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The Worry Hill - Page 11


Case Commentary

By Martha Straus

In this case study, Wagner describes a gold-standard treatment for a child with OCD, using a nuanced and comprehensive therapeutic approach. This exceptional protocol does much more than employ simple exposure techniques: it incorporates the best elements of family therapy, coaching, cognitive-behavioral strategies, and narrative work. Integrating research evidence, clinical expertise, and the specific needs of a young child and her parents, Wagner is able to effect enduring change. I suspect the clarity of explanation and speed of results will cause the uninitiated to believe this is a simple disorder to treat, but it isn't. This therapist's dexterity only makes it look easy.

I was particularly struck by the ways in which Wagner modified and infused cognitive-behavioral techniques with insights into child and family development. One of my frustrations with the application of CBT in child psychotherapy has been a tendency among practitioners to overrely on cognitive capacities that exceed a child's developmental ability, while diminishing the therapy relationship to little more than a first-session frill. In "real life" (as opposed to treatment manuals), kids often struggle with the expectations and assignments in CBT work, and have lots of other unaddressed problems. They squirm and moan, "Can't we play now?" Real-life therapists end up shooting hoops with a Nerf ball or cleverly shuffling a deck of cards to finagle five minutes of therapeutic conversation. And some kids don't do homework for school, so why should we expect that they'll do it for us?

I appreciated the amount of time Wagner takes to build a treatment alliance with this fearful child and overwhelmed parents. She allows the child to control the pace of treatment (perhaps paradoxically galvanizing her into action by suggesting that it's a hard assignment and require a long time before she's ready!). This respectful empowerment includes using child-sized imagery (e.g., riding a bike up and down a hill), careful psychoeducation, and reassurance for the parents.

Once Maria is motivated to change, the treatment moves swiftly: she practices at home and in the office to conquer, in ascending order, all the fears she's acknowledged. Notably, her parents also learn the narrative technique of externalization: they find out how to respond to their daughter by distinguishing her voice from the needy and controlling agenda of OCD.

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