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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 post was originally published on 02/13/2014 on my wordpress and is newly updated.
“Why can’t I stop thinking about this?” “Why can't I stop? I know it doesn't make sense.”
William went to the Middle East after his unit was deployed from Ft. Hood. Most of what he heard about soldiers’ experiences were rumors and media stories- he had no way to be prepared for what would happen. After nearly 6 months of swallowing sand stirred up by 110 degree winds, William had 5 days left until he would return home. Momentarily losing his hearing, all his senses were shaken when an IED tore shrapnel through his three closest friends. They were dead. Just like that. After being rushed by helicopter for triage medical care, William soon discovered he only narrowly missed death- the same shards of nails and rocks that killed his friends were found inches away from where he stood.
Returning home is where cleaning up the fragments took the longest. After being debriefed and allowed medical and family leave, Bill struggled getting back to civilian life. Some of the most difficult times he faced were trying to overcome his own unexpected reactions to situations, usually late at night where he would awake from a noise, pulling his wife down from the bed onto the floor to take cover. When he became calm, he was covered in sweat, visually stunned by recalling what had happened weeks before- and so embarrassed to be dragging his wife- literally- into the center of his problems.
This is trauma. This is the story of William’s PTSD (post-traumatic stress disorder). Hopefully his story can help bring understanding to struggles faced by those dealing with trauma and respect for our service men and women.
It’s not very difficult to have some sense of empathy for William’s situation. It’s often much harder to understand another very real and very overwhelming problem. It is called Obsessive Compulsive Disorder (OCD). You may be curious why this article spends so much time talking about PTSD, only to discuss OCD. Two reasons. OCD actually has some similar features and neurobiology to PTSD, and secondly, if we are to listen to the struggles of others, often we must start with something we do grasp a little more readily.
Whether a person is triggered into feeling distress from trauma or obsessions, their brain is becoming hyperactive in warning of a threat. This wonderful system when working properly can be nightmarish when the reactions surface out-of-context. Think of the panic you would feel if you saw someone almost being run over by a car- your fight/flight/freeze response would activate and prepare the body and mind. Now imagine it occurring at random times and being uncontrollable.
Despite popular references of, “I'm so OCD” and “He really likes the house OCD clean,” [FYI, OCD is not an adjective] this diagnosable mental health condition is a serious disorder- and far beyond a person’s immediate ability to just “stop it.” Because the anxiety and distress a person with OCD feels is so bothersome and intrusive, they naturally seek to alleviate it- sometimes with elaborate mental rituals to “do away” with the anxiety (e.g., counting, prayer, neutralizing statements) and sometimes with physical compulsions and avoidance to feel better (e.g., “I feel anxious when someone touches my clothes and need to change and wash them immediately”). To some people, this sounds "crazy." But in our age of neuroscience (and OCD is remarkably well established), we cannot deny scientifically the paint and suffering involved in the sufferer's life. Their mind- and often body- SCREAM with discomfort until they do something to alleviate it. And the compulsion works! Momentarily, at least for a bit. It problematically, though, reinforces the learning, connections, and neural pathways linked to disorder as opposed to reinforcing healthy, non-compulsive behavior.
To stand up to OCD, a person needs to ultimately eliminate all compulsions. What do we make of this? Do we expect the person with PTSD to just jump back in to just get on with their lives? Nope. Let me be clear with OCD (and this is also true of PTSD).
There is hope and very effective treatment.
We don’t have to understand, ultimately, to love. As many as 1-3 % of the population wrestle with this. Look around- that’s someone in your neighborhood or at the restaurant where you ate. Will you lend a helping hand to those who suffer? I will.
Justin K. Hughes
Check out more resources on my page dedicated to them:
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.
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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