Case Consultation: A gift to our clients and ourselves

Elizabeth Spencer

I have been in private practice for almost 25 years, and have built a network of therapists I can turn to with a tough case. Even now, though, there are cases that are more than a 5- or 10- minute discussion, and I value the chance to schedule a 20- minute case consultation session via webinar where I can review the case in depth and get help with what I might be missing.

How I wish I had had access to case consultation with an experienced clinician for 20-minute blocks as I needed them early in my career! Some of those tough early cases still stand out in my mind, and as I look back I can see what they had in common that I did not understand at the time – they didn’t fit a standard case conceptualization. I had learned how to treat someone with a fear of snakes, for example, using a standard hierarchy and exposure and response prevention. That was no help with a 14-year-old who wouldn’t go out of the house because he was convinced snakes lived in the large bushes by his front door. This teen had such a terrible fear of snakes he could not write the letter S and had stopped going to school or doing homework. I wondered, since he was homebound, was I treating him for agoraphobia? The toy snake that I usually used with such success as part of a hierarchy for snake phobia felt useless to me in the face of this suffering and disability. If you are newly in practice you might also feel stumped by what to do and how to start with a complicated case like this one.

Those of you who have taken our 12-hour webinar, Cognitive Behavioral Therapy for Anxiety and OCD, know that we start where the client and his family are. This is great news because it something most clinicians, new or experienced, are very good at doing already. Really take a look with the client at when and where his anxiety is being triggered. Use psychoeducation to explain the brain, and how the normal and useful fight or flight reaction has been hijacked by anxiety. Teach your client to keep a notebook or log of anxiety triggers, which is a crucial step for you and the client to learn together about this specific anxiety disorder for this specific person. Also be sure to check, how is the family accommodating the anxious person? It’s normal for parents to accommodate – we parents don’t like seeing our child suffer, so we go to great lengths to reassure an anxious child. Therapists can be a tremendous help to parents by explaining that accommodation does not help anxiety sufferers get well, and by setting reasonable goals for ending accommodation and increasing the child’s resilience.

My client did get well – in very little time he was able to leave his house and return to school and normal activities. As I look back it feels like he, his parents and I muddled through together. It wasn’t slick or easy but what really mattered in the end was my commitment to understand his fear and his willingness to do the work to overcome his paralyzing anxiety. Case consultation could have saved me and my client time and effort. For therapists who simply do not have the background in CBT, it could mean the difference between a client continuing to suffer and getting well. At we want all therapists to learn how to do exposure and response prevention which is proven to make an enormous difference in the lives of our anxious clients.

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