Do you have clients who fear they are the worst case you have ever seen? How do you answer their question? What are they really wanting to know? How do you address your client’s fears. I get this question a few times a week as I tend to see the most severely anxious people in my area. I am use to this question but for that particular client, it is one of the things they fear the most.

I start by validating how scared they are to be in treatment, facing their fears, not knowing if they will get better. Then I use Socratic questions to ask what they believe about their illness or maybe what was going through their mind before they asked the question. The cognitive therapy we teach clients can be used throughout your session, in whatever they present as their struggle. First we validate their feelings and show compassion. This is such a key piece and without it, you may struggle to get them todo the hard work with you in and out of session. Then we help them identify their automatic thoughts and beliefs. We teach them to be observers of their thoughts so they can better discern which are worth addressing and which are not helpful and should be treated as background noise.

Typically, clients with severe anxiety and OCD also feel hopeless and helpless. They are desperate to feel better but anxiety also messes with them by saying, “Even an anxiety expert has never seen this before and will not be able to help you”. Or their anxiety might say, “You are frustrating your therapist because you are so severe, she/he probably wishes you weren’t their client”. As you can see, there are different fears in each of these thoughts. This is why it is important that you ask the client, rather than assuming you know how to respond to their question. Once they have identified their thoughts, you can give them the facts once and help them to change their thinking to a more rational and realistic thought. This looks like, “I am coming to see Kimberly because she is trained in treating OCD and anxiety. I am worried that I will not get better. I will have to live with not knowing and get started doing the work. Staying on this side of fear only serves to keep me stuck.”

It is also possible that anxiety is trying to trick you into reassuring the client. If you have gone through this conversation once with your client, then their concerns have already been addressed. If they ask you at another session, challenge them to call it their anxiety and to live with not knowing the answer. Then move on to the next task in therapy. This can be challenging for therapists to do, but if you don’t, you run the risk of co-compulsing which is what happens when your clients compulse by asking you questions that are fear based and you respond by reassuring them. This dance can go on and on if you are not tuned into this pattern.

As you can see, there is much to teach and model for a client during a therapy session. Sometimes this occurs when we are practicing new skills with them or doing an in vivo exposure. But often, this teaching happens spontaneously just as your client’s triggers happen in real life.