“ERP (Exposure and Response Prevention) is not working.” “I’ve tried ERP before- it doesn’t work for me.” I have many current and past clients who said this once. You might think, given my practice focus, that I would simply respond by offering more ERP. Not necessarily. Let me say what I don’t do, first. I don’t automatically say, "MORE ERP!" What I do is dig deep in assessment, first. Your outcomes are highly connected to whether you have done a few crucial things in your Exposure and Response Prevention for OCD. Here are common reasons you aren’t getting the most benefit you could.
#1: You haven’t given ERP a real chance.
Let’s just start with the obvious- you can’t get the benefit of a treatment if you haven't tried it. Have you tried another approach instead that is NOT ERP?
Please note that at any given point, all of the approaches listed above (EMDR, talk therapy, etc.) can be useful for a variety of things; they are just not the clinical first option for OCD!!!
Hear me loud and clear, because it needs to be said: if you're serious about getting better and have access to it- go for the gold standard Exposure and Response Prevention. The rationale and research is extensive- you can find it in my ERP for OCD presentation and ERP for OCD Brochure.
#2: You tried and “failed.” You might need to increase the quality of your ERP or attempt another trial.
If we sit down in assessment, and you say anything like the following, the quality of ERP may have been lacking, and we need to “up your game.”
Use this handy checklist ✅:
Though this is a very thorough list, it’s not even cumulative. There are even more! All of this to say, ERP is a very deep and powerful tool. Don’t give up too soon.
#3: You gave up without considering many viable OTHER treatments.
Now that we’ve covered many reasons that ERP quality may have been lacking, there are certainly those who receive solid treatment from a trained clinician, but they still are having problems. It happens in my practice; it happens with the world’s foremost experts, too. OCD is a formidable foe, and we are complex as human beings- no one size fits all. OTHER OPTIONS EXIST!!! As you consider with your clinician what’s not working, consider the following:
#4: Though it's uncommon, you may have tried many options above. Keep pressing on.
This is part of the uncertainty we have to accept- and work towards. A generation ago the tools we have today didn't exist as they do (ERP got full steam in the 80’s and wasn’t available in your average practice until later)!!! OCD, especially severe cases, was seen as largely difficult to treat or untreatable by many providers for most of the 20th century.
I have seen personally- and the experts attest- there is usually hope for those who keep pressing on, even in the most severe of cases. Check out Dr. Liz McIngvale’s personal story to to be encouraged.
So if you have doubts and fears about ERP, have tried it and it hasn’t worked for you- or have avoided it, I have good news- there likely exists options for you. And even those who seem to run out of options can typically find many if they keep persevering. You are valuable and significant, no matter how you feel today. I hope to be an encouragement in your journey.
If you have experience with cancer treatment, you may already know what is meant when I say, “cut out the margin.” Margin is the edge or border of tissue that is being removed through surgery. Why can’t you just cut out the “bad” part? Why must you go further? Simply, it is only deemed clean when all cancer cells are removed; if you don’t remove the margin, you run the risk for recurrence. Treatment for OCD is not so different. To strengthen your outcomes and run a lower risk of relapse, you’ve ‘gotta catch ‘em all’ (compulsions). Let’s take a look at a therapy insider tip that you might not have gotten elsewhere: cut out the margin.
Why Clients Come To Me
Clients come to me ready to get unstuck. Ready to get their lives back. Ready to leave their house without a ridiculous layer of requirements they must adhere to until their anxiety lets them off the hook. To kiss their spouse without second thoughts of contamination or checking. To wash hands like their peers. To not be tormented by intrusive thoughts. To be less anxious. To be free. And many, many more reasons.
Part of the education process in my delivery of CBT [link when you have an article] from Day One looks at how you can gain as much victory as possible over your OCD- and this naturally involves looking towards the end of treatment- today. It’s important for you to know up front what you’re committing to. Though a client is often ready to move forward with their lives as soon as they see “good enough” progress, don’t settle for that.
Encouragement to Keep Going
It is important that we don’t just stop treatment once you get symptom relief. In fact, it’s important to remember what brought you to therapy in the first place. If you are treating a chronic and/or episodic condition like OCD, research is very clear on the need to take it to the endzone:
“Leaving untreated areas in OCD is problematic because it makes relapse more likely” (Gillihan et al., 2012).
I promise- this is not the same as perfectionism. I promise- this is not to hold you in therapy longer (I’ve got way too much important work to waste either your or my time). I will always try to balance celebrating your wins and working with your real-world limitations (cost, time, motivation, etc.). But I want to be very clear here: your long-term outcomes are directly connected to whether you get rid of all your compulsions or not (when possible). If you leave behind some untreated area of OCD, you are leaving room for the “whack-a-mole” presentation of OCD to grow. Fear always generalizes as it grows; unfortunately, you won’t be able over time to stick with one manifestation without it growing. One door knob you avoid becomes two. One social situation you avoid becomes more. Obsessively mentally checking your moral intentions with one intrusive thought becomes one thousand.
Cut out the margin.
Just as in cancer treatment, get the margin. Go for it. It may seem daunting and scary. Especially if you’ve been trying on your own and/or if you haven’t gained a specialized lens for one of the most debilitating conditions on the face of the planet (medical and mental- a top 10 every year). Your long-term well-being will be better for it.
This post is intended for Christians looking to deepen their faith and mental health and may not apply to my entire reader base.
A vaccine for Sars-CoV-2 is just beginning to be administered to the public as 2020 is coming to a close, and a palpable ‘shot in the arm’ brings hope for the ravages of COVID-19 for many.
Consider with me what life was like prior to 2020? What was going well? What made you long for change? My guess is that there was aplenty wrong with the world in 2019.
“So we do not lose heart. Though our outer self is wasting away, our inner self is being renewed day by day. For this light momentary affliction is preparing for us an eternal weight of glory beyond all comparison, as we look not to the things that are seen but to the things that are unseen. For the things that are seen are transient, but the things that are unseen are eternal” (2 Corinthians 4:16-18 [emphasis mine]).
Hope is always counterbalanced with another weight- fear, suffering, pain, injustice. Even a “perfect” rollout of a vaccine will leave us with a still broken world. Where is God in suffering?
The Apostle Paul had opponents who claimed that because he was suffering, this clearly meant he wasn’t in God’s will (2 Corinthians 11:24-29). Paul gave about a thousand reasons why this was not true in his entire letter. In fact, the mere existence of hope as a concept will be unnecessary, because God promises us all our hope and faith will be realized in time (1 Corinthians 13:3, then 12-13). So we wait patiently (Romans 8:25).
Indeed, “we do not lose heart” (4:1) though we are broken vessels walking around (4:7), afflicted in every way (4:8). But….BUT, “so that the life of Jesus also may be manifested in our mortal flesh” (4:11). God keeps extending grace to us in the midst of suffering- not in the absence of it- which leads to us being more thankful and God being more glorified (4:15). So we do not lose heart (4:1).
Jesus is the suffering servant, who shocked a watching world that God’s promise of salvation would come to give up his power, suffer, and wash our dirty feet (John 13:1-17).
Lest we only consider O Little Town of Bethlehem a cute ballad of Nat King Cole, let’s remember the tension of fear and hope. Phillips Brooks, in 1877, wrote it. Did you know that though he lived in the “Gilded Age” after the Civil War- that largely saw growth and prosperity in the United States- he also wrote this song smack in the middle of “The Long Depression” of 1873-1879. Furthermore, the Reconstruction Era was in full swing, with the highs of officially abolishing slavery and the lows of deep political shifts and divides, violence, and disenfranchisement of many, not the least of which was continued oppression.
O little town of Bethlehem,
how still we see thee lie!
Above thy deep and dreamless sleep
the silent stars go by.
Yet in thy dark streets shineth
the everlasting light;
the hopes and fears of all the years
are met in thee tonight. [emphasis mine]
For Christ is born of Mary,
and gathered all above,
while mortals sleep, the angels keep
their watch of wond’ring love.
O morning stars, together
proclaim the holy birth!
And praises sing—let “Glory!” ring
with peace to all on earth!
How silently, how silently,
the wondrous gift is giv’n!
So God imparts to human hearts
the blessings of the heav’ns.
No ear may hear his coming,
but in this world of sin,
where meek souls will receive him still
the dear Christ enters in.
O holy Child of Bethlehem,
descend to us, we pray,
cast out our sin, and enter in,
be born in us today!
We hear the Christmas angels
the great glad tidings tell.
O come to us, abide with us,
our Lord Emmanuel.
God is with us in suffering as He always has entered into our world- simultaneously a world of suffering and one with hope. Let us sit in this mystery and proclaim with the Psalmist, “It is good for me that I was afflicted, that I might learn your statutes” (Psalm 119:71). A bigger hope can- and does- transcend suffering. “The hopes and fears of all the years are met in Thee tonight.”
Despite how great food at Chick-fil-A is, there is a significant correlation between consuming chicken and oil being imported to the U.S. Does this mean anything? Probably not.
If you have ever dug into statistics- in the news, in school, or even through your own research- you may have learned an important principle: "Correlation does not equal causation;" in other words, just because two things are associated doesn’t mean they are related to each other. I discovered a fun little website that features "Spurious Correlations." Check out the connection between chicken and crude oil:
So there you have it, ladies and gentlemen. Eat Mor Chikin, or don't. Obviously, it’s probably ridiculous to put any significance on this. Frankly, you and I may hold some correlations that are just as absurd. Here's an example of one I did today.
I woke up with the same irritation in my left eye that I had from my contacts last night. My thoughts jumped to a torn cornea, eye irritation, my brand new 1 year supply of expensive contacts being a bad choice, to some generalized unknown disease. I don't have Health Anxiety Disorder (the disorder formerly known as hypochondriasis), but my very human brain seems to generate all sorts of interesting thoughts and hypotheses. As of this writing, they're all correlations I'VE come up with in my "I clearly know more than an eye doctor" experience.
What I'm practicing at this moment is something I teach my clients: Observe. Pause. Engage in what you know to be good and meaningful in the moment. Face obsessional trash talk. Restructure actual harmful beliefs that are believed to be true. And wait. Wait. WAIT. Sit with it in absence of an emergency or clear decision that must be made (or disordered expectation that it should be clear and you must act now).
Stepping away from the heat of the moment, I have more clarity (as we all gain perspective when we’re not entrenched in strong emotions about a topic). It's likely just some irritation. But maybe not. I'll sit with it longer. I'll work hard in delivering therapy today. I will stop ruminating on it. I can face this. I’ll use some eye drops. I can tolerate this distress. I'll likely learn this is nothing big, but even if I don't, I bet I can learn what to do and face it regardless.
These are core components of the CBT treatment of Anxiety and Fear:
So if you correlate chicken with oil imports or discomfort with disease, you might just give CBT a try so you can live a little more in the truth of reality. You might just find some more clarity, less anxiety, and/or you can handle it. I have.
[Post update 4 days later: turned out I had a stray eyelash that had lodged itself in one the pores at the bottom of my eye. Once removed, it was fine! If I had rubbed my eyes trying to make it go away out of fear, it would have made it worse- and increased the risk of harm to my eye. If I resolutely minimized it and called it ‘nothing’, I wouldn’t have calmly scheduled an eye doctor appointment where the lash was easily plucked out.]So there you have it, ladies and gentlemen. Eat Mor Chikin, or don't. Obviously, it’s probably ridiculous to put any significance on this. Frankly, you and I may hold some correlations that are just as absurd. I did today.
This post is intended for Christians looking to deepen their faith and mental health and may not apply to my entire reader base.
One of the things that is very grounding about the Christian faith is that there is not only truth/Truth we follow, but hopefully a willingness to pursue disciplines that either a) aren't comfortable, or b), may not necessarily make sense immediately. This is very helpful in therapy when clients don’t throw up resistance to the concept of a greater good through suffering- and the need to persevere in it. If you haven’t yet accepted the tenet of persevering through suffering- and not having an answer- we must first do some preliminary work. Therefore, when asking clients to consider, for example, the hard work of facing fears of certain illnesses, social rejection, or harm, there is already an excellent platform in place. However, I also see that Christians can be remarkably inflexible- myself included. I think it’s often the backside weakness of a frontside strength: commitment to truth. But a commitment to truth is not incongruous to flexibility- the practice of humility is at the heart of the Christian walk- along with acceptance of mystery and uncertainty.
A massive University of Rochester study (meta-analysis) examined over 44 THOUSAND people and found that in relationships, psychological flexibility was a unifying key to positive outcomes. Some of these positive outcomes were:
Examples of inflexibility I often hear in Christians:
In therapy and in life, we must call out seemingly true things that are actually false, or at least not the full picture (Ephesians 4:25; 2 Corinthians 10:5; Matthew 4:1-11). I'm game if you're game. Not only is humility one of the marks of the Christian life, so is living in mystery, tolerating uncertainty with patience and joy, and simply not being a ‘know-it-all.’
Examples of hardcore acceptance, flexibility, and uncertainty in the Bible:
When feeling pervasive doubt, uncertainty, and indecision, I've got to shoot straight with you: I think we Christians tend to be a bit more annoying in learning to sit with uncomfortable feelings. 🙂 There, I said it. We’re supposed to have the answers, right? Well, yes and no. We have some incredible answers and access to the living God of the universe (Hebrews 4:14-16)!! But we are not perfected, yet. Simply put, we are not God.
Want to be flexible? Be circumspect, fellow Christians, so that you don’t fall into a trap of needing to know- being unable to tolerate uncertainty. When you demand certainty and are inflexible in enduring discomfort, you’re not only missing out on some cool benefits, you’re also missing some parts of Christian virtue- and as soon as you start living in fear, you’re clearly outside of God’s desire for you. No shame, but God wants you to experience freedom! (Galatians 5:1). There are many ways to grow in flexibility. It starts with the humility to say: “I don’t know it all.” The pursuit of the “perfect” in ourselves is often the enemy of the good. Rather, pursue The Perfect One. God is patient with His children and provides wisdom to those who ask.
I had no plans to write this article today on loss and suffering. But the more I ponder the life and legacy of “Papa” and the times we are in, I believe more and more it’s a message to share. When hurting and suffering takes over and the complexities of life are weighty, I believe we can learn courage and longsuffering from the passing of a man just last week.
Three years ago in December, my wife underwent brain surgery- she had just given birth to our first child three months prior. In a month, we spent more days in the hospital than out of it. Besides prayer and connecting with loved ones, there’s not a lot you can do. This piece is not about my wife, though, it’s about Joe.
When my wife was at the edge of life and death and a room meant for waiting became one for crying and praying, the support of family and close friends was powerfully existent. But here sat Joe, and his wife Marion. We barely knew them in the grand scheme of things; however, we were suffering, and they wanted to sit with me and the rest of our close ones.
I’ve since learned many stories about this Joe, tough as nails and sweet simultaneously, his impressive life incorporated a long-standing marriage with children and grandchildren, military service, and a faithful pillar in his church. I’m not sure how much, if any, of those things I knew at that time. I only knew he was there to sit. To wait. To be with us.
Grief and suffering are some of the most complex topics on the face of this planet. We all grapple with it philosophically and existentially. The answers are not easy. But there is one thing that typically does not fail in supporting: sit with it. Sit with others as they suffer. Let me share from one of literature’s eponymous books, The Book of Job (in the Bible). Job had a few great friends when he lost nearly everything, and their support was incredible- until they opened their mouths. In the end, everyone ended up saying all sorts of crap that was untrue and without understanding, Job included. The friends did well- for as long as they just sat with their friend.
That’s the gift Joe gave to me in my time of suffering- he sat with it. Though it may be a funeral today, it is truly rejoicing at a life and legacy of a good man.
A common question I get is, “What if I get overwhelmed before we meet next?” If we have ruled out serious risks dealing with safety, usually there’s a simple tool that can seriously help (while working the treatment plan). Through the study of the brain, human behavior, and feedback from clients, here is a ripcord to pull in your emotional parachute: Pause.
If you suffer from anything like OCD, social anxiety, boundaries in relationships, panic attacks, or just get overwhelmed at times, to get out of that trench your first step will always be some sort of pause- to gain a clear head and observe what's occurring.
Whether you’re a professional who wants to be a better leader (see “Harvard Business Review’s “The Power of Pause”) or a stay at home Mom or Dad (see Very Well’s “Avoid Burnout When You’re a Stressed Stay-At-Home Mom”) or just want to increase learning with a 10 second rest, learn the art of taking breaks.
For example, exercise. What’s a goal you’ve had for yourself? Build muscle, lose weight, get toned, run faster, workout longer, heart health? All of these goals will not see large jumps of progress in a day. If the only running you've done is in your car to Whataburger, it's going to take some time to train up to a marathon. Trying to run 26.2 miles the first day is almost a guaranteed injury. It’s really not any different with mental health. In order to be successful at anything, you must be realistic as to your definition of success for today. If you get overloaded and stressed, you will need to pause in order to get out of that mental hole, and if you have any long standing patterns of problems, you'll need a strategy that can only come out of pausing and evaluating.
As we enter into the most concentrated holiday season in the world- especially the U.S.- this means a concentration of other things, as well. Family time. Work deadlines. Change to daily structure. Sickness. Time off. So if you get stuck- stuck in your emotions, stuck in a tough conversation about politics at the dinner table, stuck in negativity over your life decisions, stuck in panic, do this one thing: Pause.
That’s right, pause, Santa Claus. Feeling anxious? Pause. Stuck in depressive rumination? Pause. Enjoying the moment? Yep, pause and reflect.
Here's my "Exposure Friendly Mindfulness" video and exercise if you want a tool to help. Blessings to you, and Happy Thanksgiving.
This post is intended for Christians looking to deepen their faith and mental health and may not apply to my entire reader base.
My daughter Hattie went into hoarding mode this Halloween. Within 5 minutes, she was in MEGA-CUMULATION mode. Emily and I got some good parenting moments; “Hattie, you can choose 2 items from that basket.” (We had to say that about 30 times.)
I laugh often when she’s around food, toys, or playground equipment- like an old prospector she stakes her claim. She is offended that others dare lay claim to something she thinks should be hers! How dare they!
Now I’ll point the laughter at myself; I am not really that different. I’ve just become more savvy at being socially adept at my control attempts.
Hoarding of items to feel secure is a fairly natural response of our human nature, ranging in extremes. A scarcity mindset, i.e., “feast or famine” or to obsessively “protect what’s mine,” though, is selfish and self-focused. It does not “love your neighbor as yourself.” I recommend for myself today- and for you- to look in the mirror every once in a while and ask this tough question:
What drives you? Fear-based scarcity? GOD- as your provider? Something else?
A story may help illuminate the question. The Hebrew, ‘man hu’ means “It is manna,” and in English, “What is it?” This manna was an incredible food God provided refugee Israelites fleeing from a brutal autocracy that had enslaved them. It's all part of the incredible history of the Jewish people. God accomplished this over many years and utilized several key players, the most famous being Moses. In delivering Israel from Pharaoh and the Egyptians, God led them out through the leadership of a very imperfect man who likely had Social Anxiety Disorder, fulfilling incredible promises, miracles, and almost unbelievable wonders. It's one of the best deliverance stories, maybe in the history of history. If you haven't read it, please do so in the Book of Exodus.
So imagine being born into slavery, and you gain total freedom from an overbearing despot. But in order to get away, you must go through the desert. I feel tired and thirsty already.
In their refugee state, God promised the Jewish people refuge. But it wasn’t a magical transportation to heaven. Just days after they were freed, they felt the heat of the desert. They had to walk miles and miles. They complained. Only one of the seemingly unbelievable ways God provided for them was through fast, convenient, and sustaining food. It was manna (Exodus 16), which was given in the morning and quail at night. They were already complaing so much they said they wanted to go back to slavery because they had it better in Egypt (*face palm*). In addition to complaining, there was hoarding (Numbers 11) in desperation, lacking reliance on God. I can only guess fear would have been involved.
These details, with thousands of years of perspective can make it seem ridiculous to some when we read on paper or pixels. Why wouldn’t you just trust God when he frees you from slavery and performs many miracles before your eyes? I’m afraid my heart isn’t different. I am the same when I lack trust in God by faith.
What if you have an Anxiety or other Disorder that gives you an extra kick in the teeth? Something that makes these things extra difficult? First of all, God is patient (2 Corinthians 12:7-10; 1 Peter 3:9). Secondly, God asks us to seek Him by faith in all things, just like everyone else (Hebrews 11:6; 2 Timothy 2:4).
I have an anxiety disorder myself. And God has been incredibly faithful and gentle with me, while also lovingly disciplining me (see Hebrews 12), so that I keep seeking him. If you fall into a scarcity mindset [check out my post “Developing A Growth Mindset”], welcome to the club of being human, but if you also have a disorder that makes it even more difficult to walk by faith over fear, welcome to another club that is very large, indeed; close to half of all people qualify for one mental disorder at some point in their lives. Remember, God is patient. God also still asks us to seek Him by faith, just like everyone else. Sometimes walking by faith means praying, sometimes resting, sometimes therapy, sometimes talking, sometimes serving...you get the gist.
As with the Israelites during the Exodus, God accomplished many things over many, many years- and He still is. The Israelites feared, complained, got overwhelmed, and tried to stuff their pockets- directly lacking faith in what God was telling them and showing them. God was patient nonetheless, while he disciplined them. He’s asking us to faith. Faith that God is your provider. Not therapy. Not a nation. Not your employer. Not yourself. Not a president. Not a parent. Not your 401k.
Days out from the "great candy grab of 2020," my child's brain experienced the indelible impact of poignant pleasure: she asked daily after this if she could go to neighbor’s front porches!! As I raise her I am prayerful that she will learn well to take her fears and turn to God (and to never be ashamed to get help through CBT or medications). I pray she becomes aware of her God-given feelings and desires, and can ultimately be led back to the rock that is Christ- who is the realization of her greatest hopes and dreams.
Also, Candy is nice, too. I’ll take both, please. :)
Teddy pumped the sanitizer bottle for the second time in three minutes. “I know, I know, it doesn’t help when I haven’t touched anything else, but I want to be sure. You never know these days, right?” Freda waits to enter gatherings and meetings until everyone else has shown up- “It just helps me know I won’t run the risk of embarrassing myself.” Hassan skips driving over tall bridges. “Maybe it adds time to my commute, but I once heard of a bridge that collapsed, so you never can be too careful.”
Clinically, Safety Behaviors (aka “False Safety Behaviors”) are “unnecessary actions taken to prevent, escape from, or reduce the severity of a perceived threat” (APA PsycNet, 2020). Pursuing safety in a healthy context is valuable and will keep you alive- this is why work sites have a key motto: “Safety First.” However, notice the word “unnecessary” in the definition of a safety behavior.
If you feel fatigued, are a procrastinator, overwhelmed, anxious all the time, or just "stressed out," safety behaviors may be at play. When people start to have problems with my opening examples, they may still think that their behaviors aren't necessary to consider or aren't harmful in any way. I know! It's really tricky to differentiate at times, especially when many things we do, depending on context, can be helpful OR harmful. But imagine if there's 1,000 little examples in a day of double-checking, reassurance seeking, second-guessing- every extra second spent, movement taken, or second-guess made leads to extra stress, processing, and/or energy. When a person has a disorder like Generalized Anxiety, PTSD, Specific Phobia, Social Anxiety, and more (in OCD call them by a different term: compulsions), safety behaviors must be addressed for robust recovery.
We can categorize safety behaviors into several different types.
Any of the above might be healthy for any one person. It must be functionally assessed (what is the function of a behavior or thought?) to determine if it’s helpful or pathological (disordered). Using sanitizer after touching doors in a pandemic looks different than outside the pandemic. Checking in on your Amazon order status with an important order may help you plan your day. Having a baby monitor you look at for fun or in case of emergency can offer flexibility and safety. But for every positive example of these, there's an example that feeds fear: compulsive sanitizer use, online checking, or obsessive fear about a baby's health. You have the opportunity to evaluate your own head and heart (and may I suggest having some help with friends in the know, a therapist, a mentor).
Let's take Social Anxiety Disorder. Jenny learned to "cope" with her social fears starting in adolescence by just saying she was shy when around people. She would avoid gatherings where she had to interact with people she didn't know well, get her family to talk for her, and always carried her phone in case she needed to put in ear buds and look down. When she got to college she began to realize that events and activities she wanted to do felt really difficult. Making friends was a substantial challenge and led to shame and anger at herself and others. She couldn't place her finger on it, but felt embarrassed when talking with others and would often feel hot, her face became flush, and she would slip on her words. Her answer was to avoid and go back to her dorm to listen to music, quickly feeling better. She would later replay interactions in her mind and would run multiple mental scenarios before any social interaction. Jenny didn't realize that these were avoidance, distraction, and mental rumination/checking. They are safety behaviors, and they made her anxiety worse- much worse.
In therapy, your history will be gathered and rapport ideally built with your counselor. People who come to see me are so often relieved they're not alone, crazy, weird, or bad for struggling. How treatment goes depends on the person and their condition being treated, but transdiagnostically, when safety behaviors impair or limit a person, well want to do three key things:
Here's a personal example of how I've integrated this CBT work into my own life. I have the actual ability to speak and teach in public, write articles, and provide quality therapy. At any given time, I have had/do have various triggers to fear. For example, I gave a talk that was highly rated by all attendees (5 stars by 95%). One person literally stood up and started openly disagreeing during the talk over one quote (from an evidence based source) I had shared. I still don't know what the problem was, because it was ultimately inconsequential to the big picture, but something apparently 'hit a nerve.' Though I was still friendly with the person came redirected to talk afterwards (they didn't take me up on the offer), I unfortunately let this impact me for a bit, avoiding talks for about 9 months after, ruminating on what I did wrong and could have done better, and scanning groups of people in case my "heckler" was ever there again. I was living in fear and giving into safety behaviors.
I had always expected my nerves would calm down a bit after giving talks for 5-10 years. But unfortunately, I hadn't yet integrated CBT work in safety behaviors into my life, and so my stress remained stagnant, though I did engage in my goals (which involves public speaking). At the almost 15 year mark of giving talks, I now work on cutting out rumination at times I don't need to be thinking (going to bed, in the bathroom before a presentation, etc.), saying yes to any talk that's within my goals and expertise, and so forth. And the result is striking. My most recent presentation I gave had me observing to my wife, "Hey babe, this is really cool- I had a couple hours this morning where I didn't even think about it!" Nor was I very stressed. This takes time and growth.
You don't require a clinical diagnosis to grasp the value and benefit of catching and releasing safety behaviors. In fact, there's so much potential for the tools that almost anyone can benefit from them, whether you want to learn to work quicker, be more gentle with yourself, increase your processing speed and/or general "bandwidth" of stress tolerance.
In Conclusion. So in our world (especially the Western world) where safety is everything, go ahead and take a pause and evaluate some of your thoughts and behaviors. Ask for feedback from someone you respect (or find someone who can speak honestly to you). Do you have any limits in any sphere of life from checking, reassurance, safety aids, avoidance, or mental maneuvers? Do people say you're "tightly wound," perfectionistic, demanding, or unrealistic? Are you overly cautious? Are most people around you doing things you'd like to do but just can't? Go find the ways you "play it safe" but don't need to, and your life will be better for it.
APA PsycNet. (n.d.). Retrieved November 10, 2020, from https://psycnet.apa.org/record/2019-52029-002
Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: exposure to corrective information. Psychological Bulletin, 99, 20–35.
Blakey, S. M., Abramowitz, J. S., Buchholz, J. L., Jessup, S. C., Jacoby, R. J., Reuman, L., & Pentel, K. Z. (2019). A randomized controlled trial of the judicious use of safety behaviors during exposure therapy. Behaviour Research and Therapy, 112, 28-35. doi:10.1016/j.brat.2018.11.010
Behaviour Research and Therapy, 112, 28-35. doi:10.1016/j.brat.2018.11.010
Korte, K. J., Norr, A. M., & Schmidt, N. B. (2018). Targeting Safety Behaviors in the Treatment of Anxiety Disorders: A Case Study of False Safety Behavior Elimination Treatment. American Journal of Psychotherapy, 71(1), 9-20. doi:10.1176/appi.psychotherapy.20180001
Riccardi, C. J., Korte, K. J., & Schmidt, N. B. (2017). False safety behavior elimination therapy: A randomized study of a brief individual transdiagnostic treatment for anxiety disorders. Journal of Anxiety Disorders, 46, 35–45.
Salkovskis, P. M., Clark, D. M., Hackmann, A., Wells, A., & Gelder, M. G. (1999). An experimental investigation of the role of safety-seeking behaviors in the maintenance of panic disorder with agoraphobia. Behaviour Research and Therapy, 37, 559–574.
Schmidt, N. B., Buckner, J. D., Pusser, A., Woolaway-Bickel, K., & Preston, J. L. (2012). Randomized control trial of False Safety Behavior Elimination Therapy (F-SET): A unified cognitive behavioral treatment for anxiety psychopathology. Behavior Therapy, 43, 518–532.
Telch, M. J., PhD. (n.d.). False Safety Behaviors: Their Role in Pathological Fear. Retrieved November 10, 2020, from https://labs.la.utexas.edu/telch/files/2015/08/Safety-Behavior-Handout-latest-8.1.15-1.pdf
Wells, A., Clark, D. M., Salkovskis, P., Ludgate, J., Hackmann, A., & Gelder, M. (1995). Social phobia: the role of in-situation safety behaviors in maintaining anxiety and negative beliefs. Behavior Therapy, 26, 153–161.
I recorded a full length episode for the OCD Stories with Stuart Ralph, based in London, this summer. He just dropped the final version. You can listen FREE on all streaming platforms.
One of my goals was to speak in a way where most people could connect or find something beneficial in this podcast. I hope you enjoy!
How much do you charge?
This is a very loaded question, indeed. I’m going to give you straight answers to how much therapy actually costs, and why. If you are a consumer of health services, you’ve likely asked it many times between doctors, dentists, and insurance plans. Therapy is no different, yet it is unique in many ways. Knowing your role in securing treatment and its cost can help you achieve a win-win.
Why are you writing this?
More than a therapist, I am an advocate. This post has been a long time coming, and clinicians rarely talk about money on a personal level. When there’s a good reason to do so, it’s an opportunity for growth. This post is intended to help:
When a good or service is offered, utility and/or providing for a human need or want occurs. In fact, this is why the term “goods and services” uses the word, ‘goods.’ In less than ideal circumstances, either the service is not provided (or provided poorly), or the exchange is NET negative (i.e., the provider loses money or the consumer can’t afford a service important to them).
IDEAL: Good Service Provided <--> suitable exchange (money) = both parties win
How much is an average therapy session?
Here are common rate structures:
What is a realistic win-win?
We live in the real world. And while we can seek to change things we can change (see below under the “Systems that be” section), acceptance of what we can’t is a crucial part of mental health. Work within the reality you exist.
There will always be exceptions to the rule, and the above is no different. For example, some people offer excellent services through charity, passion for helping, faith, or other reasons. Of course, this doesn't mean that anything is free- these services are simply subsidized through that person and often additional income streams like books and speaking fees. A great example in Dallas would be the experts Drs. Harville Hendrix and Helen LaKelly Hunt. They offer free community-based marriage building seminars and trainings (Safe Conversations). Dr. Reid Wilson offers a free 2 day intensive every year at the Annual Conference of the International OCD Foundation Many churches and places of worship do the same.
How much clinicians make.
Income ranges wildly, from those famous clinicians to practice owners to social workers to private practice and more. I don’t know anyone who’s getting rich off of therapy. Most of us got into counseling/therapy as a helping profession in the first place. I told my wife when we were dating I would very likely make less than her as a nurse at a prominent Dallas hospital, and I wanted to make sure she was okay with that. Let’s just say she didn’t dump me. :) The median Master’s Level counselor in the U.S. makes about $50-75k per year. Besides gross income, clinicians have a lot of other factors that take off the top:
I’ll let you do the math.
So yes, I get it. Therapy can be expensive. If my clients say “this is expensive,” I agree. “Yes, it is. You are making a sacrifice. Thank you so much for your prioritization in being here. My goal is to help you reach your goals and get you on your way as soon as is reasonably possible (unless you want to stay around longer).”
I hope this post is helpful in helping you make a decision or in supporting others considering decisions for therapy in our current world. Remember the old truism: “you get what you pay for.” Or maybe what somebody else pays for.
 How do I come by those figures? They’re rarely published, but it is my personal experience and through research and conversations behind the scenes. This makes it subjective, but I hope it helps.
Addendum (i.e., for further reading)
It is worth noting that there are whole systems at play at any given points with healthcare. it is not the purpose of this article to get into these complexities, but I do want to at least acknowledge that they are there and need addressing in their own right.
Depending on where you were born, your skin color, or any factor of diversity, you may face a substantially harder time in life pursuing things that come easier for others. That sucks. It’s unfair; it’s unjust. I want you to know you are seen. You are heard. You have value, whoever you are.
This is where advocating for the plight of the hurting and the poor is so key. I hope you will join me in doing so if you can. Or if you are hurting and in need that you will check out one of the many resources listed on my page, https://www.justinkhughes.com/resources.html.
I hope readers will be careful in making judgments or interpretations about the intentions of others (I’m talking to you, clinicians, consumers, and advocates). PERIOD. That underscores a basic principle of CBT and emotional health.
Therapists as a whole struggle at times with charging anything. I've been there, and I still wrestle with cases of extreme need and how to approach. I remember when I helped run an intensive program for teens struggling with substance abuse. One of the young teens once exclaimed, “For $20 per person, you guys are getting rich.” We had about 15 kids a night, for 3 hours per day clinical and 1 hour admin., with about 4 staff members and an owner. That’s $15 average per employee, or Costco’s minimum wage. Some of my colleagues who charge the most are also most involved in advocacy and a number of outside free resources, be it free clinics that they put on, short-term workshops, educational content online, training of clinicians and lay persons, etc. In fact, though I may be biased here, I think that some of those that charge the most are more involved in these efforts. If they're making a decent living what they're doing, it can actually free up their time, energy, and passions for more advocacy and help.
Paying less or more does not have to be an inherent good or bad; it's often a question of many factors and considerations that you must weigh for yourself and with your loved ones. As I tell all of my clients, advocate for your health! People who are assertive in their treatment get the best outcomes.
Experiment: Look at the picture above. What do you feel? Those feelings are real. However, how you interpret what you feel makes all the difference (whether you think cats are cute, a nuisance, practical, fun, allergic furballs, or pure joy).
I see a common phrase that goes around: “Feelings are not facts.” While I agree with the inherent sentiments, it’s wrong. Feelings are facts. Your interpretation of feelings may not be factual.
Actual feelings are factual insomuch as they reflect disparate and connected processes within the body and mind, occurring in real time. They give you information. Sensations and emotions link us in to a wealth of details. Researchers have long struggled to pinpoint feelings exactly (this is one of the reasons why there are no definitive feelings charts/references and why therapists will list anywhere from 3 basic emotions and as many as 100 or more), and though neuroscience is helping us understand more what occurs biologically in the brain, the conclusion is far from definitive.
Making this separation that feelings are facts may seem a bit pedantic- splitting hairs. My first supervisor I ever had in my internship would tell me something along the lines of this: “Separating feelings from thoughts is foundational for emotional intelligence.” Agreed. And it’s just plain healthy. CBT (Cognitive Behavioral Therapy) helps us get really good at being honest with the interaction between thoughts, feelings, and behaviors. Problems with anxiety, depression, dissociation, psychosis, narcissism, and all of mental health at some level deals with how much a person is living in reality. None of us are 100% or will be perfect at it. However, we can grow. Do our thoughts line up with the bigger picture? Are thoughts and emotions congruent? Do behaviors fit what we believe? If I feel chest tightness, racing heart, or my stomach drop when I’m around another person, the conclusion is not necessarily that that person is bad or I need to get away. Yes, sometimes that is the case. I have also had these feelings around people I trust implicitly. There are a number of factors that can lead to feelings- amount of sleep I got last night, hunger, and stress in general, to name a small few.
So when people say feelings are not facts, I understand what they’re saying and support the gist. I think your mental health will thank you, though, if you appreciate that your body and brain is created to give you information- and that information is factual insomuch as it exists and is connected to you. How you interpret the meaning may not be factual. If you separate these two, you will better honor what your body and mind are telling you, while, if you pursue growth, you can learn to line up your life more congruently for your mental health and the wellbeing of those around you.
If you have obsessions on this topic, please set some boundaries up front as to how you will engage in this content, which can be distressing and triggering especially for those dealing with scrupulosity. You may easily worsen your fear if you allow yourself to obsess on the content or perform rituals surrounding it.
The unforgivable/unpardonable sin (also called the eternal sin or blasphemy against the Holy Spirit) can induce some level of fear for even the most convinced of Christians. To the person who gets stuck on the concept, such as in OCD, Generalized Anxiety, and/or scrupulosity, misery would not be too strong of a word to describe it. Personally, I suffered for several years in my childhood and for passing days in my adulthood with questioning my salvation- so I understand a lot of this on a personal and professional level. So what exactly are we talking about when we say “the unforgivable sin?”
What is the Unforgivable Sin?
Can there be a sin so terrible, horrendous and vile that it leads straight to hell without the option to ask forgiveness? Can this sin be accidental? Is it stated verbally, or through one’s thoughts, or confirmed by actions? Here are the 3 occurrences found in the Synoptic Gospels (Matthew, Mark, and Luke), describing the unforgivable sin:
What does it mean? I would like to offer you a simple explanation and definition that alleviates all fears. But I can’t, literally- I don’t have it. That would be pretty arrogant of me if revered church theologians since the time of Christ still lack a simple explanation. If you’re a super nerd like me, you may find it interesting to know that Martin Luther, John Chrysostom, St. Augustine, John Wesley, Jonathan Edwards, John Calvin (lots of guys named John, right?), and more have all had slightly different takes.
Summarizing 4 key perspectives on what the unforgivable sin is:
Context of the unforgivable sin.
For the sake of brevity and the fact that there are a wealth of commentaries and studies that explore this topic, let me just say that we must look at the whole of Scriptures if we are to take Scripture seriously. A major problem in modern day interpretation lies in “sound bites” and quick references that disregard context. Rule #1: know your context. Context is something you will be unable to get or see if you are LOCKED up in fear. Fear narrows focus. Its purpose, when functional, is to place our focus to a pinpoint so we can appropriately respond. If you have a disorder involving fear, you likely get stuck on a whole host of topics (or one major one) that requires re-learning that those without disorders take for granted.
For those of you looking simply for more knowledge on defining the topic, feel free to check out the great resources I’ve provided at the end to dig into the Scripture passages above, look at original languages and the context, audience of the passage, and so forth.
A remarkable reality is that there is no example in all of Scripture wherein a person who asks God's forgiveness doesn't receive it (which is a large support as to the views espoused in the resources, namely that blasphemy of the Holy Spirit must be a person who has decisively turned against God and rejects the opportunity to be forgiven). There are of course temporary consequences to sin and poor decisions (e.g., Moses not getting to see the Promised Land, David losing a child, Martha missing out on Jesus' presence, Peter feeling intense feelings and shame about denying Christ, etc.).
“All that the Father gives me will come to me, and whoever comes to me I will never cast out” (John 6:37).
If you suffer with the thought of the unforgivable sin and scrupulosity (like many saints throughout history), you'll need different tools to respond- rather than living in fear. 4 suggestions:
Many of you have come to this article to get "the answer" (to feel “just right” or get reassurance). The harder and necessary task of faith may be to discover how to not obsess or feed your fear (which is not God's desire for you, see "Fear Not"). If you came here today with a lack of information, then by all means go to the links below explaining some perspectives on what the unforgivable sin is. But if you're like me at times in my life, or like the clients I see daily in therapy who can get stuck on verses like these, I prayerfully ask that our Lord would grant you strength to sit with difficult Bible passages without reacting out of fear- whatever that looks like today for you, my friend.
For more information:
R.C. Sproul: https://www.ligonier.org/blog/what-unpardonable-sin/
John Piper: https://www.desiringgod.org/articles/what-is-the-unforgivable-sin
David Jeremiah: https://www.crosswalk.com/slideshows/10-things-you-need-to-know-unforgivable-sin.html
America today sees one of the highest levels of anxiety of any place in the world. We are clamoring for attention online, wanting to be seen, to be loved. Suicides by teens and young adults appear to be higher than they’ve been in years. We are the wealthiest nation on the face of the planet, and we can’t rest. We have more than anyone else (as a whole), and we can’t stop. Children who are now becoming adults are feeling this crushing weight of anxiety and expectation (whether on themselves or from outside)- ‘get the degree and the top job, get married, have the house, have children, don’t screw it up.’ And we know that anxiety has biological and genetic influences, but these are not 100% causal by any means. Our response makes a difference.
Generalized Anxiety Disorder (or GAD, the disorder most connected to general worries) is more impairing in higher income countries. The occurrence of GAD (lifetime prevalence) boiled down to:
I think the ultimate answer lies in Christ. Hebrews 4:9 says, “...there remains a Sabbath rest for the people of God.” Matthew 11:30: “My yoke is easy and my burden is light.”
*Insert deep relaxing breath.
God ordained rest from the beginning of creation. Genesis 2:2-3: says, “And on the seventh day God finished his work that he had done, and he rested on the seventh day from all his work that he had done. So God blessed the seventh day and made it holy, because on it God rested from all his work that he had done in creation.” God purposed rest for us, his creation. God wasn’t winded and saying, “Oh boy, that creating sure made me tired...let me sit back and take it easy.” We know he created it for us. Jesus states, “The Sabbath was made for man, not man for the Sabbath” (Mark 2:27). If we back up to the institution of the Sabbath given as law to the Israelites, in Deuteronomy 5:15 we are given a reason why God so seriously wanted His people to be obedient in this: “remember that you were a slave….and the Lord your God brought you out…” So to pause and rest is to say, GOD is my provider, and my striving only results in results because of God (Seriously, check out these passages: Deuteronomy 2:7; 1 Chronicles 29:12; Psalms 23 and 147:8; Matthew 6:25-33; Philippians 4:19).
Observationally, we don’t have to look far to understand our need for regenerative rest. Sleep is one of the greatest things we can “do” for our well being. Our bodies need one third of our day just to be restored. ⅓!! Living to 75 that’s 25 years of our life spent sleeping! When we try to cheat this, various problems ensue. And by the way, the U.S. has a tremendous problem with sleep, as well. It’s hard to even grasp the scope of this due to the myriad ways people attempt to rest that may not be directly researched or studied in any one experiment (sleep aids, watching media, abusing substances- including over-the-counter cough syrup and benadryl).
The Doctor Who episode “Sleep No More” features the attempt to cheat sleep and maximize productivity. Scientists discover a device (“Morpheus”) that takes only a few minutes to compress a month of sleep. Serious problems ensue (enter evil “Sandmen” into the equation, for any of you Doctor Who nerds). Sleep and rest are common themes in literature and life. No doubt, they play a substantial role in our well-being- or downfall.
Though therapy is highly efficacious in addressing disorders specifically and often helpful for much personal growth, it is not set up to be a worldview (a personal understanding or philosophy of the world)- it was never meant to be! Therapy is the clinical application resulting from theories and science on human thought and behavior, just like medical practitioners study from a particular perspective and approach (“Western”, naturopathic, Traditional/Chinese, etc.). Psychology cannot be an entire worldview, by definition, because it’s only one subset of study, research, observation, and experience.
Back to Jesus: “Come to me, all who labor and are heavy laden, and I will give you rest.” (Matthew 11:28).
Are you tired of striving in your own strength? Jesus speaks to the question of trying to be good enough. The Bible presents a very large pill to swallow that is offensive to our Western, pluralistic and politically correct sensibilities: your striving is empty without God. BUT, here is the hope, and this is the Gospel: being made right with the God of the universe through Christ, we have peace. We have freedom. We have hope. We have purpose. We are forgiven. We are loved.
From the poorest and most overlooked member in the slums of Calcutta to the Billionaire on 57th Street in NYC: You are loved. You are valuable. Striving and anxious pursuits are nothing without God- let us seek his rest.
 Newman, T. (n.d.). Is anxiety increasing in the United States? Retrieved October 07, 2020, from https://www.medicalnewstoday.com/articles/322877. “When they compare the levels of depression, no single area has significantly higher rates. When it comes to anxiety disorders, however, it’s a different story; the Americas are head and shoulders above all other regions, including Africa and Europe.”
 This is not to shame you. You may have a legit challenge with anxiety due to disorder- if so, I’m sorry! You may have tried seemingly everything to feel better and it just hangs around. Keep reading, if this is you, because the post still applies, it’s just that I want you to know that you may have it harder than others, and you may need treatment. Truly, this world is not fair. But stay with me; there’s hope.
 The disorder is significantly more prevalent and impairing in high-income countries than in low- or middle-income countries.
 Walker, M. P. (2018). Why we sleep: The new science of sleep and dreams. London, UK: Penguin Books.
 CDC - Data and Statistics - Sleep and Sleep Disorders. (2017, May 02). Retrieved October 07, 2020, from https://www.cdc.gov/sleep/data_statistics.html
All Scripture quotations are ESV.
“You want me to do what?!” Many of my clients, and particularly for the sake of this article, Christian clients, are a bit surprised when I ask them to practice exposure. Repeating scary, terrible thoughts on paper or aloud. Doing things that feel risky. It seems as a clinician I’m disrespecting your beliefs and don’t really get it. Maybe I’m asking you to do something unbiblical, blasphemous, against what God would want. But what if I do understand and am helping you live in line with your beliefs? What if exposure is a powerful tool under God’s grace (Matthew 5:45) to help you get over a disorder?
The Great Hesitation. When some clients start their treatment with me, I come across familiar hesitations when we begin discussing Exposure Therapy and facing one’s fears:
Maybe. I of course do not know your (the reader’s) story, so I cannot say for you personally. Though, here’s the problem many of my clients run into: they are reinforcing fear every time they avoid and run from thoughts/urges/impulses/feelings that are out of fear rather than a want (see an important article on this for more: FACE fear, FLEE Temptation). Some basic science is in order here: when you fight and resist a thought, it persists (e.g., don’t think of the pink elephant, trying to get a song out of your head, etc.). That’s the way it’s supposed to work- a threat believed to be a threat is supposed to feel like a threat.
This is where exposure therapy comes in. As a summary, exposure is the systematic and intentional triggering of fear while minimizing- and ideally eliminating- all pathological responses. In the therapy process, when I start to introduce clients to the idea of sitting with fear mindfully and not fighting it, most have hesitations. “You’re telling me to do what?! You want me to repeat these horrific thoughts again and again?!” I get it; it seems paradoxical. Most people can rather quickly wrap their heads around an exposure to an overt situational fear (like holding a kitchen knife when you have an intrusive harm fear) but have a harder time understanding exposure for other “Pure O” intrusions, such as harm and scrupulosity, like the following:
The above are examples of intrusive thoughts; they are counter to what a person holds as their overall value and pursuit, or “ego-dystonic.” If you want to know all about treating these thoughts through imaginal exposure, check out the article “Flip the Script- A Guide to Imaginal Exposure.” And yes, I’ll tell you right now that if a person obsesses on the above or has ritualistic behaviors and avoidances, we are going to work with leaning into the discomfort of these, not ignoring them.
The clinical rationale. In all disorders featuring anxiety and fear, there is a problem with the system that signals something is wrong. It’s broken. Doesn’t work right. It’s a fire alarm that goes off when there’s no fire. A missile alert with no missile. Depending on fear, a person might feel a range of things: fear, disgust, anger, sadness, loneliness, dread, regret, chest tightness, racing heart, sweaty palms, neck and back tension, and extensively more. We tend to feel the feelings that a signal dictates. For example:
In disordered behavior, people become over-focused (or under) on a narrow set of experiences. People who are overly vigilant can run into some of the very problems they seek to avoid, or a different set of problems. Examples:
The Biblical rationale.
If we are to change the outcomes for people who suffer from disorders, psychology has developed some very solid tools. If you believe, like I do, that the Bible is God’s Word and is meant to have authority in your life, then you’ll likely need a good biblical rationale for exposure therapy. Here goes on my end, but I am going to ask you personally to dig in. This is your decision. Don’t rely on some therapist to tell you what to think- talk to God, pray, use the brain He’s given and be open to the teaching of trustworthy others (2 Timothy 4:2).
Truth is very important in the Christian faith (John 17:17; Psalm 145:18; Proverbs 12:22; John 4:24; 1 Corinthians 13:4-6). If part of being the church of Christ is to speak the truth to one another, including difficult things like anger (Ephesians 4:15, 26), I remind clients often that if you have intrusive, obsessive, or otherwise bothersome thought or feeling, being open about them and calling them out is simply being honest. It’s being truthful. God knows what’s going on in your head (1 John 3:20)!
When Philippians 4:8 is brought up, it is sometimes a “proof text” on how you “should always thinking positive.” That’s a remarkably short-sighted, superficial view.
“Finally, brothers, whatever is true, whatever is honorable, whatever is just, whatever is pure, whatever is lovely, whatever is commendable, if there is any excellence, if there is anything worthy of praise, think about these things.”
This clearly can’t mean to not think about negative things, evil, or something terrible. If so, we’d never be able to ask forgiveness of our sins by calling them out and repenting! One of the ways that we can think on things like justice, honor, love, etc. is by calling out the opposite: injustice, dishonor, and selfishness. It is in acknowledgement of problems that the solution can be instilled.
God knows our hearts (Proverbs 21:2; 1 Samuel 16:7; Jeremiah 17:10; Acts 15:8; Romans 8:27). If you’re afraid you might do something bad, do you believe God knows that? And if you’re going to do something bad and be unrepentant, then you aren’t going to repent, right? And if that’s the case, why are you trying? If you’re doomed, what’s the point in trying to change that? If there’s a chance- even if you don’t feel like it in the moment- just a small chance that you can take to God your innermost thoughts and feelings and get love and grace and forgiveness and peace and patience, is it worth it to you? Would you be willing to try?
Walking with God means we are “...casting all your anxieties on him, because he cares for you” (1 Peter 5:7). Nowhere in the Bible does it say you will not feel anxiety or struggle with anxiety. It tells us how to frame it (1 Peter 5:7; Philippians 4:6-8), that fear is not God’s heart for us (1 John 4:19), and that he loves us in it (each of these references prior reflects God’s gentle, patient love). The Bible is not a psychology textbook or methods and techniques class. While we walk with Christ, we learn to depend on God by faith. Sometimes that’s therapy, medication, prayer, community, repentance, exercise, gratitude, acceptance, rest, or any number of things.
Obviously, we are not going to find a passage that says, “do exposure therapy” (and of course, “pay good money for it”, ha!).
Compassion and Understanding to You
When clients come to me with thoughts and behaviors they are bothered by, the last thing they want to do is to look it squarely in the face or write it down or say it aloud (It’s called exposure for a reason). But in reality, this is what helps shine the light on it- calling it out in truth. It calls it to the table to do business. In the end, you must personally seek the Lord, and I hope through prayer, His Word, and community to determine what steps you will take in anything important in life. I do hope that if you can benefit from something like Exposure Therapy, you will find, as I have, that it is a tool, albeit human and imperfect, that God has graciously allowed us to discover, maybe like penicillin, insulin, the benefits of exercise, or Vitamin D.. May the created point back to The Creator and show His goodness and love.
“If you then, who are evil, know how to give good gifts to your children, how much more will your Father who is in heaven give good things to those who ask him! (Matthew 7:11, ESV).
“For he makes his sun rise on the evil and on the good, and sends rain on the just and on the unjust” (Matthew 5:45 b, ESV).
“...He cares for you” (1 Peter 5:7b).
A few extra readings on the Biblical rationale for treatment (medicine and/or therapy):
NOTE: Emotional Content- Mature Readers Only Please
Imagine intentionally telling yourself- again and again- "Maybe I’ll get sick and die.” Or, “I’ll have a sudden urge to kill someone." Or, “Maybe I blasphemed God and will go to hell." What if your therapist asked you to repeat these things to yourself? Does that sound like negative self-talk? A cause for grave concern? Not if they’re intrusive thoughts. If they are, in exposure therapy you would most likely learn to repeat these thoughts over and over.
Why in the world would I do that?
This can be hard to understand. It’s initially counterintuitive. There is a purpose behind what I'm sharing, so stick with me! In fact, the purpose is so distinctive and powerful, that for many people, entering willfully into sitting with scary content is the only thing that will help them overcome tremendous fear and consequent suffering.
I'm referencing the use of Imaginal Exposure.
Are you a newbie to what OCD, PTSD, Anxiety Disorders, CBT or Exposure Therapy is? You will want to understand these before trying to grasp Imaginal Exposure- which might otherwise seem strange, weird, harmful, or negative. Done well, it's none of these. To those of us who use it every day, it's a high horsepower beast of a tool that ages like a fine wine- with time, discipline, skill, and determination the end product typically is first-rate. By first-rate, I also mean clinically first line treatment (highly recommended with the best evidence) for Anxiety, OCD, Phobias, PTSD, Social Anxiety, and more. Let’s jump in.
Exposure Therapy, in a phrase, is the systematic and intentional triggering of fear while minimizing- and ideally eliminating- all pathological responses. Imaginal Exposure accomplishes this with thoughts and ideas. It is done in the context of addressing unhelpful/pathological responses to fear. Hear me loud and clear: fear is a healthy emotion in context- we need to honor it when we use it in a healthy way. Exposure, though, is about facing fears that are creating problems for an individual- pathological (disordered) fears.
Think of a TV set. Friends. Frasier. The Office. It appears so real- so NYC, Seattle, or Scranton. Have you ever seen behind the scenes? It's funny what effect a studio tour or footage has on the mind when you have the "curtain pulled back." Imaginal exposure capitalizes on the brain's creative ability. We’ve done this for even longer as humans through verbal storytelling. It's part of what makes us wonderfully human. From a threat preparedness standpoint, the ability to imagine and conceptualize problems (like children getting injured or killed from a safety hazard) helps us think through problems and find solutions, when done appropriately. Imagination can be wonderfully delightful (a good book, a child’s creativity), highly practical (designing safety procedures), it can also become nefarious (a traumatic memory, a panic inducing nightmare, constantly running worst case scenarios).
If you have a phobia of spiders, the average person may think along the lines of Fear Factor, that old TV show that threw people in a literal pit with their feared object in order to “face” their fears. Rarely would that work, if ever, if you have an actual phobia- without structuring it appropriately and having "buy-in" to the process. CBT and Exposure therapists use a treatment plan and usually stair-step their approach (through a hierarchy) to inhibit the learned fearful response. Here is a sample hierarchy with arachnophobia (1 is easiest, 10 most difficult):
1-6 are actually Imaginal Exposures. They don't involve direct confrontation. In-vivo (situational) exposure (7-10) implements exposures in a real life setting. E.g., if you pathologically fear you will get sick and die from touching a door knob and not washing, the situational exposure is to touch the door knob ultimately and experientially test the hypothesis of “what if I get sick and die?” Many fears in life, though, either cannot be accessed through in-vivo exposure or have a strong mental component to them. Common examples are:
Why would these responses lead to problems? Simply put- they reinforce fear, disgust, and other strong responses out of context. We call these either compulsions or safety behaviors (unnecessary anxiety based reactions). A person who gives into them consequently learns they need these responses to protect themselves. Enter the heightened level of disability that sufferers of OCD, Anxiety, and PTSD face.
Here’s the good news. Exposure lets you gain appropriate control. It is learning to play offense rather than defense. It is very active, and it can lead to a greater sense of confidence and acceptance.
How do I do imaginal exposure? The first thing we do besides good education and understanding exposure is gaining a strong assessment- it must underlie good exposure. Know what you’re working with. Make a list of your obsessions or bothersome thoughts. See a specialist. Get educated. Get to know your symptoms, your motivations for getting better, and start a running log (monitoring) daily. Once you have a tally of key examples, placing them on a hierarchy really helps to get a road map and be realistic and also to monitor progress (like the one above for arachnophobia).
Once you’ve got your hierarchy, we consider conceptualizing the core fear behind an uncomfortable thought or action. Start simple; don’t overthink it. Here’s a “downward spiral” vignette for a person who fears they might one day “snap” and kill someone.
Therapist: So what about that bothers you?
Client: I don’t have control.
Therapist: So what?
Client: This terrifies me.
Therapist: So what?
Client: It may just happen, I might just snap, so I
need to be hypervigilant all the time.
Client: Yeah yeah, I get it. I suppose it’s impossibly tiring; I will always have to be in a careful state to make sure I don’t harm someone.
Therapist: Anything else?
Client: I don’t think so right now.
Therapist: This is the core fear we will begin basing your exposures on: “I must always be hypervigilant to not harm someone.” This is the hypothesis we will be testing experientially.
Once you have hierarchy examples in which you've identified your compulsions or safety behaviors, along with core fears, determining the type of exposure (In-vivo, Imaginal, and/or even Interoceptive or Virtual Reality- see The Four Types of Exposure Therapy) is important. The best exposure seeks to maximize learning and go as far as is needed to eradicate pathological responses.
Let’s take an intrusive, unwanted thought like, “What if I jumped off this bridge?” When it is ego-dystonic, imaginal exposure would seek to respond with a strategy like writing/saying/hearing/reading something like the following: “What if I jumped off this bridge?” many times and over many minutes, all the while sitting with the feelings without compulsing. Once a person can tolerate facing their fear at a lower level, they can then move up the hierarchy and face higher and higher ones, in this example it might involve riding in a car over a bridge. At a later point, they would likely want to visit a bridge and walk across, getting as close to the edge as would be appropriate. Pairing an imaginal script with the situational would address any thoughts the person attempts to suppress, neutralize, or avoid. Here is a sample hierarchy (incorporating in-vivo, imaginal, interoceptive- bodily sensation exposure, and virtual reality):
A good summary of these steps I usually take in exposure therapy can be found in my guide, “Thriving Mental Health.”
Scripting is observation in its basic form. It’s taking what you already fear and calling it out.
Popular forms involve scripts/stories, videos, and audio tracks/loops. Creative ideas:
How does it work? Why does it work? People smarter than me call this the mechanism of change. You’re going to love this response: we don’t know exactly how exposure works. We can theorize. There are roughly 6 theories (some are often combined) as to how exposure therapy works:
Problem Solving & Tips. There are small and large nuances alike involved in imaginal exposure. Here is a list of some key tips, but remember that this is one of the key benefits of a specialty provider of exposure therapy. You can additionally look at “10 Tips for Effective ERP,” which covers important details related to all types of exposure.
Catch All Compulsions. Mental compulsions and avoidance are compulsions. Reassurance from others (including your therapist) is compulsive. Learn to get rid of all of it. Distraction from fear is avoidance. Gotta catch ‘em all!
Conceptualize Your Core Fear. Skipping your core fear conceptualization.
Face, don’t Escape. Use your script to face fear- NOT escape fear. Anything to relieve fear in the moment can lead to reinforcing fear.
Remember the Framework. Face fear by sitting with it and/or don't pathologically respond. It might seem like you're allowing something bad (in fact, that's almost a guarantee you will feel this way). Dig into your commitments and motivations to stick with challenging exercises. Our goal is to go as far as your fear/disgust/etc. makes you run. However, sometimes we do go further with an exposure than thoughts go. We must seek maximum disconfirmation of fear, which means pushing exercises further than you initially want (because seeking relief and comfort and perceived safety got us in this mess in the first place).
Get Messy. Expect to mess up exposure. It’s naturally mucky, and no one does it perfectly. However, those who stick with it and keep working on it are more likely to achieve better results.
Get Support! You are a complex being in an interconnected world. You will likely need to incorporate various supports in your life for long-term success. Involve your loved ones. I get it- it will typically feel very odd to get your family members involved in scripting with you- but often remarkably helpful when your system is healthy and supportive.
Hard to catch. Many clients exclaim that predominantly internal OCD themes are very challenging to work with because they are so difficult to catch. True, at first. But they can be treated just as successfully, and once you know how to work with them, they are very treatable. In a sense, covert obsessions (“Pure-O”) and mental rituals can be more difficult to notice and catch than overt behaviors and processes like washing. But to be clear, OCD in any form is no cake-walk, nor do folks who have more overt rituals have it better, per se. They are just different. Also, there is always a mental process behind overt behaviors, which also must be addressed in treatment. Last of all, though all treatment is on paper the same, everyone’s experience is personal to them; certain themes (like sexual, religious, etc.) can lead to tremendously higher amounts of shame, guilt, anger, or any number of feelings.
Matching game. Match the script to the actual content of your thoughts that you need to face to overcome and maximize your strength training. Make sure the content of exposures fit with the content of your obsessions.
Prepare. A healthy mind is not made in comfort. Prepare to feel uncomfortable. The inverse of taking on too hard of exposures is not pushing oneself enough. The reality of scripting is that it can seem monotonous. It can seem really scary. It does trigger at least some distress.
Proper Dosing. When we utilize medication, we often consider dosing. It’s not a foreign concept for many aspects of life. Applied to cooking we measure ingredients, in learning a new subject we stair-step difficulty and measure as we go along. A lot of people come to mental health with expectations that deeply rooted patterns and habits, behaviors and thoughts will somehow magically vanish. We’ve got to be realistic. The more severe a case, the higher the “dosing” is typically needed for therapy and exercises. I often point out that if you have 4 hours of compulsions/safety behaviors rituals per day, you will need to get to the point where this number is ideally zero. The “dosing” then of treatment is a lot higher than someone with 1 hour of these pathological responses.
Relapse Prevention Planning. When you’re feeling better, don’t just move on and say, “Thanks, it’s been fun!” Have a plan. Develop this with your team.
Strength Training. One of the most significant errors clients report to me prior to therapy was trying to “lift too much weight” consistently before they were ready. If you can’t face a level 3 on your hierarchy without compulsing, you’re not ready for a level 10. But as soon as you know how not to compulse or do a safety behavior in the face of fear, CONGRATS!! This is one of the greatest achievements, and now you can move the ball forward with other examples.
Type Matters. Remember that though we are discussing Imaginal exposure, it is usually best to make sure to do in-vivo exposures with things that you can face in real life. Though you can always pair imaginal with situational, you must go as far (or further) than your obsession goes.
Fin. Imaginal exposure may seem odd, counter-intuitive, and harmful at first. The reality is that it's just what the doctor ordered to start playing offense with problems and not be a victim of cycles of fear and relief. If you've made it this far, you've got some guts. I hope you've been encouraged. Let's do this.
“You need to pray about that.” “Resist those thoughts; they are from the enemy.” “Don’t think on such things.” I often hear confusion from Christians on how to engage- or not engage- with fear based thoughts, urges, and sensations. This led me to do a deep dive into Scripture to see if there are any differences between responding to fear vs. temptation. Spoiler Alert: there are. We must learn to face fear and flee temptation.
Joy* came in to see me because she was getting overwhelmed- having panic attacks and getting stuck in making decisions. Most of all, she was terrified of the doubt that she wasn’t walking with God. These are weighty things to carry. Joy is an incredible woman of faith. Loved ones agreed (though she’d never tell you this). Due to her obsessions and intrusive thoughts, she couldn’t stop compulsively asking God for forgiveness when feeling like she’d sinned, constantly evaluating things as small as the way she walked and the facial expressions she carried when around others. She would often have thoughts that went counter to what she believed: “Maybe your anger is just the same as wanting to kill someone.” “You’re not close to God- you don’t feel His presence.” “Are you sure you are living your life fully for Him?” “Your attraction to other men is lustful- you’re supposed to feel pleasure seeing your husband.” These thoughts and their consequent feelings led to a lot of avoidance- dodging men, running from ‘scary’ Scripture passages, avoiding going out in public.
It is impossible to read very far in the Bible without coming across some variation of “fear not!” It is the most common directive in the Bible- occurring more than any of the following “do nots:”
Growing up, I was involved in a Christian subculture that took an oft avoidant stance to things perceived as risky. I remember some varying examples from different people through the years: some condemning rock music and drums, dating, kissing before marriage, alcohol in any way, dancing, mental health medications, and playing cards. Of course, each Christian must develop their conscience and walk with Christ, so I am not here to make decisions for you on any of these topics. There are a lot of decisions in a lifetime that will necessitate flexibility and exhibit differences between believers- they are not all black and white (cf. Romans 14, Galatians 5), though some are. To understand why these often well meaning folks said what they said would require knowing the context. I know many times I have heard believers condemn alcohol for anyone it is out of themselves or loved ones having problems with alcohol- which would be one of the best reasons not to drink! However, we must be careful not to make a rule or law of conscience generalized to everyone that is not specifically laid out for all believers (check out TGC’s article on conscience). Unfortunately, I heard plenty of cautions from people rife with fear.
For Christians, hypervigilance as to spiritual matters is out of place. Vigilance is called for in the things we must be alert about. Hypervigilance is being on edge, fearful, shaky. Before Christ was crucified he prayed that his followers would be protected, but still present in the world (John 17:15). Healthy and spiritually mature individuals have developed discernment of separating good from evil while being present in the world (Hebrews 5:14)- part of growth requires learning how much focus and time to prioritize on any one thing.
Stick with me closely here: this is where I want to delineate between fear and temptation. I believe it’s a crucial difference- one that has led to a lot of personal growth and change along with that of many clients.
Let’s first view some key texts on temptation:
With a misappraised lens we might think God would have us constantly eschewing evil, always looking over our backs for sin crouching to get us (Genesis 4:7). Nope. Context is key. There’s a bigger picture.
Both in Bible reading and In CBT (Cognitive Behavioral Therapy) a key thing we do is to look at context- understanding one thing through the larger picture (i.e., for Bible reading, observing before interpreting; in CBT, we assess the larger connection between feelings, thoughts, and behaviors). Here is the broader backdrop for all the above Scripture passages:
There you go. I hope these key passages have helped identify a trajectory for facing temptation- knowing that hypervigilance or persistent fear is unbefitting God's will for believers.
What if something I fear is also a desire? Or becoming a desire? This is a common question I get when helping clients call out and lean into their fears in therapy.
As mentioned concerning the 2nd passage above (1 Corinthians 6:18), sometimes people run into things they simultaneously fear and are a risk at the same time (egosyntonic and egodystonic). Maybe it’s abusing substances for the addict, fear of harming a child while also having actual anger outbursts, or being scared by unwanted thoughts on suicide for the depressed person who sometimes contemplates suicide. This gets a little tricky, and I have to admit, makes the process in therapy a little more challenging. I like a good challenge! It’s important to do a little more assessment and separate out the two domains. On this topic, let me just say that’s what makes therapy all the more important. Get a professional outside of yourself who can help you separate the two and know how to address both sides of the problem- a mixed desire with simultaneous lack of desire to act on a behavior.
A final word. Deuteronomy 31:8: “ It is the Lord who goes before you. He will be with you; he will not leave you or forsake you. Do not fear or be dismayed.”
Being overcome with fear is not what God desires for His children. I myself and a lot of fellow Christians can be so torn up with fear when facing uncertainty or a perceived threat, forgetting that this fear itself is not from God.
Fear manifests in all sorts of ways- ways that are often overlooked and (sometimes applauded!) by fellow believers in areas such as perfectionism (think of the workaholic in a church setting), over-thinking and analyzing (the person who appears to study the Bible often but are obsessed with minute details and not relationship), and rugged self-reliance (not submitting to authority, relying on community, and otherwise being a ‘lone ranger’). We can often call these things high standards, thoughtful, and independent. Insomuch as any of these things lead to a lack of dependence and faith on God through fear, we have entered into another formidable foe in and of itself! Whether it comes from our brains (the flesh), other influences (the world), or the enemy (the Devil) (Ephesians 2:2-3).
Fear and temptation are two different things. Responding to them requires a different stance. However, they can easily be confused with the other. My prayer for you today, my friend, is that you would know the freedom and joy that is in Christ the solid rock, who will complete the work He has started in you (Philippians 1:6).
*Joy is not this client’s given name and is a composite of case information to protect patient confidentiality. There are thousands of cases very similar to this.
Every reference in this article is ESV.
In advance of the full episode of the OCD Stories podcast being released Fall 2020, Stuart Ralph released a special members only listen. I hope you'll check it out.
COMING SOON- the OCD Stories podcast episode with Stuart Ralph
When we recently moved to the house we are currently in, we got an extra bonus with some “smart home” features. Far from a ‘techie,’ I quickly got frustrated in the first week. When I didn’t know how most of it worked, I began to become irritable. This is not a growth, learning, or curiosity mindset.
This is a problem. Why do I expect to get everything on the first try? What leads to seeking accomplishment over growth? This is not who I want to be or what I want to impart to my wife or child or others. This is the way of the world. Busy. Hurried. Trying to do more and more. Have you also caught these moments where you have forgotten the powerful God we serve? Oh how we can fall into “The Hurried Spiritual Life” (click to see my blog post on the topic). Worth and value is so easily tied to performance and accomplishment. But with the Lord it is not so (here’s a couple kickin’ passages on the topic: John 9, Psalm 46:10).
2 Corinthians 4:18 reminds us to “look not to the things that are seen. For the things that are seen are transient, but the things that are unseen are eternal.” Prior to this in verses 16-17, we’re reminded not to lose heart while our earthly bodies are wasting away, and affliction creates a ‘weight of glory’ (an excellent C.S. Lewis book, fyi). Suffering and hurt is inevitable in this world- it will either break you or build you. Romans 8:18-19 reminds us, “For I consider that the sufferings of this present time are not worth comparing with the glory that is to be revealed to us. For the creation waits with eager longing for the revealing of the sons of God.” This is a growth mindset.
Getting the lights to work in my house isn’t significant suffering. First world problems. But the reality still exists: suffering exists in many forms, both extreme and small. I have experienced both, and I will experience more. My focus when I get frustrated over things not going my way is so often earthly- temporal. It’s results-driven, not growth oriented. It’s accomplishment over development. It’s the ‘click’ over the long road of growth. Becoming insta-famous over being faithful in the little things. So I will keep turning my eyes to Christ in each and every thing.
Prayer: Lord, I thank you for your unending love and longsuffering with us. I ask that you’d make me humble and open my heart to you- to what you are doing and continuing to do in the world and through me. I ask you to fill me with your Spirit to make known fruit so that I can be patient and gracious with others- who also suffer. I ask that you’d speak through me and that I’d listen as you speak through others. In Christ, Amen.
“Beloved, we are God’s children now, and what we will be has not yet appeared; but we know that when he appears we shall be like him, because we shall see him as he is” (1 John 3:2).
21 Ways To Thriving Mental Health from an Anxiety Specialist
Katherine didn’t understand why this pandemic hit her so hard. In fact, she was embarrassed that it did. “I mean, my routines and orderliness can be a little overboard, but I’ve never had difficulty getting by day-to-day. I cry at the drop of a hat and just don't know what to do." I was so honored that she admitted she was struggling, because in that honest vulnerability, she is now getting help.*
In this time of COVID-19, there is a common expectation: the misconception that "healthy" means we won't feel anxious - or the opposite: success is defined by feeling completely safe, confident, or certain. That's crap.
Though it’s nice to feel less anxious, it’s not always reality, even if we’re doing all the right things. I mostly work with clients by helping them learn to stay focused on things of value, regardless of how they feel. Overall anxiety reduction is a result of various factors and is rarely immediate. In time, with supportive factors, anxiety often will go down. Jesus himself felt greatly distressed and overwhelmed, at times, too, if you didn’t know. He wept, sweated, pleaded, was scared, bled, and got angry and frustrated. He understands because he can actually relate - physically and emotionally. He gets Katherine's suffering - and yours, too.
Life involves not only facing bad things that don't happen, but also bad things that do. The question is, are you trained and ready? Can you still keep your focus even when the world around you and inside of you seems to be in chaos? Here are some quick tips to help you stay grounded in reality.
1. Be assertive. Routines have changed. We have to communicate to make the covert overt, like telling your loved one if you need a break to recharge (they can't read your mind!).
2. Be careful of untrue thoughts. Unrealistic thought patterns negatively impact our entire life, like All-or-Nothing Thinking. For example, "Since I’ve been eating poorly it doesn't make a difference if I exercise.” Katherine, mentioned earlier, fell into this trap by believing she was doing a terrible job simply because she felt overwhelmed. Mental health is based on grasping reality to the extent we can. Watch your thoughts and line them up with reality as much as possible.
3. Don't over-consume on substances. Caffeine and alcohol are certainly the most popular substances to monitor.
4. Downtime/Mindfulness/Quiet. The importance of giving our brain pauses and rest cannot be overstated. During a crisis, we need more intentionality to slow down unhealthy processes that are automatic or deeply ingrained. Learn to be mindful, slow down the process, and/or meditate on something beneficial- like how much God cares for you and promises to never leave or forsake you. Benefits range from increased focus and function to decreased stress and disease.
5. Emotions, Thoughts, and Behaviors - Tune In. Be aware of your thoughts, emotions, and behaviors. God gave you these - learn to pay attention to them and discover how to respond - sometimes in ways you might not expect.
6. Exercise. Exercise is highly connected to mental health. If you’re stuck in the house, there are ways to get creative. Make a game with a fitness tracker! Compete with others! Set up prizes for yourself or children! Get outside where possible and get moving.
7. Get Support. Use trustworthy support. Few things in life (if any) are done well without support. One place to get support is through an online or in-person Live Second Group.
8. Have fun! We all need reminding to pursue fun. Even the term ‘recreation’ is based on the concept 'recreate '- “to give new life.”
9. Medication. Medication can play a necessary role in well-being. You don’t need to feel shame if you can use a physiological boost for your brain health. Consult a health professional if this would be the right option for you.
10. Normal structure. Our brains integrate information we don't need to remember and becomes second nature. So when you change your routine massively, you will feel out of balance. That’s okay! Try to make use of old structures while learning to develop new ones!
11. Nutrition/Diet. Be careful not to overindulge on carbs and sugars - the snacky & sweet food you may feel the urge to “pound,”which can offer quick energy and pleasure, but overconsumption won’t benefit you. In fact, it will impact you negatively.
12. Prayer. Open communication and presence with the God of the universe is what we access through prayer! His power is what I need; it's really good to follow a big God who is over all our circumstances.
13. Prioritize. Limit inputs of information and stimulation or your brain will do its best to force limits and push you back into what’s called “homeostasis” (or balance), which can lead to feeling burnout and depression.
14. Serve others. Loving our neighbor as ourselves is beautiful. Not only does it help them, but we also can find much encouragement and joy. Learning and growth is often solidified when we can teach, pass along, and serve. Win-win.
15. Sleep. As one of the most important contributors to all aspects of health, good sleep is a necessary foundation to good health.
16. Spend/Save/Give money. Work from a budget. Spending money can be satisfying. Giving it away is powerful to others and ourselves. Taking on unnecessary debts, overspending and being miserly or hypervigilant all lead to stress in different ways.
17. Socialize. We are social beings. Direct contact releases neurotransmitters! But so can positive interactions in this time where we can’t touch much. Wow! For the time being, technology, phones, letters, or writing on messages on cardboard goes a long way.
18. Spirituality/Faith. What do you live for? What do you believe? And are you living congruently with it? Are you allowing yourself to ask questions and pursue guidance, support, and practices around what is good and true and beautiful and lovely? To discover more about what it looks like to follow Jesus watch this.
19. Sunlight. Not only is sunlight important in Vitamin D production, natural light is linked with numerous processes ranging from sleep to mood and much more. If you must be indoors or have limitations on natural light, find ways to maximize it.
20. Supplements. There is good evidence that several supplements can aid in mental health; some linked most commonly to mental health are Vitamin D, B Complex, and Omega-3 Fatty Acids (always follow your doctor’s advice).
21. Your context is your context. Don't compare. "Comparison is the thief of joy." When we look at where we are, don't let expectations crowd out what you're supposed to be about.
Keep in mind this is educational content and not intended as a substitute for professional advice, treatment, or diagnosis. Any of these tips will come across as too simple for someone suffering highly.
*All names and details used are obscured to protect patient confidentiality, including using a mixture of case information.
The Guide above is provided entirely for free to newsletter subscribers.
One of my first questions to a professor in my earliest IOCDF BTTI (Exposure Therapy training) at Massachusetts General Hospital was, “What happens if someone actually gets sick after a contamination exposure?” I haven’t forgotten the simplicity of the answer that went something like this: “People get sick all the time. Yes, that might create some additional hesitancy to face exposures at first, but you have an incredible opportunity for learning.” Life involves not only facing bad things that don't happen, but also bad things that do.
Exposure Therapy involves the systematic confrontation of fearful triggers while reducing and eliminating fearful, pathological responses. In the end, it can relieve a lot of suffering.
During this global pandemic of COVID-19, people actually are getting sick. One might not think the principles of exposure therapy would apply (i.e., "Don't you do exposure therapy for risks that don't happen?"). Quite the contrary. I believe exposure therapy provides one of the best evidence-based ways forward, helping us stand up to fear we need to squarely face. So today, whether you have a disorder or not, there is an opportunity for learning and growth in the face of COVID-19.
This guide, "Thriving Mental Health Alongside COVID-19," is dedicated to my clients and the IOCDF and provides a thorough summary of the main steps of Exposure Therapy with me, with key tips for general mental health. May you be enriched by this!
Whether you have a mental disorder or not, there is an opportunity for learning and growth in the face of COVID-19 (SARS-CoV-2). Now, more than ever, we need stable footing to stand on. People go to every extreme. You don't have to. Mental health is about being grounded in reality, insomuch as we can grasp it.
Getting sick will happen. Yes, people die. Relationships break up and fail. Businesses go under. We might get it wrong. However...many people can experience health. Some people live with purpose and to the full (which is not the same as perfect). Relationships can be incredible. Businesses can thrive. We can get things right.
When I utilize the method of Exposure Therapy in counseling (a subset of Behavioral and Cognitive Behavioral Therapy), it involves the systematic confrontation of fearful triggers while reducing and eliminating fearful, pathological responses. It is Gold Standard treatment for OCD & Phobias, and is a first line treatment for all Anxiety Disorders and PTSD. What we think happens is that relearning occurs, which for most increases confidence and decreases disruption in life when they follow the treatment. Exposure, then, gives us two opportunities:
2. To learn we can face it anyway.
Its principles connect us to some of the best of life: face the thing you have reason to face; gain the opportunity to live more fully.
This guide is a very brief summary of the main points of the exposure therapy process with me, particularly with clients who have OCD and Anxiety. Many of my clients actually are faring better in this crisis than people I have talked to and seen in the general public- and why wouldn't they?! They've been training and learning- and now it's game-time.
Click "Read More" for a Summary
Exposure and Response Prevention (ERP), the gold standard treatment for OCD, can be fairly straightforward once understood. However, certain nuances are crucial for facilitating learning, growth, and maximal fear disconfirmation (fancy terms for successfully overcoming fearful responses). Here are 10 tips- click on the picture for a downloadable version:
Adapted from: Abramowitz, J. S., & Jacoby, R. J. (2015). Obsessive-compulsive disorder in adults. Boston, MA: Hogrefe Publishing.
I am honored to be surrounded by incredible people who exhibit incredible strength and faith in the most trying circumstances. These past few weeks as the Coronavirus has led to increased fears, panic, product hoarding, and expressed racism, I have seen the stellar example of many clients and friends wading these uncertain waters with confidence, skill, and calm.
Many of you know that treating OCD and Anxiety Disorders is how I spend most of my time clinically. Despite the fact that the 'neurotypical' person may think those with disorders are probably “going crazy” right now with the Coronavirus (and it’s definitely been really hard for many), I have found in my practice much the opposite. I am observing right now during the Coronavirus pandemic how those who have trained themselves to persevere through difficult stressors and triggers- with intentional acceptance of uncertainty, mindfulness rather than obsession, and valued action rather than compulsion- are revealing how beneficial the training of the mind and heart is. I have personally experienced more frantic, panic-induced efforts by folks I’ve come in contact with outside therapy than inside my office. I’ve also seen several of my Christian clients reveal an incredibly deep faith that inspires me (even if they suffer with worry and anxiety).
For those of us as Christians, we can rely on awesome skills we develop in therapy, and it also needs to go deeper than skills. Here are some questions to help you consider the truth we stand on:
Are we walking by faith, not by sight?
“So we are always of good courage. We know that while we are at home in the body we are away from the Lord, for we walk by faith, not by sight” (2 Corinthians 5:7, ESV).
Do we believe nothing- nothing- can separate us from the love of God?
“For I am sure that neither death nor life, nor angels nor rulers, nor things present nor things to come, nor powers, nor height nor depth, nor anything else in all creation, will be able to separate us from the love of God in Christ Jesus our Lord” (Romans 8:38-39).
Do we practice mindfulness in what's true?
“Finally, brothers [and sisters], whatever is true, whatever is honorable, whatever is right, whatever is pure, whatever is lovely, whatever is admirable—if anything is excellent or praiseworthy—think on these things. Whatever you have learned or received or heard from me, or seen in me, put into practice. And the God of peace will be with you” (Philippians 4:8-9).
Are we loving our neighbor (which is everyone- see Luke 10:25-37)? Considering others’ needs?
“Each of you should look not only to your own interests, but also to the interests of others” (Philippians 2:4).
I hope you are encouraged- as I have been by others’ faith today- in where our focus as believers is to be. Faith. Hope. Love. The greatest is love.
Justin K. Hughes
If you have a child, significant other, or friend who has OCD, you likely know the suffering it can create. Or maybe you don’t; that’s okay. The unfortunate reality for most clients once they appear in my office is that OCD has culminated in tremendous levels of stress and disability. 14-17 years from the onset of OCD is the average needed to obtain evidence-based treatment. By this time, OCD is typically well-developed. Sometimes, it can function under the level of awareness, even when severe. Family members often feel guilty that they missed it for so many years. You are not alone. This article presumes basic knowledge of OCD, so if you are brand new to the topic, I recommend a primer, such as the following on my OCD Resources page: Intro brochure, ERP for OCD Presentation, and the IOCDF’s “What You Need to Know About OCD”
OCD is an extremely debilitating disorder as a whole, ranking as one of the top ten medical and mental illnesses in the world- right alongside such things as Heart Disease, Major Depression, and COPD, according to the World Health Organization. With 2 out of 3 people reporting severe impairment at some point in their lives (e.g., work, relationships, school), you can count on OCD to create an ever increasing set of problems- without effective treatment. Furthermore, around 90% have at least one comorbid mental disorder, such as Major Depression, Panic Disorder, or a Substance Use Disorder. OCD has a tendency to make sufferers “hostages"- feeling stuck in an ever-narrowing loop of behaviors and/or thoughts that usually seem nonsensical to the person themselves, which tends to drive even more shame. Families and support are collateral damage. It is crucial to identify the threat and connected suffering of OCD in order to fully address its impact- and to have the proper perspective and motivation in getting necessary treatment.
Do Your Research
Attempt to really understand your loved one’s suffering, and understand how to help, howa not to help, and how to stay healthy yourself. Finding effective support and treatment is crucial. You don’t have to have diagnosable OCD to be an incredible advocate. Myself and a majority of my OCD specialist colleague/friends do not have diagnosable OCD. Knowing treatments that are effective helps to stay grounded and focused. In short, a specific subset of CBT (Cognitive Behavioral Therapy) known as ERP (Exposure and Response Prevention) is the Gold Standard in treatment. SSRI medications (and clomipramine, a TCA) are used as the first line psychopharmacological treatments. Supportive psychotherapy is not evidence-based first-line treatment for OCD. You may love a counselor who is very supportive, but if they’re not doing some sort of exposures or behavioral experiments, and there’s not a noted clinical reason why they cannot, consider an OCD specialist, because they are not following clinical practice guidelines. Again, check out my Intro Brochure and ERP for OCD Presentation for more on the research and specifics.
Make the Unseen Seen
Taking OCD seriously involves seeing it- and you may help your loved one see it more clearly through your loving support. When it is beneficial to a client, I almost always recommend involving a supportive loved one at some point in treatment. We would consider it odd or unusual not to involve a family member in many other medical treatments. A major challenge with mental illness is making the unseen seen.
Be Realistic With Expectations
One of the roles I serve is setting expectations. Consider how a coach might observe, teach, encourage, and challenge based on a fitness or performance goal. I know OCD from the inside; you can, too. I want to prevent “injury” from occurring in clients who are overeager and might overwhelm themselves jumping in unrealistically- in order to make progress quicker than their skill and training can support. I’ve seen this occur when clients start with the hardest thing they can imagine doing without the support to do it- they usually get burned out or drop out of treatment altogether if they don’t redirect this focus into systematic, consistent, and sustainable work. Conversely, some sufferers have low motivation or may be depressed. Walking together in the trenches and valleys, I seek to boost their perspective to know there is hope when they don't feel it. You cannot “cure” / overcome core fears in OCD with a single exercise, so pushing a loved one to do something they are terrified of can backfire- reinforcing fear vs. disconfirming it; we need to consistently, systematically face fears by addressing with a strategy and a plan.
Be careful to not underestimate how much of a problem OCD can create- and in turn, how much work and growth is needed to learn to say no to all the compulsions that exist for an individual. When there are additional treatment factors (comorbidity and severity, among others, negatively influence outcomes), they can complicate the learning and growth process . Probably the most common error I see in practice is an underestimation of how much treatment and work is needed to accomplish clients' and families' goals (e.g., in terms of number of sessions, practices at home). We also want to be realistic about outcomes, i.e., getting better. Though the treatments for OCD are highly efficacious for most and can be life-changing in a short amount of time for some, practicing patience in your individual situation is key. No one case is exactly alike. You as a family member can help spell out hope or chaos in expectation-setting- helping your loved one in staying the course without being overly idealistic or nihilistic in their views of getting better.
Facilitate buy-in by reinforcing the principles of what it takes to get better. Validate growth- and always validate the person's value and importance, no matter how much they struggle. Remember to encourage yourself, too!
Support: Don't Accommodate or be Emotionally Explosive
Support needs to strike a balance between being overly-accommodating and overly-emotionally expressive (outbursts, hostility, negativity, etc.). The well-researched terms we use to describe these are Family Accommodation (FA) and Emotional Expression (EE). Break the Cycle!! Don’t Do Compulsions for them (by proxy). Begin (with a plan) to minimize your accommodation. Typically in therapy, I help to incrementally get rid of accommodation altogether without “pulling the rug out” too fast (i.e., in one day). Therapeutically, all client rituals must ideally be terminated to maximize outcomes. Helping a loved one ritualize only feeds the cycle. Don’t Give Reassurance. To do this well, you often need to be involved in the prior steps this article elucidates. It can be tricky to know what is reassurance and what is not. Ask questions of your loved one. If they are not open to sharing, you may have to do your best to set your own boundaries, make an informed guess, and base your limits on your own personal boundaries until they're willing to communicate further. Part of feeding obsessions involves engaging the content of obsessions with logic, emotion, and reactions. The person with OCD must learn to live their goals and values without following the content of obsessions. Be careful not to get pulled in, either through accommodation or emotionality. Offer to go to therapy with your loved one if they are willing. You can also gain much support by doing your own therapy, as well! Part of support may be helping covering costs of therapy. Just to be clear- you get to have your own emotions, whatever they are! But EE refers to when these emotions are expressed in harmful ways.
Make Space for your Own Growth and Boundaries
You are a person with your own thoughts, feelings, life to live and decisions to make. Having healthy boundaries for yourself and family is very important. Helping does not mean loss of your own identity and responsibilities. It is not over-extending, nor is it avoidance of problems. Review the chart above. Your situation is your situation; there is a lot of similarity and variety (homogenous and heterogenous) to stories around OCD. You will likely be encouraged at how others feel similarly; but you also have unique factors that make your story your own- be careful not to compare unnecessarily. For goal and boundary setting, Contingency/Behavioral Contracts might be helpful, especially if you are responsible for someone with OCD (i.e., a child), or if you just need clear guidelines of involvement (how and when to discuss obsessions, financial support, reinforcements and privileges, etc.). Your own support and therapy can help you with you own growth and boundaries. Refer to the IOCDF’s excellent tool to “Find Help.”
You can be a crucial source of ongoing recovery, similar to how a coach or trainer might help. We all need reminders, especially in dealing with a consistent need (exercise, diet, and chronic disorders). You can be part of the team surrounding a sufferer to help them be aware of any new compulsions or problems that may arise. You may want to communicate with them in advance about how to best bring up concerns when they are observed. You can be part of the team that cheers them on and helps with motivation! Remind them of their values and why they want to grow (i.e., to go to school, work, not be controlled by OCD, feel better, enjoy life, help others, grow as a person, etc.).
Practical Tools for You
I often have my parents and significant others complete several documents and incorporate various tools. Each situation will vary, but commonly I use:
If you have made it this far to read this article, you are quite likely a key support of someone who has OCD. It is then very likely that you care and want to make a difference. You rock. Keep up the good work.
Calvocoressi, L., Lewis, B., Harris, M., Trufan, B. S., Goodman, W. K., McDougle, C. J., & Price, L. H. (1995). Family accommodation in obsessive compulsive disorder. American Journal of Psychiatry, 152, 441-443.
Depression and Other Common Mental Disorders: Global Health Estimates. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO.
Gillihan, S. J., Williams, M. T., Malcoun, E., Yadin, E., & Foa, E. B. (2012). Common Pitfalls in Exposure and Response Prevention (EX/RP) for OCD. Journal of obsessive-compulsive and related disorders, 1(4), 251-257.
What You Need To Know About Obsessive Compulsive Disorder. (n.d.). Retrieved February 2, 2020, from https://iocdf.org/wp-content/uploads/2014/10/What- You-Need-To-Know-About-OCD.pdf
An editor for the American Counseling Association reached out to me about OCD from a Specialists' perspective. (I was so proud of them for doing their research with multiple specialists!!). The following are excellent questions that may help inform their ACA magazine article in February 2020. Whether they utilize any of these or not, I hope they are helpful for you as they cover important questions to consider with regard to treatment.
"What presenting issues might bring these clients into counseling?"
"What are some “red flags” for counselors to listen for that might indicate OCD in a client who came in for something else (anxiety, ADHD, etc.)?"
If a counselor begins hearing the exact same things, worded or behaved in similar ways, this is a good indicator to watch out for. Many of my clients are good at exactly quoting themselves on what they've said before. Obsessions are repetitions on a theme; if you get good at catching the theme, you can usually spot an obsession miles away.
At its core, it's not remarkably difficult to identify criteria in OCD (in most straightforward cases) if a counselor brushes up on what they're looking for (dust off that DSM-5!).
Furthermore, if a client isn't improving from certain methods (especially things like Cognitive Restructuring in CBT), this is "Getting Stuck 101" and needs further assessment. Most of my clients have had prior experience with a counselor who had no idea how to treat OCD from an evidence based way and approached the same as regular old automatic negative thoughts. This is not typically helpful.
"What counseling methods/techniques can be helpful when working with clients with obsessive behavior and/or OCD? Please explain how this/these method(s) work well for this client population. If possible, please talk about a case example (without identifying information) who worked with you and showed improvement. What were his/her presenting issues, what methods did you use and what issues did you focus on in counseling sessions?"
Exposure and Response Prevention (ERP) is the GOLD standard treatment (which is a very specific subset of CBT). It is indicated as the starting point for all OCD treatment. This is a strong statement, but it is backed by the research (the most RCTs by far) and organizations like the IOCDF, APA, and so forth. SSRI (and Clomipramine, a TCA) medications are also first-line psychopharmacological treatments, though with less effect on average than ERP. Both combined can be helpful, though may not necessarily increase the overall benefit of just ERP alone. Another first-line treatment for OCD (though not the "gold standard") is Cognitive Therapy with Behavioral Experiments. Along with medications, it is seen as sometimes a more agreeable option for those who are hesitant to engage in exposure therapy (which intentionally and repeatedly provokes distress in order to respond differently- i.e., without compulsions).
Adjunct therapies, medications, and treatments are utilized. In the interest of brevity, research has discovered the integration of Acceptance and Commitment Therapy (ACT), Motivational Interviewing (MI), and other techniques can be helpful to provide well-rounded treatment and/or facilitate the practice of ERP.
To share a classic example [identifying factors changed to protect confidentiality- this type of case is remarkably common], one woman came to me with severely distressing thoughts about harming her children (no history of harm or abuse). She knew it was irrational, yet it felt so real to her; the more these intrusive thoughts continued to appear, the more difficult it was for her to determine her intent from confusing feelings and "impulses" to stab her kids. Upon receiving a diagnosis of OCD, I thoroughly assessed history with symptoms, and educated on the CBT model for understanding OCD treatment with a rationale for CBT and ERP. We discussed medication options, to which the client was willing to pursue with their Psychiatrist. The client was very cooperative due to a high willingness and intrinsic motivation to be able to engage at home with her two children and spouse. As can be very typical, the stress also took a toll on most every area of life, making work difficult. Once we began ERP, we started with doable exposures while learning how to stay present with triggers and distress- without compulsing. Upon successful practice of more manageable triggers on their hierarchy, they- with the incredible support of their spouse and church and loved ones- made a jump in their exposure work that began with "scripts" (imaginal exposure stating/writing distressing thoughts and quickly progressed to holding knives and stating these feared thoughts aloud) and transitioned to practices situationally at home, holding knives and saying scripts aloud (in separate rooms appropriately not in front of their young children). The incredible support around this client, along with a sense of strong purpose, helped facilitate (this is part of ACT) the integration of ERP into daily life. They would be considered recovered at this point, scoring so low on the Y-BOCS (gold-standard assessment in rating severity) that their symptoms are sub-clinical. In relapse prevention planning, they understand the chronic nature of OCD and the necessity of staying on top of their good progress, with the plan to follow-up at occasional intervals for "booster sessions." I gain so much joy from stories like these.
"People with an OCD diagnosis may be taking medication and seeing other professionals (psychiatrists, psychologists). How could a counselor work in tandem with these other professionals? Please include a case example, if possible."
Coordinating care can be difficult, but worth it for the best client care! Although seamless communication and record exchange between providers is likely ideal, it just rarely happens in real life. Working within the space and limits that exist, I have found that outside of those very few therapists and Psychiatrists I can have near immediate communication with, it is still very helpful and feasible to at least request/give one way communication to a provider. In complex cases, it is almost unheard of for me to not outreach another provider that is connected somehow to shared treatment concerns. I think we need to be realistic about other providers' schedules and communicate what we can- how we can. This often looks like me leaving a Psychiatrist a voicemail after release is given- and not hearing back- but at least they have the information. It may be coordinating with another therapist who is treating other concerns. Early on, I used to welcome other counselors working at the same time on separate diagnostic concerns. Though I may work with someone now who is seeing another professional for something like, say, Depression, it is usually quite imperative that I make known to the patient and also the other provider the pitfalls of feeding compulsions through reassurance, ruminating, and so forth. This is a great opportunity for education of those who are not specialists in OCD. But OCD being as debilitating as it is (2 out of 3 people experience severe impairment at some point in their life), I need to work hard upfront to educate especially the patient about how hard they will need to work (and not undermine) their exposure therapy. Also, many other comorbidities can often improve significantly just by treating the OCD first.
"How, particularly, are counselors a “good fit” for helping clients with obsessive behaviors? How can they help people with OCD differently than a psychologist would?"
It has been my personal experience that my colleagues who are counselors (Master's level, typically), bring to the table incredible creativity and "outside the box" thinking. Many of the hands-on resources, videos, blogs, and social media that exist to help the sufferer of OCD often come from Master's level clinicians. I believe there is great flexibility many of my counselor colleagues have (which is a positive and a weakness all at the same time, sometimes lacking the rigors of adhering to the evidence based treatment protocols).
There are actually quite a few more Master's level clinicians than Psychologists, and there is a great need for more clinicians offering great treatment. Counselors can help fill this gap.
"As a practitioner who specializes in working with OCD, is there anything else you would want counselors who don’t specialize in this area to know?"
For many reasons, I love work with clients who have OCD. I have found they are some of the kindest, hardest working, conscientious individuals on this planet. This is where I believe many of their personality strengths arise once moving through pathology. It is a joy every day to see recovery, growth, and maturity bloom out of suffering.
"Any main take-aways to share?"
OCD Treatment can be so rewarding! It has very effective treatments for most, very clear evidence, incredible improvement that can be witnessed in a short period of time, and there are wonderful opportunities to get invested in this world with a community of professionals, sufferers, and supporters who are incredible.
~Justin K. Hughes
Those who know me know that I see people as individuals and hate to make generalizations. However, it seems to me that those suffering from OCD are among the kindest and most understanding people I have ever met.
A Psychotherapists' thoughts on healthy living.
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