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.

Uncharted waters: Expanding a psychotherapy practice in uncertain times.

Uncharted waters: Expanding a psychotherapy practice in uncertain times.

“We’ll never make it!”

Glum from Gulliver’s Travels by Jonathan Swift

It started as early as my first year of college, some 20-odd years ago. I was in an abnormal psychology classroom in Boston, eager to finally get moving on my wished-for career as a psychologist that I had dreamed about for years. A professor I was working with at the time (AKA Dr. Glum) seemed determined to crush my hopes and dreams of becoming a clinical psychologist. “You’ll never make it.” “There’s no future in seeing therapy clients unless you want to work 70 hours a week in a community mental health center.” “And you can forget about getting to do research unless you happen to draw the golden ticket and get an academic job, but those are pretty much going the way of the dinosaur too.” While I might be taking some liberty on Dr. Glum’s actual words, there was a clear message she was trying to impart to us. The field of outpatient psychotherapy practice was on its deathbed and we’d better run the other way, fast!

I’ve heard this mantra of “you’ll never make it” throughout much of my training and well into my career. I still hear it today on professional listservs, among concerned graduate students, and even by those of us practicing in the field. Even just this week a colleague on a professional listserv posted a link to short cartoon about the futility of attempting to become a clinical psychologist. I found the video both somewhat offensive and tired– it’s still beating the same old “you’ll never make it” tune.

Of course much of what is being said has merit. We do have the problem of too many psychologists compared to demand. And we do need to be responsive to the changing landscape of healthcare in our country. But, is it impossible for a resourceful, skilled, well-trained psychologist to be successful in developing an outpatient clinical practice in this era? I choose to believe ABSOLUTELY NOT!

In fact, we here at Portland Psychotherapy continue to expand. We continue to invest in the concept that there will be a continued demand for quality, science-based outpatient psychotherapy. And I believe that demand extends to those in solo private practices as well. I know we are often looking for referrals to other providers who practice science-based psychotherapy and are frustrated when our “go to” referrals are often full. There is, and I think there will continue to be, demand for clinicians who are exceptional at what they do.

So rather than giving up, maybe the thing to do is focus on what makes us unique. In the case of clinical psychology, what I think us unique among other mental health providers is our strong foundation in and commitment to science. That means not only practicing “evidence-based” therapy, but also “science-based” therapy. For me, that also means being a true scientist-practitioner, one whose clinical work is informed by research. And just as science is always progressing, so too does our field need to continue to progress.

I maintain that all of the fear-mongering that’s been tossed around for at least the last 20 years is both destructive and disingenuous. Even with the glut of psychologists, it’s not like people are going unemployed. The APA Center for Workplace Studies reports that less than 1% of psychologists (Ph.D. or Psy.D.) can’t find a job. Dr. Glum was wrong! It is possible to develop a thriving clinical practice. It’s even possible to research in private practice, like we do at Portland Psychotherapy. So, if this is your passion, become exceptional at what you do, focus on what makes your contribution unique, and be resourceful. Rather than trying to scare off our competition with the “you’ll never make it” cries, join forces with other like-minded colleagues who are dedicated to being exceptional at what they do, let others know about your excellent work through good marketing, and work together to help support each other.

Counseling Today article on the ongoing debate about the role of evidence-based practice

Counseling Today article on the ongoing debate about the role of evidence-based practice

On a professional listserv, I learned an esteemed colleague Trent Codd, Ed.S, was quoted in a recent article called “Proof Positive” published in Counseling Today, a core publication for the American Counseling Association. Trent is the founder of the Cognitive-Behavioral Therapy Center of Western North Carolina in Asheville, NC. I see Trent at conferences and am part of a committee he chairs for the Association for Behavioral and Cognitive Therapies. He also interviews top notch professionals in his podcast at BehaviorTherapist.com. He’s a busy guy!

The topic of the article is the role research should play in the counseling profession. This is an often contentious issues that’s been brewing for decades. It’s grown more heated as various agencies are increasingly pushing for treatments with significant research support.

I have a great deal of respect for Trent and was impressed with his willingness to confront difficult issues in a direct and tactful manner. For example, Trent cautions that lack of awareness about research can result in therapists using ineffective and even harmful treatments with clients. He uses Critical Incident Stress Debriefing (CISD) as an example of a widely used treatment that may actually hinder recovery from trauma but is used by therapists who may be unaware of the research. (If you’re interested, I wrote a blog post summarizing the research literature on CISD for the blog Psychotherapy Brown Bag.)

Of this problematic divide between research and practice, Trent says:

“I wish I knew what to recommend to remedy this problem,” he says. “This is something that I’ve spent quite a bit of time thinking about over the years. I think the only thing that will make a difference is a change in the professional counseling culture. The bottom line is that we, as a profession, are going to have to agree that this is important. Unless that happens, I don’t think much change is going to occur.”

 

The tension between people who believe psychotherapists should be more bound to empirical evidence and those who want to be free to practice however they want is an issue that boils over in professional listservs and publications from time-to-time. I think this recent article is a good encapsulation of both sides of the debate. You read it for yourself here.

Renouncing “reparative therapy”: A giant in the field admits his humanity

Renouncing “reparative therapy”: A giant in the field admits his humanity

Robert Spitzer, MD, one of the most influential voices in modern psychiatry, readily admits that he has always been drawn to controversy. He definitely has been at the heart of the controversy about sexual orientation and identity since the 1970s. It was during that time that Dr. Spitzer was instrumental in getting homosexuality removed from the DSM-III thereby declassifying it as a “mental illness.” However, the biggest controversy he may have been a part of was his more recent work on so-called “reparative therapies.” And now his recantation of that work may be one the last (he’s 80 years old now) and possibly one of the most important contributions Dr. Spitzer will make. In an inspiring act of courage and scientific integrity, Dr. Spitzer has written a letter to be published in the Archives of Sexual Behavior in which he states, ““I believe I owe the gay community an apology for my study making unproven claims of the efficacy of reparative therapy.”

The study that Spitzer is referring to is the highly influential 2003 study he conducted and that was published in the Archives of Sexual Behavior (published, it should be noted, without going through the standard peer-review process) in which he concluded that the majority of participants in his study, who were self-selected as being highly distressed about their sexual orientation, reported having changed their sexual orientation from homosexual to heterosexual. The result was a study that has been widely misused for political purposes to state that homosexuality can (and should) be “cured.” While Spitzer has, reportedly, always disagreed with this interpretation of his study, he has now publically denounced the study as being based on flawed science. All of the findings in the study were based exclusively on self-report from a “highly motivated” sample. In addition, this was not a study of the effectiveness of any type of particular therapy–nearly ½ of the participants never even engaged in any therapy at all. Basically, his study, which has been cited for nearly 10 years as “scientific proof” that sexual orientation/identity can be changed, consisted of interviewing people who reported that they had, in the past, been highly distressed about identifying as homosexual and now felt that they were more strongly identified as heterosexual.

Dr. Spitzer is certainly not alone in his criticism of reparative therapies. In fact he is a bit late in his critique. In 1997, the American Psychological Association came out with a resolution specifically stating that there is no scientific merit to claims of therapies being able to change sexual orientation and condemning the practice of such therapies. In 200, the American Psychiatric Association followed suit and published a resolution challenging the “validity, efficacy, and ethics of clinical attempts to change an individual’s sexual orientation.” Just last week the World Health Organization came out with a report stating that these type of therapies are “a serious threat to the health and well-being — even the lives — of affected people.”

The problem with science is that it is conducted by humans, and we humans have our own preconceptions, egos, and agendas that can get in the way of our science. What is heartening is that someone like Spitzer, a giant in the field, can finally take a stand and correct what he has called his “only professional regret.”

Defending behavioral science

Defending behavioral science

A couple weeks ago, the New York Times posted an opinion piece which presented a very pessimistic and narrow view of the behavioral sciences. While I agreed with some of the points of the author, particularly the need for more randomized controlled trials of psychosocial interventions, I also think he “threw the baby out with the bathwater.” While we haven’t solved all the problems of humanity through behavioral science research, we have managed to discover a range of interventions that have been shown to work.

In response to the NY Times article, a local colleague and friend at Oregon Research Institute, Tony Biglan, wrote an excellent response. In his post, he outlines some of the research-based intervention that have been shown to work.

In a time of decreasing funding for research and particulary for behavioral research, it’s important that we advocate for the importance of science-based psychotherapy and related psychosocial interventions. If you like this piece, consider passing it on, blogging about it, or tweeting it. There are buttons right at the bottom of this page that make it easy to pass along.

UPCOMING TRAINING EVENTS

An Introduction to Exposure Therapy for Anxiety Disorders: Traditional and Inhibitory Learning Approaches

Dr. Brian Pilecki
January 29, 2021 from 12:00pm-1:30pm PST
Exposure therapy is the gold-standard treatment for anxiety and obsessive compulsive and related disorders. The aim of this workshop is to provide a solid foundation in theory and knowledge for those newer to exposure therapy. This workshop will include a brief history of exposure therapy, including a description of its roots in classical and operant conditioning. Read More.


Using Acceptance and Commitment Therapy to Guide Flexible Exposure

Dr. Brian Thompson
February 26, 2021 from 1-2:30pm

Drawing from the ACT model, participants will learn to conceptualize and create exposure exercises to maximize flexibility. We will explore common pitfalls in using ACT as a context for exposure and how to create ACT-consistent exposure exercises for clients who are skeptical of “acceptance” and appear disinterested when you try to engage them about values. The presenter will use practice-based data to support these principles (Thompson, Twohig, & Luoma, in press). Read More.


An Introduction to Psychedelic-Assisted Psychotherapy for Clinicians

Dr. Brian Pilecki and Jason Luoma, Ph.D.
March 26, 2021 from 9am-12:10pm

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 in therapy using a harm reduction approach. The current legal status of psychedelics will be reviewed, including Oregon’s recent passing of an initiative to legalize psilocybin-assisted therapy. Finally, diversity issues around lack of access for underserved and non-majority populations will be explored. Read More.


How to be Experiential in Acceptance and Commitment Therapy

Jason Luoma, Ph.D.
April 23, 2021 from 12-1pm

Acceptance and commitment therapy (ACT) is, at its core, an experiential treatment, but is frequently delivered in a non-experiential way. Experiential learning involves going beyond verbal discussion, insight, and explanations of experience. But how do we do this in ACT and how do we know when we are spending too much time engaged in non-experiential modes of learning? This workshop will outline a simple model you can use to identify when you are in less or more experiential modes during therapy and easy methods to switch to more experiential modes. You will then have a chance to practice it in breakout groups and get feedback. Read More.


Case Conceptualization in Acceptance and Commitment Therapy

Jason Luoma, Ph.D. and Dr. Brian Pilecki
May 21, 2021 from 12-2pm

This workshop provides a chance to learn concrete methods for conceptualizing cases from the perspective of Acceptance and Commitment Therapy. Formulating a useful case conceptualization is a foundational clinical skill that is essential in delivering effective treatment, and one that can be often overlooked in the process of working with clients. Participants will learn several formats for doing formal case conceptualization outside of session as a means to further develop knowledge and skill with ACT theory, as well as to learn a means to enhance treatment planning. The importance of ongoing case conceptualization throughout a course of treatment will be emphasized, as well as common pitfalls in conceptualizing client problems. Participants will also have a chance to practice newly learned skills with a case in breakout groups. Read More.


ACT Precision Training: In-Session Case Conceptualization in Acceptance and Commitment Therapy to Help You be Focused and Strategic in Your Interventions

Jason Luoma, Ph.D. and Jenna LeJeune, Ph.D
June 18, 2021 from 12-2pm

This workshop provides a chance to learn and practice in-session, in-the-moment case conceptualization of cases from the perspective of Acceptance and Commitment Therapy. This workshop focuses on helping you use ACT theory & in-session clinical markers to make more precise and strategic interventions. The main goal of this workshop is to help you become more adept at identifying in-session client behaviors that are indicators for particular ACT processes that are likely to be most relevant. The workshop uses a process we call ACT Circuit Training, which involves intensive analysis of a video of an ACT session and intentional practice in conceptualizing client behavior and generating possible ACT responses, followed by discussion and feedback. Read More.


ACT Agility Training: In-Session Case Conceptualization in Acceptance and Commitment Therapy to Increase Flexible Responding

Jason Luoma, Ph.D. and Jenna LeJeune, Ph.D
July 16, 2021 from 12-2pm

This workshop provides a chance to learn and practice in-session, in-the-moment case conceptualization of cases from the perspective of Acceptance and Commitment Therapy. This workshop is intended to help therapists be more flexible and nimble in their use of ACT processes, strengthening their ability to fluidly shift as needed between processes within sessions. Therapist learning ACT often develop tunnel vision, focusing too much on particular processes or responding rigidly when more flexibility is needed. 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.

December 11th, 2020 – Ethical and Legal Considerations in Providing Psychedelic Integration Therapy with Brian Pilecki, Ph.D. & Jason Luoma, Ph.D.
January 8th, 2021 – What’s it Like to Trip? The Patient Experience in Psychedelic-Assisted Therapy with Brian Pilecki, Ph.D.
February 12th, 2021 – 5-MEO-DMT with Rafael Lancelotta, M.S.
March 12th, 2021 – What does Psilocybin-Assisted Therapy for Depression Look Like? A Clinical Case Presentation based on a Recent Clinical Trial from Johns Hopkins with Alan K. Davis, Ph.D.
April 9th, 2021 – Gregory Wells, Ph.D.
May 14th, 2021  Research on MDMA and Psychedelic-Assisted Therapy: An Overview of the Evidence for Clinicians with Jason Luoma, Ph.D.