Anger and OCD – Getting Mad…

Posted by in ACT, CBT, General, Harm-Related Symptoms, Obsessive-compulsive disorder (OCD), OCD “I hate having OCD! Why can’t these thoughts just stop?!?! How can I be the person I was before?!?!” Many people with OCD are extremely familiar with the anxiety-related aspects of the disorder. OCD is an anxiety disorder after all, so it’s not terribly surprising that anxiety is often core to its experience. But anxiety is certainly not the only emotion that shows up in OCD. I’ve discussed briefly how some people with OCD have symptoms of guilt, shame, disgust, and depression, and how treatment may sometimes need to be modified when these emotions are primary aspects of the disorder. Today, though, I’d like to comment briefly on anger and OCD, which I don’t think I’ve mentioned explicitly in previous posts. Anger can be a powerful force in many people’s OCD. What’s the relationship between anger and OCD? Actually, the relationship between OCD and anger is complex, in that it’s mediated by obsessions, compulsions, or even reactions to developing the disorder. Anger and OCD: Anger as a Trigger for Obsessions Anger is sometimes entwined with anxiety and contributes directly to some types of Pure-O OCD. For example, anger can be a trigger for some people who have harm OCD (e.g., What if getting mad means that I’m capable of harming my family members?). Individuals with violent OCD obsessions may fear becoming angry, because they may fear that it will lead to them “snapping” or losing control. Anger is also sometimes present for those who have OCD with suicide obsessions. For example, “If I feel that I hate my life or am angry with myself, that might mean that I’ll end my own life.” In this context, anger also signals danger and is linked to fear. OCD and Anger: Examples of Anger Triggering OCD Obsessions I felt really mad at my parents, and then I almost felt like I wanted to hurt them. Does that mean I’m a dangerous person? I was arguing with my mom, and I felt an urge to punch her in the face, and I think I actually wanted to. What does that mean? I felt really mad and frustrated at my children, and I wanted to lash out at them. Does that mean that I could actually physically hurt them? I yelled at my kids, and I KNOW I enjoyed it. How messed up is that? Does that mean I really want to hurt them?...
read more

ERP Tip of the Day #2

Posted by in “Pure-O” Symptoms, CBT, Checking-Related Symptoms, Contamination/Health-Related Symptoms, ERP, ERP Tips, Harm-Related Symptoms, Obsessive-compulsive disorder (OCD), OCD, OCD - Treatment, Sexual Symptoms It’s ERP tip time. This series of posts focuses on tips to enhance the effectiveness of your exposure and response prevention (ERP). If you’re interested in more ERP tips, click the following link for all the posts in this series. Exposure and Response Prevention (ERP) Tips for OCD Without further ado, here’s another ERP tip to consider when designing your next exposure. ERP Tip #2 When completing your next exposure, avoid rules that dictate what you’re allowed to think during the exposure. If you try to complete an exposure without having a certain bad thought, chances are that you’re setting yourself up to think that very thought. Instead, design your exposure around having that very same unwanted thought. I love it when people with OCD do exposure, but I don’t love it when they have a long list of impossible preconditions that dictate the form of their OCD exposure. The most glaring example of this is when people dictate the thoughts that they should have during exposure. OCD ERP Tip Don’ts What I don’t like: I’m going to touch that doorknob, but I really hope that it’s not wet or slimy. When it’s wet or slimy, it makes me think that it has blood on it, and that I might really be contracting AIDS. I really don’t want to die, so I’m okay with touching that doorknob, just as long as it’s dry as a bone, so that it doesn’t freak me out. What I don’t like: I’m willing to walk across that mystery spot in the parking lot, just as long as it doesn’t look at all red or brown or sticky or possibly organic in some form or another. If it looks that way, it really freaks me out and then it makes me think that I’m tracking AIDS blood everywhere. What I don’t like: I’m willing to look at pictures of kids, just as long as I don’t have sensations in my groin. When I have those sensations, it really freaks me out and I think there may actually be something wrong with me. What I don’t like: I’m okay with holding my baby, just as long as I don’t think about throwing him down the stairs, snapping his neck, or doing something inappropriate to him. If those violent OCD thoughts show up, I’ll be really freaked out, and I won’t be able to handle it....
read more

ERP Tip of the Day #1

Posted by in “Pure-O” Symptoms, CBT, Checking-Related Symptoms, ERP, ERP Tips, Harm-Related Symptoms, Obsessive-compulsive disorder (OCD), OCD, OCD - Treatment, Sexual Symptoms Starting today, I am going to start posting random ERP tips as they occur to me, as there are certain roadblocks that many of my OCD patients tend to encounter. If it’s helpful for my patients, maybe it’s helpful for you. If you’re interested in more ERP tips, click the following link for all the posts in this series. Exposure and Response Prevention (ERP) Tips for OCD These posts will probably be a bit shorter unless the concept requires a more thorough discussion. Please feel free to leave comments below, if you need more information. Today’s tip is… ERP Tip #1 Do not label your rituals as ERP. Instead embrace openness, defenselessness, and vulnerability. You might think that you never do this, but it happens more often than you think. Some people that I know will encounter triggers for their OCD in a normal, everyday situation. In the past, they might have avoided this trigger by closing their eyes or walking away. However, now that they’re trying to practice non-avoidance and deal effectively with their OCD, they may force themselves to look directly at their trigger. So far so good, right? No rituals in sight yet, but… BAM! They find themselves staring intently at the trigger as a way to internally check their physical or emotional response to it. I see this happen commonly with sexual obsessions (particularly people with pedophile OCD [POCD] and sexual orientation OCD [sometimes called HOCD]) and violent obsessions, but it can occur for virtually any type of OCD. For example, someone with pedophile OCD may be looking at the trigger while intently monitoring their groinal response to the child they see. If they don’t notice arousal sensations, they pat themselves on the back. They think they’re doing exposure by looking, but they are actually performing a reassurance-based checking ritual. These rituals make you feel good in the moment, but they further link the perception of a trigger with the mental ritual of checking (and consequent reassurance), which ultimately perpetuates the OCD cycle. The better alternative is to look at the trigger, feel whatever you feel, try to resist internal checks…but if you do check, SPOIL THE RITUAL! Remind yourself purposefully that it’s possible you might still be attracted to children. Why would I suggest such a thing? Because OCD is smart. The good feeling that comes from reassurance is transient. If you reassure yourself,...
read more

Imaginal Exposure vs. In Vivo Exposure for OCD

Posted by in “Pure-O” Symptoms, CBT, Checking-Related Symptoms, Contamination/Health-Related Symptoms, ERP, Harm-Related Symptoms, Obsessive-compulsive disorder (OCD), OCD, OCD - Treatment, Sexual Symptoms As I’ve talked about in numerous posts, overcoming OCD involves learning to co-exist with doubt and uncertainty. This idea can be a bit counter-intuitive at first, as many people initially expect OCD treatment to reduce uncertainty. One therapeutic approach that helps with this process is exposure and response prevention (ERP) for OCD. Not surprisingly, ERP consists of two parts: 1) exposure, and 2) response prevention. An exposure is when you do something on purpose to provoke an anxiety spike. By definition, exposures are not accidental; rather, they are pre-planned, deliberate offensive strikes against your OCD. Exposures are designed to help you build up your tolerance to fear-producing situations. Exposures are often completed according to an exposure hierarchy, meaning that people typically complete lower level exposures (i.e., less distressing exposures) before gradually working up to higher level ones. Response prevention refers to the idea that after the exposure, you will allow your anxiety to naturally decrease on its own without artificially forcing it to decrease prematurely through rituals. Response prevention is most effective when one resists ALL rituals, including both behavioral and mental rituals. Behavioral rituals may include things like washing, checking, or rearranging; whereas mental rituals may include self-reassurance, thinking “safe thoughts”, praying, or mental review. Avoidance is also considered a ritual. Exposures come in two forms: in vivo exposure and imaginal exposure (also referred to as “scripting“). In Vivo Exposure for OCD When we think about exposure therapy for OCD, we often think first about in vivo exposure. In vivo ERPs involve directly exposing yourself to feared situations in real-life. For example, a person with contamination OCD might develop a hierarchy of in vivo exposures that involve purposefully touching “dirty things” like doorknobs, light switches, trashcans, animals, or even toilets. The goal of these in vivo exposures is to face the fear directly without ritualizing. This means that after touching these contaminated objects, the person would refrain from washing their hands, using hand sanitizer, getting reassurance, mentally reviewing reasons why it’s okay to not wash, or doing anything else to neutralize the perceived danger of the situation. Likewise, someone with harm OCD might develop a hierarchy based on putting themselves in feared situations. These feared situations should evoke the fear directly or present opportunities for the person to act on the fear. For example, someone who is afraid of stabbing their spouse might expose themselves to situations such...
read more

Common Misconceptions About Anxiety & OCD Treatment

Posted by in ACT, Anxiety, CBT, ERP, Mindfulness, Obsessive-compulsive disorder (OCD), OCD, OCD - General, OCD - Treatment, Treatments People new to OCD treatment often walk through the door with more than a few misconceptions. Here are some common ones: Misconception 1: Anxiety is bad. Actually, anxiety is a normal, functional, biologically-based phenomenon that every person is capable of experiencing. The only people who are truly anxiety-free are dead people. The rest of us (the living ones, at least) will find that anxiety will be a part of our lives, at least to some extent. Some anxiety is good and can be helpful. For example, it’s probably good to have some anxiety when you’re studying for a test. This anxiety can help motivate you to prepare sufficiently. Similarly, it’s probably good to have some anxiety about doing dangerous things, such as driving too fast — this anxiety might just save your life. Of course, not all anxiety is good or functional. Some anxiety spikes occur for no good reason and don’t have an upside. These false alarms make us feel bad for no good reason. Panic disorder is the perfect example of this. In panic disorder, your fight-or-flight system gets continually reactivated in situations where it isn’t warranted. Treatment of panic disorder involves learning to disregard the danger messages attached to your panic symptoms. The goal of OCD treatment (or the treatment of any anxiety disorder, for that matter) is not to eliminate anxiety, but rather to recalibrate your anxiety system so that there are fewer false alarms, and anxiety is again serving a useful purpose. When you finish OCD treatment, you’ll still have anxiety. It just won’t be standing in your way like it is now. Misconception 2: Avoidance is an effective solution for anxiety. There is no denying that avoidance is an effective solution for reducing anxiety. However, the anxiety-reducing effects of avoidance are short-lived and come at a great cost. Reliance on avoidance as a coping strategy may reduce your anxiety in the short-term, but it dramatically increases anxiety over the long-term. If avoidance is left unchecked, anxiety often grows to a point where it becomes debilitating and interferes with our functioning. Why does this happen? In essence, avoidance brainwashes us to believe that if we didn’t avoid, the worst would have happened. Let’s examine this in relation to a common contamination OCD thought: “Germs are everywhere. If I don’t touch the dirty doorknob, then I won’t get sick.” Avoidance of the doorknob prevents anxiety...
read more

Teen Social Anxiety Group (Cognitive Behavioral Therapy/Group Therapy)

Posted by in CBT, Group Therapy, Social Anxiety Teens with social anxiety unite! In this paid treatment group, teens will support each other in developing cognitive behavioral skills to combat social anxiety. This workshop will be interactive and fun. Note: If you are an adult with social anxiety, there’s a group for you coming soon! If you’re interested, please call our office or reply to this email so that we can better gauge demand for an adult social anxiety group. With the new school year quickly approaching, there is no better time to work on tackling your social anxiety. The intent of this group is to provide a supportive environment for developing cognitive behavioral skills and completing exposures. Because social anxiety can co-occur with other types of anxiety, you do not need a social anxiety diagnosis to benefit from this group. In some cases, this group may also be helpful for individuals with obsessive compulsive disorder (OCD), body dysmorphic disorder (BDD), panic, agoraphobia, and others who may be self-conscious or concerned what others may think of them. This group will meet on Saturday (8/17/13), 11am-1pm. The fee for attending this group is $100. Insurance will not be accepted; however, if you have out-of-network benefits, you may be eligible to submit your bill for reimbursement by your insurance company. Subsequent 2-hour sessions may be held based on interest and/or may be held in conjunction with an adult social anxiety group. Participants MUST BE APPROVED BY DR. SEAY in order to attend. Future meetings will be announced via our Events calendar and email distribution lists. Space is limited, so please secure your spot today by calling our office to register. Questions about this group should be directed to me (Dr. Seay) at (561) 444-8040. The group will meet in my office in Palm Beach Gardens, FL. The address is 11641 Kew Gardens Avenue, Suite 207, Palm Beach Gardens, FL 33410. Thanks, and I hope to see you at our...
read more

Worry & “What If” Questions

Posted by in CBT, ERP, Generalized Anxiety Disorder (GAD), Obsessive-compulsive disorder (OCD) Anxiety, Worry, & What If Questions If you have anxiety, it’s likely that you wrestle with worry and “what if” questions. Many what if questions are easily recognizable and start with the obvious, “What if…?” Others are more subtle and begin with phrases like “How am I ever going to…?” By definition, what if questions prompt us to solve problems that haven’t actually happened yet. The possibilities are truly endless. These worries may involve fears about current situations or about situations set far in the future. What if questions are often difficult to resist because by answering them, we often feel that we become more mentally “prepared” or “ready” to deal with life’s uncertainties. In fact, many individuals feel stressed out if they ignore their worries. They think that because what ifs involve potentially dangerous situations, it’s irresponsible or reckless to ignore these worries. By answering what ifs, they hope to have a better degree of control if and when these situations actually arise. Many individuals with anxiety disorders like obsessive-compulsive disorder (OCD) or generalized anxiety disorder (GAD) struggle with what if questions and other worries for hours each day. How often does this “mental preparation” actually pay off for people with anxiety? Almost never. That’s because mental reassurance (a type of mental ritual) is capable of providing only transient relief. We may feel prepared for a few seconds, minutes, or hours, but the feeling eventually wears off and then we feel compelled to re-board the what if train. Because life involves infinite possibilities and our current situation is constantly changing, the scope of potential what if questions is limitless. You could literally spend the rest of your life preparing for every possible contingency in the hopes that you would be in a better position to deal with it (if and when it actually happens). However, you can never be fully prepared.  Perfect preparation is only a mirage. Providing specific answers to your anxiety’s what-if questions is like trying to fill a colander with water. You can spend time doing it, but it’s never going to get you anywhere. Moreover, you’ve wasted a lot of water in the process. Similarly, there are consequences to answering what ifs. What are the consequences of answering what if worries? Answering what if questions substitutes thoughts for action. Because only action can create lasting change, answering what ifs is an avoidance behavior. Time spent...
read more

Does Non-Avoidance = Exposure? No! Anxiety Disorder Treatment Principles for OCD, Panic, Social Anxiety, & Phobias.

Posted by in CBT, ERP Anxiety Principle of the Day: Non-Avoidance is not equivalent to exposure. Although exposure is predicated upon the purposeful non-avoidance of anxiety-related stimuli, non-avoidance of anxiety triggers is not equivalent to exposure. What is non-avoidance? I liken non-avoidance to being in a particular place at a particular time. Essentially, it involves being in a situation in which your anxiety is triggered by proximity to anxiety-related cues. Non-avoidance requires no action on your part aside from being physically present in the situation. As such, like a hole, it’s possible for a person to accidentally stumble into a non-avoidance exercise. Isn’t that the same thing as exposure? No. Exposure is not merely a situation, and as such, it can’t be entered into by accident. Although exposure therapy has situational elements, it is a dynamic experience that has best practices, as well as Do’s and Don’ts. It is also based on a specific “philosophy of doing” that has essential cognitive components. When done properly, exposure is a personal, deliberate, and reasoned assault against your anxiety. In contrast to simplistic non-avoidance, exposure is premeditated and thoughtful, it has cognitive and emotional goals, it is prolonged, and it is grounded in pragmatic application of sound theoretical principles. That can be a tall order for individuals new to exposure. That is why I often suggest that people begin exposure therapy under the supervision of a therapist who specializes in anxiety disorders. When I see a patient for the first time in my Palm Beach, Florida office who has struggled with chronic anxiety, they often tell me that they’ve completed “exposures” in the past and that “exposures” didn’t help them get better. In fact, these patients are most often misconstruing non-avoidance exercises for exposure exercises. They might have been in the right place at the right time, but they weren’t doing the right types of things while they were there. Let me illustrate the difference between non-avoidance and exposure. Suppose I have arachnophobia, and I have decided to overcome my fear of spiders. To accomplish this end, I will no longer actively avoid spiders. I will operate according to a new set of principles that involve not letting spiders dictate my behavior. I’ll go outside when I want to, and I’ll even tolerate being in the same room with a spider when I see one. These are sound non-avoidance guidelines. The difference between non-avoidance and exposure is...
read more

Exposure Therapy’s Most Common Mistake: All Eggs in the Habituation Basket

Posted by in CBT, ERP, Obsessive-compulsive disorder (OCD) Many people have an incomplete understanding of exposure therapy… …be it exposure and response prevention (ERP) for OCD, intentional mistake practice for social anxiety, or interoceptive exposures for panic disorder… This is true for exposure newbies, seasoned exposure veterans, and even some good CBT therapists. This limited understanding is based on the following flawed logic: Premise 1: Anxiety disorders involve fear. Premise 2: Fear is reduced through habituation. Premise 3: Habituation is accomplished via exposure. Conclusion: Habituation is the process by which individuals recover from anxiety disorders. Note: This conclusion is only partially correct. Exposure, when done right, is about much more than just habituation. It’s about learning to see the world in a new way and developing a different type of relationship with your symptoms. Exposure can help you challenge unhealthy, false beliefs about yourself and the world; learn to take risks and make choices that are consistent with what you want out of life; develop confidence in your ability to overcome challenges; and learn to tell the difference between you (the person) and your symptoms. The next time you complete an exposure, ask yourself, “Why am I doing this exposure?” If your only answer is “To habituate,” you might need to re-evaluate what you’re doing in therapy. What have you learned from your exposures? How has your relationship with your symptoms changed as a consequence of challenging them? Please share below. …or continue the discussion on Facebook, Twitter, or...
read more

OCD Treatment (ERP & CBT): Exposure & Cognitive Restructuring

Posted by in CBT, ERP, Obsessive-compulsive disorder (OCD) Question: To what extent would a change of mindset (e.g., changing my expectations for myself) be helpful in recovering from OCD? What is likely to happen if I delay formal treatment with a psychologist and work instead on changing my own mindset? OCD Treatment Components: Cognitive Restructuring + Exposures Regardless of whether or not it occurs in the context of formal psychotherapy, changing your mindset will be a critical component of your recovery. If you do any reading on cognitive behavioral therapy (CBT), you’ll see this referred to as “cognitive restructuring.” Devoting time to challenging and modifying your underlying belief system is essential for fighting OCD, but research on OCD indicates that this process alone will probably be insufficient if it’s not integrated with appropriate exposure-based behavioral strategies (e.g., exposure and response prevention [ERP]). OCD Treatment Delays In general, I do not advocate treatment delays. As you get older, OCD tends to become more intractable and intertwined with who you are, making it more difficult to separate yourself from your OCD. Moreover, most people find that their rituals morph and expand over time, if left untreated. Nevertheless, everyone is different with their own unique biology and experience. There is certainly no guarantee that in your particular case, your OCD will get worse over time. However, the prevailing view is that earlier treatment is more effective and staves off later problems. This is why I recommend early treatment for kids, teens, and adolescents with cases of early onset (pediatric) OCD. OCD Professional Treatment vs. Self-Help Strategies The best thing you can do for yourself is to combine cognitive techniques (e.g., cognitive restructuring) with the behavioral components of exposure and response prevention (ERP). The basic principles of treatment will be the same whether you are tackling symptoms related to checking, potential danger/disaster, harm, repeating, washing/contamination, or another type of compulsive behavior. There are some good self-help books available to provide general guidance, but these resources typically are not a good substitute for individual therapy conducted by a trained psychologist. You will be most likely to progress quickly if you have an OCD specialist physically present to educate and guide you through early exposures. For tips on completing ERP exposures, please refer to my earlier post on identifying and resisting subtle rituals, which will help you maximize your treatment gains. Questions? Comments? Tips for challenging OCD-related cognitions? Share below. …or continue the...
read more

OCD Treatment: OCD vs. Me. How do I Tell the Difference?

Posted by in CBT, ERP, Obsessive-compulsive disorder (OCD) Question: Because many of my OCD rituals are related to my professional identity, I’m worried that changing my rituals will somehow change those parts of me that I like (e.g., my personal goals and ambitions). Should I be concerned about this? Early Onset OCD in Kids & Teens (Pediatric OCD) Many people worry that by fighting their OCD, they will lose essential parts of themselves. This is particularly true for adults with obsessive compulsive disorder, who have had to deal with OCD for most of their lives. Because OCD often begins early in childhood and can have a chronic course, it can be difficult to separate yourself from your OCD symptoms. In many pediatric OCD cases, kids with OCD exhibit symptoms by age 10. Shockingly, in certain cases, even toddlers can show clinical signs of obsessive-compulsive disorder. There are some documented cases of 2-year-olds demonstrating early onset symptoms, which certainly underscores the genetic underpinnings of the illness. In early onset cases, symptoms tend to worsen when the child begins going through puberty. Not everyone develops OCD as children, however. Other individuals don’t exhibit significant obsessive compulsive symptoms until later in life (e.g., late teens/early adulthood). Regardless of the age of onset for OCD, the average amount of time between symptom emergence and treatment is greater than 10 years. During this intervening period, individuals with OCD often lose sight of who they are and find it difficult to separate themselves from their OCD symptoms. Where does the individual end and OCD begin? This is particularly true in cases involving perfectionism, scrupulosity, Pure-O symptoms, harm and/or sexual obsessions, and hoarding, in which symptoms tend to intermingle with personality traits, guilt, and shame. OCD Compulsions Reflect Symptoms, Not You The reality is that rituals do not make you who you are. You are a person first and foremost, and your drives, desires, and ambitions are uniquely yours. I conceptualize rituals as symptoms of an illness. They don’t make you who you are; they’ve simply been a maladaptive coping strategy you’ve used to manage your anxiety. Ultimately, this strategy has proven to be more detrimental than helpful. If anything, your symptoms tend to hide who you actually are. OCD is greedy, and it likes nothing more than to wreak havoc on your confidence, sense of humor, and interpersonal relationships. Oftentimes, when individuals with OCD commit to treatment, they rediscover positive aspects of themselves...
read more

Fear, Doubt, Uncertainty, ERP, & the Monster Under the Bed

Posted by in CBT, ERP Everyone I know has, at some point, had to deal with the monster under the bed. Some do it with grace. Others falter. I’ve always been clumsy. I can vividly recall many terrified nights from my childhood, when I would lie rigidly in my bed, utterly paralyzed by fear. Afraid to make the slightest movement, to breathe, to call out for my parents…lest I be detected by IT. The pounding of my heart would be so loud in my ears, and my breathing so ragged, that I could swear the entire house could hear me. And yet…no one came to help. The moment would stretch out like taffy. At some point, my raw fear would ever so subtly decline, freeing me up to end the stalemate in one of several ways. Some nights, I would call out for help. On other nights, I would launch myself out of bed and across the room to flip on the light-switch, banishing the darkness with welcome illumination. However, in retrospect, the most helpful nights were those nights I didn’t look. On those nights, my stubborn streak would embolden me to hunker down and not look. I would sit in bed with fear, doubt, uncertainty, and resolve. “Bring it on, monster.” And you know what? The monster never came. My monster doesn’t bother me anymore. Does yours? Share below… …or continue the discussion on Facebook, Twitter, or...
read more

Social Anxiety Treatment: CBT & Intentional Mistake Practice (an example)

Posted by in CBT, Social Anxiety When I was a kid, one form of mischief that was briefly popular in my neighborhood was crank calling strangers. Usually, the bravest kid in the group would pick up the phone, and with the encouragement of all the other kids in the room, would dial a random telephone number. A brief, very Bart Simpson-esque conversation would then ensue. Usually it would go something like this: Kid: Hello, ma’am. I am conducting a brief survey for the Grocer’s Association. Do you have a minute to answer a quick question? Stranger: Of course. How can I help you? Kid: I was wondering if you have Sara Lee in the freezer. Stranger: Why, yes I do. Kid: Well then let her out!!! We would then bust out in laughter and hang up the phone, leaving the recipient of our phone call both perplexed and annoyed. This process would typically repeat itself two more times before we got distracted by something more entertaining. It’s pretty interesting to consider in retrospect.  What strikes me is this: Typically, the bravest kid in the group would make the first phone call. However, once the ice was broken, kids of nearly any temperament would then follow. Even kids who were shy by nature became emboldened after making just a few phone calls. In this situation, just as in any other social anxiety-related situation, practice helped.  Even if you feared potential embarrassment at first (e.g., freezing up, not knowing what to say, stuttering, tripping over your words), these fears quickly dissipated with practice.  Moreover, the social nature of the prank was able to quickly transform what might have been a troubling, socially-awkward situation into something more game-like.  It’s simply harder to feel afraid when you’re trying to one-up your friends. Of course, friends are also good at helping keep anxiety in check. For every kid prone to catastrophizing, there’s another laid-back kid who would set the record straight. Social Anxiety & Intentional Mistake Practice: CBT in Action As I mentioned in an earlier blog post, one key to recovering from social anxiety is something called “Intentional Mistake Practice” (IMP).   For some individuals with social anxiety, engaging in intentional mistake practice can be one helpful component of cognitive behavioral therapy (CBT) for social anxiety.  IMP gives you the experiences you need to recalibrate your thinking about social situations. In reality, other people are far less critical and are less aware of our behavior...
read more

Therapy as Science: You + Your Therapist + Scientific Method

Posted by in CBT, General I consider myself a scientist.  I wear this hat officially when conducting research, but I also wear it every time I sit with a patient.  In my research, my science is pretty self-evident: I identify a research question, develop falsifiable hypotheses, and then collect quantifiable data to see whether or not the phenomenon I’m studying behaves the way I think it does. A very similar process unfolds when I work with you in my clinic.  However, from your vantage point, you might not realize it right away.  Nevertheless, we are two collaborative empiricists. Most often, you will define the “research question”.  Usually, this is the very reason that you’re coming to see me.  Sometimes the questions we think we’re asking are not necessarily the ones we should be asking.  For example, questions like, “Why is this happening to me?” are often disguised ways of asking, “How can I change this?”  If that’s the case, I’ll help you refine your question.  Our questions will also be guided by the data you bring to your initial assessment.  These data points include your responses to various questionnaires, as well as other important information we discuss (e.g., current symptoms, symptom history). Next, we’ll develop hypotheses about which strategies are most likely to be helpful for you.  Since I’m an evidence-based medicine kind-of-guy, I’ll let you know what research studies say about the types of interventions that are most likely to be effective for resolving your “research question”. Although not everyone is the same and responds to the exact same treatment protocol, we’ll let science be our guide.  For example, research studies tell us that cognitive behavioral therapy (CBT) is great for reducing symptoms of depression, whereas something called exposure and response prevention (ERP) is particularly good for treating OCD. We will then implement our plan and collect data to make sure we’re moving in the right direction.  These data points include answers to questions, such as: How is your anxiety changing as you are getting more practice with exposure? What are you doing now that you’ve avoided in the past? How does your day-to-day life reflect your personal values? How effective are you at work, at home, and in social situations? How many panic attacks are you having per week/month/year now compared to the past? These are just a few simple questions (there are many, many  more), but as you can see, each...
read more

The Power of Being Selfish: Selfishness as a Key to Mental Health

Posted by in CBT I’m about to tell you something that your mother might not approve of…so for those of you sensitive souls out there, you might want to click on something less controversial. Here it is: It’s okay (and sometimes even essential!) to be a little bit selfish. Conventional wisdom, and our parents, often tell us that it’s not okay to be selfish.  If you want to be an effective parent, you must learn to put your kids’ needs before your own.  Likewise, to be a good spouse, you must learn to  honor your partner’s needs.  These are truths, and if you aren’t living these truths in your daily life, it is likely that your relationships have suffered. However… As with anything, these truths must not be taken to extremes. I found myself thinking about this idea over the weekend as I was talking to a friend going through a particularly challenging situation.  In some cases, to be healthy, wealthy, and wise…we need to make specific efforts to honor our own needs.  If we don’t, we run the risk of completely burning ourselves out and suffering the ill effects of depression, stress, and anxiety. What do I mean by honoring our own needs? Some examples of this might include: Celebrating your own successes at work, school, and home. Recognizing and utilizing “me time” when needed. Setting and enforcing appropriate boundaries with others. Allowing yourself to feel pride in something you do well. Learning how to gracefully say “no” to others. Letting other people know your true opinions and feelings. Accepting help from others (even when you could do the same job yourself). Technically, these things are selfish. But they are also essential ingredients for health, success, and wisdom. Go tell your mother it’s okay to be selfish sometimes.  She’ll be grateful. Questions? Comments? Sound off below. …or continue the discussion on Facebook, Twitter, or...
read more

Specific phobias: symptoms & CBT treatment (reader question)

Posted by in CBT, Phobias Question: Basically, I wanted to know from an expert, what can a phobia do to a person? How does it affect them mentally? Also I see that you’ve got a new treatment philosophy — is there any way you can talk me through it? One of the goals of cognitive behavioral therapy (CBT) is to learn to better understand the interrelationships among thoughts, feelings, and behaviors.  Once you understand how these things are connected, it gives you a lot of power to implement change. Most people who seek therapy do so because they are experiencing an emotion they don’t want to have.  In the case of depression, the person might feel sad.  In the case of a phobia, the person might feel scared.  People often have trouble modifying these feelings directly because emotions tend to be somewhat involuntary.  If you’re sad or scared, there isn’t really a switch you can flip to feel better.  We, as humans, can’t modify our emotions through sheer act of will.  Fortunately, CBT gives us the tools to modify our thoughts and behaviors, which then indirectly affect how we feel.  Relative to our emotions, we have much more control over our behavior and (to a somewhat lesser extent) our thoughts.  Through behavioral and cognitive changes, we can effect changes in how we feel. My treatment philosophy acknowledges this explicitly.  If you are trying to overcome a fear of heights (acrophobia), for example, you could talk about your fear everyday for the rest of your life.  However, talk alone would never help you overcome your fear.  When it comes to overcoming an anxiety disorder, there’s a place for talking, but there’s a larger place for action.  When I work with people on overcoming fears, I help them understand what creates and maintains fear, but my larger goal is to help them develop the confidence and willingness they need to face the fear directly.  We then go out together in the real world to challenge the fear.  We would proceed in a very systematic way (going from easier “exposure” exercises to more challenging ones), but if the person really wanted to get a handle on the fear, we would eventually go up in skyscrapers, ride roller coasters, take a plane ride, etc…whatever we would need to do to help the person overcome his/her phobia.  There are many unique in-vivo exposure opportunities throughout the greater Palm Beach, Fort...
read more