CBT with Complicated Clients – Part I

Elizabeth Spencer

Some clients have enormous burdens from anxiety and other problems that complicate treatment. Sometimes clinicians can refer complicated clients to a more experienced clinician in their area, or even to regional or national partial hospitalization programs. However, many of the clinicians we work with are the only choice for the clients they have in their practice since they are at a community mental health clinic, school, or college, or are the only CBT clinician treating anxiety and OCD in their community.

Cases that are complicated fall into two broad categories: severe disability due to anxiety, and anxiety combined with another serious health, mental health or economic problem.

I think about Evelyn, who was 25, married, and she and her husband lived with her parents due to her anxiety. We met only by secure video because she was homebound with agoraphobia. Her husband went to work at a 9-5 job every day, but the family had staggered schedules so that someone was always home with Evelyn. She was never alone in the house. She left the house with one or her parents or her husband only in the evening after traffic had abated so if she felt panicky she could quickly return home. Evelyn was a smart woman who had gone to college online. She had landed a job as an editor and worked remotely from home. The complicated way that Evelyn and her family had learned to cope with her serious disability amazed me. She had the first type of problem – a severe disability from anxiety, along with a family that had learned to accommodate her so that she was trapped with this limited life she had managed to carve out for herself.

In terms of health complications, I think about Joy who was 19 and diagnosed with epilepsy. Her neurologist had advised her that feeling intense emotion like the panic attacks she struggled with would trigger seizures. She had managed to get her GED but had not been able to go to high school and she never held a job. Joy’s mother was fed up with trying to help her and wanted her to apply for disability and just accept that she would live her life at home dependent on others. In addition to her epilepsy and panic disorder, Joy’s mood had been falling as she became more and more depressed. Joy was essentially homebound as well, due to her avoidance of panic that might trigger her epilepsy.

These cases are examples of the profound level of difficulty that some of our clients are up against. We as clinicians work to find positives and strengths with our clients from the beginning of our work, but with some clients even this is a struggle. Part of the problem of course is our goal to have CBT treatment be brief as well as to help our clients live lives that are not diminished by anxiety. With complicated clients it is important to be realistic and find something that can be improved with the work possible in the situation. Both of these clients had treatment situations that were not limited to a few sessions, so the therapists had an opportunity to really get to know the clients, improving the client’s sense of confidence in working together as a team. Both these clients needed a chance to be in the driver’s seat, helping set even small goals because they had been dependent on others for most of their lives. Evelyn set a goal of being able to visit a friend who lived two miles from her home. Joy set a goal of going on a daily walk with her younger sister when she got home from high school. These were modest beginnings but for both women, accustom to failure, they felt empowered by their ability to choose a direction and implement it. Both women benefited from the behavioral changes made in getting out into the world a bit more than they had been able to manage before treatment, as well as feeling supported by their therapist’s, who provided lots of cheerleading.

Complicated cases can overwhelm even seasoned CBT clinicians. Make sure you get support from colleagues or case consultation so you provide the best treatment you can.

In part II of this topic, I’ll suggest other resources to connect with to help challenging clients

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