Transcript of 2nd Session between Charles Balis, M.D. and Ms. Rachel Tanner, Tuesday, October 7, 1997 at 1:00 pm.

Dr. Balis: Hello, Rachel. How are you today?
Ms. Tanner: Hello, Doctor.
Dr. Balis: Have a seat. You look different. Do you want to talk about it?
Ms. Tanner: My nose? I guess I have to, right? I mean that's why I'm here.
Dr. Balis: How did it happen?
Ms. Tanner: Well, when I get home from the Hairport, I feel really stressed most of the time. I have to just sit for awhile. Well, actually I never just sit because I'm too nervous, but you know what I mean. Anyway, the other day I was at home at my desk, and I got out my close-up mirror and started to work on the blackheads and dirt that builds up on my nose during the day. I used my fingernails to scrape my face. I guess I got carried away. It scabbed.
Dr. Balis: Yes, I can see that. Are you putting anything on it?
Ms. Tanner: Gram has some stuff that comes in a tube that's supposed to be good. This has happened before.
Dr. Balis: I see. By the way, during our first session, you said that you were afraid your symptoms might get worse because of meeting with me. Did they?
Ms. Tanner: I haven't scraped my face in a long time, so that's not good. But I haven't been counting things as much. Oh, and it took me a long time to get to sleep the night after our first session.
Dr. Balis: Hmm. Remember I wanted to show you some relaxation techniques? Are you interested in trying one today?
Ms. Tanner: What do I have to do?
Dr. Balis: Get settled in the chair--try not to move after you do--close your eyes, listen to what I say, and try to follow my suggestions. Visualize.
Ms. Tanner: You're not going to hypnotize me, are you?
Dr. Balis: No, I just want to help you relax. My goal today is to try to keep your hands still for a few minutes. Eventually, I want you to learn how to increase that time by trying this technique on your own. It will take concentration. So first of all, is there anything distracting you at this moment?
Ms. Tanner: You mean in this office?
Dr. Balis: Yes.
Ms. Tanner: That clock ticking. And the bubbling of the aquarium, but actually the aquarium is kind of soothing.
Dr. Balis: I'll take care of the clock. Get yourself settled into that chair. Is that where you want your hands to rest for the whole relaxation?
Ms. Tanner: Um, I can't move?
Dr. Balis: That's the idea. I suggest putting your palms face down on your lap.
Ms. Tanner: I'll try it. Yeah, that feels okay.
Dr. Balis: Close your eyes. Your gaze should be downward--as if you're looking into your cheekbones. Tighten the muscles in your face. Really crunch up. Now relax them. Your forehead is free from worry; your eyebrows are relaxed. Keep your hands in your lap, Rachel.
Ms. Tanner: Sorry.
Dr. Balis: Your jaw is not tense. Your tongue should be resting against your lower teeth and against the bottom of your mouth. Your teeth just barely meet. Keep breathing steadily through your nose. Hands still. Raise your shoulders until they almost touch your ears. Good. Now let them sink away from your head as your muscles relax. Your collar bones are descending making your neck feel longer. Breathe. Hands still.
Ms. Tanner: Argh! It's hard!
Dr. Balis: Tighten your buttocks for three seconds. One. Two. Three. Let go. Feel yourself sink into the chair. Gravity is pulling you securely into the comfort of the cushion. Your arms are not resisting as they rest. Keeping your hands on your lap. Clench both fists, tighter, tighter. Now let them go. Breathe. Digit by digit relax you fingers. Let your thumbs rest. Release the index fingers. Now the middle. Ring and little fingers are completely limp in your lap. Very good. Deep breaths. Wiggle your toes and curl your feet inside your shoes. Now relax them. I want you to stay immobile for three full breaths. Inhale deeply through your nose. Now exhale all the air through your nose. Imagine your breath is a wave slowly filling your body and then slowly exiting. It's hard to tell when one breath ends and the next begins. Two more breaths. Let the air come all the way into your body, then release all of it. Last breath. When you've finished exhaling, very slowly begin to open your eyes. Slowly! Focus at first only on your hands which are quiet in your lap. Now let your gaze lift and focus until you slowly take in the rest of the room. That was very good, Rachel.
Ms. Tanner: It was hard to get started, but then I didn't want it to end.
Dr. Balis: You did fine, Rachel, just fine. How did it feel?
Ms. Tanner: I felt trapped at first. I didn't think I could do it when you said I couldn't move. How long did that last?
Dr. Balis: How long do you think it lasted?
Ms. Tanner: About five minutes?
Dr. Balis: Less than two. I'll give you a tape that has several relaxations of varying lengths. It's a commercial tape, so it'll be someone else's voice--a woman, as I recall.
Ms. Tanner: I'll try it.
Dr. Balis: Excellent. I'm pleased that you are willing to do some homework. You have to remember the goal while you are relaxing, however: to keep your hands completely still. Also, get rid of all of the distractions before you begin. You might want to tell your grandmother that you would like not to be disturbed for a reasonable amount of time. You can lay down or sit, whatever is most comfortable. Did you notice how your hands looked at the end when you were opening your eyes? They were completely motionless. Remember that image. You can do it. Any questions?
Ms. Tanner: Not really. What if I can't do this at home?
Dr. Balis: You have to train your body to relax, so don't give up or get discouraged. It may take several tries. If you like, we can practice this again together during our next session. I'm pleased with your response today. I want you to start feeling like you're in charge of your OCD.
Ms. Tanner: Doctor, when should I do the relaxation tape thing? Would it help to do it before I go to bed?
Dr. Balis: There's a good chance that it will, yes. But experiment and try relaxing at different times of the day--when you have an opportunity, of course. You have to try and see what works best for you. How many hours of sleep is normal for you?
Ms. Tanner: Here's a typical routine. I take a short shower, then Gram rubs my feet with lotion because I get psoriasis really bad. Then I brush my hair. Then I get into bed. I usually turn on the radio and lay in the dark thinking. It's hard to say when I fall asleep. I would guess I get about five or six hours a night.
Dr. Balis: Hmm. Is that enough? If you could, would you sleep more?
Ms. Tanner: I don't know.
Dr. Balis: Okay. Did you try writing a journal?
Ms. Tanner: Yes, I wrote twice. I forgot to bring it with me.
Dr. Balis: Do you remember what you wrote about? Is there anything you wish to discuss?
Ms. Tanner: Well, actually yes. I had a major panic attack.
Dr. Balis: Is that something new?
Ms. Tanner: Kind happened yesterday. Swimming is the one thing that relaxes me and helps wear me out. But the public pool became a nightmare to me because of the hygiene thing. Gram put in a lap pool so that I could swim at home. She uses it too, of course, but it's a daily thing for me. Anyway yesterday, I was sitting on the edge putting on my cap, and I noticed three blackbirds on the other end of the pool. They were in the shallow gutter taking baths. I guess you could say I lost it.
Dr. Balis: What happened?
Ms. Tanner: Well, they contaminated the water. Birds have all kinds of lice and dead skin, plus there was a feather floating on the water. I took one look at that feather coming towards me and started choking. I didn't think I was going to be able to move. That feather just bobbed and bobbed getting closer and closer until I almost puked. I finally crawled across the deck to the outdoor shower, but barely. The whole time I was showering off, the birds continued bathing, leaving their filth behind.
Dr. Balis: Was your grandmother aware of all this?
Ms. Tanner: She noticed right away that I wasn't in the pool for my usual length of time. She came out when I was toweling off and asked what happened to my legs. See? She knew what to do about my legs, but she wasn't sure what to do about the pool water.
Dr. Balis: The pool water is usually treated with chlorine to make it difficult for germs to live. And the creatures that parasitize birds are generally not interested in humans. Additionally, I'm sure your grandmother maintains the pool at the proper p.h.-level...
Ms. Tanner: She reminded me of all that. And I watched her pour in more chemicals right after the incident. Like I said before, a lot of my reactions aren't really logical. I know this. I'm a mess, Doctor.
Dr. Balis: Tell me something, Rachel. Are there times in your life when you feel like you might want to hurt yourself?
Ms. Tanner: Like my mother did? Doctor, that's why I stopped driving. This disease or disorder or whatever can make you feel pretty crappy. A lot of what I do stems from not measuring up, disappointing people, not being able to share my life with someone because I'm so weird. So the temptation to off myself does come up. It would be so easy to do it in a car. I was getting really scared--not to mention exhausted--whenever I drove somewhere. The concentration it took to keep it together would absolutely wear me out. Then I'd have a hard time getting to sleep thinking about who I could've killed including myself.
Dr. Balis: Is that why your grandmother drives you here?
Ms. Tanner: Yes, she is my safety.
Dr. Balis: Safety?
Ms. Tanner: Without Gram I wouldn't be able to really go anywhere other than work. I'm safe with her. I'm only talking about going to the grocery store, the library, the Hairport, and the video store. The rest of the time, I stay in the car or at home.
Dr. Balis: Hmm. I think it's significant that your life is so impacted by your OCD. It's keeping you from enjoying certain privileges that most of us take for granted. Rachel, you're an attractive, articulate young lady. You have skills, education, and you're well-cared for. You mentioned feeling trapped during the relaxation. I'd imagine that your OCD gives you that feeling as well, right?
Ms. Tanner: Of course. Damn it! Why do I always end up crying in your office?
Dr. Balis: You're frustrated. I suspect you might even suffer from a depression. I've noticed your honesty with me, and you seem very willing to work hard. I'm encouraged that you can make progress. But it's not going to be easy. Lots of things will surface as we continue with therapy. Things may get worse before they get better. We'll take it a day at a time. Okay? Need another tissue?
Ms. Tanner: Rats. I think I opened this thing up again.
Dr. Balis: I'll get you something for it.
Ms. Tanner: Thanks.
Dr. Balis: Will this help?
Ms. Tanner: Yes. A little lamb?
Dr. Balis: It's good cheer.
Ms. Tanner: You're going to make me cry again. I'm not used to getting presents. Do you always keep a bunch of little stuffed animals around for your crying patients?
Dr. Balis: You never know when they'll be useful. Feel better now?
Ms. Tanner: A little. You're sweet, Doctor.
Dr. Balis: Well, our session is over. I want you to continue writing in your journal and try the relaxation tape. Take care, Rachel, and I'll see you at our next session in two weeks. Let's see, that's October 21st at one o'clock.
Ms. Tanner: Thank you, Doctor. Goodbye.
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