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!
This post is intended for Christians looking to deepen their faith and mental health and may not apply to my entire reader base.
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
This post is intended for Christians looking to deepen their faith and mental health and may not apply to my entire reader base.
“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.
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
This post is intended for Christians looking to deepen their faith and mental health and may not apply to my entire reader base.
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
This video and guide below were specially formulated to help you be mindful in an "Exposure-Friendly" way.
This one's a bit different from the average mindfulness practice you might be familiar with. The reason it's called "Exposure-Friendly" is that it is specially designed to help a person be mindful of whatever they are experiencing, not just attempting to feel better. This is a hallmark of exposure therapy: being able to tolerate distress without engaging in pathological responses (rituals, safety behaviors) that negatively reinforce fear. Distractions and relaxation when facing our fears can backfire (see the research at the end of the Guide). So if we need a different set of tools to face fear, here's one of them. I hope it helps.
Music: As Leaves Fall
Thanks to Jonathan Hoxmark on Unsplash for this beauty!
Perfectionism and OCD
What is perfectionism? Oxford dictionary defines it as “refusal to accept any standard short of perfection.” That’s automatically problematic. Perfectionism leads to a circumscribed focus, stress, and suffering for not only individuals, but for loved ones nearby who feel the weight of being perfect.
Is this the same as OCD? Nope. OCD and perfectionism often get confused. They both can affect and drive distress in one another, but they are separate. OCD involves unwanted (intrusive) thoughts, urges, and impulses that cause distress; furthermore, compulsions are repetitive behaviors or thoughts that attempt to reduce distress or prevent something bad from happening. Perfectionistic manifestations of OCD, often referred to as “just right / not just right” fit this categorization. Separately, in Perfectionism, someone pursues “perfect” thought, behavior, or action initially out of interest or enjoyment (rather than to suppress an intrusive thought/urge/impulse, like in OCD). There are typically problems that go with this, however. So a difference between the two is that OCD is ego-dystonic and Perfectionism is typically ego-syntonic (you can check out my video here explaining the difference).
Examples of perfectionistic thoughts and behaviors[4,5]:
I am a "recovering" perfectionist. And it’s a problem when I’m not, well, “recovering” from it. One of the mechanisms that keeps perfectionism going is the belief that it is helpful (this is a “Positive Belief” about perfectionism, and it is a cognitive distortion). When I succeed at a task- and especially if I get a lot of praise, it is a natural reinforcer that I must be doing well. However, if I spent 8 hours researching, writing, and proofing this blog today, that is problematic for me at this point in life (and I easily can spend that much time). What is a problem or not sometimes depends on the person and their situation- maybe a journalist would spend that much time or even more, but I am a full-time clinician with a family, church, volunteer involvements, and hobbies. If I make this post “perfect,” in my perfectionism, I will seriously miss out on other things.
This pursuit of perfection doesn't stop with one blog post. It will always generalize if allowed. So if I let it, the pressure of perfection will continue (and does, at times) to move on to other things like caring for my home, caring for people in my life, my relationship with others, my diet, exercise, my spiritual walk, my car, money, and so on. And being honest with you, these things are tied up in anxiety and simultaneously selfishness- attempting to control these things rather than to engage with them/others in a meaningful way by learning to lean into the fear and live based on what is valuable.
Parenting is probably the single biggest event that pressed me with the realization I need really challenge my perfectionism. There are two stark realities to me in life: I can either do my work/relationships/home life/etc. “perfectly” and end up in an ever narrowing scope of anxious overwhelm trying to keep all the balls in the air, OR learn to tolerate the distress that comes doing things "not just right" and focus on the big picture, growing towards what I love and value. And the reality usually is that in time, this fear habituates when not engaging in avoidance, rituals, or control strategies.
Whether in therapy or personal life, to change how I behave and think and respond in life, I need to be aware/monitor what it is that needs to change (good therapy, support, and resources such as on my website can help). Even if I know what needs to be done, if I can’t effectively observe and catch it when it occurs, I will not be able to change it. Next, I will need tools and strategies to effectively grow and mature. In therapy, some of these are Exposure Therapy, Cognitive Restructuring, and more. In essence, at the point of the problem I must be able to insert the solution- and consistently. Lastly, I want to continue to monitor and gain feedback to incorporate learning and solidify growth. I don’t want to oversimplify this- if you are having a problem with any of the areas I have discussed, please reach out to a competent trusted person and/or therapist.
Today I gave myself the time limit of 3 hours- start to finish- to research, write, upload and post. And it’s simultaneously stressful and joyous at the same time. I’m going to do a behavioral experiment and keep doing it- “testing” whether or not my choice(s) in leaning into my fear of failure a) doesn’t end up as bad as it feels like it will, and/or b) I was able to handle or face it anyway. We’ll have to see- I'm leaning in!!!
Justin K. Hughes
 First of all, it’s a whole mess to even get into a truly perfect standard- if I make and continue to make mistakes, I am not perfect. I cannot even begin to conceive what perfect is, then, since I would make a mistake in defining “perfect.”
 The Diagnosis of Obsessive Compulsive Personality Disorder (OCPD) may apply when a person pursues perfectionistic behavior to pathologically disordered levels.
 Grayson, J. (2014). Freedom from obsessive-compulsive disorder: a personalized recovery program for living with uncertainty. New York: Berkley Books.
 Minirth, F. B., & Meier, P. D. (2015). Happiness is a choice: enhance joy and meaning in your life. Grand Rapids, MI: Spire.
This post is intended for Christians looking to deepen their faith and mental health.
The Bible has a lot to say about fear and anxiety. In fact, some variation of “do not be afraid” is the most common directive in Scripture, occurring in some fashion more than ‘do not steal,’ ‘do not kill,’ and even ‘love your neighbor.’
How do anxiety and fear work? When we study these constructs in research, we are understanding mechanisms through which the body/brain is informed to face a threat or danger. We can argue these responses are inherently good, with their purpose being survival, protection, and preparedness. Its activation results in the sympathetic nervous system being primed: adrenalin and noradrenalin are produced, cortisol increases, heart rate increases, blood flow moves to muscles and away from extremities, speed and depth of breathing increases, and many other physiological changes occur. I’m grateful to have these responses- when they are in context. Out of context, they suck, to put it bluntly. Problems like panic attacks, worry, phobias, obsessiveness, skin/hair picking/pulling, preoccupation, social fears, avoidance, and more can be quite terrible.
One of the things I love most in my walk with Christ is context. Direction.
“The Lord is at hand; do not be anxious about anything, but in everything by prayer and supplication with thanksgiving let your requests be made known to God” (Philippians 4:5b-6, ESV).
What is being said here? Partly, “Do not be anxious about anything.” Since anxiety is a feeling of imminent threat- or in other words, it’s at hand- it’s very interesting that immediately before this phrase in Scripture we have another observation revealing a different type of imminence: “The Lord is at hand.”
In the context of the Lord being near we are told, “Do not be anxious.” This Greek word for ‘be anxious,’ μεριμνᾶτε (transliterated as “merimnate”), means to be divided and distracted, fearful, and caring for things that are out of context.
Sounds a lot like anxiety disorders, right? Yep. Or even just day to day worry/anxiety? Yep. When a person feels anxiety and fear and misinterprets this as significant, a person’s entire life and values can shift to focus on whatever is the subject of their fear, whether classified medically as a disorder or not. This can lead to a preoccupation with avoiding something or someone (spiders, relationships, sex, social situations) to obsessively checking to make sure everything is okay (car, stove, locks, bodily sensations, health, perfectionistic behavior), or pursuing something (money, security, approval of others)- and MUCH more.
To help work through these things and avoid pathological responses, I believe we need supports like therapy, help from friends, breathing techniques, mindfulness, exposure techniques, etc. This only underscores our complexity (we are “fearfully and wonderfully made” yet simultaneously all messed up) and highlights what we are told in Scripture about our limits. We can rightly use these tools to help us, just as we do nutrition, medicine, community, and so forth. But there is one thing these tools can’t do on their own: attach us to the very God of the universe and give us a lasting hope and focus- with meaning and purpose at the highest level.
So God gives us a jewel of a passage in Philippians 4 where we are kindly reminded what our attention is to be on (context), and a little bit of how we can live it out (practice). It is well known within the anxiety treatment world that even the most effective therapies (here’s looking at you, classic CBT, which I love and specialize in) often need supports to connect to larger beliefs, values, and commitments (ACT, DBT, and MI are some of the most common modalities). If we don’t connect a person to larger motivations and goals than “I just want to feel better,” it is often near impossible for a person to grow with sustainable change for the long term because they don’t have a sufficient reason and value to keep them invested. God gives us this.
Want more? Well, there’s two tips in the next two verses, Philippians 4:8-9
“Anxious for nothing” will take a lifetime to put into practice. I’m grateful to have the opportunity.
 Continued misinterpretation and repetitive experience of these symptoms worsens disorder, like in Panic Disorder, GAD, Phobias, OCD, PTSD, and more.
 Bible Hub. (n.d.). 3309. merimnaó. Retrieved July 13, 2019, from https://biblehub.com/greek/3309.htm
 I think it’s very important to note that we have to be very careful with saying anxiety/fear is sin- and what we mean by this. A lot of Christians get tripped up on this, and many, ironically, become more anxious. The extent of this point would likely require an entire book, so I will not take the space here to elaborate.
 Psalm 139:14; Genesis 1:26-27
 Jeremiah 17:9; Romans 3:23
 Psalm 73:26; 2 Corinthians 12:9-10
 Oh yes, there’s a whole lot more in Scripture on this topic. Let's not reduce a couple sentences into a "how-to-manual."
The Myth of Disappearing Distress. If I do the right things, I won't have to face suffering, right?
It's easy for me as a therapist to exhort my clients to stay focused on the prize DESPITE the distress they feel. How easy it is to get off track! And while it's also easy for me to tell someone else this, it can be very cumbersome to do in practice. I, too, struggle to keep focused when challenges hit. But I'm always best prepared when I lean on my team: #support #faith #accountability #truth.
In Vivo Exposure
Directly facing feared objects or situations, examples include:
Getting on a flight, touching a doorknob that feels “contaminated,” not going back to check a lock, or going to a social gathering.
Good exposure attempts to match the content and detail of a person's fear as close as possible. So, for example, if a person fears “going crazy” in a social setting, the best exercise will be working up to facing that, not just exposing to the thought or word. On the other hand, if the fear is that a person will have inappropriate impulses (to harm, sexually, etc.), sitting with the intrusive thought and being present will serve best.
Imaginal exposure involves accessing the content of fears and anxieties through cognitive means. For example, a fear that someone will fail, make the wrong decision, harm someone, die, or choose the wrong relationship are not accessed by activating these life occurrences. They are addressed imaginally.
There are many ways to practice Exposure imaginally, but the most common are writing scripts, stories, listening to recordings, watching videos, or using visualization.
To be clear, Imaginal exposure often is the most confusing and hardest to grasp of exposure practices, as it seems to be creating negative thoughts or “bringing” unrealistic and negative thoughts on- the seeming antithesis of most of psychology and cognitive therapy. But what is really done here is only facing what a person is already experiencing, thinking and feeling.
Intentionally bringing up physical sensations that are feared, such as:
Heart racing, shortness of breath, sweaty palms.
Ways to do this when a person's health allows are breathing through a cocktail straw, breathing rapidly, or sitting up quickly.
Virtual Reality (VR) Exposure
With the advent of new technology, we have a recently emerging type of exposure. Some may class Virtual Reality into imaginal exposure, but it can be seen as a cross between in vivo (situational) and imaginal. This is especially helpful with treating disorders such as Flying Phobia, where the access to an actual plane and flight to practice can be cost-prohibitive and difficult.
What is Exposure Therapy?
Exposure therapy is a psychological treatment that is practiced in Behavioral and Cognitive Behavioral Therapy (CBT). It is indicated as a first line treatment for a number of disorders such as
Exposure therapy helps clients to systematically confront fearful stimuli along with changing fearful responses. This relearning increases confidence and decreases disruption in life. Over time, discomfort and fear typically decreases through active engagement rather than avoidance, suppression, neutralization, or ritualization.
The evidence base is very strong for its use and effectiveness, though it is currently only applied a minority of the time in clinical settings.
How Do You Do Exposure Therapy?
The principles of exposure may be simple, but the specifics- personalized to any one individual- involve many working parts.
Did your anxiety increase over flying after news of the engine failure on Southwest Flight 1380? Even a little?
I have booked plane tickets twice since the incident in mid-April 2018, and when choosing seats, I hovered precariously as I decided whether to select my favored window seat, or if I go for the "safer" aisle. My wife mentioned slight concern over the window seat because of the tragedy that occurred.
Working closely with the CBT treatment of Anxiety Disorders and OCD, I knew the moment I read the news- first about engine failure and the sad death of a wife and mom, Jennifer Riordan, and more recently the loss of cabin pressure and a window crack on a separate flight- there would be increased fear and anxiety about flying. Why? Flying commercially is statistically more safe in the U.S. than it’s ever been. Even with these incidents. Even with 100 of these incidents.
The fear is natural, and even normative, to some extent. It makes sense that we’d instinctually be a bit curious about our well-being in a metal tube soaring at 500 mph with tons of jet fuel propelling it. Even the possibility of flight has been denied in most of human history.
But what about when fear starts to cause problems ? Affect choices? Leads to avoidance of life pursuits and goals? Or becomes one more in a cumulative list of anxieties and worries? One way to be 100% certain that you will increase your fear load is by giving the aforementioned flight(s) unrealistic credit. By associating personalized, catastrophic meaning to a situation that is one of the safest things you can do (safer than riding a bike), a distortion has taken place. Some disorders, such as Specific Phobias, PTSD or OCD, make it pathologically difficult (i.e., neurobiologically) to change how one feels and thinks, regurgitating fear quicker than your vertigo-experiencing seatmate with their airline-branded “barf” bag.
With Flight 1380 being the first fatality on a U.S. passenger airline since February 2009 (over 9 years), flying on a plane is a remarkably secure form of travel. Unconvinced? Check out Forbes’ mining of some reputable stats.
Here’s the thing; education and stats are helpful, but only go so far. Fear is more than a reasoning thing- or in neuro terms, more than a prefrontal cortex (PFC) thing. Fear is an emotional thing. An amygdala thing. A learned response and genetic thing, along with a pervasive attitude and decision thing. It’s something that can destroy, harm, and erode, or it’s something that can be used in its rightful context, and set aside when not useful (e.g., PTSD treatment where a person can balance both safe and smart decisions, while facing disordered fear, so they can live life more fully).
So if you’re like most people who need a bit more than statistical education to counter anxiety and become stress resilient, remember this:
What you think and believe (cognitively) is vitally important.
What you do (behaviorally) is vitally important.
Your health and well-being are intricately tied to these. Small decisions today can lead to a long-term impact. For many of us, the greatest threat we face today is fear. So I chose the window seat.
“I am an old man and have known a great many troubles, but most of them never happened.”
A Psychotherapists' thoughts on healthy living.
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