We're an equal team
In CBT, the relationship between the therapist and the client is collaborative and so is the entire process of therapy. You’re an expert on you and the therapist is an expert on how to treat anxiety disorders. So, in effect, you and your therapist are joining forces. As such, it’s most helpful that you’re open and honest about all aspects of the process including sharing information about your history and background, your symptoms, collaborating on homework assignments, challenges you faced with homework, and last but not least, your rapport with your therapist.
It can often be difficult to discuss certain aspects of your life during the intake process. I saw a client who came to me for treatment of obsessive-compulsive disorder (OCD). For our purposes here, I’ll call her Jane. During the evaluation process it was really difficult for Jane to discuss how she was drugged and raped by somebody she considered a friend. We spent a good amount of time discussing it. It was important for me to assess whether she had any symptoms of post-traumatic stress disorder (PTSD) related to the episode. Getting the information was very important for the treatment plan but doing it sensitively and at Jane’s pace was equally important. A therapist can’t help you if you’re not forthright. We need all the pieces of the puzzle to make sense of it and both you and your therapist are responsible for putting the puzzle together. A completed puzzle helps us understand how to tailor the treatment for your benefit.
There are times when clients are embarrassed about their symptoms. Most frequently, I see this with OCD, skin picking, and hair pulling. For example, clients may feel ashamed that they’re having obsessions about hurting people they love or molesting children. Jane had severe OCD and endorsed both these obsessions in addition to some others. It took her some time to open up. My job was to do thorough psychoeducation about OCD and give her a strong sense that I’ve heard it all before; that’s not a stretch given that I’ve been treating OCD and anxiety disorders for several years. Together we worked on the steps in therapy like creating hierarchies (a list of thoughts, images, and impulses that cause anxiety starting with the least difficult to the most difficult) for both themes – obsessions of violence towards others and obsessions of molesting children. We worked on exposure and response prevention (ERP) in session before assigning it for homework. ERP is the gold standard for treating OCD. We discussed homework every week. My goal was to help Jane be honest about what she was willing to take on in any given week. Usually, this is based on a number of factors like where we are in treatment, the hierarchy, the level of anxiety experienced, how much practice the client has had, the client’s willingness. My job is to encourage/push the client to keep moving forward but within limits. We always work on setting concrete observable goals. More on setting goals and homework assignments in another post to follow.
There are times when clients get mad or upset with their therapists. It’s all part of the process especially when working on anxiety disorders where our goal is to have clients face situations that they’re anxious about. I say to my clients at the outset that I’ll be sensitive and thoughtful but there may be times when you will be upset with me. Jane did get angry with me, more than once about pushing her to face her fears. We discussed her feelings towards me and I explained my motivations. We worked through the rough patches together. It’s very important for the therapeutic relationship and for the client’s continued benefit that we hash it out in session and work through any “therapeutic ruptures”.
Common pitfalls
Underestimating the collaboration between you and your therapist can lead to a less than effective therapeutic relationship. I say to my clients “I’m not an authority figure, we work together”. Keeping things from your therapist or misleading them will only result in adversely affecting your therapy. Moreover, not discussing negative feelings towards your therapist won’t give them a chance to address the issue. Doesn’t it make sense to discuss it with them and work through the issues?