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The hardest part of being a CBT therapist

Usually in the first session with a new client I am able to end with the client having a notebook with a diagnosis, a brief outline of how we will work together using CBT, and a homework assignment so he or she can track symptoms until we next meet. Of course, I also want the client to feel I have listened to their problems, and to feel a sense of hope that they will recover. It’s always a lot to cover!

Session two usually includes drawing a brain to understand how anxiety and OCD bully us — I like to use an image of an imaginary dragon, but every clients gets to pick an image or just think about their over-active amygdala.

With all that foundation, now comes the hardest part of my job. Setting the first few homework / exposure / practice plans. That’s the way I explain it to my clients, and that helps us work collaboratively on what would be a reasonable place to start. I can’t read their minds or the future, so I don’t have any extra powers to help. I have found over the years that experience treating similar problems doesn’t help much either since everyone is different about how hard they are willing or able to work.

To help us set the stage for success, I like to tell a story about a woman with OCD I worked with several years ago. She had lived on her own for 10 years and had developed severe rituals about right vs. left. She had to enter her apartment with her right foot, and store her shoes with the right shoe facing one way and the left the other. She had to have the right-hand doors of her kitchen cabinets open an inch. The list of ways things had to be went on and on, and she lived in fear that if she didn’t do something just right, her mother and sister who were very dear to her would die horrible deaths. She knew on some level that wasn’t completely true, but she was so concerned for their safety that she willingly sacrificed herself by diligently holding to the compulsions she felt kept them safe.

She came to see me two months into a new romantic relationship, because she knew she could not have this person over to her apartment without either revealing the OCD or ignoring the OCD and risking the safety of her mother and sister. She was stuck between her OCD and her desire to make this relationship work. Session one went about the way it usually does, with my letting her know this was OCD, which she had suspected but not been diagnosed with before. I gave her my usual short outline of how we would work, and hopeful comments about getting well. When I saw here the next week, instead of reviewing her homework tracking triggers, she surprised me by saying she was well. She said she had listened to what I said, realized it was going to take going through the fire of not knowing if her mother and sister would be safe even if she didn’t do the compulsions, and she decided to do it all at once. She took a few sick days from work and spent 48 hours sweating and fearful, but entering every room with her left foot first, switching all her shoes, and opening all the left-hand doors. When she saw me, she no longer had any obsessions. She thanked me and said good-by.

I was and still am humbled by the experience, as I am with so many of the courageous people I work with every day. She gave me a tremendous gift that day, which I try to pass along to my new clients. Sometimes, jumping in and working very hard very fast is a great strategy. It wasn’t what I advocated to her; she just came up with it on her own. Sometimes it works out wonderfully, as it did for her. The flip side, of course, as we see with clients over and over, is sometimes too hard too fast leads a person to feel hopeless. On the other hand, sometimes working too slowly leads to hopelessness.

Finding that sweet spot, that place where a client can make progress and feel successful, that is the hardest part of my job, and why being in a collaborative relationship with each client is essential.

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