Embracing Uncertainty as a First-Year Therapist Treating a Patient Who Has Obsessive-Compulsive Disorder

Feelings of uncertainty can be a central challenge for therapists starting clinical training. This account illustrates how a first-year therapist tackled themes of uncertainty in treating a patient who has obsessive-compulsive disorder (OCD). The therapist’s supervisor explains the utility of a parallel process during supervision, highlighting its use to educate the therapist and optimize treatment.

Case Presentation by Mr. Aston, Therapist

Mr. C, a college freshman, presented with fears of being contaminated and contaminating others (obsessions) and reported excessive hand washing (compulsions). He had partially responded to treatment with fluoxetine before being referred for augmentation treatment with exposure and response prevention (EX/RP). He had no prior suicide attempts or hospitalizations and reported no other psychiatric diagnoses, trauma, or general medical problems.

As a first-year therapist, I looked forward to helping Mr. C with EX/RP, an evidence-based treatment in which patients are encouraged to challenge their assumptions about their intrusive thoughts (obsessions) while refraining from compulsions that decrease the associated anxiety (1). We constructed an exposure hierarchy of situations that triggered his obsessional thoughts. As we progressed through his fear hierarchy, Mr. C reported feeling increasingly ready to try more difficult exposures. Three weeks into treatment, I asked him to read a graphic first-person account of being contaminated with an infectious disease. We tracked Mr. C’s anxiety level by using subjective units of distress, rated from 0, no anxiety, to 100, most anxiety ever experienced. While reading the script, Mr. C reported a rating of 80, the highest level he had experienced in therapy. When I noticed that Mr. C started to disengage from the exposure, I started a dialogue to help him to remain connected with his anxiety. I didn’t want Mr. C to miss an excellent learning opportunity.

Mr. Aston: “Maybe you are already infected and there is nothing you can do about it.”

Mr. C: “Yes, maybe I am infected. And maybe this disease will make me lose my mind.”

Mr. Aston: “Yes. There’s a chance you will lose your mind. . . .”

Mr. C [beginning to shake]: “And maybe I will spread it to my family and they will all die because of me.”

Mr. Aston: “It’s a possibility. Great work. What is your [distress] level?”

Mr. C [noticeably distressed]: “I’m at a 90 now. I don’t think I can handle this.”

My heart sank. A thought flashed through my mind that someone reading a transcript of this therapy session would probably be appalled. Who would reinforce such horrific lines of thought? Even though my approach was supported by my understanding of OCD and EX/RP, it felt wrong to praise Mr. C for imagining such awful scenarios. I started checking his facial expression, trying to reassure myself that he would be okay. Feeling unsure about whether I had pushed him too hard, I advised Mr. C to stop the exposure. For the rest of the session we focused on relaxation exercises. Even though his anxiety normalized (distress rating of 40) by the end of the session, I felt uneasy. I wondered whether a more experienced therapist might be better equipped to treat Mr. C. Later that evening, I returned to the EX/RP manual. I reread sentences and paragraphs, wanting to be certain I fully understood how to deliver EX/RP. Looking for reassurance that I was on the right path, I scheduled a meeting with my supervisor.

Case Discussion

Dr. Rodriguez, Supervisor

Mr. Aston’s clinical presentation indicated that Mr. C’s symptoms were improving and that he and Mr. C had a strong therapeutic alliance. As Mr. Aston mentioned, he was worried about correctly applying the exposures to Mr. C. During supervision, I noticed that Mr. Aston was describing his own uncertainty as a first-year therapist. I shared this observation with him and reflected on my own feelings of uncertainty when I was a first-year therapist (a feeling often experienced by new trainees). Mr. Aston continued to describe ways in which his uncertainty manifested: checking Mr. C’s facial expressions, rereading paragraphs in the exposure manual, and worrying exposures were “too much” for the patient. As I talked to Mr. Aston about this, I noticed my heightened awareness of being new to supervising clinical psychology students. I became self-conscious about my suggestion that Mr. Aston write up his clinical experiences with Mr. C as a case report. Once I became more aware of this emotional reaction (feelings of uncertainty as a supervisor), I recognized that we were engaged in a parallel process. During my psychiatric residency, I had learned from my supervisor that parallel process is an informative tool for advancing patient care (2).

Parallel process (also known as “the reflection process”) was discovered by Harold Searles in 1955 (3), and his seminal concept paper has since been cited more than 400 times (4). Parallel process occurs when similar patterns are mirrored in the relationship between patient and therapist and between therapist and supervisor. Searles described it this way: “The supervisor’s emotion is a reflection of something which has been going on in the therapist-patient relationship and, in the final analysis, in the patient” and “may offer clues to obscure difficulties besetting the patient-therapist relationship”(3). Although a full discussion of parallel process is beyond the scope of this account (4–6), a supervisor can use parallel process (in addition to other reflective techniques) (7) to better understand the case, educate the therapist, and optimize treatment.

Using Searles’ approach, I identified the parallel process as avoidance of anxiety generated by doubts about one’s ability to perform. The patient’s exposure filled him with anxiety of potentially infecting his family, leading to doubt about his abilities to perform exposures and thwarting his full participation in the exposure. The therapist’s internal reaction was to doubt his ability to apply exposures correctly rather than committing to fully applying the exposure therapy. As Mr. Aston’s supervisor, I was doubting my ability to supervise the therapist, rather than strongly encouraging him to continue applying the exposures. With the parallel process identified, I was able to support the therapist in several ways. First, I emphasized the importance of the EX/RP model and the strong evidence base for its efficacy. Second, acknowledging out loud and embracing my own uncertainty about my abilities as a supervisor allowed Mr. Aston to embrace his own uncertainty about being a therapist and model this process for his patient. With Mr. Aston’s renewed commitment to ramp up exposures and support, the patient was able to accept his own uncertainty and tolerate the anxiety generated by increasingly challenging exposures.

Mr. Aston, Therapist

I was surprised to hear that my supervisor also experienced uncertainty in her role. When she told me about her process, my own uncertainty felt less like a problem requiring a solution and more like an understandable and tolerable part of life. The conversation helped me realize how my desire for certainty might be interfering with my ability to model for my patient openness to uncertainty. I discovered my worries about delivering EX/RP were common. A survey of therapists by the Anxiety Disorders Association of America (8) reported that therapists who regularly utilize exposure therapy endorse reservations about the treatment. Further, clinicians’ negative beliefs about exposure therapy may lead to suboptimal treatment delivery and may negatively affect patient outcome (9).

As I learned to accept my uncertainty, the quality of my work with Mr. C improved. Each session became a new opportunity for both of us to embrace our uncertainty. After several months of embracing his darkest fears, Mr. C began to smile during exposures. He would even laugh at his obsessional thoughts when they flashed through his mind. During an exposure near the end of treatment, Mr. C exclaimed with great exuberance, “I have never felt more alive in my entire life!” I was amazed by his ability to face his greatest fears.

It was a gift to celebrate with Mr. C as he found freedom from OCD. As beginning therapists, we often learn treatment protocols from manuals. Our patients, however, teach us about courage. I am grateful that Mr. C gave me the opportunity to learn from his treatment and, ultimately, accept my own uncertainty.