What is Exposure Therapy?

Exposure therapy is a broad term used to describe a collection of techniques used to treat anxiety.  Exposure therapy in early forms was referred to a systematic desensitization.  Systematic desensitization had individuals confront an anxiety provoking situation while also engaging in a relaxation technique.  The philosophy here was to use counter-conditioning by having the person in an anxiety provoking situation while providing their body with incongruent feedback of relaxation while confronting a normally fearful object or event.  Over time researchers became curious as to what was causing the reduction in anxiety with systematic desensitization.  Was it the relaxation?  Just exposure to the feared object?  Or relaxation and exposure together?  They conducted what is called a component study to determine what part of the treatment was doing the heavy lifting so to speak.  The results suggested that the relaxation portion of systematic desensitization was not doing much at all and may actually be counter productive but the exposure portion seemed to be doing most if not all of the good.  These studies confirmed that the mechanism known as habituation was responsible for most if not all of the treatment gains.  Habituation is quite simply the reduction of anxiety just with exposure to the feared object and the passage of time.

Most modern treatments for anxiety disorders used what is known as gradual or graduated exposure.  What this means is that the therapist and patient produce a list of feared situations from easiest to hardest.  They begin with easier feared situations and simply expose themselves to them until habituation is allowed to have its effect.  Once this occurs and the person has mastered the exercise they move on to more challenging exercises.  When doing exposure it is very important that the patient remain in the exposure exercise trial until habituation has occurred and there anxiety has decreased 50 to 75 percent before stopping the exercise.  If the person stops doing the exercise early escape conditioning can occur and will cause the anxiety to get worse, meaning the exposure exercise did not help but actually made the person sicker!  This is why it is important that if you are very anxious and are seeking exposure therapy that you seek assistance from a qualified person who has experience doing behavior therapy and more specifically exposure therapy. 

As you can tell exposure therapy is work.  You must do homework outside of therapy sessions or it is unlikely you will make significant gains.  This is a form of therapy where active participation and significant effort is needed on the part of the patient in order for gains to occur.  I have often characterized myself as a “glorified coach” when doing exposure therapy.  I the therapist can merely guide, suggest, advise, and cheer-lead.  The patient must go out on the field and make it happen.  Thankfully, if done correctly, with patience, and time, exposure therapy is approximately 80 to 90 percent effective for many of the anxiety disorders.  It is a very rewarding form of therapy because you can see your progress and feel the difference it is making.   If you or a loved one experiences significant anxiety I encourage you to seek out a qualified therapist that can use exposure therapy. 

What IS Obsessive Compulsive Disorder (OCD) and What is NOT

I wanted to take this opportunity to go over a major misconception people have about what obsessions qualify under the rubric of obsessive-compulsive disorder or obsessive-compulsive behavior.  The general public seems to have a general belief that virtually any repetitive behavior falls under the definition of “obsessive.”  Below is a list of behaviors that people commonly mistakenly believe are obsessive in the genre of OCD:

1. Finger nail biting (sorry this is called a bad habit)
2. People who collect things they enjoy (this is called a hobby BUT hoarding useless items is much different)
3. People who drink to much alcohol (please see addiction)
4. People who gamble too much (see gambling problem)
5. Usually young men who are overboard with pornography (impulse control problem)
6. People who like to steal things (kleptomania)
7. Children with ticks (usually tick disorder or Tourettes disorder)
8. People who have repetitive negative thoughts about themselves, the world, and their future, (this is depression)
9. Superstitious or religious activities such as praying
10. People who are particular but have no anxiety.

From this list it is easy to see that there are many conditions, situations, and behaviors that are repetitive.  We could spend the entire evening going over the diagnostic criteria from the DSM-IV-TR for OCD to completely delineate the exact definition of what is obsessive-compulsive but one only needs to understand one basic concept.  Anxiety drives OCD behaviors.  The function of the repetitive behavior is to decrease anxiety in the short-term.  The person often times is well aware that the worries they are having and the subsequent actions to reduce anxiety (rituals) are completely irrational, yet the feel compelled to do the rituals because they seek to reduce the tension and anxiety.  The rituals or actions are done to ESCAPE anxiety.  The person feels they have no choice but to do them.  Several of the behaviors listed above are either enjoyable, reinforcing (feel good,) or are not driven by anxiety.  Therefore they are not in the realm or spectrum of OC.  If you or a loved one are unsure what qualifies as OCD, please call a qualified professional.  There is nothing wrong with picking up the phone and calling to ask a question.  I have fielded many calls seeking information like this and have never had a problem answering them.

Dr Jim

Tips for Successful New Year’s Resolutions

As a new year approaches now is the time many people begin contemplating new year’s resolutions. Often these resolutions end in failure. Experts place the failure rate as high as 90 percent. This may not foster an encouraging picture but there are several things people can do to increase their chances of success. Below is a list of suggestions.

1. Develop a measurable goal. Often time people are not able to articulate exactly what their goals are in terms of measurable outcomes. Make sure when developing a resolution that progress can be measured in some way because this allows you to see progress and is encouraging.

2. Create smaller goals. Many times people are able to identify where they want to go in terms of final goal but feel overwhelmed by the size of what it is they need to accomplish. If a doctor has told you to lose 50 to 80 pounds that is overwhelming. Perhaps breaking that down and saying, “I will lose 10 pounds in the first month” is a good small goal towards the larger goal. Once a small goal is reached you can set your sights on the next sub-goal.

3. Write a plan. Writing out your plan makes it real, provides you a reference source, and helps hold you accountable to yourself. Some examples of this include a meal plan, a family budget, or a project checklist.

4. Make goals attainable. Not being realistic is one of the major pitfalls that sink a goal or change. Instead of a shoot for the sky type of philosophy, try to develop a medium range goal to start. Achieving this will allow you to sit back, reassess, and decide the next attainable goal.

5. Measure and track progress. Tracking progress is the number one way to convince yourself that your efforts are working. It positively reinforces (rewards) you when things are going well. Tracking goals will also hint to you that maybe you are doing something wrong. For example experts have shown time and again that keeping a physical record of a habit we are trying to tackle automatically reduces that habit by 1/3rd. That’s a big effect!

6. Have a routine. Doing positive behaviors as part of a routine makes it more likely they will be repeated. For example many of the fitness folks I know always work out at the same time of day and those times are “reserved” for their workouts. If time is reserved in the day for positive action toward a goal a person also feels some pressure to do the activity because they reserved time for it. Again, it is another way to hold yourself accountable by setting time aside.

7. Develop a community or support from people seeking the same goal. There is nothing more powerful that having other people to bounce ideas off of or seek support about some goal you are working towards. Whether it is a quit smoking group or an exercise group, all help encourage you toward your goal. You are far less likely to skip that cycling class when you know all of your friends are going to be there expecting you.

8. Keep an “oops” in perspective. Understand that you are not perfect and will make mistakes. I always try to remind people that it is better to spill three drops of milk than the whole gallon. If you get off track toward your goal don’t beat yourself up. Take corrective action as soon as you are able to resume your plan. If you allow the failure experience to sink you because you were not perfect then the whole goal is lost. You don’t need to be perfect and you never will be.

9. Avoid “risky” situations. This seems like it would be easy but many times people overestimate their willpower and end up in situations where they used to engage in a bad habit and are unable to resist. A good example of this is somebody who is trying to quit smoking but is used to smoking while playing cards with friends. Going and playing cards is a situation that makes it more likely the person will falter and smoke a cigarette because the situation itself will trigger a drive or an urge to smoke all on its own.

10. Be positive about your goal. Be excited and happy about what you’re doing. If you are negative about quitting smoking, losing weight, or getting into shape you will be far less likely to stay with the goal.

11. Understand and accept temptation. People who do not plan to be tempted are more likely to be blind-sided and pushed off track from their goals. Plan for when you will be tempted or at risk and be ready with how you will deal with this situation. For instance, if you are trying to eat healthy you should have an idea about what to order or ask for when you go out to eat. When at a pot luck, party, or gathering you should already have in your mind a list of foods that are better choices for you.

12. Reward yourself in a healthy way. When you reach sub-goals celebrate by buying yourself something as a reward. For example, somebody who has lost the first 20 pounds could go out and buy some new workout clothes. A person who is finally able to run 3 miles without stopping could buy themselves a new pair of running shoes or an mp3 player. Doing this helps encourage them on their journey and makes it more likely the positive behavior will be repeated.

James A Burns, PhD

Genesis Counseling Services is a state certified outpatient mental health and substance abuse treatment clinic, one of the three largest in Rock County. We were established in 1988, and have a 23-year reputation for providing quality services. Our staff has varied clinical orientations but the most dominant orientation is cognitive-behavioral. We are open from 8:00am to 8:00pm and schedule Saturday hours as needed. Our location in downtown Janesville is easily accessible and professional. I am very proud of our staff and our facility is second to none in comfort and professionalism. There is not a single outpatient mental health facility that makes the investment Genesis does to provide a top notch setting for patients and staff. We would like the opportunity serve you in your time of need. Please feel free to call us at (608) 757-0404      .

How to Control a Panic Attack

Controlling a Panic Attack Using Respiratory Control

The most common question people ask is what they can do to prevent, reduce, or control a panic attack.  Panic attacks are very common and studies have shown that as many as 33% of the population will have a panic attack at some point in their lives.  If you are reading this article it is likely you have experienced this before or know somebody who has.  As a precautionary note, I am assuming you have already been to your doctor or the emergency room (not uncommon) and they have told you “there is nothing wrong with you.”  Panic attacks are very frightening and produce strong physiological symptoms of fear that if misinterpreted can develop into panic disorder.  Not all people who have a panic attack will develop panic disorder but knowing what a panic attack is can help prevent the development of panic disorder.

A panic attack is defined by the Diagnostic and Statistical Manual of Mental Disorders IV (DSM IV-TR) as four or more physiological symptoms of panic that peak within 10 minutes.  The symptoms include:

1) Palpitations, pounding heart, or accelerated heart rate

2) Sweating

3) Trembling or shaking

4) Sensations of shortness of breath or smothering

5) Feeling of choking

6) Chest pain or discomfort

7) Nausea or abdominal distress

8) Feeling dizzy, unsteady, lightheaded, or faint

9) Derealization (feelings of unreality) or depersonalization (being detached from oneself)

10) Fear of losing control or going crazy

11) Fear of dying

12) Parasthesias (numbness or tingling sensations)

13) Chills or hot flushes

These symptoms are symptoms of fear itself.  When these occur unexpectedly the person is likely to look outside of themselves into their immediate environment and try to ascertain what is causing the symptoms.  What is threatening?  They are rapidly trying to identify the threat.  Unable to find anything they immediately begin to believe that something internally must be wrong with them.  When this happens their anxiety mounts and the symptoms will quickly intensify.  Quite simply the person’s body is identifying threat when no threat is present.  Once their body has misidentified that threat is present it immediately responds by “setting off the panic alarm.”  The spiraling chain of events has caused a panic attack.  So where does it begin?

Researchers do not have a definite answer but one of the major contributors to the onset of a panic attack is what is referred to as autonomic arousal.  This is a phrase that describes the feeling of being keyed up, anxious, nervous, upset, worried, or unsettled.  As a person becomes more aroused physiologically their body also turns up their blood pressure, heart rate, and respiratory rate because the body is under stress and needs more energy to be in this aroused state.  Our body can only make more energy through cellular respiration and to do this it needs more blood flow and more oxygen.  Unfortunately people often times fail to perceive this increase in arousal and it “sneaks up” on them.  When they do finally notice it they perceive it as a sudden change and believe something must be wrong with them.  Then it’s off to the races.  Since a panic attack increases several physiological markers in our bodies, it must be possible to intervene somewhere.  The best place to do this is respiratory rate. Today you will learn how.

Before we learn respiratory control let’s talk over a few things.  First, learning respiratory control is NOT a treatment for panic disorder.  Respiratory control is a technique to combat the impact and strength of a panic attack.  Treating panic disorder is much more involved than any self help book or article can tackle.  If you are concerned you may have panic disorder you should see a qualified professional who has expertise in cognitive-behavioral assessment and therapy.  Second, this technique takes practice before it will work.  You should practice at least twice per day for 20 minutes each session.  More practice is always better.  Third, you may feel an urge to gasp for air.  Understand if you are an anxious person your body has become accustomed to over breathing and needs to be retrained.  It will resist this so you must force your body to adhere to the cadence we will outline.  Fourth, always take regular size breaths (NO DEEP BREATHING HERE) and breathe ONLY through your nose.  Fifth, make a conscious effort to breathe using your stomach muscles and not your chest.  Your chest should not move.  Sixth, stick to the count and do not let your mind wander.  Concentrate especially when you are just learning the technique.  Let’s go through it.

1.  Regular sized breath in.
2. Once at the top of the breath (you have breathed all the way in) count to 3 slowly
3. After counting to 3, slowly breathe out
4. Once at the bottom of the breath (breathed all the way out) count to 3 slowly
5. After counting to 3 breathe in and repeat the cycle

The technique is very effective if practiced.  If a person becomes skilled using it our body CANNOT resist and the anxiety will diminish.  It is impossible for our body to remain in a highly anxious or aroused state if a person is able to turn their body down physiologically.  You must practice the technique and don’t give up or become disheartened if it does not work immediately.  If this or other techniques do not work see a qualified professional such as a psychologist or a counselor.

James A Burns PhD

Welcome to our Blog

Genesis Counseling Services now has a blog where we will publish articles, recommend books, or videos that we feel are relevant to mental health in general.  A “blog” typically is a less formal type of writing than peer reviewed scientific journals and A LOT less boring.  I will try to keep the posts informative, factual, and entertaining.  The information I post in them is the information to the best of my knowledge and I will attempt to cite sources when they are major.  I will not cite a source for every single sentence which would be typical in a peer reviewed journal or dissertation.  I have already finished some of those and despite my graduate school adviser being a good soul I do not wish to repeat the experience.  With that in mind I am a licensed clinical psychologist in Wisconsin and my training is in cognitive-behavior therapy with exposure to other more eclectic orientations.  Much of my graduate training is research oriented including extensive training in data analysis, research design, and science in general.  I feel that early in my career I produced enough knowledge to come to the conclusion that I did not wish do that as a career (academician) but lately I am more of a consumer of scientific knowledge.  I will try to make it as informative yet entertaining as I can.  If you have any suggestions please feel free to submit them.  I will always sign the blogs that I write and if I have guest writers they will as well.  As with many blogs understand that this is a public forum and you are to be on your best behavior.  I reserve the right to delete your posts if they are deemed inappropriate. Also I will not answer case specific questions, provide treatment, or advise you personally through this blog.   I will only cover and discuss topics in a general sense.  Since I am not right in front of you and do not have ALL of the information it would be inappropriate to offer specific treatment recommendations and such.  I hope you understand.

James A Burns PhD or Jim or Dr Jim