About 10 years ago, I was working in a well-known treatment program that targeted anxiety and OCD. People would fly in from all over the United States to stay for 3 weeks and have 90-minute treatment sessions every day. The program used a method called “exposure and response prevention” which essentially means walking people through their worst fears until they have extinguished their fear responses.

Those who feared disorder and uncleanliness would be taken to the hospital cafeteria to put their hands on blots of mustard or bits of undigested potatoes left on food-smeared tables. Those with a fear of blood would be taken to hold their hands on a dried gash of what could have been blood (or an exploded ketchup packet?) on a particular spot on the wall in one of the stairwells of the hospital. As I mentioned in a previous blog post, I used a cockroach to help a patient overcome contamination type OCD. I even took someone with a fear of dying into the morgue to watch a live autopsy of a victim of a motor vehicle crash.


One day, a father brought his junior-high-aged daughter into my office. The presenting concern was “not wanting to go back to school” because of social anxiety.  I think I would approach the problem differently now that I am more advanced in my skills, but at the time, I rolled up my sleeves and cheerfully told her that we would have that problem taken care of in a matter of days. I charted an ambitious treatment program for her which involved exposures for her social anxiety, basically setting up social experiments and talking to strangers all over the hospital. We could start by talking to some of my fellow providers, who had agreed to participate in the initial social anxiety exposures for my patient. I told her that we could mix it up and jump on a few loops of the hospital shuttle, talking to some of the fellow passengers in the shuttle along the way. I was eager to launch into this treatment protocol with her. After all, a well-established body of research suggested that it was likely this would help her overcome her social anxiety.

She never came back.

Her father called four days later, delighted to report that I had “worked a miracle.” She was back in school and told him that she had decided she would rather just go back to school “as long as she didn’t have to see that lady again.”

I actually chalk this up as a treatment failure. To me, the success of treatment is not solely dependent on the outcome achieved—it is about the process as well. It is about the trust we develop and the therapeutic alliance that is generated from this trust. It is about how my patients come to understand that I have their back. Success is also partly dependent on my sense that I have been able to intentionally facilitate a growth process for the patient. There was nothing intentional about this outcome. In fact, I did not predict how aversive this treatment would seem to my young patient, which in retrospect is now laughably obvious to me.

At this point in my career, I could not see myself using the same approach without being transparent about these things. However, while I might consider it manipulative to use this strategy intentionally, I could see myself telling a future patient this story and asking them if, in their case as well, the treatment we might come up with might actually be worse than the original problem. And if it were, could we come up with something creative that might address the problem in a more gentle, collaborative way? (We could work under the agreement that if we did not make clear, positive headway within the first 5-6 sessions, we could always consider such a treatment as an option to be considered with the idea that sometimes it is better to endure more pain in the short term in order to have a better life in the long arc).

Perhaps though, when the treatment itself appears more painful than the presenting problem, conditions are especially ripe for creating alternative approaches that may be even more powerful for a particular client?

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