would find sitting and watching the beauty of a lake to be relaxing, so I had mistakenly assumed the same for Mr. D. Thankfully, he was comfortable enough to tell me what was working and what was not working in his treatment. About 70% of psychotherapy patients are significantly improved within about 3 to 6 months. However about 10% are worse off, often because the therapeutic relationship was not established well enough for a fully open therapeutic relationship or the therapist was too rushed or too much one-size-fits-all in approach. Also, some people relax more with breathing, some with progressive muscle relaxation, some with meditation and/or imagery, some with combinations of each. Some people are workers and some are watchers and a hundred other variations that good psychotherapists are taught to recognize and adjust for and since every detail cannot be known ahead of time, effective psychotherapists are open to their own ignorance and biases and are open to learn from and be guided by their patients (the same is true of other health care providers as well).
The good news is that for Mr. D and many patients, an empathic, devoted, trustworthy therapeutic relationship with me, allowed him to fully disclose and to openly discuss his unique views and needs; thus allowing me to better understand and more accurately evaluate his needs as well as his on-going response to the treatment plan we had mutually agreed upon. In about 6 weeks of time, Mr. D was already feeling better, coping better with the relaxation exercises and had been able to manage a few highly anxious evenings and remain safe and well at home with no new ER visits or 911 calls (He had always used oxygen to home and this was reenforced by his providers with once weekly home nursing visits scheduled). With consent, communicating with his home health providers further reinforced the goals I was working with him on.
At this time, we continued to practice his relaxation skills in the first half of our weekly sessions, but moved along to addressing other, longer-term or underlying issues impacting on his depression. He was lonely and together we discussed options to increase his social support (of course therapy itself as an interpersonal relationship based on honesty and respect and is in itself helpful in reducing the sting of loneliness). However, the more independent means and culturally relevant means for addressing loneliness, the better for long term improvement. We did some research on community resources near to him and found a local veteran’s group (all men) that met weekly for a meal and dominoes and chit chat among friends at a near- by senior citizens center (there were even several WWII vets and several widowed men active in the group). Mr. D was able to attend and found he enjoyed himself much more than he expected. This community group (really just a group of friends who shared veteran status) began to lift his mood further and offered an outlet to look forward to most weeks. He even was able to exchange phone numbers with a few members who began to call upon Mr. D on occasion.
Finally, we spent time discussing his grief from the death of his wife and making space for Mr. D to talk about his feelings, gain supportive feedback and normalization about the complexities of grief, and begin to be able to remember positives about his wife and their lives together in a way that lifted his spirits, rather than only the emptiness that came to him before. In working on grief and loneliness we used a more person-centered, existential and narrative approach to therapy. Exploring the meaning he found in his life and how grief and living alone could be reconsidered as new chapters in the overall story of his life; offering practice in living rather than only in dying, which is where he had been stuck.
These additional weeks of therapy also provided more time for him to continuing and practice relaxation coping skills, and for the SSRI anti-depressant to work (and the medication did seem to help his mood, sleep and appetite, so he felt more energy and just better overall). After about 3 months total of psychotherapy care, Mr. D was doing much better and we agreed to stop active visits with a planned follow up once a month over the next three months and an open door to call and came in if needed. After a total of 6 months he remained much improved and had not required any ER visits in this time. He did remain on his anti-depressant as monitored by a very informed physician.
Mr. D was a sweetheart. He was a brave and good man who had come upon some hard times as he aged; the death of his wife and his own declining health being the main two issues. It was an honor to get to know him and be a small part of his life. I loved his honesty, courage and sense of humor. Though many years have passed, I have never forgotten him and the lessons he taught me about how every detail, word and impression can make a difference in how or if someone makes changes and finds improvements in health and life via active mental health care. Thanks Mr. D!