Transcript of 1st Session between Charles Balis, M.D. and Ms. Rachel Tanner, Tuesday, September 23, 1997 at 1 pm.

Dr. Balis: You must be Ms. Tanner.
Ms. Tanner: Yes. Hello Doctor.
Dr. Balis: Sit anywhere you like. Or don't sit. Whatever makes you most comfortable.
Ms. Tanner: You have a file on me already?
Dr. Balis: Yes, of course. And I'll be adding things to the file as I'm documenting your progress.
Ms. Tanner: It's not easy being here.
Dr. Balis: I know it must be difficult. But I'm glad you are sharing your feelings. That's a good start, Ms. Tanner. Would you rather I call you Rachel?
Ms. Tanner: Yes. I guess I should call you Doctor, right?
Dr. Balis: I would prefer it.
Ms. Tanner: My grandma made me see you.
Dr. Balis: Yes, but you are here.
Ms. Tanner: I'm curious, what did she say about me?
Dr. Balis: I'll be honest with you, Rachel. Your grandmother is worried about you. She sees you spending a lot of time on almost ritualistic grooming. She's very proud of your ambitions and of your accomplishments, yet some of your behaviors she witnesses at home are perplexing to her. Do you know what she is referring to?
Ms. Tanner: Yes. I do what I have to do to get through the day. Or night.
Dr. Balis: She said you have a lot of nervous habits.
Ms. Tanner: Yeah?
Dr. Balis: Can you give me more details about that?
Ms. Tanner: I can tell you a lot about what I do. My question is will you understand? No one has so far. My grandma doesn't; she thinks I'm procrastinating. Or crazy. She hasn't said it to my face, but that's probably what she thinks.
Dr. Balis: Hmm. I will do my best to try to understand you, Rachel. Why don't you try telling me what's going on.
Ms. Tanner: I hope you're ready for this. Whew! Take counting, okay? I have to count to get through certain everyday things like brushing my hair. I try to brush it 20 times. But if I think I've miscounted or brushed one side more than the other, then I have to start over again for another 20 times. The thing is that lately I doubt myself and become less and less sure that I've counted right. I think I've lost some hair from brushing so much. That's probably why Gram panicked.
Dr. Balis: Would you describe your hair brushing as a ritual?
Ms. Tanner: I guess so. I do it several times a day and always in a certain way. Brushing my teeth, filing my nails, walking from one place to another in my house--those are all things I seem to get caught up in. I can't not do them. I used to spend a lot of time in the shower.
Dr. Balis: Did you count in the shower?
Ms. Tanner: No. I had a certain order that I would wash myself. If I washed something out of order--like my right arm before my left--I'd have to start over. The order was hard to remember--actually, I think it changed from week to week--so I'd get it wrong a lot. I spent three hours in the shower once.
Dr. Balis: Was your grandmother aware of this?
Ms. Tanner: Sort of. She was yelling at me outside the locked bathroom door. Then she tried to pick the lock. I think she was scared, even though I was yelling back that I was okay. Somehow, she knew I was having a problem. Then she changed the door handle to one that doesn't lock. Then she started timing my showers. If I didn't finish in ten minutes, she would turn the water off. I mean at the valve outside!
Dr. Balis: How much time do you spend on your rituals during a typical day? Two hours? Four?
Ms. Tanner: On a typical day, probably four hours. That's for things that would take about one hour for a normal person. Doctor Balis, I've told you a lot about myself. Can you tell me something about you?
Dr. Balis: Sure. I've been a doctor for many years, although I've only been a psychiatrist for about three years. I spent the first couple of years in a psychiatric clinic at Columbia University in New York. And then about a year ago, I started my San Francisco practice--that's when I moved to the Bay Area. But you are the patient, Rachel. We need to focus on you. Okay? Now, why do you think you need to do your rituals?
Ms. Tanner: I just need to.
Dr. Balis: Is it like an obsession?
Ms. Tanner: I guess.
Dr. Balis: Have you ever heard of Obsessive-Compulsive Disorder or OCD?
Ms. Tanner: I think so. So now I have a label. How does that help me? How can you help me?
Dr. Balis: There are many ways that people with OCD can function effectively. The first step is being diagnosed. From the symptoms that you've just described to me and from watching you here in my office, I believe that you might have OCD. But I need to learn more about you and your rituals. Then I think I will be able to help you. Do you want my help, Rachel?
Ms. Tanner: Yes.
Dr. Balis: Good. The more you are willing to share with me, the more successful we will be.
Ms. Tanner: I'm afraid that the more I talk about it with you, the worse it's going to get by bringing it to the surface, you know? I feel maxed out already. Some days, it's all I can do to survive a few hours at the shop. It's like I can hardly wait to get out of there, so I know?
Dr. Balis: Tell me about your work situation. Do you have rituals there?
Ms. Tanner: Well, manicures are all about rituals, right? There is a definite order to everything. That's what I love about my work. My obsess...OCD helps me in that case, I guess. I can count file stokes on each finger, count strokes of the brush when I'm applying color, set the timer for exactly five minutes, and stuff like that. Fives are good.
Dr. Balis: Fives?
Ms. Tanner: Fives are good--five strokes, five fingers, five minutes--and so are multiples of five--five, ten, fifteen, twenty, and so on. Anything else throws me off, and I have to start over which can create real problems.
Dr. Balis: Hmm. Your Grandmother told me that your problems started after your mother died?
Ms. Tanner: Yes. That was about three years ago. My mom died in a car accident. I think she might have been OCD, too. The more I think back on things she used to do, the more I realize she probably was. She always worried about my brother and me. I just thought it was a mom-thing, you know? Protection and fear about her babies.
Dr. Balis: What kinds of things do you remember your mother doing that might have been OCD?
Ms. Tanner: Well, every time we would go somewhere, she would have to check the house. I mean lights, heater, the stove, the doors, the dog, the appliances. Sometimes, three times. She would ask us to help her, and we would try. But in the end, she couldn't be satisfied until she had personally done the checking. She was always so careful with us kids in car--white knuckle, you know? She never got on the freeway and always took the side streets. Always went the same way, every time. I could tell you stories...
Dr. Balis: Hmm.
Ms. Tanner: For years, I felt like her accident was my fault. I had a list in my head of all the things I could have done differently.
Dr. Balis: What kinds of things?
Ms. Tanner: I tried to help her around the house, but it seemed like things had to be done a certain way. You don't know how hard it is to live with someone like that--like a perfectionist, only worse. I'd try to take shortcuts. She made me feel like I never did a good enough job. It became a joke with my brother and me--cleaning our rooms. We'd stash stuff under the beds, lie to her about dusting. So I guess my list includes all that dishonesty. We kind of mocked her.
Dr. Balis: Why do you think that her death might have been your fault?
Ms. Tanner: Because we were mean to her. I think it was a suicide. The day she died, she took the car out by herself. She hadn't done that in years. I think she was so disappointed with us and so unhappy with her life, that she gave up. We might have been to blame.
Dr. Balis: Do you still feel that way?
Ms. Tanner: Not really. Well, maybe. You wouldn't believe the thoughts in my head. I don't want you to think I'm crazy.
Dr. Balis: Rachel, OCD is a complex disease. It can cause depression and anxiety, but that doesn't mean you're crazy. And sharing the thoughts that plague you could be a relief in itself.
Ms. Tanner: I mean, all the things I do are not really for the right reasons. Why do I retrace my steps? Why do I have to put my left shoe on first? Why do my nails have to be perfect? I guess it's because if I think I'm doing things the right way, then...
Dr. Balis: Rachel?
Ms. Tanner: I'm sorry. I don't know. I'm just so frustrated. I know I can't bring my mother back. I keep thinking that I've used up all my chances. I have to be good from now on to make things balance out--that's what I tell myself. But there's no logic to what I do. These rituals don't have a whole lot to do with my mom's death. They seem trivial, but I still have to do them.
Dr. Balis: A lot of OCD sufferers obsess about doing things the right way. But that obsession is OCD talking, it's not the real you. Your thoughts get trapped into a rerun mode and play over and over again, is that right?
Ms. Tanner: Exactly.
Dr. Balis: You said you had lists. Do you find yourself checking things, too?
Ms. Tanner: Certain things, yes. My lists are different than my mom's. Mine aren't related to safety as much as order. Oh, and personal hygiene.
Dr. Balis: Your hands and your hair.
Ms. Tanner: Yes.
Dr. Balis: Hmm. Tell me about your living situation.
Ms. Tanner: My dad left just before I turned twelve--happy birthday to me. I've lived with my grandma ever since my mom died. Gram gives me a lot of space. I have my own room. We eat dinner together every night. She's kind of a loner, so it works out.
Dr. Balis: Do you think your grandmother has OCD, too?
Ms. Tanner: If she does, she keeps it hidden. Or else I'm so preoccupied with my own stuff that I don't notice hers. Doctor, how long does a session last?
Dr. Balis: About an hour. I know that it's getting late, but let me ask you just a few more questions. Have you ever kept a journal?
Ms. Tanner: No.
Dr. Balis: I'd like you to try to write down some of your feelings or thoughts during the week. It might be a good way to record the subtle changes that you'd feel as you continue therapy. If you want to bring the journal to our sessions, we can talk about it here together. But it's up to you.
Ms. Tanner: I could try that. Thanks, Doctor Balis.
Dr. Balis: In our next session, I want to talk to you about some relaxation techniques. Can we meet next week?
Ms. Tanner: I'd prefer once every two weeks, if you don't mind.
Dr. Balis: As you prefer. Let's see, that'll be October 7th at 1 pm, okay?
Ms. Tanner: Okay. Are you going to talk to my grandma again?
Dr. Balis: Not right away. Do you have reservations about that?
Ms. Tanner: Not really. I'll talk to her, too--about the condition of your nails, of course.
Dr. Balis: I didn't think they were that bad--good to hear some humor from you.
Ms. Tanner: I'm not kidding!
Dr. Balis: Goodbye, Rachel.
Ms. Tanner: Goodbye, Doctor.
Arrow, Straight, Left, Earlier Arrow, Straight, Right, Later

Button to Dr. Balis' Notes Doctor Balis' Notes on this Session

Button to Rachel Tanner's Transcripts Transcripts of Rachel Tanner's Communications
Button to Rachel Tanner's Patient File Rachel Tanner's Patient File

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