Using TLC to Learn About Hair Trichotillomania

Using TLC to Learn About Hair Trichotillomania

A few years ago, my clinic director suggested I check out trainings offered through the Trichotillomania Learning Center (TLC), a grassroots hub for information on trichotillomania and skin pulling (or dermatillomania). He knew about my interest in structured treatments for anxiety disorders and thought it might be useful for me to look into training.

Although TLC offered a DVD training program, I decided to wait until there was an actual physical workshop. In retrospect, I don’t know why I was so attached to in-person training. Having attended my fair share of workshops and even having co-led some myself, I’m fully aware that 1-2 day workshops are pretty limited in what you actually can learn. Intellectually, I figured the training DVD’s were probably a better value, but I allowed my conditioning to overrule my reasoning.

Also, I’m a little embarrassed to admit, but when I read that the previous training was run by the Behavior Therapy Center of Greater Washington, I assumed “Washington” meant neighboring Washington state, and that the training would be held in Seattle. More than a year later, I checked back, realized, “Oh, it’s Washington, DC!” and dutifully ordered their Virtual Professional Training Institute (VPTI).

I have no excuse for my mistake—I had even clicked on their website and somehow missed the distinctive JEFFERSON MEMORIAL on the website landscape banner!

 

The Virtual Professional Training Institute is Awesome!

For under $10, the VTPI is a bargain. It features over 9 hours of DVD training and a collection of pdf’s of research articles. You can send in the post-test to earn 16 CE credits and certification on their website. Developed in 201, the information is pretty current. The DVD kicks off with a documentary called Bad Hair Day, and the remainder includes lucid presentations by experts Charles Mansueto, Ph.D., Ruth Golomb, LCPC, and Fred Penzel, Ph.D. (Mansueto and Golomb are part of the center in DC.)

TLC

Not long after I finished the training, I ordered some books from TLC. (I figured they could use my money more than Amazon.) Included on the packing slip was a charming personal touch that illustrates the grassroots origins of TLC. Written in green ink was a quick note: “Thank you – Donna – TLC.”

Great New Book on OCD for Clients

Great New Book on OCD for Clients

Recently I read OCD: A Guide for the Newly Diagnosed. As the book is aimed at a lay audience, I’ve already written a post for our client-centered companion blog, The Art and Science of Living Well. However, because OCD is rare enough that many professionals don’t know a lot about it, I thought I’d give the book a mention here.

The book came out this year and was written by Michael Tompkins, PhD, who works at a private practice in the Bay area and is an assistant professor at the University of California, Berkeley. Its chock full of up-to-date information and provides a wonderfully concise summary of the ins and outs of having OCD.

I’ll confess here that I often find it tedious to read through books written for a lay audience. With OCD, however, I whizzed through it across two evenings. The book condenses a wealth of information into an economical readable format that’s about the length of a novella.

Want a brief overview of medications and augments for OCD that are supported by research? It’s there. Want some advice on how or whether someone with OCD might seek accommodations at work or school? It’s there, too.

Dr. Tompkins’ writing is direct and precise, yet his concern and compassion for those with OCD shines through.

I realize I’m harping a bit on economy of the writing. Perhaps I’m a bit finicky, or perhaps I’m too practiced in sifting through journal articles for what I want to know to read anything word-for-word anymore, but wordiness drives me up the wall. Most of the time, I find myself skimming through self-help books just wanting to get it over with.

I will clarify here that OCD is not a self-help book; rather, it’s provides an overview of options for someone with OCD, and it lists a number of self-help books in its References section.

OCD: A Guide for the Newly Diagnosed. I recommend picking it up for your professional library if there’s even a possibility you might work with someone with OCD. It’s a up-to-date and handy resource.

An Overview of the Emotional Processing Theory

An Overview of the Emotional Processing Theory

NOTE: This post is part of a larger series of on the theory, practice, and research on exposure therapy. If you are interested in other posts in this series, you can find them here.

Twenty-five years ago, in an attempt to create a unifying theory that would explain the processes of and guide the use of exposure in the treatment of anxiety disorders, Foa and Kozak (1986) developed the emotional processing theory (aka, information processing theory). The emotional processing theory has since guided an enormous amount of research, particularly for posttraumatic stress disorder (PTSD). Dr. Foa drew from the theory in developing prolonged exposure, a landmark PTSD treatment and the gold standard approach to PTSD treatment.

Much of my experience with the emotional processing theory comes from my training in prolonged exposure. When I was originally trained in prolonged exposure, I had the impression that it was more on the behavioral side of cognitive behavioral therapy. However, in reading about the emotional processing theory in greater depth, I realized that, although prolonged exposure looks procedurally like behavior therapy, the theory behind it is more of a product of the cognitive revolution with its emphasis on the computer as a metaphor for the human mind.

According to the emotional processing theory, fear is activated through associative networks that include information about the feared stimulus, escape or avoidance responses to the feared stimulus, and the meaning of the fear (e.g., threat or danger). Fear becomes problematic when it is intense to a degree that it gets in the way of functioning, or when it persists even when there are no clear indications of danger. In these instances, there may be maladaptive or pathological fear structures. The theory holds that chronic avoidance (e.g., escape behavior, avoidance, dissociation) often leaves these maladaptive schemas in place, as people do not remain in a situation long enough for new learning to occur.

Emotional processing theory proposes that exposure can alter the relationships between the fear stimulus and these networks. For this to happen, the network must first be activated, and then new information must be encoded that is incompatible with what is in the fear network. This is accomplished through habituation. Staying in contact with a fear stimulus until there’s a reduction in anxiety allows for the encoding of new information that is incompatible with the fear stimulus (e.g., it’s not dangerous). For example, in someone with OCD, repeated exposure to an obsession while refraining from engaging in a particular ritual serves to disconfirm maladaptive beliefs about the importance of the ritual in keeping harm away.

I break this process down with greater detail below.

Fear Structures

We’ll start with fear structures. Originally proposed by Lang (1977), fear structures are cognitive networks of maladaptive thinking that become activated through fear or anxiety. For people with anxiety-related problems, there are two common maladaptive beliefs about the fear stimulus: 1. That anxiety or distress will escalate to the degree it becomes unmanageable (e.g., “I can’t handle this”); 2. The feared stimulus or their experience of anxiety will cause harm (e.g., “I’ll lose control” or “I’ll go crazy”). For example, someone with panic disorder might think, “I’m going to die” when they start to notice panic cues like shortness of breath.

The major problem, according to emotional processing theory, is that people with anxiety disorders usually engage in some form of escape or avoidance behaviors when they feel anxious. As a result, they don’t remain in contact with their anxiety long enough to disconfirm the fear structure. Over time, people continue to engage in disruptive behaviors (e.g., escape) whenever they experience fear. An unfortunate side effect of continued avoidance behavior is that people’s lives begin to constrict in order to avoid things that trigger the fear structures. Their lives become narrower and more confined (e.g., they stop leaving the house).

Disconfirming Fear Structures Through Habituation

The solution then, according to the emotional processing theory, is for people to stay with their anxiety long enough for it to reduce on its own. Research suggests that so long as we don’t actively feed anxiety through worry, it tends to go down on its own after about 45 minutes –what is called habituation to the feared stimulus. Through repeated habituation, they begin to learn that what they’re afraid will happen (e.g., “I’ll go crazy”) doesn’t occur, and/or that the feared consequences are less likely to occur or are milder than expected (e.g., “If people notice I’m anxious, they’ll laugh at me”).

Foa and Kozak (1986) suggested that exposure weakens associations and replaces maladaptive fear associations with more adaptive ones. However, this view was revised in Foa and McNally (1996), where the authors incorporated animal behavior models of exposure from the lab of Bouton. Bouton’s work suggests that exposure does not actually alter associations so much as creates new, competing associations. What this means is that following exposure, there may now be two associations: a pathological one and a non-pathological one. Ideally, the person begins engaging in behaviors that are more in accordance with the non-pathological association, strengthening it over time.

Here’s an example: A motor vehicle accident survivor develops a fear structure involving thoughts that all automobiles are extremely dangerous. As a consequence, he stops driving. The therapist might arrange a series of exposure exercises involving automobiles. The person might start by sitting in a parked car each day until his anxiety decreases. He may then drive very slowly on low traffic streets, working his way up to driving again. The man may retain the association that all automobiles are dangerous, but through exposure a competing association that harm is unlikely accompanies it. The man may then make choices in accordance with this second association (e.g., the choice to drive a car).

A Glimpse Into the Future of the Emotional Processing Theory

This is a brief sketch of the emotional processing theory. It has been hugely influential in guiding research on anxiety treatment, particular for posttraumatic stress disorder and obsessive-compulsive disorder. The application of the emotional processing theory to PTSD has led to a very successful treatment—prolonged exposure. However, treatments may be effective even if the theories guiding them are not entirely accurate.

As I’ve written in a previous post, the main area in which newer research has brought the emotional processing theory into question is its emphasis on habituation. There’s no reason to offer a complete retread of the post, but newer research suggests that it’s not necessary for someone’s anxiety to go down during exposure in order for him or her to benefit. Additionally, McNally (2007) argued that the concept of “fear structures” is vague, circular, and not supported by research. Dr. Craske at UCLA, in particular, has criticized the principles underlying the emotional processing theory (See Craske et al, 2008 for a summary of exposure research; Baker et al, 2010, for study from Craske’s lab questioning the usefulness of habituation in predicting treatment outcome).

In upcoming posts, I’ll be discussing newer research that challenges the emotional processing theory, and that offers glimpses into where our understanding of exposure may go.

For more information about Emotional Processing Theory

If you want to read more about emotional processing theory, here’s a good book:

 Pathological Anxiety, Emotional Processing in Etiology and Treatment (2005), by Barbara Rothbaum.

Or for the most widely used guide for Prolonged Exposure, the main therapy approach guided by emotional processing theory, see:

Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences Therapist Guide (2007) by Edna Foa, et al.

For more about exposure therapy, check out my other posts on the topic.

UPCOMING TRAINING EVENTS


Using Acceptance and Commitment Therapy to Guide Exposure Therapy: The Basics

Brian Thompson, PhD, Brian Pilecki, PhD, and Joanne Chan, PsyD
September 17th, 2021 from 12-3pm

This is a beginner workshop intended to provide the foundations of exposure therapy including types of exposure interventions and design effective exposure exercises for various anxiety disorders and OCRDs. Participants will learn how to use ACT processes to guide the implementation of exposure techniques and how ACT processes may be enhanced by traditional exposure methods. This workshop will provide some background in theory and will emphasize applying exposure to clinical contexts using case studies, exposure demonstrations, and the practice of new skills by participants. Read More.


Overcoming Barriers to Effective ACT-Informed Exposure Therapy

Brian Thompson, PhD and Brian Pilecki, PhD
October 15th, 2021 from 12-3pm

This workshop will offer a brief introduction to Acceptance and Commitment Therapy-informed exposure and focus on practical ways to address common problems in implementation. Case examples will be provided to illustrate common client barriers such as lack of buy-in and difficulty grasping core ACT concepts. Strategies for overcoming these barriers will be offered and participants will have the opportunity to practice newly acquired skills through role-plays and break-out rooms.Read More.


An Introduction to Psychedelic-Assisted Psychotherapy for Clinicians

Brian Pilecki, PhD and Jason Luoma, PhD
October 22nd, 2021 from 9am-12:15pm

Psychedelic assisted therapy is emerging as a highly effective form of mental health treatment. This workshop will provide health care professionals an overview of this new clinical area. The workshop will highlight the importance of preparation and integration, as well as how to use a harm reduction approach to provide therapeutic support to clients using psychedelics on their own. The current legal status of psychedelics will be reviewed, including Oregon’s developing a legal psilocybin-assisted therapy program. Finally, diversity issues around lack of access for underserved and non-majority populations will be explored, as well as the prevalence of cultural appropriation and colonialism in modern psychedelic medicine. Read More.


Acceptance & Commitment Therapy – An Experiential & Practical Introduction

Jason Luoma, PhD and Jenna LeJeune, PhD
November 13th and 14th, 2021 from 8:30am-4:30pm
at Milagro Theatre- El Zocalo
This two-day in-person workshop provides a thorough overview of the theory, principles, and techniques of Acceptance and Commitment Therapy. It is intended for those who are relatively new to ACT and for those who have done some reading on their own about ACT but who may not have had the opportunity to participate in more experiential learning, observe models, or receive feedback while using the ACT model. Read More.


Ethical & Legal Considerations in Psychedelic Integration Therapy

Brian Pilecki, PhD and Jason Luoma, PhD
November 19th, 2021 from 9am-11am

There is an increasing demand from clients seeking therapeutic support in their personal use of psychedelics. However, many clinicians interested in psychedelic preparation and integration are unsure as to how to provide these services as psychedelics mostly remain illegal. In this workshop, we will outline legal and ethical frameworks relevant to providing therapy to clients around their personal use of psychedelics, as well as describe how harm reduction approaches are suitable for this developing clinical area. Read More.


De-Mystifying Self-As-Context in ACT: Practical Strategies for Clients

Brian Pilecki, PhD and Kati Lear, PhD
December 3rd, 2021 from 12pm-1:30pm

This workshop will outline how self-as-context can be used to conceptualize commonly discussed topics in therapy such as self-esteem, confidence, identity, and inner conflict. Participants will learn how to flexibly practice practical self-as-context interventions that can be used with clients, as well as have a chance to practice newly learned skills through structured role-play exercises in breakout groups. Read More.


Values in Therapy: An Intro to Working with Values from an ACT Perspective

Jenna LeJeune, PhD
January 21, 2022 from 12pm-2:00pm

This workshop will provide a theoretical and conceptual overview of values from a contextual behavioral science perspective. We will cover the “what”, “why”, “when”, and “how” of values within ACT. While we will also provide an overview of various values exercises and measures that can be used with clients, the emphasis in this workshop will be on providing a foundational framework that will help clinicians approach values work from a functional perspective rather than a primarily technique-focused approach. Read More.



Culturally Responsive Therapy: How to Apply Anti-Racist Values in Session

Christy Tadros, LPCC and RaQuel Neal, LCSW
February 4th, 2022 from 1:30pm-4:45pm
and February 5th from 9:00am-12:00pm

This 2 day 6-hour training will help therapists develop their ability to support clients from a different racial background than them, with a particular focus on Black, Indigenous and People of Color. Through a multicultural social justice framework, it will integrate research and clinical experience to teach a therapeutic model for rapport building, assessment, and treatment. This model is not a rigid therapeutic modality, but provides a contextual lens to build a strong, culturally grounded therapeutic relationship. It is a flexible model and can align with many therapeutic modalities, including a contextual behavioral approach to therapy. Read More.


Truffle Hunting: Bringing Values to Life in the Therapy Room

Jenna LeJeune, PhD
February 25, 2022 from 12pm-2:00pm

This brief workshop is designed to help clinicians deepen their values work with clients by shifting the focus from the content of values conversations to the quality of those conversation. By listening for and deepening the qualities of effective values conversations participants will get a taste for how more experiential and relationally-based values work can supercharge therapy. Participants will have opportunities to both observe demonstrations and practice in small groups with the benefit of feedback. Read More.


Values Prototyping: Using Action to Help Clients Explore Their Values

Jenna LeJeune, PhD
March 18, 2022 from 12pm-2:00pm

This workshop will focus on one specific experiential tool called “values prototyping” that helps clients learn more about their values through engaging in intentional valuing. As participants will hopefully already have a solid foundation of some of the core concepts of the values process in ACT, this workshop will dive right in on how to use values prototyping to help clients learn more about what they would choose to value in their life. You will have the chance to practice developing a values prototype in small groups with the benefit of feedback, so that by the end of the workshop you will be able to use this tool in your work with clients. Read More.


The Invitation to Change Approach: Helping Families Affected by Addiction

Jeff Foote, PhD and Cordelia Kraus, LPC, CADC 1, certified CRAFT clinician
May 13th and 14th, 2022 from 9:00am-5:00pm
at University of Portland, Terrace Room
This two-day in-person workshop will provide skills training for professionals focused on the process of working with clients who have a loved one struggling with substance use issues. The Invitation to Change Approach draws on CRAFT (Community Reinforcement and Family Training), MI (Motivational Interviewing), and ACT (Acceptance and Commitment Therapy) to provide a compassionate and collaborative way of working with the families and concerned significant others of people who struggle with substance use. Read More.


Therapy and Research in Psychedelic Science (TRIPS) Seminar Series

Second Friday of each month from 12:00 PM – 1:00 PM (PT)

TRIPS is an online seminar series that hosts speakers discussing science-informed presentations and discussions about psychedelics to educate healthcare professionals. This series was created to guide healthcare providers and students preparing to be professionals towards the most relevant, pragmatic, and essential information about psychedelic-assisted therapy, changing legal statuses, and harm reduction approaches in order to better serve clients and communities. This seminar series is a fundraiser for our clinical trial of MDMA-assisted psychotherapy for social anxiety disorder that Portland Psychotherapy investigators are preparing for and starting in the Fall of 2021. All proceeds after presenter remuneration will go to fund this clinical trial. Read more.

October 8th, 2021Psychedelic-Assisted Therapist Training: Current Perspectives and a Look Forward with Dr. Elizabeth Nielson

November 12th, 2021Psychedelic Research: Implications for Palliative Care and End-of-Life Existential Distress with Anthony Bossis, Ph.D.

December 10th, 2021Implementing Culturally-Attuned & Anti-Racist Psychedelic Therapy: Impact over Intention with Jamilah R. George, M.Div., M.S.

January 14th, 2022Psilocybin-Assisted Therapy of Major Depressive Disorder using Acceptance and Commitment Therapy as a Therapeutic Frame with Jordan Sloshower, MD, MSc

February 11th, 2022 – Drug-Drug Interactions Between Psychiatric Medications and MDMA or Psilocybin with Aryan Sarparast, MD