One of the benefits of having treatment with someone who specializes in the treatment of people with anxiety and related disorders is their familiarity with evidence-based treatment protocols.
Even when a therapist follows protocols, everyone has differences that can interfere with treatment, and therefore addressing those obstacles is critical. The core of my treatment is Cognitive Behavior Therapy and Exposure and Response Prevention. When appropriate, incorporating other evidence-based treatments can be beneficial in providing patients with the highest quality of care and the best opportunity for success.
Sometimes people ask how multiple fears or OCD themes can be treated simultaneously. A huge benefit to CBT and ERP are that they generalize, meaning the treatment is essentially the same regardless of the content.
This means that treatment is not teaching patients that 1 + 1 = 2, it’s about teaching addition. If you only know 1 + 1 = 2 then that is the only problem you can ever solve. But if you know addition, you learn the formula, and no matter what numbers are throw at you, you know how to handle it. This means that once patients understand how anxiety is treated, any fear or theme can be addressed, as the person already has the nessesary tools.
Cognitive Behavioral Therapy (CBT) – Over the past couple of decades, CBT has become a buzz term in the psychology world. This is due in part to the extensive evidence that shows its effectiveness in treating an array of psychological issues, as well as its estimated length of time before its effects kick in. CBT focuses on the relationship between thoughts, emotions, and behaviors. Research has shown that all three of these factors are directly related to one another. Intervening either at the cognitive and/or behavioral will in effect alter the other two components. Because emotions cannot be directly changed, to effect a change in emotions, a person needs to alter their thinking and behaviors. This is the primary way to treat anxiety and related disorders, as research has shown it to be most effective and long-lasting. More information about CBT is available from the Association for Behavioral and Cognitive Therapies.
Exposure and Response Prevention (ERP) – A CBT technique that research has shown to be effective and is the gold-standard in the treatment of anxiety, OCD and related disorders. This technique involves exposure to a distressing trigger without engaging in any rituals. Through ERP, two changes occur: habituation and inhibitory learning. Habituation is the brain and body’s natural decrease in distress without engaging in rituals. The body learns that rituals aren’t needed for the distress to decrease, and as habituation continues, there is more long-term relief than the short-term relief achieved by rituals. The second change is inhibitory learning, or new safety learning. Because we can’t unlearn something, we want to provide additional information and experiences so that the initial response changes over time. Through inhibitory learning, a person understands that although a trigger may be distressing, it’s most likely not going to occur, and if it does, it likely will be less catastrophic than feared. More information about ERP is available from the International OCD Foundation.
Mindfulness – There are many misconceptions about mindfulness, mainly that it’s about relaxation, requires significant training, and can only be done at certain times or in specific situations. The two core principles of mindfulness are about being present and non-judgemental. The goal in being present is to get out of your head and into your body and increase your awareness of what’s going on around you. If’ you’re focused on the thoughts in your head, you’re not listening to what the people standing right in front of you are saying, which can lead to missing out on there here and now, and the living part of your life. The aim of the non-judgemental component of mindfulness is recognizing something for what it is. That means a food might be salty or bitter, but that’s more accurate and clear than saying it’s “bad,” as that thought is formed again in your mind and not in the present. Mindfulness aides in distress tolerance as well as enjoyment of your current life. More information about mindfulness is available from Anxiety.org.
Acceptance and Commitment Therapy (pronounced ACT, not A-C-T) – ACT is form of CBT that incorporates acceptance, mindfulness, and behavior-changing strategies in order to heighten psychological flexibility in an effort to be present and engaged in life with the goal of living life in the service of an individual’s life goals and values rather than in the service of symptom reduction and managing anxiety. More information about ACT is available from the International OCD Foundation.
Dialectical Behavior Therapy (DBT) – A modified form of CBT, DBT focuses on emotion regulation and distress tolerance, and aims to increase a person’s emotional and cognitive regulation by learning about triggers that lead to reactive behaviors. Although not developed specifically for people with anxiety and related disorders, DBT skills can be beneficial in addressing behaviors that may be inferring with the successfulness of treatment. More information about DBT is available from Marsha Linehan, PhD, ABPP, the developer of DBT.
Habit Reversal – The go-to treatment for Body-Focused Repetitive Behaviors (BFRBs) as well as tic disorders has been habit reversal. This technique is about doing a behavior that is a competing response for the undesirable behavior or tic. For example, if a person pulls their hair when watching TV, we want to find something else to occupy that hand, as they will no longer be able to pull if their hand is occupied. Examples might include using a fidget toy or sitting on their hands. Similarly for tics, the behavior doesn’t allow for the person to engage in the tic. More information about Habit Reversal is available from the Child Mind Institute.
A Comprehensive Model for Behavioral Treatment (ComB) of Trichotillomania – The more recent treatment for BFRBs comes from finding that for some people, habit reversal is not enough. With ComB, we have patients track their behaviors, identifying what’s going on in five areas: sensory, cognitive, affect, motoric, and place. These components allow us to add in interventions to reduce the likelihood of someone engaging in BFRBs, more than just behaviorally. More information about ComB is available from The TLC Foundation for Body-Focused Repetitive Behaviors.
Cognitive Behavioral Intervention for Tics (CBIT) – CBIT is a newer model of treatment for tic disorders. This treatment consists of three steps. We first need to raise the individual’s awareness of their urges to tic, as well as the tics themselves. Next, we identify competing behaviors, or behaviors that make it difficult or impossible to tic. Examples can include putting your tongue on the roof of your mouth to prevent a vocal tics, or stiffening one’s neck to stop from rolling. The key to effective competing responses is not only to prevent the tic, but to be less noticeable than the tic. Once we determine effective competing responses for someone, we implement change to their daily routines to help reduce tics. More information about CBIT is available from the Tourette Association of America.
Harm Reduction – The concept of harm reduction comes from substance use treatment, and in the anxiety & OCD worlds is primarily used in the treatment of Hoarding Disorder. The idea behind harm reduction is that if a person is unable or unwilling to eliminate a dangerous behavior, we want to reduce the risk of harm. In treating Hoarding Disorder this includes clearing pathways in a home and ensuring that if there was an emergency such as a fire, the person could safely escape. The concept can also be applied to other disorders as a stepping stone in treatment. If a person is washing their hands with bleach and isn’t ready to stop, we might consider a different and safer cleaner in the interim, because even though the goal is routine hand-washing with soap, the jump for many is too great to make all at once. The goal of harm reduction is just that, taking steps to help make patients safe as they make progress in treatment. More information about Harm Reduction is available from the San Francisco Bay Area Center for Cognitive Therapy.