Here we will describe one unusual clinical case related to the creation of a special prescription, which was subsequently used many times in work with obsessive subjects. In our opinion, in this case, it is precisely the fact that this «invention» was the result of a diagnostic error and the resulting therapeutic procedures that are not quite suitable for the case itself, which is of particular interest. As a result of this diagnostic error, a situation was created that led to a decisive rejection of the therapeutic maneuvers undertaken — they had to be adapted to the situation. This required an unusual surge of creativity, which led to a real dismantling: problems. Since all this would not have taken place without the original error, it seems to us that sometimes an error that has occurred, if used flexibly by the therapist, can become a path to discovery and a productive impetus for the development of therapy. No therapist can do without mistakes, but many therapists do not accept failures, while the acceptance and analysis of their own mistakes leads to a significant improvement in their own ability to therapeutic intervention.
In the case described, a young woman with severe phobic symptoms, an employee, twenty-six years old, turned for help. In the past two weeks, she had been forced to temporarily leave her job due to increasingly frequent anxiety crises and activity-blocking panic attacks that made it impossible for her to work as an accountant in one firm.
With the help of well-developed speech and with surprising conceptual clarity, this young woman herself presented her own symptoms as typically phobic, giving them a detailed and exhaustive presentation by describing panic attacks and her state of anxiety. She reported that she studied her symptoms in some psychology books.
The therapist allowed himself to be deceived by this «perfect» self-diagnosis and readily embarked on therapeutic maneuvers, punctually following the phobic treatment protocol. In the second session, the woman reported that she felt a little better and that when she recorded the panic attacks in the «logbook» they were reduced. She handed over to the therapist the journal she received at the first session, completely filled with notes, along with another journal, also full of notes, which she herself made, using the copy received at the session as a model. This fact somewhat surprised the therapist, who, however, did not attach much importance to it and continued to use the usual scheme of intervention for phobic disorders.
In the third session, the patient reported that her symptoms had decreased in frequency and intensity, but again she brought back two completely written notebooks. The therapist reminded the woman that she should have stopped keeping a logbook and continued the session in the usual therapeutic sequence. In the fourth session, regarding the prescribed half-hour «fright fantasy», the patient reported that she was completely unable to feel bad or anxious during this half-hour, no matter how hard she tried to think of the worst situations or fantasies, on the contrary, thinking about all this, she wanted to laugh. In addition, she stated that at this stage she feels able to try to return to work. However, it was strange that despite the cancellation of the prescription two sessions ago, this time she also brought two completely written “logbooks”, saying that while writing down, she felt better, received relaxation.
Then the therapist had some doubts, especially since looking at the notes, he noticed that the patient wrote down not only critical episodes, but also everything that she thought about, thoughts, emotions, ideas, etc. However, as the symptomatic situation improved, the therapist continued with the usual treatment. At the fifth session, the young employee said that she returned to work without any problems, she had only a few episodes of anxiety, but they were manageable. Nevertheless, she again produced two complete notebooks. When asked by the therapist what function this daily laborious exercise served for her, she replied that it was important for her to write it down, because this way she felt that she would not develop phobic manifestations. Her literal words were: “You know, doctor, it is very important for me to write down, although it costs me time and labor, because I realized that in this way I control my fears. I think writing removes my frightening ideas, as if by writing I am making certain things stay outside of me.»
The therapist then had an epiphany about this behavior, which seemed inconsistent with the diagnosis of the phobic subject and his usual reactions to the treatment given: he realized that the subject before him was mainly obsessive. The patient did not interrupt the entries in the logbook because she had an obsessive belief that if she stopped following this prescription, she would return to her fears and panic attacks. In practice, the entries in the «logbook» were turned by her into an obsessive ritual that served to delay the symptoms. This observation was then strengthened by further exploration of certain aspects of the woman’s personal life, which were initially overlooked in the heat of the apparently effective treatment and on the basis of the patient’s initial diagnosis of phobia, suggested to the therapist by the patient herself. Indeed, as a result of this study, it was found that the patient came into phobic crises after a long period during which she felt compelled to repeatedly repeat certain behavioral rituals throughout the day. These rituals in work activities led her to extreme self-doubt, to the need to repeatedly control everything, she was never calm and confident in her own actions, and so on until panic crises began to appear. Consequently, panic attacks were only the most prominent symptom of the young woman’s obsessional problems. Accordingly, the initial diagnostic hypothesis, set aside by the patient’s self-diagnosis, did not fit the case, and the intervention based on this diagnosis led to concrete improvements in her behavior as a result of the «obsessional ritualization of the prescription.» Of course, this could not be considered a success, since if the “ritual” was removed, the situation might collapse again. The therapist felt in crisis, not knowing how to deal with such a confusing situation that had developed due to his intervention. He decided to wait and, without declaring anything that he understood at that moment, told the woman that she could, if she found it useful, calmly continue to take notes and bring him notebooks with notes.
The problem in this situation was the following: how to direct the intervention to obsessiveness. Without violating the small behavioral improvement achieved by inadequate treatment? How to remove the obsessional ritual produced by the therapy without creating other problems? It was during these torturous reflections that the therapist came up with an idea that was as strange as it was effective.
In the next session, after listening to the patient’s report, pleased with her constantly improving situation, and receiving two more «logbooks» full of notes, the therapist gave her the following prescription: «All this is very good, but we can do more. And in order to achieve this, you, as always, will have to complete the task that I will give you, literally.
Considering the importance to you of writing down your thoughts and ideas, as well as your emotions and critical moments, I give you a notebook and the following task. Every time you have the urge to write something for me, you write down ten times the phrase that I will write now on the first page of the notebook. This phrase is in English, you understand a little English, don’t you? But, as usual, do not ask any questions now, I will give all the explanations related to the task after it has been completed. For now, just do it!”
On the first page of the notebook, I wrote: “Think little and learn by doing!” (Think less and learn by doing!) At the seventh session, the woman came in irritated and reported that she felt she had been treated like an idiot. Because, while rewriting the given sentence, she realized the stupidity of the action she was performing, taking into account the meaning of the phrase. Accordingly, she completed the task only twice and then stopped, and, in addition, tore out two pages with these notes. Finally, she stated that whenever she had the urge to take notes for a therapist, she automatically felt like an idiot and therefore did not write anything else.
The prescription, despite the indignant reaction of the patient, was extended without any explanation for the next week.
In the eighth session, the patient stated that she had not written anything and that she did not even feel like taking notes for the therapist. But most importantly, during these two weeks, her stunning well-being continued to increase. She reported that at the moment she feels really good, there are only sporadic reactions of anxiety, which are immediately reduced and controlled. All this happens without the need to resort to the «obsessional ritual» of entries in the «logbook».
The therapy continued for two more sessions, held at a greater time distance, they were aimed at the final redefinition of the personal autonomy acquired by the patient. We can end the description of this particular case with a reminder of the need to constantly evaluate our own therapeutic intervention. If an intervention turns out to be inappropriate, one must have sufficient mental flexibility to modify and reorient it according to the requirements of the case. As in the example described, this can lead to the development of new effective strategies.
Therefore, the error, as happens in the case of prescribing a little disorder, becomes an element of breaking the previous equilibrium: this breaking, if accepted and used, can lead to the creation of a new, more effective equilibrium within some system, in this case, within the therapeutic system. .
Case 4: Reveal an embarrassing secret
A young man of twenty-nine, tall, blond, handsome, charming and well-to-do, actively courting women, many of whom tried to seduce him, having the fame of a real playboy, came to ask for help because of his «dramatic» problem. He said that for about a year he had not been able to achieve a satisfactory erection and, accordingly, the possibility of penetration and a positive course of sexual intercourse. The young man was unable to explain to himself how this problem could arise, especially considering the fact that in the past he had many women and a lot of successful sexual intercourse. Recently, whenever he was in a situation leading to sexual intercourse, his erection was normal until the moment of penetration, after which it decreased to a completely flaccid state of the penis, so that the young man was depressed and experiencing a feeling of shame and humiliation. , was forced to interrupt all activities. See →