When Therapy Works Fast |

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She arrived exactly on time, dressed professionally and without a single wrinkle, and spoke as clearly as if she were articulating for a crowd. Her handbag gleamed expensively, and her shoes didn’t match the weather, but somehow remained clean and dry. I don’t judge my patients by their appearance, but, in this case, it seemed like she was doing her best to show that she had everything under control. It took her three minutes to break down in tears.

Obsession With Scabies

Scabies, she said. Because I wasn’t familiar, she described them to me: many-legged microscopic mites that burrow into human skin to dig tunnels and lay eggs, causing tremendous itching and inflammation. They’re spread by skin-to-skin contact or by shared clothing, like hats or bedsheets. Hearing it, I felt a brief twinge of concern, but she put me at ease immediately, saying she’d had scabies more than three months earlier and had, since then, been medically cleared.

Which, in turn, was exactly the issue. Despite multiple visits to her doctor—various doctors, in fact—and a successful round of medication treatment, she hadn’t been comfortable since the infestation began. At night, she couldn’t sleep: Each prickle or feathery sensation, she believed, could be a sign that the scabies were coming back. She had repeated nightmares about tiny mites biting her and digging into her skin.

Each morning, she’d wake up and strip the bed to look for spots of blood, then toss the sheets into the wash on the hottest possible setting. She’d replaced her bedding twice and had thrown out more than half of her clothing. Her partner was exhausted with her constant focus on scabies, especially because the patient kept asking her partner to look over the skin of her back for any telltale signs. At work she found herself distracted; she took frequent breaks to visit the ladies’ room, where she would partially disrobe and look over her legs, arms, and midsection for new sores or bites. Her employer had begun to wonder why she was so often absent from her desk.

Breaking the Cycle

She came to me for help. Medical treatment had solved the problem, but it left some significant issues untreated. She was obsessed with scabies (in that she couldn’t stop thinking about them) and had a series of compulsive behaviors stemming from this obsession: the washing, checking, and asking for help. Yet the checking only diminished her anxiety for a short time, and when it built up again, the need to check again came back even more strongly. She needed to find some way to break the cycle. Perhaps psychotherapy, which she hadn’t previously tried, could make a difference?

It occurred to me after our first meeting that a potential course of therapy would likely, for this patient, be unpleasant. As well-manicured as she appeared, when she talked about scabies, she could barely hold herself together. The thoughts made her squirm and could bring her to the brink of tears. She couldn’t describe their life cycle or the symptoms she’d endured without feeling nauseated. To me, this seemed like a good place to start. I asked her in our second session to search the Internet for five of the largest, most high-resolution photos of scabies mites, and the painful rashes they created, that she could find. I then told her to rank the photos from least disturbing to most. For the next four sessions, she and I would examine these photos together, starting with the least difficult and progressing further each time, always zooming in on what she found to be the most unpleasant details. Initially, she had trouble looking at the photos at all, but no matter how much trouble she had getting started, after five or ten minutes, she’d report that her feelings of disgust and anxiety had faded away.

From her history and the details of her employment, I understood her to be a person who placed a premium on rational thought and decision-making. So I started with psychoeducation, and I called attention to the way the itch-anxiety-check cycle tended to reaffirm her checking habits. I also asked some fact-based questions about scabies, with particular attention to the question of when and how they could return. She easily filled me in, as she’d done a great deal of research about the mites, but didn’t seem to recognize the implications of the fact that they couldn’t live for more than three days without feeding.

Taking note of the intensity of her fear of scabies, I asked her to put some numbers to her thoughts: What was the real likelihood of another infestation? She had some trouble with this but eventually came up with a number: All things considered, she was probably only 0.5 percent likely to experience a recurrence of scabies in the next 10 years. Half of one percent. She told me it surprised her to have generated this number herself, because—before she’d thought it through—she would have imagined the likelihood to be much higher.

We then got to work on her habits of checking herself and her environment for signs of microscopic mites. She made a list of the ways in which she had been trying to prevent re-infestation, and I asked her to arrange this list according to how much anxiety each habit could relieve—from least effective against anxiety to most. When she saw the list in written form, she said she could see that several of its items had not been effective at all. At my encouragement, she agreed to eliminate the bottommost two habits on the list from her repertoire before our next session.

Next, this patient took a big step: to stop checking her clothing and her body for scabies during work days. She knew this would be uncomfortable, and it was, but after a few days, she reported that the pressure to examine the skin of her legs and arms had abated, and said she could get through a workday without interrupting herself. She said, however, that her morning body-checking ritual—which she performed immediately upon getting out of bed—would be the hardest to discontinue, because she worried the most about her itchy skin in the mornings. To chip away at this, I asked her to create a list of other explanations for the itches she experienced. She admitted that she had once been told by a dermatologist that she suffered from “xeroderma,” which means “dry skin,” and noted that this could easily be the root cause of her itching.

While coming up with these problem-solving strategies and alternate explanations, she and I continued to review the close-up photos of scabies mites. Each time, I asked her to narrate the thoughts and feelings she had and to describe her level of anxiety. During our fourth session, the patient spontaneously remarked that it would be impossible for scabies mites to exist in her apartment because she had had no clear symptoms for a much longer time than the mites could have lived without biting her. She also admitted that her scabies nightmares had abated somewhat, and said that although she had still dreamed about the mites once or twice, the dreams were not as scary as they once had been.

By our fifth session, she said she no longer felt any pressure to check her body for bite marks in the mornings or at work. She agreed, somewhat reluctantly, to stop checking her bedsheets for bugs each morning, which greatly relieved her partner. She began to say she felt sheepish or embarrassed about her irrational thoughts when it came to the checking behavior she had held on to for so long; we then talked about the difference between noticing a genuine itch and checking her body in response to a burst of anxiety. We did look through a few more magnified photos of scabies mites, which she said were “gross” but which no longer caused her much of an increase in anxiety. At the end of the session, we reviewed the experience of therapy overall, which the patient described as “empowering.”

“I feel a lot more in control,” she said. Our therapy ended shortly thereafter.

Not every course of treatment is this concise, or this focused; much of the time, people who benefit from psychotherapy simply need a dedicated time and space to talk things out. At other times, it’s the trusting therapeutic relationship that helps people get better. But in some cases, therapy can make a very big difference in a short time. Before this patient and I parted ways, I let her know she could come back to me for a “booster session” if she happened to notice an uptick in her level of itch-related anxiety. I’ve thought of her from time to time since then, but I’ve never heard from her again.

Names and details about this case have been changed, in some cases significantly, to protect the confidentiality of the person or persons involved. However, the length and course of treatment described here are accurate.

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