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Evidence-Based Treatment Options

Cognitive-Behavioral Therapy (CBT) is an umbrella term used to describe interventions that operate under the belief that negative feelings and behaviors result from the way you perceive and interpret situations around you, rather than the situations themselves. CBT is structured, goal-oriented, and educational, with the goal of helping you to identify, evaluate, and modify unhelpful thinking patterns and behaviors. This approach empowers you to become your own therapist and problem-solver, so that you not only feel better, but stay better.  

Introduction to CBT

1. You text a friend, and they don't respond.

2. You text a friend, and they don't respond.

3. You text a friend, and they don't respond.

4. You text a friend, and they don't respond.
1. "Did I say or do something wrong? Is she mad at me?"

2. "Is she okay? What if she was hurt/in an accident?"

3. "She's probably busy.  I'll check in with her later."

4. "She's always doing this! Is it that hard to text me back?"
1. Anxious (on edge, replaying conversations, poor focus)

2. Scared (racing heart, rapid breathing)

3. Calm (will continue with
daily routine)

4. Angry (feeling tense, raising voice, banging fists)

In the example above, you will notice that the situation remained the same, but the resulting feelings and behaviors varied.  This shows that it is not a situation that determines our emotions and actions, but the way we think about and perceive them.  The goal of CBT is not to think more positively, but to think more rationally about situations, and to strengthen our problem-solving abilities.  In addition to challenging unhelpful thinking, CBT also targets unhelpful behaviors, such as avoidance, checking, worrying, among others.  

Specific Cognitive-Behavioral Therapies

Exposure and Response Prevention (ERP)

ERP is an effective treatment for Obsessive-Compulsive Disorder, as well as other anxiety and avoidance-based conditions.  The goal is to gradually expose you to your obsessions, triggers, and avoided situations, without engaging in rituals to reduce the accompanying anxiety/discomfort.  While initially this is challenging, after repeated exposures, your body begins to gather evidence to gradually disconfirm and/or think differently about a particular fear or sensation.  You may also give your body a chance to habituate to the discomfort you experience in the triggering situation. Think about jumping in a cold pool during the summer.  Initially, the water is cold, and you may want to get out, but after staying in for a period of time, your body gets used to the water.  This is called habituation.  Exposures are done in a hierarchical manner, which allows for your confidence to build as you confront more challenging triggers. 
I take a team approach with clients, helping them to engage in exposures during session first, before collaboratively assigning homework to continue practicing at home.  With treatment, clients feel a greater sense of freedom, independence, and confidence, knowing that rituals/compulsions are no longer a necessary, and time-consuming part of their everyday lives.

Acceptance and Commitment Therapy (ACT)

ACT is another form of Cognitive-Behavioral Therapy, and a helpful adjunct to ERP. The goal of ACT is to increase one's flexibility and openness to experiencing uncomfortable thoughts and feelings, while continuing to engage in behaviors and activities that are meaningful, and in line with one's values.  ACT focuses on being mindful of unwanted thoughts and feelings, without acting on them in ways that will sabotage your ability to lead a fulfilling life.

Inference-Based CBT (I-CBT)

Used to treat OCD, I-CBT defines obsessions as doubts that arise due to a distorted reasoning narrative.  In other words, individuals are reasoning themselves into their obsession/doubt using logic that feels convincing and real, yet has no basis in reality. These narratives involve a distrust of their senses, irrelevant associations, and an over investment in remote and hypothetical possibilities, which together, cause inferential confusion (drawing conclusions that confuse reality with the imagination).


The focus of I-CBT is to help clients identify their own reasoning narrative that has led to their obsessional doubts. Once clients can understand the process that has led to their inferential confusion, they can work to develop alternative narratives that align with reality and their senses, and no longer lead to obsessional doubt.  Without obsessional doubt, the rest of the obsessional sequence no longer exists, including the intense drive to engage in compulsions behaviors.  I-CBT is a cognitive treatment intervention, while ERP is more behavioral based.


The Obsessional Sequence

internal or external

may look like "what if," "maybe," "might be," "could be," etc...

if my obsessional doubt was true, this would mean _______.

what makes the consequence feel so bad?

internal or external behaviors I do to help myself feel better

Comprehensive Behavioral (ComB) Treatment 

Used in the treatment of body-focused repetitive behaviors (BFRBs), the ComB model focuses on the assessment of five key factors/categories (1. Sensory,  2. Cognitive,  3. Affective,  4. Motor,  5. Environment) that contribute to the maintenance of unwanted picking and pulling behaviors, then developing a highly individualized approach for treating each factor.

Treatments involve a combination of sensory substitution techniques, cognitive interventions that target unhelpful thinking patterns, emotion regulation strategies, stimulus control procedures (modifying one's environment), awareness and competing response training, mindfulness, relaxation skills, among others.

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