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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 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. Interoceptive Exposure 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.
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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. Assessment
According to Dictionary.com, their word of the year is "Misinformation." Defined as "false information that is spread," misinformation occurs "regardless of whether there is intent to mislead." Misinformation, and its brother, disinformation, can be harmful. Clearly. Though much of the current state of discussion around this concerns external affairs. Much of what we are responsible for at least begins internally (how we respond and engage). Aligning our thoughts, beliefs, and behavior with reality- what's true and realistic- is a crucial "mechanism of action" that helps facilitate positive outcomes. This is particularly true in the method of therapy I use- CBT (Cognitive Behavioral Therapy), We know that cognitive distortions [click for pdf list] only prevent us from succeeding and growing. These errors are harmful especially when they are consistent approaches to thought, such as All-Or-Nothing Thinking (I missed my workout today; I might as well skip this week), Mental Filtering (I know they said they enjoyed meeting me, but they must not like me because they talked more to other people), and jumping to conclusions (I just know that she got off the phone quickly because she thinks I'm an idiot!). The deeper these go, the more impactful they are and harder to break. So in a world of misinformation, make sure you first tell yourself the truth, whether it's difficult or comforting. In this time of the year that is special, wonderful, challenging, or downright awful for some, what can you do? Be realistic. Tell yourself the truth, and to others. Align your thoughts, beliefs, and actions with commitment, purpose, and meaning (and if you're not sure what yours is, find it with help!), and try to get as close to what's honest and accurate. Be a good researcher (humble). Don't get snowed by misinformation. Give the gift of realistic, truthful thinking. Your brain will thank you (and probably everyone else will, too). Merry Christmas, and Happy Holidays! Yours truly, ~Justin  Photo by Toa Heftiba on Unsplash  Photo by Dhiva Krishna on Unsplash Yesterday and today both I witnessed bad car wrecks. I haven’t seen a car wreck in over two years. Not only have I been more cautious driving since, today I caught myself telling my wife possible reasons for seeing two crashes in a row.
“Hey babe, maybe people are absent-minded with summer and vacations. Be careful.” Possible. However, I inferred meaning that may have nothing to do with what actually happened. Do you ever do that? Read into what your significant other is saying? What your clients are thinking? Make an assumption? We all do that. Decisions. Determinations. Judgments. I work with thoughts and thinking day-in and day-out. A big part of my job is to help folks live in reality. Correcting distortions and errors in their thinking is a large part of this. Of course, as a human being, I experience this just as much as the next person. It is a discipline to not only look to logic and reason, but also to connect with emotions and experience- and attempt to be grounded. I hope I always continue to work on this. So the reasons why a nice Mercedes got its hood completely crumpled may not really be in my purview. Nothing wrong for me to guess. However, it is significant for me to stay aware that my thoughts stick close to reality, because the further they diverge from it in day-to-day life, the more likely I am to make determinations that are wrong. The more I do this, the more firmly rooted my beliefs become. My emotions will follow my beliefs. And my beliefs determine my course. My course affects others. Others affect history. See where this is headed?  Photo by Jonatán Becerra on Unsplash Incredibly sad is the news that in a matter of days, two revered, loved, and famous celebrities committed suicide. This morning I was hit by discovering that after Kate Spade ended her life, Anthony Bourdain also ended his. After I prayed for their families, I knew I needed to send out this blog.
Suicide is an incredibly complex issue. Let me be simple at the risk of sounding reductionistic. Working in various settings in mental health for around 13 years, I have seen incredible hope bloom out of the desolate landscape of deep, dark depression. I have seen hope abound where there seems to be no hope. Personally, I have lost a friend, a neighbor, and a fellow college colleague to suicide over 15 years- and those are just the closest to me. There’s more. It’s so sad. But there is hope. How can I say this? I see it every day. None of us can ever fully control even our own best intentions for ourselves, let alone outcomes for others. Even as a counselor, I don’t have any more ultimate power to stop someone from committing suicide. Treatments that work for most are readily available. Treatment is often very effective. Sometimes several tries and different types of programming are needed. But you must take a step. Maybe it is to help, maybe it is to seek help. Things that don’t work:
Things that do work:
If you or someone you love struggles, please seek help! My industry’s entire focus is helping people. Please call 911 or go to the hospital if your life- or someone else’s- might be in danger. There is no shame in this. Reach out to a therapist who is experienced in treating your concerns. May you find hope for yourself or others- hope that runs deeper than the saddest and darkest moment. National Suicide Prevention Lifeline Call 1-800-273-8255 www.justinkhughes.com/resources Look under “Crisis” or find other helpful resources. Sincerely, Justin  Photo by Owen CL on Unsplash 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. ~Justin “I am an old man and have known a great many troubles, but most of them never happened.”  Photo by Leio McLaren on Unsplash “Security is mostly a superstition. It does not exist in nature, nor do the children of men as a whole experience it. Avoiding danger is no safer in the long run than outright exposure. Life is either a daring adventure, or nothing.” – Helen Keller
I don’t want to live my life being overly cautious, but rather appropriately cautious. We are discovering in the research of anxiety disorders, OCD, and now depressive disorders, that possessing an Intolerance of Uncertainty (IU) is a common construct linked with higher anxiety and life disruption. What is IU? My favorite definition: “Belief that uncertainty, newness, and change are intolerable because they are potentially dangerous” (Steketee et. al 2005, p. 125). IU links threat with uncertainty. But is uncertainty a threat? Take a moment and ponder one of your favorite memories. What did it involve? Was there any risk? Any vulnerability? Any chance of failure? Most of the best life stories I hear are of those that involve, well, all of these things. A person who cannot tolerate not knowing actually misses out. How? Isn’t knowledge power? What happens is this: the more control a person must have, the less control a person has. The more certainty that is sought, the more narrowly circumscribed life becomes. Quick examples:
Want to know how you handle uncertainty? Take the free IUS-12 assessment here. [Go to "Read More" below to find out how to score the assessment.] Let’s be clear: everyone is uncomfortable with some uncertainty. And reasonable protection from risks is part of being wise- which can also be subjective. But the more you necessitate that certainty must exist, the following is more likely to happen:
In the research on IU, there are also two subset strategies identified: Prospective anxiety (desire for predictability) and Inhibitory anxiety (uncertainty paralysis) (Fourtounas et. al 2016).
If you struggle with any of these, the next questions is this: How do I live with uncertainty and anxiety, while also taking suitable precautions? The solution is fairly straightforward, but not easy. Once a problem area has been identified (along with what is reasonable, normative, or within your values), gradually and consistently gain ground by pressing into your fear without using a false reassurance strategy that reinforces the false threat of uncertainty. In therapy, one of the most powerful tools that exists to deal with uncertainty is what we call Exposure and Response Prevention (ERP). This is the single most effective tool in treating OCD, and it is very valuable in other disorders. The reasons it usually has to be done in therapy are several:
I personally love Exposure because it helps me face life with a “bring-it-on” attitude rather than a “stumble-through-best-I-can.” ERP in therapy is very specific, very structured, and very powerful. However, even the person who is not in therapy can benefit from its principles:
“Some men storm imaginary Alps all their lives, and die in the foothills cursing difficulties which do not exist.” ~Edgar Watson Howe So what uncertainty are you not letting yourself live with? When is ‘not knowing’ unacceptable to you? Uncertainty is not the problem. It is unrealistic to be 100% certain about most everything in life. Life has few certificates of guarantee, and those are only as good as what is backing them. Ready to face your uncertainty? ~Justin Most people think I’m an extravert. They see me being sociable, laughing, communicating- and the consensus is, “There’s NO way you’re an introvert.” My friends have confused being outgoing with being extraverted. In fact, even in counseling, the average person I work with believes that extraverts are outgoing and communicative, introverts shy and introspective. And though this can apply, it is not actually the technical definition- nor the most helpful definition of what it means.
Simply put, think “Recharge” when thinking Introversion / Extraversion (I / E). I will spare you the extensive history of folks like Jung and the modern day Myers-Briggs test, and there are many wonderful resources available on our topic we are considering- so feel free to consult my friend, “Google,” for more on the topic. I have come to believe that, at least in terms of personality psychology, understanding and application of this domain is one of the most significant for personal success. I am an introvert. Most of my life I have tried to be an extravert. Most days now I accept how I function, but I still find myself expecting I will magically change this. I find myself around groups of people almost all day for several days in a row, and I wonder, “Why am I getting so edgy, tired, and experience a pressure to just want to go home and get away? I want to just be able to power through!” Ohhhh yes. That’s right. I’m a mid-level introvert. Many claim that our world rewards extraverts. Maybe that’s true. But I know that if you are an extravert, your success is not handed to you on a platter. In fact, some of the hallmark characteristics of the introvert include abilities that many with extraverted tendencies desperately want. The best way to think about I / E is, “How do I recharge? Where am I most focused (the external world or the internal world)? How do I get energy? In what capacity do I restore and recharge my batteries?” If your answer is a clear, “With people!” or “Alone!” you may have a more obvious answer. If it’s a mix of the two, you may be more in the middle, or an “ambivert.” (There’s testing you can do to figure this out better, such as the MBTI or five factor model testing (FFM)/”Big Five”) But the answer to this question is pivotal to how you approach life- and frankly, how you NEED to approach life. No one questions the merit in stopping to eat a meal or getting a good night’s rest. But, how easy it is to question the way our own body and mind gets its energy back! For me, I question myself usually because I want to be more “productive,” able to knock out more things to be “successful.” But getting more stuff done is not necessarily a good thing in many circumstances. When dealing with buried emotions with clients, I often say a phrase my supervisor taught me: “Emotions buried alive never die.” We therefore have to deal with these emotional “undead.” So it is with how we recharge. Our needs will eventually come up, and if we haven’t been nurturing them in a reasonable way, they will come up with a vengeance, ready to threaten burnout and exhaustion. One of the keys to the application of one’s recharge style is how to work within a system of an infinite number of variables, styles, and circumstances. Put another way, we must learn to function both independently and dependently in the system with which we find ourselves. Extraverts, you will need to find ways to connect with others, but have to be disciplined (and usually work harder) at resting and reflection. Introverts, you will need to find ways to be alone and collect your thoughts, but have to be disciplined (and usually work harder) to make sure you stay social. “Ambiverts,” well, you’ve got it all together. :) All joking aside, ambiverts will need to find ways to connect and be alone, but have to be disciplined to have a foundation that allows them not only to “go with the flow,” but to make choices for both ends of the spectrum rooted in their own convictions. My personal journey with I / E will always be evolving as life changes and I transition through different stages. It is nice, now, to not have to waste energy in being the “vert” I want to be and focus on living faithfully with the reality that is. ~Justin {And just for the record, my writing of this blog was 90% introversion, 10% feedback from others.}  You may have just gotten an activity tracker over the holidays, or maybe you’ve already jumped on the bandwagon of wearable tech. Not only do activity monitors like Fitbit, Apple Watch, and Spire track steps, heart rate, sleeping, and more, you can turn your tracker into an ally for mental health.
Here’s how. Being able to track and monitor your thoughts, mood, emotions, symptoms, and sensory experiences is arguably one of the central tenets of most schools of therapy. It is nowhere more prominent than in Cognitive Behavioral Therapy (CBT), where awareness of internal processes is a first step to changing outcomes. For years, techniques such as journaling and monitoring have been used, but this new technological age adds a few extra tools that can be a boon for awareness. But you also have to build the emotional intelligence and discipline to catch what’s going on and translate that into meaningful action. Following are some tips. (Remember that some people will have more stress by using a monitor- if so, practice these same tips without help from Mr. Fitbit).
Justin  In this season of rush....I hate to admit it. Mom and Dad, please don't laugh too hard when I say....this.... I sometimes miss being told what to do. There. I said it.
I remember the drill of childhood. "When did you last eat? Here, have some food." "Looks like you could use a hug." "You're getting cranky; it's time for a nap." In my super-mature “I'm-smarter-than-a-child” mentality, I miss some of the plainest truths in life. One of these is the importance of rest. It’s the weekend before Christmas, and all through my house are temptations to “achieve” and find my worth in what I do and the approval of others. I’m trying to step back and rest. And I often will remind myself, “I’m more efficient when I rest.” What’s funny about that statement is that I still am finding an excuse for resting. What would it be like if I stop running the show for a moment? Slowing down the crazy pace of life is not only a discipline, it is an act of faith- one that acknowledges that I don’t control all and know all. And I don’t have to carry the universe on my shoulders. That’s freeing. I hope you “achieve” some great rest during this time of the year. Merry Christmas and Happy Holidays!! Yours truly, Justin |
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Justin K. Hughes, MA, LPC
Owner, Dallas Counseling, PLLC
justin@dallascounseling.com
P: 469-490-2002
17330 Preston Road, Suite 102D
Dallas, TX 75252
Owner, Dallas Counseling, PLLC
justin@dallascounseling.com
P: 469-490-2002
17330 Preston Road, Suite 102D
Dallas, TX 75252
©2019 Dallas Counseling, PLLC
View our Privacy Policy here.
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