An Interview with Michelle Craske, PhD, on “Maximizing Exposure Therapy for Anxiety Disorders”

An Interview with Michelle Craske, PhD, on “Maximizing Exposure Therapy for Anxiety Disorders”

In my ongoing series of posts about exposure therapy, I’ve written several times about the work of UCLA professor Michelle Craske, PhD. Dr. Craske has been on the cutting edge of exposure research, and her work has undermined the traditional notion posited in in the emotional processing theory that habituation to a feared stimulus is important in exposure work.

The Society for a Science of Clinical Psychology has posted an interview that Dr. Jacqueline Persons conducted with Dr. Craske on “Maximizing Exposure Therapy for Anxiety Disorders.” This approximately 47-minute interview is an excellent introduction to and distillation of Dr. Craske’s work. The webpage also includes a pdf of a 2014 paper Craske authored summarizing this model.

Dr. Craske’s model focuses on using exposure to cultivate inhibitory learning to create new learning that overrides the fear-based association called excitatory meaning. The idea is that through repeated exposure, new learning occurs that contradicts the unhelpful more fear-based associations that result in anxiety and avoidance behavior.

3 considerations in the inhibitory learning model for conducting exposure with a client

In her interview, Dr. Craske emphasized three important things to consider in using exposure:

  1. What does this person really need to learn (i.e., inhibitory learning) in order to be less afraid of the fear stimulus (i.e., excitatory meaning) that will lead to improvement?
  2. How can the exposure exercise be designed to maximally benefit that learning; that is, how can the exposure exercise “violate” what that person expects will happen (e.g., usually something bad) based on the excitatory learning?
  3. New learning will occur both during the exposure exercise and long afterward through a period of consolidation. Consequently, whether someone’s distress diminishes (i.e., habituation) during the actual exposure exercise is not as important as the actual learning that may occur during and following the exposure.

Role of cognitive restructuring

Dr. Craske also had some interesting things to say about the role of cognitive restructuring in exposure work.  In traditional CBT, exposure work may be preceded by cognitive restructuring. According to Dr. Craske, preceding exposure work with cognitive restructuring may actually undermine the exposure work by softening the violation of the person’s expectations—the expectations based on the excitatory meaning of the feared stimulus. Consequently, Dr. Craske stated her lab will do cognitive restructuring after the exposure work as a means to help consolidate the new learning (i.e., inhibitory learning).

Check out the tables on the linked research paper!

Dr. Craske’s work can be a bit dense to read. Even if you don’t intend to read it, I encourage you to download the 2014 paper that is linked to the interview. Following the Reference section are 6 tables that offer concrete examples for using inhibitory learning to conduct exposure with specific anxiety-related problems and deepening the impact of the exposure. The paper also includes clinical examples and can serve as a useful reference for the interview.

In conclusion

If you have any interest in exposure at all, I encourage you to listen to this interview with Michelle Craske on “Maximizing Exposure Therapy for Anxiety Disorders.” She speaks very clearly and elegantly about her work on inhibitory learning in manner that is very accessible.

The link also allows you to download a research paper summarizing this work. Download it. Even if you’re not up to reading a 30-page research article, it provides a nice reference and includes clinical examples and tables with suggested wording for setting up exposure exercises.

A special “thank you” to Dr. Jacqueline Person for conducting the interview, and to the Society for a Science of Clinical Psychology for posting it!

Brian Thompson Ph.D.

Author: Brian Thompson Ph.D.

Brian is a licensed psychologist and Director of the Portland Psychotherapy Anxiety Clinic. His specialties include generalized anxiety, OCD, hair pulling, and skin picking.

Psychiatry Advisor Informational Page on Trichotillomania

Psychiatry Advisor Informational Page on Trichotillomania

I’ve been working with trichotillomania (i.e., hair pulling) for several years now and am always happy to see this understudied problem receive more press.

I recently came across a useful informational page on trichotillomania on the Psychiatry Advisor website. The page provides concise, up-to-date info on “trich,” including behavioral and pharmacological treatment, and diagnostic considerations. It is a great reference for anyone new to trichotillomania.

You can check it out here.

Brian Thompson Ph.D.

Author: Brian Thompson Ph.D.

Brian is a licensed psychologist and Director of the Portland Psychotherapy Anxiety Clinic. His specialties include generalized anxiety, OCD, hair pulling, and skin picking.

Shorter Imaginal Exposure Sessions as Effective as Longer Exposure for PTSD

Shorter Imaginal Exposure Sessions as Effective as Longer Exposure for PTSD

Prolonged exposure (PE) is an evidence-based cognitive behavioral treatment that uses imaginal and in vivo exposure in the treatment of PTSD. Imaginal exposure involves the client recounting a core traumatic event in great detail repeatedly in session, and then listening to an audio recording of the exposure daily between sessions. In additional to imaginal work, clients engage in in vivo (Latin for “in life”) exposure to trauma-related triggers. Exposure is done until the client habituates to the trauma-related similar, and/or until PTSD symptoms are largely resolved, according to the PE model.

For those unfamiliar with exposure therapy, you can read more about other blog posts I’ve written on exposure.

Standard PE sessions are too long for how most therapists now practice

The research supporting PE is impressive, and I’ve always been impressed with the relative simplicity of its protocol. However, one concern I’ve had about the treatment protocol is that sessions are 90 minutes long, which is nearly impossible to have covered by insurance nowadays. When medical billing codes were revised in 2013, the code for a 90 minute session was cut, and 60 minutes became the longest standard session for which a therapist could bill. This change made PE out-of-step with the practice limitations of many therapists in the US.

To their credit, PE researchers responded to this concern in a recent study (Nacasch et al., 2015). This study is an improvement of a similar study (van Minnen & Foa, 2006) from several years ago.

The study

In the most recent study, 39 veterans were randomly assigned to 10-15 sessions of PE at either 90-minute with 40 minutes of imaginal exposure each session, or 60 minutes with 20 minutes of imaginal exposure each session.

What did they find?

  • Participants in the 60-minute sessions improved just as much as those in 90-minute sessions. There was no difference in outcome between the 2 groups at treatment completion.
  • Although participants in the 90-minutes sessions exhibited greater habituation to trauma-related stimuli, this didn’t impact the overall outcome for either group. I interpreted this as further evidence that, contrast to the emotional processing theory underlying PE,  habituation is a poor marker of improvement in exposure. The authors defend between-session habituation to some degree but admit that it does not seem to be a necessary condition for improvement in PTSD.
  • Very interestingly, even though participants in the 90-minute session condition were receiving twice as much therapy, they did not improve any more rapidly than those in the 60-minute session condition. Both groups completed treatment in the same number of sessions. In this instance, more is not necessarily better.

Summary

This is an extremely important study in that it provides evidence that—for prolonged exposure, at least—not only do people show as much improvement in 60-minute sessions as 90-minute sessions, that 20 minutes of imaginal exposure is no less effective than 40 minutes per session.

Shorter sessions and shorter exposure times can reduce the burden (e.g., time; money) for clients, and it makes it more feasible to offer evidence-based treatments such as PE in settings where 90-minute sessions are not covered.

My hope is that the main researcher and PE core originator, Dr. Edna Foa, does a similar study with her OCD exposure protocol, too, which also relies on 90-120 minute sessions!

If you want to read the full article yourself, the published version is behind a pay wall. However, one of the authors made the “in press” version available here.

Brian Thompson Ph.D.

Author: Brian Thompson Ph.D.

Brian is a licensed psychologist and Director of the Portland Psychotherapy Anxiety Clinic. His specialties include generalized anxiety, OCD, hair pulling, and skin picking.

ACT for Social Anxiety – A Great Self-Help Book and Treasure Trove of Resources

ACT for Social Anxiety – A Great Self-Help Book and Treasure Trove of Resources

I’ll make a confession here: I’m a failure at bibliotherapy. By bibliotherapy, I mean assigning a self-help book to a client and following it along with the client in order to guide treatment. For clients who are interested in self-help resources, I’ll make recommendations for books that clients can read on their own as a complement to treatment, but I feel stifled at the idea of using the book to guide treatment.

The authors of Mindfulness and Acceptance Workbook for Social Anxiety & Shyness have made things much easier for therapists like me. The book is based on a group treatment for social anxiety that has been studied in two published research studies—an initial pilot followed by a randomized controlled trial.

On their website (www.actonsocialanxiety.com), the authors offer a downloadable treatment manual based on their book. The manual is an adaption of the group treatment manual they (Jan Fleming, MD and Nancy Kocovski, PhD) used in their research studies. It includes copies of the handouts, so you don’t have to press your book against the photocopier—which I find a bit of pain to do in the digital age.

If you visit the publisher page on the New Harbinger website and register, you can also download audio files of the exercises (e.g., mindfulness exercises) and a separate collection of the handouts.

I’ve not had a chance to use the book in therapy yet, but I’ve read through it and am very impressed with it. The book is engagingly written, includes interesting exercises, and is relatively concise (I prefer brevity in a self-help book).

For all these reasons, I highly recommend Mindfulness and Acceptance Workbook for Social Anxiety & Shyness. You can find additional resources at the authors’ website and on the publisher’s website (under the “Accessories” tab—but you must register). Check it out—it’s one of the better self-help books I’ve read and the resources the authors provide are extremely generous.

Treating Skin Picking with Acceptance-Enhanced Behavior Therapy

Treating Skin Picking with Acceptance-Enhanced Behavior Therapy

Excoriation or skin picking has often been in the shadow of its nearest relative, trichotillomania or repetitive hair pulling. One good thing to come out of the DSM-5 was that it finally made skin picking disorder an official diagnosis—excoriation. Prior to the DSM-5, there was no official diagnosis for this condition. I suspect the lack of official diagnosis slowed research into skin picking disorder. As a consequence, there are few published treatment studies for excoriation.

A recent study looked at the use of an acceptance-based protocol that was originally created for trichotillomania. The protocol is Woods & Twohig’s Trichotillomania: An ACT-enhanced Behavior Therapy Approach therapist guide, part of the respected Treatments That Work series of treatment manuals published by Oxford Press. The protocol combines Habit Reversal Training (HRT) with Acceptance and Commitment Therapy (ACT). From the study description, the protocol remains largely the same as the published trichotillomania version, except that information about hair pulling is swapped out for skin picking.

The study

Four people with excoriation completed courses of AEBT. Three of the four completed treatment in 10-sessions—the standard protocol length—whereas the 4th completed 25 sessions of treatment. All four responded to treatment, although the individual who completed 25 sessions (“Rose”) struggled with periodic lapses (sudden increases in picking) during treatment. Of note: one of the primary treatment responders (“Amy”) completed all but the initial session through web-based video-conferencing. Treatment appeared to successfully address both skin picking as well as co-occurring problems including anxiety, depression, and life stress.

Because this is a small, uncontrolled study, results should be interpreted cautiously. However, it provides some additional evidence that the AEBT protocol is as effective for skin picking as it is for hair pulling. One prior multiple baseline study of AEBT included 2 participants with skin picking and also found reductions in pulling.

For therapists interested in treatment excoriation and trichotillomania, the AEBT protocol is a commercially available and flexible treatment manual with very good research support for hair pulling and some very promising evidence for its use in treating excoriation. Additionally, this study provides some evidence that treatment produces changes in conditions that are co-morbid with picking such as anxiety and mood problems. I draw from the treatment manual in my own practice and have found the handouts and treatment framework particularly helpful.

If you’re interested in reading the full study, you can download a pre-publication copy here.

UPCOMING TRAINING EVENTS


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 11, 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.

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

May 13th, 2022Implementing Culturally-Attuned & Anti-Racist Psychedelic Therapy: Impact over Intention with Jamilah R. George, M.Div, M.S.