In Part I of this series the fictitious patient, Keith, set out to find CBT therapy for his anxiety. He came across advertisements for two local therapists, and after the first session with each therapist he asked himself three standard questions about what happened.
Those first two therapists failed Keith’s evaluation, and Keith is not sure what to do next. His work is now badly affected, and his annual appraisal is due.
Keith’s boss is worried. Keith’s appraisal is going to look bad, and that’s going to make the boss look bad. The boss suggests postponing the appraisal so Keith can ask the Occupation Health department if they can help. Keith is doubtful, but he makes his way to the annexe where the Human Resources people work.
The Occupation Health department turns out to be a gawky-looking girl whose desk is piled high with procedure manuals. She explains the situation. The company has a contract with an employee assistance programme (an EAP), and the EAP has a contract with a nearby psychology centre. All it takes is these forms to be filled in, and these managers to sign them, and Keith can be treated by a psychologist at the company’s expense.
The director of the psychology centre, Xavier, is a chartered clinical psychologist and accredited CBT therapist. He’s middle-aged and looks expensively dressed. He speaks slowly and precisely, with the air of a rich and kindly but slightly absent-minded uncle.
Keith is bowled over by a sense of being personally valued, not just valued by his company who are providing the treatment, but also by the staff of the psychology centre and by Xavier himself.
And for the first time, Keith finds that someone really seems to understand the strange and disabling feelings that he has — seems to understand them almost better than he understands them for himself. On several occasions he finds himself struggling to find the words to explain something, when Xavier just sums it up in a way that shows he knows exactly how Keith feels.
Towards the end of the session, Xavier tells Keith that it’s time to wrap things up for this week, and asks him if there’s anything else he wants to bring up before they end the session. Keith is eager to know whether his problem can be cured, and how long it will take.
Xavier laughs, and smiles at Keith in that kindly but slightly-absent-minded-uncle way, “Oh, I’m sure you’ll be alright, you know…we’ll just see how it goes, don’t you think?”
At home that evening, Keith goes over the session in his mind, and particularly that last remark. He asks himself the three questions:
Xavier made him feel liked and valued, and the amazing thing was that Xavier really seemed to understand his difficulties. So Xavier certainly passed the first two tests. But when it came to number 3, Xavier failed. There seemed to be no plan of action. It was as if he didn’t know what to do, or didn’t really care — as if it wasn’t important to him.
And with that thought, Keith begins to think that maybe the whole session was an act on Xavier’s part. Keith decides to ask the girl in Occupational Health if he could use the EAP to see a different therapist.
Psychotherapy is hard work for the therapist. It doesn’t only require skill, it requires real commitment to each individual patient, and willingness to struggle with ideas and feelings in order to get to the bottom of the problem and find a solution. Xavier’s tremendous personal warmth and analytical skill don’t completely make up for the distancing tactics that he uses to avoid commitment. Though successful as a businessman, he’s flawed as a therapist.
The following week at the psychology centre, Keith’s appointment is with Will, a former NHS mental health nurse. Will had trained to do CBT while in the NHS, and shortly afterwards he left to work for the psychology centre.
Just like the week before, Keith feels valued and understood during his session with Will. But while the director of the centre seemed slightly vacant, Will seems to be puzzling over something all the time. He seems to be forming a plan.
They spend quite a lot of time going over how Keith’s difficulties affect his life, and they establish a goal for the course of therapy — that Keith should be able to reduce his anxiety to the point where his work is no longer affected.
As Keith begins to realize that Will both understands and cares, he starts to feel quite emotional. But then talking about a plan, talking about being cured and becoming normal, this overwhelms him. He breaks down and sobs for a short time. Will is just quiet. He doesn’t laugh this off or comment on it. Keith realizes that Will has seen this all before. An idea forms that this really is therapy.
Will then explains how CBT works. In CBT, he says, Keith will learn to identify the triggers that make him anxious, and he’ll learn about the mental processes that maintain his anxiety. Finally, he’ll learn to change his behaviour so that he can deal with the triggers in a better way.
Keith’s homework task is to fill in a worksheet every day, describing situations that he faces throughout the day and giving each situation an anxiety rating from zero to five.
That evening, Keith meets his brother to evaluate the session. Keith feels that Will genuinely seemed to like him, he seemed to understand exactly what Keith’s problems are, and he had a clear and thoughtful plan for dealing with them. Will passed all the tests. This is exactly what therapy should be. Keith can’t wait for next week’s session, can’t wait to get started.
In the next episode, Keith changes his mind about Will, but he also discovers that he can get treatment from the NHS without a long wait.