So can you think of an example of something that's happened recently?

Yeah. My daughter has been, she's actually been sick and so she had a fever yesterday and they started her on an antibiotic and I had to go pick it up from the drugstore and that's like, I don't usually go there. It's hard to get there. Like, it's not right in the neighborhood.

Any expressways or bridges to get there?

Not expressways, but it's busy. It's busier and it's like in a mall so, you know, there's like...

Any four lanes or six lanes?

Four lanes, yeah.

Four lanes.

So it just, it's not someplace I usually would go and if I was going to go, usually I would either have her go with me or my husband go with me, but she was sick and he was at work and...

So to try to understand what goes through your mind, let's try to take you back and now you know that the prescription's there and your daughter's sick and I guess you don't want to ask her to drive over there.

I sort of did.

Yeah, probably not the wisest idea. So, you're thinking about doing the drive and what's going through your mind? What are the thoughts that are churning inside?

I'm just, you know, I'm sort of thinking about going there and I'm already starting to think, well, you know, what if, you know, what if I'm driving and somebody crashes into me?

What if I'm driving and I can't do it? You know, what if I just have to stop because

I can't do it anymore and, you know, it was raining and I'm sort of like I've got this picture of myself like out in the middle of the road and, you know...

What's the picture look like? You're out in the middle of the road and it's raining.

I'm stranded and it's dark and my, you know, my shoes are gone. I'm just like, it's like

I, it would be a million miles to get back home.

Pretty miserable.

Yeah, yeah.

Pretty scary.

Oh, terrifying.

Yeah.

And I just, it's so hard to get there.

And Kate, as you put yourself back into that situation and have those thoughts going through your mind, what kinds of feelings go along with it? You know, by feelings, I mean things that are inside, like fear, anxiety, physical things that are going on.

Well, fear and anxiety and I just feel really shaky and I feel really like lightheaded and dizzy and I just don't feel like I can breathe very well and I feel like I'm going to like fall over.

Is this a panic attack now? You told me about having some panic attacks.

I've had worse ones, but it's getting there.

Not quite to a panic, but, you know, it's brewing.

Yeah.

Okay.

Yeah, it feels like it might.

Yeah, yeah. Well, what I think we might do to try to move things along toward getting a plan of attack on this is to actually sketch this out and see if we can figure out some things we might be able to start doing to give you a better handle on it that you have right now.

Okay.

So let's put some boxes here and one of them is going to be event. These are the things that trigger your anxiety. And in this case, the event was...

Having to drive to the pharmacy.

Drive to pharmacy. And then this next box I'm going to label something we call automatic thoughts. And by automatic, I mean that they occur relatively automatically. They just sort of pop into your mind and you don't stop to check them out.

Okay.

And we all have these kinds of automatic thoughts. You know, I have them. Everybody I know has them. They're inner thoughts. In fact, if you think about it for a minute, we probably have a lot more thoughts we don't speak out loud that are part of our inner dialogue than thoughts we actually end up speaking aloud to other people. And I suspect that you have lots of those thoughts. And you just gave me some examples of them. So that's why we call them automatic.

So the...

Yeah.

Like the what ifs.

Yeah. So let's put a couple of those down in this box.

Okay.

In the automatic thought box. And they are...

What if someone runs into me?

Yeah. What if... What else?

What if I get stranded?

Get stranded.

Uh-huh.

I can't do it.

I can't do it. And there was this image about the rainstorm and you don't have any shoes on and so forth.

Yeah.

What should we put down for that?

I think what if I... What if I can't get back home?

I can't get back home. Sort of lost.

Yeah.

Yeah. What if I end up on this road forever?

And then we're going to put another box. There's a sort of a chain of events here.

The event can make you think in ways that stir up feelings of anxiety and so forth.

So if you're thinking like this, it makes sense that you'd be feeling pretty nervous inside and you might have some of these physical reactions.

Let's put those in here. This is the emotions box.

And they are much shaky, you said.

Yeah.

A lot of fear.

Yeah.

If we're going to rate that fear on a zero to a hundred scale and zero is none at all and a hundred is the maximum anyone could ever get, where would you be at this point?

Oh, I'd say about an 80.

80. Pretty high.

Yeah.

It's gone higher though, I suspect.

Oh, yeah. Yeah.

But at this point it's an 80. Okay. And then you had some other feelings inside?

Well, yeah, I sort of felt like I might fall over.

And what else?

My heart was pounding and I didn't feel like I could breathe very well.

How about your stomach? Any flip-flops in your stomach or anything like that?

Yeah.

So a lot going on here.

Yeah.

And a pretty high level of distress.

Yes.

And then we're going to complete this loop by putting a box we're going to call behavior.

This is how you actually acted when you were in this situation.

So what did you do after you had these thoughts and you had these feelings?

I went to the pharmacy.

You did do it?

I had to.

Okay. And what was it like for you when you were going to the pharmacy and driving there?

It was so bad.

Mm-hmm.

I just, you know, I think I left permanent marks on the steering wheel because I was holding on to it so tight.

Okay. So you were gripping tightly.

Yeah.

So in this case you actually did go to the pharmacy.

Maybe there's some damage to the steering wheel or something like that.

Yeah.

I hope not.

But I really had no choice. I mean, I think usually I wouldn't go to the pharmacy.

So you were boxed in this time.

I would call my husband and say, can you pick it up on your way home?

Get an escape route if you would.

Yeah.

Mm-hmm.

So usually you would avoid this.

If we looked at this as a model for many of these situations about driving and feeling anxious, the usual behavior would be to try to get out of it or avoid it.

Is that right?

Oh, yeah.

Okay.

And so if you do avoid it, then what happens?

Well, I feel better.

You feel better?

It's like such a relief.

Relief.

Uh-huh.

Better.

Relief.

The emotions calm down now, right?

Well, yeah, because I don't have to worry about it.

So that's what happens for a single episode of this anxiety.

I'm wondering, though, if we look at the impact on you of avoiding and getting relief overall as far as managing driving, what do you think it does there?

Well, I feel like I don't really have much confidence when it comes to this to being able to do it.

Okay.

So in a way, it decreases your confidence over time.

I think so.

Yeah.

I suspect that not doing it repeatedly gives you this belief about your capacity to do these driving things.

And what's that belief?

Yeah.

I don't feel like I can do it.

I can't do it.

Yeah.

I don't feel like I can do it.

I can't do it.

I can't do it.

And I don't do it.

So it really comes back to this thought, I can't do it.

Yeah.

Uh-huh.

And you can't do it and you don't do it.

Right.

So here's this chain of events.

Events trigger thoughts.

We call them automatic thoughts.

And then they influence your emotions, these feelings you have.

And then that influences how you handle the situation.

Uh-huh.

Okay.

Now, let's think together for a moment before we wrap up of how we might proceed to try to give you some help with this.

So, let's take a look at these thoughts for a minute.

Do you know anybody else that drives regularly that might think differently than you?

Yeah.

Okay.

What would be an example?

I mean, I think almost everybody.

I think most people drive without too much problem.

Okay.

But, like, my sister loves to drive.

Yeah.

I mean, she just, she drives every opportunity she gets.

Uh-huh.

So, for some reason, we don't know exactly why, but the key thing here is not looking at why, but to help you with actually making change in this.

Uh-huh.

But you do have some differences in the way you think about driving that might be something that we could begin to work on in our sessions.

Uh-huh.

We might, for example, check it out, you know, what's the chances of someone slamming into you?

Or what's the chances of you being stranded out there on the highway?

And even if you were stranded, is there a way you could cope with that or manage that so you can get back home?

So, these are some things that we could begin to do.

Yeah.

So, I'm going to mark here.

Okay.

We could work on these thoughts.

Okay.

And then, by working on the thoughts, we might be able to help you reduce the emotions, but there are also some things that I might be able to teach you that you could use to reduce this level of distress that you have.

Oh, that would be really nice.

To be able to calm yourself down in situations.

So, we'll have some, try to build some skills to manage your emotions.

And then, on this behavior side, one thing that we might begin to work on is helping you gradually begin to take on some of these driving things so that you can build your confidence back up.

Mm-hmm.

And again, build your skills to do it.

Mm-hmm.

And I can see that that causes a little bit of edginess here.

What were you thinking when I mentioned that?

I was thinking that I hope that this doesn't, like, make me worse.

Okay.

You know, like, trying to do some of these things.

Yeah.

Well, I'm glad you gave me that feedback.

That's an example, by the way, of me wanting to hear from you about the way you're responding to what I'm saying.

I certainly wouldn't want to do anything to make you worse.

Okay.

Okay.

Or to cause you too much anxiety.

Uh-huh.

And what we'll try to do is pace it just at a level that's right for you.

Okay.

So that you can make some progress and get to the place you want to be, which is to be able to, you know, drive to your new office.

Mm-hmm.

Across that big bridge.

Mm-hmm.

And maybe even, you know, drive those couple hours to—

Visit my son.

Visit your son.

Yeah.

Right?

Yeah.

So what do you think?

Well, I think that that would—if I could do those things, it would be really nice.

Yeah, I think it would be really nice, too.

So that would be our goal.

Yeah.