​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.  

• Checking
  • Physical items (stove, locks)
  • Internal sensations (heart, breathing, health)
  • Emotions (Did I feel like I expected to? Should I feel this way?)
  • Tasks (Homework, work emails, social media posts)
• Reassurance
  • Asking questions when you know the answer
  • Needing repetitive validation relationally
  • Checking with teacher/boss/clergy repeatedly
• Mental Rituals/Maneuvers
  • Distraction
  • Mental Review
  • Counting, Praying, Superstitious rituals
  • Rumination
• Safety Aids
  • Rescue medications
  • Only going somewhere with another person
  • Extra water, food
• Avoidance
  • Activities (trying something new, foods, news, tv shows, songs)
  • Bodily sensations (increased heart/breathing rate, exercise)
  • Emotions (anger, sadness, fear)
  • Memories (unpleasant, challenging)
  • Thoughts (intrusive, unwanted)
  • Places (being alone, crowded places, negative past experiences)

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:

1. Get educated on the process.  
2. Identify all safety behaviors.
3. Begin to strategically, often hierarchically (based on what you can tolerate at the moment), remove safety behaviors and engage in meaningful, valued and healthy actions and thought processes. 

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. 


​

References:
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 see a common phrase that goes around: “Feelings are not facts.”  While I agree with the inherent sentiments, it’s wrong.  Feelings are facts.  Your interpretation of feelings may not be factual.  

Actual feelings are factual insomuch as they reflect disparate and connected processes within the body and mind, occurring in real time.  They give you information.  Sensations and emotions link us in to a wealth of details.  Researchers have long struggled to pinpoint feelings exactly (this is one of the reasons why there are no definitive feelings charts/references and why therapists will list anywhere from 3 basic emotions and as many as 100 or more), and though neuroscience is helping us understand more what occurs biologically in the brain, the conclusion is far from definitive.  

Making this separation that feelings are facts may seem a bit pedantic- splitting hairs.  My first supervisor I ever had in my internship would tell me something along the lines of this: “Separating feelings from thoughts is foundational for emotional intelligence.”  Agreed.  And it’s just plain healthy.  CBT (Cognitive Behavioral Therapy) helps us get really good at being honest with the interaction between thoughts, feelings, and behaviors.  Problems with anxiety, depression, dissociation, psychosis, narcissism, and all of mental health at some level deals with how much a person is living in reality.  None of us are 100% or will be perfect at it.  However, we can grow.  Do our thoughts line up with the bigger picture?  Are thoughts and emotions congruent?  Do behaviors fit what we believe?  If I feel chest tightness, racing heart, or my stomach drop when I’m around another person, the conclusion is not necessarily that that person is bad or I need to get away.  Yes, sometimes that is the case.  I have also had these feelings around people I trust implicitly.  There are a number of factors that can lead to feelings- amount of sleep I got last night, hunger, and stress in general, to name a small few.

So when people say feelings are not facts, I understand what they’re saying and support the gist.  I think your mental health will thank you, though, if you appreciate that your body and brain is created to give you information- and that information is factual insomuch as it exists and is connected to you.  How you interpret the meaning may not be factual.  If you separate these two, you will better honor what your body and mind are telling you, while, if you pursue growth, you can learn to line up your life more congruently for your mental health and the wellbeing of those around you.  ​

America today sees one of the highest levels of anxiety of any place in the world.[1] We are clamoring for attention online, wanting to be seen, to be loved.  Suicides by teens and young adults appear to be higher than they’ve been in years.[2]  We are the wealthiest nation on the face of the planet,[3] and we can’t rest.  We have more than anyone else (as a whole), and we can’t stop.  Children who are now becoming adults are feeling this crushing weight of anxiety and expectation (whether on themselves or from outside)- ‘get the degree and the top job, get married, have the house, have children, don’t screw it up.’   And we know that anxiety has biological and genetic influences, but these are not 100% causal by any means.  Our response makes a difference.[4]

• “Like most individual characteristics, psychopathologic symptoms are determined by many factors. The individual family environment is a relatively weak predictor of neuroticism and other personality traits, with genetics explaining much more of the variance…. There are also strong cultural influences on psychiatric symptoms — that is, an environmental influence outside of the individual family. Over time, American culture has increasingly shifted toward an environment in which more and more young people experience poor mental health and psychopathology, possibly due to an increased focus on money, appearance, and status rather than on community and close relationships” (emphasis mine).[6]

Generalized Anxiety Disorder (or GAD, the disorder most connected to general worries) is more impairing in higher income countries.[6]  The occurrence of GAD (lifetime prevalence) boiled down to:

• Countries with the following incomes:
• Low:        1.6%
• Middle:        2.8%
• High [U.S.]:    5.0% 

This is different from OCD, for instance, which sees about a 1-2% worldwide occurrence and doesn’t seem to vary a whole lot from country to country.  Depression seems to occur fairly consistently across the world, as well.  

I think the ultimate answer lies in Christ.  Hebrews 4:9 says, “...there remains a Sabbath rest for the people of God.”  Matthew 11:30: “My yoke is easy and my burden is light.”  

*Insert deep relaxing breath.
  
God ordained rest from the beginning of creation.  Genesis 2:2-3: says, “And on the seventh day God finished his work that he had done, and he rested on the seventh day from all his work that he had done. So God blessed the seventh day and made it holy, because on it God rested from all his work that he had done in creation.”  God purposed rest for us, his creation.  God wasn’t winded and saying, “Oh boy, that creating sure made me tired...let me sit back and take it easy.”  We know he created it for us.  Jesus states, “The Sabbath was made for man, not man for the Sabbath” (Mark 2:27).  If we back up to the institution of the Sabbath given as law to the Israelites, in Deuteronomy 5:15 we are given a reason why God so seriously wanted His people to be obedient in this: “remember that you were a slave….and the Lord your God brought you out…”  So to pause and rest is to say, GOD is my provider, and my striving only results in results because of God (Seriously, check out these passages: Deuteronomy 2:7; 1 Chronicles 29:12; Psalms 23 and 147:8; Matthew 6:25-33; Philippians 4:19).

Observationally, we don’t have to look far to understand our need for regenerative rest.  Sleep is one of the greatest things we can “do” for our well being.[7]  Our bodies need one third of our day just to be restored.  ⅓!!  Living to 75 that’s 25 years of our life spent sleeping!  When we try to cheat this, various problems ensue.  And by the way, the U.S. has a tremendous problem with sleep, as well.[8]  It’s hard to even grasp the scope of this due to the myriad ways people attempt to rest that may not be directly researched or studied in any one experiment (sleep aids, watching media, abusing substances- including over-the-counter cough syrup and benadryl).

The Doctor Who episode “Sleep No More” features the attempt to cheat sleep and maximize productivity.  Scientists discover a device (“Morpheus”) that takes only a few minutes to compress a month of sleep.  Serious problems ensue (enter evil “Sandmen” into the equation, for any of you Doctor Who nerds).  Sleep and rest are common themes in literature and life.  No doubt, they play a substantial role in our well-being- or downfall. 

Though therapy is highly efficacious in addressing disorders specifically and often helpful for much personal growth, it is not set up to be a worldview (a personal understanding or philosophy of the world)- it was never meant to be!  Therapy is the clinical application resulting from theories and science on human thought and behavior, just like medical practitioners study from a particular perspective and approach (“Western”, naturopathic, Traditional/Chinese, etc.).  Psychology cannot be an entire worldview, by definition, because it’s only one subset of study, research, observation, and experience.

Back to Jesus: “Come to me, all who labor and are heavy laden, and I will give you rest.” (Matthew 11:28). 

Are you tired of striving in your own strength?  Jesus speaks to the question of trying to be good enough. The Bible presents a very large pill to swallow that is offensive to our Western, pluralistic and politically correct sensibilities: your striving is empty without God.  BUT, here is the hope, and this is the Gospel: being made right with the God of the universe through Christ, we have peace. We have freedom. We have hope. We have purpose. We are forgiven.  We are loved.

• “Therefore, since we have been justified by faith, we have peace with God through our Lord Jesus Christ” (Rom 5:1).
• “Thou hast made us for thyself, O Lord, and our heart is restless until it finds its rest in thee” (St. Augustine of Hippo).
• “Unless the Lord builds the house, those who build it labor in vain.  Unless the Lord watches over the city, the watchman stays awake in vain.  It is in vain that you rise up early and go late to rest, eating the bread of anxious toil; for he gives to his beloved sleep” (Psalm 127:1-2).
• “Cease striving and know that I am God” (Psalm 46:10a).

From the poorest and most overlooked member in the slums of Calcutta to the Billionaire on 57th Street in NYC: You are loved. You are valuable. Striving and anxious pursuits are nothing without God- let us seek his rest.

References:
[1] Newman, T. (n.d.). Is anxiety increasing in the United States? Retrieved October 07, 2020, from https://www.medicalnewstoday.com/articles/322877.  “When they compare the levels of depression, no single area has significantly higher rates. When it comes to anxiety disorders, however, it’s a different story; the Americas are head and shoulders above all other regions, including Africa and Europe.”
[2] 

• ​Oren Miron, M. (2019, June 18). Suicide Rates in Adolescents and Young Adults, 2000 to 2017. Retrieved October 07, 2020, from https://jamanetwork.com/journals/jama/fullarticle/2735809
• Santhanam, L. (2019, October 18). Youth suicide rates are on the rise in the U.S. Retrieved October 07, 2020, from https://www.pbs.org/newshour/health/youth-suicide-rates-are-on-the-rise-in-the-u-s
• https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_09-508.pdf
• https://www.cdc.gov/nchs/data/databriefs/db352-h.pdf

[3] Silver, C. (2020, September 18). The Top 20 Economies in the World. Retrieved October 07, 2020, from https://www.investopedia.com/insights/worlds-top-economies/
[4] This is not to shame you.  You may have a legit challenge with anxiety due to disorder- if so, I’m sorry!  You may have tried seemingly everything to feel better and it just hangs around.  Keep reading, if this is you, because the post still applies, it’s just that I want you to know that you may have it harder than others, and you may need treatment.  Truly, this world is not fair.  But stay with me; there’s hope.
[5] http://www-personal.umich.edu/~daneis/symposium/2012/readings/Twenge2010.pdf
[6] The disorder is significantly more prevalent and impairing in high-income countries than in low- or middle-income countries.
[7] Walker, M. P. (2018). Why we sleep: The new science of sleep and dreams. London, UK: Penguin Books.
[8] CDC - Data and Statistics - Sleep and Sleep Disorders. (2017, May 02). Retrieved October 07, 2020, from https://www.cdc.gov/sleep/data_statistics.html
All Scripture quotations are ESV.  

“You want me to do what?!”  Many of my clients, and particularly for the sake of this article, Christian clients, are a bit surprised when I ask them to practice exposure.  Repeating scary, terrible thoughts on paper or aloud.  Doing things that feel risky.  It seems as a clinician I’m disrespecting your beliefs and don’t really get it.  Maybe I’m asking you to do something unbiblical, blasphemous, against what God would want.  But what if I do understand and am helping you live in line with your beliefs?  What if exposure is a powerful tool under God’s grace (Matthew 5:45) to help you get over a disorder?

The Great Hesitation.  When some clients start their treatment with me, I come across familiar hesitations when we begin discussing Exposure Therapy and facing one’s fears:

• What if I really am at risk of doing this thing I fear?  Won’t exposure make it worse?
• Are you asking me to do something that could go counter to my faith?
• Don’t I need to avoid this thing rather than giving it more credit?
• Isn’t this a spiritual problem?  Shouldn’t I pray more about this?
• Isn’t this Satan telling me lies?  
• If I have “bad thoughts” (thoughts of harming someone, making someone or myself sick, perverted sexual thoughts), shouldn’t I be on guard?  Flee temptation?  

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:

• “I’ll be responsible for my child’s death.”
• “I’ve picked the wrong person to be with.”
• “Maybe that bump I heard in my car was a person.  Should I check to see if they’re okay?”
• “Was I just attracted to a dog?  Did I just get turned on?”
• “I must not believe in God because I feel numb when I say His name.”
• “What if I just get up and run into oncoming traffic?”

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:

• If you have ever thought someone nefarious was following you, you might have felt fear, suspicion, anger.  
• If a child cries after something you say, you might would feel sadness, regret, or shame.  
• When you say something socially that is a ‘miss,’ you might think you’ve totally embarrassed yourself.

When is a time you felt something strongly that turned out to be fine?  

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: 

• If you repeatedly fear you might say something wrong and avoid talking in social settings, in time others may actually start to avoid you or stop talking to you altogether since they can’t have a conversation with someone who won’t engage them!  
• Overwashing and cleaning the body leads to less resistance to germs, increased cuts and open skin with greater risks of various health problems.  
• Spiritually, a person who compulsively prays that they will be kept safe will be over-focused on small details (saying a certain thing a certain way, fearfully repeating the same thing, or maybe focused on only a narrow scope of safety like driving, contamination, or health).  This will lead to loss of seeing the bigger picture.  

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).

 

An editor for the American Counseling Association reached out to me about OCD from a Specialists' perspective.  (I was so proud of them for doing their research with multiple specialists!!). The following are excellent questions that may help inform their ACA magazine article in February 2020.  Whether they utilize any of these or not, I hope they are helpful for you as they cover important questions to consider with regard to treatment.  



"What presenting issues might bring these clients into counseling?" 

• Intrusive thoughts!  Many of my clients initially seek out counseling because they have been plagued by intrusive, unwanted thoughts.  They wonder what this says about them, even though there is often some sense of it being senseless and out-of-context (we call it ego-dystonic).  
• "Tipping point" behaviors- people start to notice problems in routines that begin taking too long, physical  pain caused from washing, mental stress from extensive rituals (needing to "feel" a certain way, pray a certain way, walk through doorways multiple times, pick 7th item at the grocery store, and so on).
• Family, friends, and spouses are a great source of support (and pressure, at times), which can help lead to a client first coming for a session.  Some of my clients (more often than not, in the pediatric population) have low motivation for themselves, and it is a concerned loved one who (hopefully lovingly, sometimes not) asks them to seek treatment.

"What are some “red flags” for counselors to listen for that might indicate OCD in a client who came in for something else (anxiety, ADHD, etc.)?"
If a counselor begins hearing the exact same things, worded or behaved in similar ways, this is a good indicator to watch out for.  Many of my clients are good at exactly quoting themselves on what they've said before.  Obsessions are repetitions on a theme; if you get good at catching the theme, you can usually spot an obsession miles away.

At its core, it's not remarkably difficult to identify criteria in OCD (in most straightforward cases) if a counselor brushes up on what they're looking for (dust off that DSM-5!). 

Furthermore, if a client isn't improving from certain methods (especially things like Cognitive Restructuring in CBT), this is "Getting Stuck 101" and needs further assessment.  Most of my clients have had prior experience with a counselor who had no idea how to treat OCD from an evidence based way and approached the same as regular old automatic negative thoughts. This is not typically helpful. 

"What counseling methods/techniques can be helpful when working with clients with obsessive behavior and/or OCD? Please explain how this/these method(s) work well for this client population. If possible, please talk about a case example (without identifying information) who worked with you and showed improvement. What were his/her presenting issues, what methods did you use and what issues did you focus on in counseling sessions?"
Exposure and Response Prevention (ERP) is the GOLD standard treatment (which is a very specific subset of CBT).  It is indicated as the starting point for all OCD treatment.  This is a strong statement, but it is backed by the research (the most RCTs by far) and organizations like the IOCDF, APA, and so forth.  SSRI (and Clomipramine, a TCA) medications are also first-line psychopharmacological treatments, though with less effect on average than ERP.  Both combined can be helpful, though may not necessarily increase the overall benefit of just ERP alone. Another first-line treatment for OCD (though not the "gold standard") is Cognitive Therapy with Behavioral Experiments.  Along with medications, it is seen as sometimes a more agreeable option for those who are hesitant to engage in exposure therapy (which intentionally and repeatedly provokes distress in order to respond differently- i.e., without compulsions).

Adjunct therapies, medications, and treatments are utilized.  In the interest of brevity, research has discovered the integration of Acceptance and Commitment Therapy (ACT), Motivational Interviewing (MI), and other techniques can be helpful to provide well-rounded treatment and/or facilitate the practice of ERP.

To share a classic example [identifying factors changed to protect confidentiality- this type of case is remarkably common], one woman came to me with severely distressing thoughts about harming her children (no history of harm or abuse).  She knew it was irrational, yet it felt so real to her; the more these intrusive thoughts continued to appear, the more difficult it was for her to determine her intent from confusing feelings and "impulses" to stab her kids.  Upon receiving a diagnosis of OCD, I thoroughly assessed history with symptoms, and educated on the CBT model for understanding OCD treatment with a rationale for CBT and ERP. We discussed medication options, to which the client was willing to pursue with their Psychiatrist.  The client was very cooperative due to a high willingness and intrinsic motivation to be able to engage at home with her two children and spouse. As can be very typical, the stress also took a toll on most every area of life, making work difficult. Once we began ERP, we started with doable exposures while learning how to stay present with triggers and distress- without compulsing.  Upon successful practice of more manageable triggers on their hierarchy, they- with the incredible support of their spouse and church and loved ones- made a jump in their exposure work that began with "scripts" (imaginal exposure stating/writing distressing thoughts and quickly progressed to holding knives and stating these feared thoughts aloud) and transitioned to  practices situationally at home, holding knives and saying scripts aloud (in separate rooms appropriately not in front of their young children).  The incredible support around this client, along with a sense of strong purpose, helped facilitate (this is part of ACT) the integration of ERP into daily life. They would be considered recovered at this point, scoring so low on the Y-BOCS (gold-standard assessment in rating severity) that their symptoms are sub-clinical. In relapse prevention planning, they understand the chronic nature of OCD and the necessity of staying on top of their good progress, with the plan to follow-up at occasional intervals for "booster sessions."  I gain so much joy from stories like these.


"People with an OCD diagnosis may be taking medication and seeing other professionals (psychiatrists, psychologists). How could a counselor work in tandem with these other professionals? Please include a case example, if possible."
Coordinating care can be difficult, but worth it for the best client care!  Although seamless communication and record exchange between providers is likely ideal, it just rarely happens in real life.  Working within the space and limits that exist, I have found that outside of those very few therapists and Psychiatrists I can have near immediate communication with, it is still very helpful and feasible to at least request/give one way communication to a provider.  In complex cases, it is almost unheard of for me to not outreach another provider that is connected somehow to shared treatment concerns. I think we need to be realistic about other providers' schedules and communicate what we can- how we can. This often looks like me leaving a Psychiatrist a voicemail after release is given- and not hearing back- but at least they have the information. It may be coordinating with another therapist who is treating other concerns. Early on, I used to welcome other counselors working at the same time on separate diagnostic concerns. Though I may work with someone now who is seeing another professional for something like, say, Depression, it is usually quite imperative that I make known to the patient and also the other provider the pitfalls of feeding compulsions through reassurance, ruminating, and so forth. This is a great opportunity for education of those who are not specialists in OCD.  But OCD being as debilitating as it is (2 out of 3 people experience severe impairment at some point in their life), I need to work hard upfront to educate especially the patient about how hard they will need to work (and not undermine) their exposure therapy. Also, many other comorbidities can often improve significantly just by treating the OCD first.  

"How, particularly, are counselors a “good fit” for helping clients with obsessive behaviors? How can they help people with OCD differently than a psychologist would?"
It has been my personal experience that my colleagues who are counselors (Master's level, typically), bring to the table incredible creativity and "outside the box" thinking.  Many of the hands-on resources, videos, blogs, and social media that exist to help the sufferer of OCD often come from Master's level clinicians. I believe there is great flexibility many of my counselor colleagues have (which is a positive and a weakness all at the same time, sometimes lacking the rigors of adhering to the evidence based treatment protocols).

There are actually quite a few more Master's level clinicians than Psychologists, and there is a great need for more clinicians offering great treatment.  Counselors can help fill this gap.

"As a practitioner who specializes in working with OCD, is there anything else you would want counselors who don’t specialize in this area to know?"
For many reasons, I love work with clients who have OCD.  I have found they are some of the kindest, hardest working, conscientious individuals on this planet.  This is where I believe many of their personality strengths arise once moving through pathology. It is a joy every day to see recovery, growth, and maturity bloom out of suffering.

"Any main take-aways to share?"
OCD Treatment can be so rewarding! It has very effective treatments for most, very clear evidence, incredible improvement that can be witnessed in a short period of time, and there are wonderful opportunities to get invested in this world with a community of professionals, sufferers, and supporters who are incredible. 

Sincerely,
~Justin K. Hughes

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

$1.6 Billion.  That's 1,600 x 1 MILLION Dollars.  For the person who won roughly that amount in South Carolina (and the rest of us):

Would it surprise you that your emotional well-being really doesn't improve by becoming wealthy?  There’s been a host of research in recent years that look into happiness and money.  Possibly the most commonly known one is the National Academy of Sciences study on well-being and money.
This study’s now famous $75,000 mark suggests that a person’s emotional well being (how they feel day-to-day) AND their evaluation of life (their overall perspective of how they are doing) improves up to the point of earning $75k per HOUSEHOLD in the United States.  Beyond this mark, emotional well-being doesn't significantly improve, though a person will evaluate their life as better if they earn beyond this mark.  To quote their findings, “We conclude that high income buys life satisfaction but not happiness, and that low income is associated both with low life evaluation and low emotional well-being” (Kahneman, et al. 2010).

So what do "happy money" spenders do?  Research by Elizabeth Dunn and Michael Norton in Happy Money: The Science of Happier Spending (2014) reveals how money is spent makes the crucial difference in happiness.

1. Buy Experiences.
   • Connect with people; target experiences over stuff.
2. Make It A Treat.
   • Making something special and novel increases its enjoyment.
3. Buy Time.
   • Make time to slow down and pursue what's valuable to you.
4. Pay Now, Consume Later.
   • First, don't consume with money you don't have.  Second, enjoy at a later point- anticipate.
5. Invest In Others.
   • An incredible thing happens when we give: happiness.  "It is more blessed to give than to receive" (Acts 20:35, The Bible, ESV).

Are you making the most of what you have?  Are you caught up in materialism and consumerism?  Today is always a great day to do something different.  

Yours Truly,
Justin K. Hughes, MA, LPC