Is Exposure Practice More Effective in the Morning?

Some studies have looked at enhancing exposure therapy by administering glucocorticoids, steroid hormones that increase levels of cortisol in the body. The exact mechanisms are not quite understood but studies have found that participants given glucocorticoids show better outcomes in exposure therapy for people with spider phobia (Soravia et al., 2014) and fear of heights (de Quervain et al., 2011). It is speculated that higher levels of cortisol enhance learning during exposure.

Rather than rely on drug administration, a new study researcher Dr. Alicia Meuret and colleagues studied a more naturalistic means to harness the exposure-enhancing effects of higher cortisol. People naturally have higher levels of cortisol in the mornings upon awakening.

In a blog post about the study, Dr. Meuret is quoted:

“The hormone cortisol is thought to facilitate fear extinction in certain therapeutic situations,” said Meuret, lead author on the research. “Drugs to enhance fear extinction are being investigated, but they can be difficult to administer and have yielded mixed results. The findings of our study promote taking advantage of two simple and naturally occurring agents – our own cortisol and time of day.”

Study

In this new study by Dr. Meuret and colleagues, 26 people with panic disorder were treated with 3 sessions of weekly exposure therapy followed by a fourth session 2 months later. Participants collected saliva samples at set points during the day which the researchers tested for cortisol levels.

Findings

Consistent with prior studies, the researchers found that higher cortisol levels were associated with a quicker response to treatment.

Moreover, participants who had morning sessions—when natural cortisol levels are higher—showed greater improvements at the end of treatment and 3 months later than participants who attended evening sessions, when cortisol levels are lower.

Some final thoughts

It’s important to keep these results in context. This was a pilot study showing a large effect in a small sample. Results in smaller samples are more prone to being influenced by outliers or other factors, and this study needs replication in order to be more confident about the findings. In particular, it’s possible that therapist expectancy may have had an effect here, as it doesn’t appear the therapists were blinded to the study hypotheses. Nevertheless, this is an intriguing and interesting study.

Limitations aside this study does suggest that—all things being equal—it might be advantageous to schedule exposure sessions earlier in the morning when cortisol levels are higher. The mechanism is not quite clear, but there is evidence that cortisol may enhance learning associated with exposure.

You can read the original blog post about the study on the Southern Methodist University website.

If you’d like to download a copy of the journal article, it is currently available on the authors’ ResearchGate page.

If you or some you know is struggling with anxiety-related problems, please check out the Portland Psychotherapy Anxiety Clinic.

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.

What Kind of Exposure Do You Want, Goldilocks?

What Kind of Exposure Do You Want, Goldilocks?

Understanding factors that contribute to outcome are crucial as we continue to refine treatments and revise the theories that underlie them. In a study published in the Journal of Anxiety Disorders, Norton and colleagues (2011) examined the role of activation and habituation in exposure therapy. The rationale for study was based on the emotional processing theory, which I’ve written about previously.

By activation, the authors mean how distressed the person becomes during the exposure exercise. Habituation refers to the reduction in distress when someone is confronted with a fear inducing stimuli. I’ve written in greater detail about habituation and some problems in using it as a marker of change. In this study, the focus was on within-session habituation—the degree to which distress reduced during a particular exposure session. In this study, the authors appear favorably disposed towards the emotional processing theory while still acknowledging research that does not support some of its proposed mechanism of action.

The Set-up

The sample consisted of 106 people who were enrolled in studies of a transdiagnostic protocol for a cognitive behavioral treatment for anxiety developed by the first author. The 12-session protocol included cognitive restructuring as well as exposure. According to the article, the protocol can be adapted to a variety of anxiety-related problems. Initial sessions begin with psychoeducation, self-monitoring, and cognitive restructuring, before shifting into 6 sessions of exposure therapy. The remaining sessions shift back to cognitive interventions before ending with relapse prevention. Because of missed session and treatment incompletion, the researchers focused their analyses on the first three exposure sessions.

How Do Activation and Habituation Relate to Dropout and Treatment Outcome?

As the authors examined habitation and activation across three exposure sessions, I’ll step back and focus on the broad findings of the study.

1. Clients were more likely to drop out of treatment if their anxiety was too high or too low during the first exposure session. Dropouts were also higher among those who didn’t show a decrease in anxiety (i.e., habituation) during the first session. (These trends weren’t found in the second and third exposure sessions.)

What does this mean? It’s hard to say for certain, but the findings suggest people with really high anxiety during the first exposure session who don’t experience a reduction in anxiety during the exposure may be at a greater risk for dropping out of treatment. In my mind, it might be worth spending some time preparing clients for this possibility, perhaps even normalizing it.

2. Contrary to what the emotional processing theory predicts, people with lower anxiety overall during exposure tended to have better outcomes at the end of treatment.

This is tricky to interpret, too. The authors suggest that too much anxiety may inhibit treatment, which is not inconsistent with the emotional processing theory.

Should Activation Be “Just Right”?

With so many variables (e.g., three exposure sessions, high/low activation, habituation, dropout, symptom reduction), we should be cautious in interpreting these findings. Should anxiety during exposure like Goldilocks and the Three Bear—not too high, not too low, but just right? Or alternatively, people with high anxiety the first time may be frightened off by treatment, and people with low anxiety may not have been engaged to begin with. Unfortunately, these variables were not manipulated experimentally, so it’s difficult to know what causes what.

Painting in broad strokes here, it does appear that how a client experiences the first exposure session is important. It may be worth processing a client’s experience afterward, responding to any questions or concerns, and renewing commitment to treatment. This study also illustrates how complicated it is to try to understand potential variables when conducting exposure therapy.

A Meta-Analysis Comparing Psychotherapy and Medication for OCD

A Meta-Analysis Comparing Psychotherapy and Medication for OCD

This post was featured on our client-centered blog The Art and Science of Living Well, but I thought it would be of interest to therapists as well.

The post is about a finding from a meta-analysis by Cuipjers and colleagues that looked at studies comparing medication against psychotherapy in the treatment of anxiety disorders and depression. For obsessive-compulsive disorder, the researchers found a clear advantage of evidence-based psychotherapy for OCD above medication.

You can read the post by clicking here, and it includes links to the original article, which you can download for free.

Using ACT to Guide Exposure-Based Interventions for PTSD

Using ACT to Guide Exposure-Based Interventions for PTSD

Some of us at Portland Psychotherapy have a new article that was just published in the September 2013 issue Journal of Contemporary Psychotherapy. This has been a 2-3 year work in progress, so we’re super excited to see it in print.

It came to fruition from my ongoing interest in the use of exposure in Acceptance and Commitment Therapy.

Here’s the Abstract:

Exposure is considered one of the most effective interventions for PTSD. There is a large body of research for the use of imaginal and in vivo exposure in the treatment of PTSD, with prolonged exposure (PE) therapy being the most researched example. Acceptance and commitment therapy (ACT) has sometimes been called an exposure-based treatment, but how exposure is implemented in ACT for PTSD has not been well articulated. Although support for the use of ACT in PTSD treatment is limited to a handful of case studies and open trials, research suggests ACT is particularly useful in flexibly targeting avoidance behavior—arguably the most important process in the continued maintenance of PTSD symptoms. The purpose of this paper is to explore the use of exposure within ACT in PTSD treatment. Through an overview of PE and ACT, and with the use of case examples, we describe how ACT principles and techniques may inform exposure-based treatments for PTSD in order to create more flexible approaches. In addition, understanding exposure within an ACT framework may also contribute to clarifying processes of change.

If you’d like a copy of the article, feel free to email me:  bthompson@portlandpsychotherapyclinic.com

Videos of Exposure Therapy

Videos of Exposure Therapy

A picture is worth a thousand words, so I thought as part of my continuing sequence on exposure therapy, I thought I’d share some videos I like.

I should offer credit to Kelly Koerner and Gareth Holman at Practice Ground, who introduced me to many of these videos through an excellent online exposure training they offered. I’ve done two online trainings through Practice Ground and they were both excellent—I highly recommend checking them out!

Snake Phobia

Anxiety disorder guru David Barlow invited Swedish expert Lars-Göran Öst to Boston to demonstrate his one-shot 3-hour simple phobia treatment for a woman who was extremely afraid of snakes. Öst shows a charming mix of compassion and good humor as he gently guides a terrified woman through the treatment.

Click here to watch the video

Panic Disorder

This is a nice example of a man deliberately exposing himself in public to sensations associated with panic disorder. One thing I like about it is that he acknowledges that it can be uncomfortable to do these things in public, yet he does it anyway.

Agoraphobia

Here’s a video showing a woman with agoraphobia engaging in exposure with her therapist and on her own:

Brief Informational Video

This last one isn’t a demonstration of exposure therapy so much as an informational short. It’s about the best advertisement for exposure therapy I could imagine. Good productions values, brief, filled with helpful statistics, and featuring some of the biggest names in exposure therapy:

UPCOMING TRAINING EVENTS


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 Hilton Garden Inn Portland Airport
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.

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