On an unremarkable day, I walked out to the waiting room to meet a new client for an intake session. Right away, I saw that Eileen was pretty much a carbon copy of me. Same height, hair color, eye color, and even body type. During our interview, I realized that beyond our physical similarities, Eileen and I shared several aspects of our personalities and mannerisms. We shared a love for sarcasm and wit, a penchant for Hispanic culture, and boasted an extreme closeness with family. We even wore similar clothing.
Strangely enough, this wasn’t the first time I had experienced this identification with a client in the past couple of weeks. At the same time that I began working with Eileen, I began to see Kate, another client with whom I also shared striking commonalities. Much like with Eileen, Kate and I shared physical similarities, we both felt a passion for higher education (read: nerdy interests), and felt a strong connection to being nurturing in interpersonal relationships. We enjoyed travel and exercise, and shared a sense of a wandering spirit.
Although I felt very similar to these two women, I was also very different in one important way: Kate and Eileen were both suffering from crippling anxiety. I was not.
Both Kate and Eileen experienced symptoms of obsessive-compulsive disorder (OCD). While Eileen was primarily a “checker” and would obsess about whether or not her stove was off or if a man she liked had texted her, Kate obsessed about moral failures such as being an unfaithful girlfriend or losing control and hurting someone. While I feel fortunate that our work together helped relieve symptoms for both women, I believe that these two clients may have impacted me in an even more significant way than I impacted them.
For both Kate and Eileen, exposure and response prevention (ERP) was the first line of treatment to decrease their most troubling symptoms. This form of treatment entails exposing the client to situations or stimuli that trigger obsessions and to deter the client from engaging in compulsions that would usually be performed in an attempt to lower anxiety. In this way, the client must “sit with” the anxiety she experiences in order to allow it to decrease in time, on its own.
Interestingly, my treatment of the two clients who had very similar symptoms was in some ways, quite disparate. With Kate, we clung tightly to the manual, whereas with Eileen, treatment began with ERP but followed a modified course.
After much reflection on this experience, I realized that in some ways, my treatment of Kate and Eileen mirrored my journey as a clinician learning to find my own style. I felt extreme comfort in the manualized, empirically-backed treatment. I felt safe in this world that was strict, clear, and definitely worked.
In another way, I was yearning to stretch outside of my narrow range of treatment approaches. I wanted to take pieces of the therapy modality of which I had grown comfortable with, and combine it with other methods to forge my own style, my own orientation. Thus, my experience with these two women was more than treatment for the clients; it also represented a journey I endeavored on as a clinician.
Kate found success quite easily in ERP. She had already received treatment for OCD in college, so the background work of understanding the effects of her rituals and how anxiety functions and decreases on its own was established. We created imaginal exposures about her cheating on her boyfriend or killing someone she loved while also using CBT for her depression and social anxiety (e.g., behavioral activation and social anxiety exposure). One type of exposure was to have her hold a knife when around a family member, which is something she avoided for fear that she would hurt someone. This was approached slowly, first holding a butter knife and working upwards as she learned that her anxiety would naturally ebb in time. Kate quickly grasped cognitive interventions and pointed out her own maladaptive thinking with ease.
Treating Kate was comfortable. I had my own “security blanket” of manualized treatment. For me, my work with Kate demonstrated a need to connect to a treatment I felt confident in, supported in, and knew was empirically-based. In short, I knew it worked. I stuck to a treatment that Kate already knew, and in this way, validated her previous therapy while obtaining my own validation.
It was as if I craved safety in the treatment with Kate, and by staying in ERP, the fears I had of my incompetence were masked by the efficacy I knew was proven in this type of therapy. Kate quickly responded to and enjoyed this treatment, which paralleled my own affinity for ERP.
Through ERP, Eileen quickly embraced the concept that her rituals were maintaining her disorder because the relief she felt from ritualizing was only helpful in the short-term. With this knowledge, she rapidly eliminated many of the compulsions related to her morning routine. She noticed that by allowing her anxiety to fall organically, her overall anxiety lessened over time.
Though the improvement in her OCD was encouraging, other issues soon came into focus once her main concern was diminished. I took chances in my treatment with Eileen. I went “off script”, partially due to her changing presenting problem as therapy progressed. She started to experience symptoms of social anxiety, anger towards her family, and bulimia. In fact, as Eileen’s compulsivity reduced, her underlying emotions—the very ones her OCD sought to hide—began to emerge.
Instead of dealing with each type of problem separately, we discussed how similar the problems really were. Underneath the pain of each symptom was fear of being unlovable and incompetent.
After a few weeks of engaging in these difficult sessions, Eileen came in with a realization: it was okay. If she never fell in love, never succeeded in her career, or was humiliated, it would be okay. From there, gains were easy to come by. It seemed that over night, upon realizing that everything was “okay,” a form of non-judgmental acceptance, her symptoms fell away swiftly.
Apart from the beauty we experienced in the precipitous drop in symptoms, my experience with Eileen showed what another part of me needed in my journey as a therapist. It became increasingly clear in my work with Eileen that I was hoping to move outside of strict manual-adherence to create my own style.
As Eileen let her anxiety fall naturally, mine did, too. It lessened over time. By clinging to a manual I maintained, not my disorder, but my lack of self-confidence in who I am as a clinician. I began to embrace the straying beyond the boundaries of the manual in order to find what my client needed most. This freedom, though somewhat invigorating, was terrifying in its own right. If Eileen’s symptoms worsened, I didn’t have an “evidence base” to blame for a faulty treatment. If it didn’t work, I would have to accept that some of the accountability was my own.
Two Realms of Treatment
The experience of treating Eileen and Kate was a vital journey for all of us. My clients obtained treatment that helped them create fulfilling and functional lives that were not riddled with crippling anxiety; it allowed them to experience joy and love that was not hidden by fear.
For me, it was an opportunity to grow. I was—and am still—grateful for my then-supervisor who gave me the tools, but then also encouraged me to practice them in my own unique way. Through my work with Eileen and Kate, I explored my own fears of letting down my clients, of causing harm instead of helping.
I exposed my feelings of inadequacy as a new therapist in a field that was seemingly full of experts. As an inexperienced clinician, I felt immense pressure to succeed, to help, to know the “right” thing to do, the “perfect” thing to say.
In some ways, as I helped Eileen and Kate tackle their core fears, I was tackling mine. I was afraid of incompetence and failure, of letting my clients down with my own inadequacy. Because of these fears, I held my own rituals; I clung tightly to a manual to avoid the fear that I felt, much like Eileen checked the stove to avoid her feelings of incompetence.
I also learned to break free of my rituals, much like Kate and Eileen did. I began to assert that I could offer a solid treatment that not only included a foundational manual, but my own style and my own touches as well. I found that manualized treatment is very helpful for some, but for others, one size does not fit all. In those cases, I was competent to adjust and change my treatment to best relieve my client’s symptoms.
It seems that just as much as I was there to help Kate and Eileen, they were in my life to help me grow and to challenge my own core fears as a clinician.
This ability to step outside of my fear of inadequacy is a long battle that I imagine will continue throughout my career. Even while writing this article I asked my co-author and current supervisor, “Do I have the expertise to write this piece? Do I have a right to share my limited knowledge?”
Clearly, my journey towards confidence as a clinician is not complete, though I know my first steps were taken as I learned from Kate and Eileen. And through my continued introspection and supervision, I know the lessons I learned from them about embracing myself as a clinician and freeing myself from fear of incompetence will continue to grow.