Transcript of 8th Session between Charles Balis, M.D. and Ms. Rachel Tanner, Tuesday, February 17, 1998 at 3:00 pm.

Dr. Balis: Long time no see, Rachel. How are you?
Ms. Tanner: So so.
Dr. Balis: How is school going for you? Did you register?
Ms. Tanner: Yes. I'm taking Speech, Modern Poetry, and Anthropology. It's quite a load; I'm barely keeping my head above water. I wish I could just attend classes but not have to do any work. It's a drag. I have two papers due next week and two tests this week.
Dr. Balis: You're still taking the medication, right?
Ms. Tanner: Yes, but...
Dr. Balis: But what?
Ms. Tanner: I don't think it's working that well.
Dr. Balis: Why do you say that?
Ms. Tanner: Can't you tell? I thought you, of all people, would notice right away how crappy I look. And I look how I feel.
Dr. Balis: There's a lot more stress in your life now. How has that manifested itself?
Ms. Tanner: What do you mean? Could you try not to sound too much like a doctor?
Dr. Balis: What makes you think the Fluoxetine is not working?
Ms. Tanner: Let's see, where should I start? I'm sleeping about four hours a night, if that. My grandma is bitching about being my chauffeur. I have to read most assignments four times because I can't concentrate. It takes me all night to write one page that I'm still not happy with. Want more?
Dr. Balis: I understand that school puts a lot of strain on you, Rachel. But what you've described is fairly typical for most students who care about their performance. Let's take one thing at a time. I'm concerned that you are not sleeping enough, and yes, I did notice that you look tired. Tell me about your evenings.
Ms. Tanner: Gram and I are still eating dinner together, but she's ragging on me most of the time. I get restless with the small talk at the table because I have so much to do. It isn't that satisfying for either of us. Then I head to my bedroom where I spend the rest of the night reading, writing, and suffering. Sometimes, it's two o'clock before I realize it.
Dr. Balis: Are you still swimming? Do you continue to write in your journal?
Ms. Tanner: I swim every other day. Nothing...well, almost nothing can interfere with that. The journal is dead. No time.
Dr. Balis: Hmm. You should try to maintain a balance between school work and the other things that you enjoy. You need to release the tension in healthy ways.
Ms. Tanner: I'm dealing with it.
Dr. Balis: How?
Ms. Tanner: I have my ways.
Dr. Balis: Rachel, I detect hostility from you today. I need you to be open and honest with me and help me to help you.
Ms. Tanner: You want to help me? You could have helped me by suggesting that I wait, that I recover a little longer before going back to school. You could have reminded me of how stressful it is to run around registering at the last minute for classes that I don't want to take, trying to buy books that the bookstore just ran out of, going to hell and back to find out what everyone knew except me: that the room number had been changed. I don't know why I'm doing this to myself!
Dr. Balis: Hmm. What can I do for you right now?
Ms. Tanner: Get me a glass of water.
Dr. Balis: Sure. You want to try some guided relaxation?
Ms. Tanner: I'm not sure I can sit still enough for it to do any good.
Dr. Balis: Let's try it. Finish your water, and we will try a brief breathing session.
Ms. Tanner: Okay.
Dr. Balis: First of all, get settled so that you can close your eyes and listen. Take three regular breaths through your nose. Exhale completely each time. Good. Now, very slowly inhale--no noise--until you've filled your lungs. Try to quiet your body, Rachel. Silently exhale through your nostrils. Slowly! Gently push all that air out. Breathe this way three more times on your own. When you are done, open your eyes.
Ms. Tanner: Hmm.
Dr. Balis: Need some more water?
Ms. Tanner: Yes, please.
Dr. Balis: You said you were having trouble concentrating while reading, and you were not content with your finished written products. Do you think your OCD is interfering somehow?
Ms. Tanner: I have to reread the passages because I'm afraid I might have missed something. I go over and over them, and then the words don't even make sense. I tried getting up and walking around to clear my head, but then I started counting steps again. I made up this stupid rule--I can't sit down and try reading again until I've walked fifteen steps. They have to be perfect steps or the reading won't be perfect. I slipped back into the counting. And with the writing, it's like it has to be flawless. I do it on the computer first, and I fix my spelling and do a grammar check. But I don't trust the computer, so I print the first draft, then write the whole thing out by hand. Then I put that away for awhile and make more changes later to get it right. Every time I look at my writing, I find something else to change or make better. How can I ever be sure that it's right?
Dr. Balis: I want you to try something. I want you to write a paragraph for me about...let's see...write a short note to your brother about anything you like. Here is paper, here is a pencil. No, use a pen.
Ms. Tanner: This is silly. Why?
Dr. Balis: Actually, this is a valid method for OCD patients. You are going to write a letter to your brother, put it in an envelope, and seal it. We are going to walk down to the mailbox and mail it together. If it has mistakes, so be it. If it's not perfect, so be it. The idea is to take this extra energy off your writing, this need to be perfect. The perfection issue is getting in your way. I assume your brother is a person you trust. I suggested him because he won't criticize, and probably won't even notice any errors in your note to him. Am I right?
Ms. Tanner: Probably.
Dr. Balis: This technique is called "response prevention." Do you know why?
Ms. Tanner: Because by mailing it, I won't be able to change anything. I can't respond to the letter like I would to the other things I write, because it will be buried in the mailbox on its way to my brother's house.
Dr. Balis: Exactly. So pick a simple topic or just say hello to your brother in a short note. Take four or five minutes.
Ms. Tanner: Okay, I guess.
Dr. Balis: And address the envelope. Here's a stamp.
Ms. Tanner: Are we really going to go mail it?
Dr. Balis: Yes. I want you to see that laboring over your written work is not going to change the basic message. You are smart, and your writing is clear and comprehensible. It is good to be conscientious about your performance at school. It is not good to be obsessive about it. Hopefully, through this exercise, you'll make the transfer to your schoolwork. It doesn't have to be perfect, it just has to be enough. Now, you said something earlier that I cannot dismiss. You said you have ways of relieving your tension. I believe you said, "I have my ways." What did you mean?
Ms. Tanner: I've been bad.
Dr. Balis: Go on.
Ms. Tanner: At first, I did it without even thinking. Then, it seemed like it was soothing. Now, I'm back to my old bullshit. I already mentioned that I started counting again. But I've lost some hair, too. On my first speech, I wanted to do really well. I was charged up about it. I worked on my note cards for two hours before I realized that I'd pulled out quite a bit of hair. You can't really see it because it's all underneath, but still...
Dr. Balis: I see. But this behavior brings you comfort.
Ms. Tanner: Sort of. I mean, I feel bad afterwards. But I can't really help it or stop it when it's happening.
Dr. Balis: Actually, you can stop it. You've done it before, and you'll stop it again, Rachel. You have to replace the act with something more positive. Writing in your journal was supposed to that. It replaced the other activities. Walking a dog, playing the piano, jumping on a trampoline are all things you can do to occupy your time, your hands, and your mind. Do you still have the relaxation tape I gave you?
Ms. Tanner: I think so. It's been a while.
Dr. Balis: You have to answer to your OCD. Tell it who's boss. OCD is a paper tiger, but taming it is a constant job. You were able to let up a bit in your regimen, but now it's time to get tough again. Understand?
Ms. Tanner: Yes. It's not easy. I guess the stress of school brought up the old stuff. I got weak.
Dr. Balis: You are just as strong as you ever were, Rachel. You have a lot of tricks up your sleeve. You have to employ all the strategies that have worked in the past again. I know school is important to you. I would like to see you succeed. Canceling sessions won't help, either. Make room for important things; make room for Rachel. Are you ready to go for a walk?
Ms. Tanner: Ready as I'll ever be.
Dr. Balis: Our next session will be March 3rd then, correct?
Ms. Tanner: Two weeks.
Dr. Balis: Shall we go?
Ms. Tanner: This feels weird.
Dr. Balis: We don't have far to go. The mailbox is just around the corner.
Ms. Tanner: Okay.
Dr. Balis: Let's cross here, so we don't have to go through, what I affectionately now call, the Lake District. It always floods at that intersection. Does this seem like a lot of trouble?
Ms. Tanner: It's kind of fun, actually. Want to go to the post office instead?
Dr. Balis: I have a four o'clock waiting for me.
Ms. Tanner: Yes, I noticed. She didn't look so good. But then, who am I to say?
Dr. Balis: Do you have any reservations about letting this letter go?
Ms. Tanner: Sort of. I rushed through it, because I didn't want to make you wait. Now, I wish I could open it up and look it over one more time.
Dr. Balis: Everyone makes mistakes. Even I do, once in a while.
Ms. Tanner: It doesn't really say anything important. Do I have to send it? You've proven your point.
Dr. Balis: I know this must be difficult for you, but don't feed your OCD. Don't let it have power over you. Have you started the two papers that are due this week?
Ms. Tanner: I only have a few notes. I was going to work on one of them tonight. It's due Monday, but it only has to be one page.
Dr. Balis: I want you to set a timer for 25 minutes when you start to work on it. When the timer goes off, stop, get up and move around, get something to drink. Distract yourself for at least fifteen minutes. Then set the timer for another 25 minutes. Return to the paper, and try to wrap it up. Don't edit it until you've written it all the way through. Once the timer goes off a second time, don't touch the paper again until tomorrow. Then edit it one time only, and be done with it.
Ms. Tanner: 25 minutes doesn't sound like enough time, Doctor. What about 40?
Dr. Balis: Okay, 40. But impose these time restrictions on yourself. You can train yourself to work efficiently within self-imposed time limits. Try it, will you?
Ms. Tanner: That sounds like it might work.
Dr. Balis: Let's mail this thing.
Ms. Tanner: Here goes nothing!
Dr. Balis: How do you feel?
Ms. Tanner: Fine, until my brother gives me shit for my spelling.
Dr. Balis: Is that something he would do, really?
Ms. Tanner: Actually, he makes more mistakes than I ever would.
Dr. Balis: Rachel, it will be fine.
Ms. Tanner: There's my grandmother.
Dr. Balis: Great, Rachel. Our next session will be March 3rd.
Ms. Tanner: Two weeks.
Dr. Balis: See you then. Take care, Rachel.
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