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


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