Approach
What is Cognitive and Behavioral Therapy

Cognitive and Behavioral Therapy (CBT), a hybrid of Behavioral Therapy ( BT) and Cognitive Therapy (CT), focuses on modifying maladaptive thoughts and behaviors to achieve psychological change. Behavioral Therapy has it's origins in a cumulative body of work spanning 19th century classical conditioning to Systematic Desensitization developed in the mid 1950s. Behavioral Therapy views psychological disorders as learned or conditioned behaviors that can be unlearned and changed through behavioral modification.

Cognitive Therapy was developed in the 1960s by psychologists Albert Ellis and Aaron Beck. Both Ellis and Beck argued that BT’s hard rejection of the "unscientific" theories and practices of psychoanalysis erred in overlooking the role of cognition in psychological disturbances. Independently they emphasized the role of cognitive process in the development of psychological conditions where “maladaptive” beliefs give rise to distorted interpretations that in turn drive emotional distress. Cognitive therapy looks at how a situation or event is interpreted by the person. Click here. for see a graphic representation of automatic thoughts and core beliefs in Beck’s model.

Today CBT boasts over 30 years of research, validating it’s efficacy and status as the treatment of choice for for a range of conditions. This dissemination has contributed to a dynamic evolution of CBT, as methods have been adapted to the unique characteristics of the conditions being treated. This, in turn, has attracted new generations of researchers with increasingly diverse clinical interests. Unfortunately, competing theoretical and clinical orientations have also emerged, and their co-existence has not always been harmonious. Consequently, modern CBT, in spite of having shared origins and a common foundation is not a unified method but a canvas of diverse approaches and practices.

In recent years, I have also incorporated research from modern neuroscience as well as aspects of the HeadSpace program mindfulness meditation program. In addition to expanding my clinical perspective, both have, without doubt, made my work more effective

Across the spectrum of cognitive and behavioral therapies, in a generic sense, I lean heavily toward the cognitive therapy orientation. But me speciality training in the treatment of Obsessive Compulsive Disorder has most influenced my clinical development, and ultimately lead me to the Inferential Based Approach (IBA)- a new generation of cognitive therapy, developed by Kieron O’Connor, a clinical researcher at the University of Montreal in Canada.

Although my practices have been shaped by these models and practices, time has also taught me that dogmatic adherence to a particular school of thought can be counter- productive. Consequently, I believe that it is important to remain fluid in the application of interventions. Thus, the choice of method will often depend on the anxiety disorder in question as well as the strategic requirements of the particular treatment moment.

For, example, I follow the established protocols of David Barlow’s Panic Control Therapy- a cognitive and behavioral approach that remains the gold standard for the treatment of panic disorder; whereas, I consider the behaviorally-based systematic desensitization to be the first line treatment for phobias, claustrophobia and even blood/injection phobia. At any given point during treatment, however, I will freely and strategically toggle between models and methods, as needed, to best leverage change regardless of the condition I am treating.

Inferential-Based Approach (IBA)

The Inferential Based Approach (IBA), as noted above, was developed by Kieron O'Connor, professor of psychology at the University of Montreal, for the treatment of OCD. IBA represents a significant innovation in cognitive therapy, and, I believe, it is likely the most consequential contribution to the theory and psychotherapy of OCD in the past 30 years. Dr. O'Connor's, research has centered on how people with OCD reason. Unlike the Beckian theory that obsessions are the product of maladaptive interpretations of intrusions, he argued that obsessions were embedded in unique doubting narratives, characterized by a confusion between reality and imagination or possibility.

In IBA, where obsessions are viewed as a drift from reality, exposure is termed “reality sensing”, as there is a re-grounding to what really is vs what is possible or imagined

IBA posits that while in normal doubt, we rely on direct evidence and what our senses perceive, in obsessional doubt, direct evidence and reality are discounted in favor of imagination or remote possibility: If we see dark clouds and wonder if it will rain, that doubt has a resolution. However, re-checking a door that we indeed locked, does not. No amount of checking can resolve a doubt born of imagination and based on distrust of what our senses know: we cannot lock a door that we only imagined to be unlocked.

IBA is more effective, in my experience, in that it drills down into the logic of how obsessions are "constructed" allowing for a much more granular map of process and content than do other models. Knowledge of process undermines imagination and strengthens trust in reality, empowering the person to power past the paralysis of fear that inevitably stands in the way of change. Although IBA was developed and validated for the treatment of OCD, I have found that the approach also nicely augments the treatment of other anxiety disorders, such as generalized worry as well as panic with and without agoraphobia. Even in the case of specific phobias, which respond well to traditional exposure and habituation, IBA can break a treatment impasse, when insidious, obsessional-type narratives are present.

My Approach To Exposure Tasks

Although, I strongly believe in establishing clear and measurable behavioral goals, in my approach, the “C” in CBT, is the figure in the ground of treatment. In behavioral therapy this focus is inverted, where exposure is essentially a stand-alone method. Cognitive therapy emphasizes how meaning enters into the equation, where there are multiple possibilities of interpreting situations. As such, exposures are viewed as behavioral experiments to test alternative "hypotheses". In IBA, where obsessions are viewed as a drift from reality, exposure is termed “reality sensing”, as there is a re-grounding to what really is vs what is possible or imagined. I generally frame behavioral goals through the lens of reality sensing, although I also believe that the perspective of behavioral experiments, at times, can be useful. Again, as I explained above, the choice of method or how an intervention is framed is fluid and tactical for me.

I do not believe that the unnatural exposures many behavioral therapist still use- such as touching a toilet seat and then licking one's fingers when treating contamination obsessions-are necessary or even appropriate.

I generally reserve my use of language and concepts of "exposure" to the treatment of phobias and panic. When setting up exposures, the goals I establish with clients are, “naturalistic”. That is, I seek natural reset points toward the end of recovering and moving back into “normalcy”. Consequently, in my practice, exposure involves facing what is avoided or feared in the the relevant context, while respecting the individual’s personal values and remaining within the bounds of what is reasonable and culturally acceptable.

I do not believe that the unnatural exposures many behavioral therapist still use- such as touching a toilet seat and then licking one's fingers, when treating contamination obsessions-are necessary or even appropriate. However, I consider the way (ERP) is used to treat tormenting, repugnant obsessions even more problematic. This method involves having clients write out detailed scripts of their tormenting obsessions in which they actually commit the horrific acts they imagine they are capable of and then listening to these torturous narratives repeatedly until “desensitized”. As I explain on the OCD page of this site, I believe that, in addition to increasing the risk of drop out, I consider these exposure methods not only to be misdirected, but also counter-productive and potentially harmful. In the words of a former client when describing such exposures: “it’s like being asked to desensitize to heights by climbing on a unicorn.” In the case of tormenting obsessions specifically, I would say that this is like having to imagine and fully immerse yourself in the idea of being crushed in an elevator [complete with funeral and grieving family] to overcome claustrophobia.

Treatment

Prior to setting up an appointmen tI, I conduct a brief telephone screening, to review anxiety symptoms as well as my methods and practice environment

Assessment Phase
  • Review of assessment questionnaires
  • Review of medical and psychological risks
  • Review of motivation for change
  • Review of symptoms
  • Review of family/biological history
Treatment Phase
  • Psychoeducation regarding the anxiety condition(s) being treated and review of the specific treatment approaches to be used and defining treatment goals
  • Staged treatment modules adapted to the condition(s) being treated are begun, including manuals, handout, graphics supplemental readings, treatment strategies, techniques, tools.
  • Exposures, reality sensing or behavioral experiments are introduced, and progress is tracke though the use of daily symptom logs and task monitoring sheets
  • Treatment setbacks and resistance are regularly flagged and incorporated into the treatment process and goals and strategies are modified and based on this assessment of progress and challenges\
Termination or Extended Interval Maintenance

Once goals are met, treatment either ends or moves into a maintenance phase of extended-interval sessions for a period of time. Therapy sessions at termination typically include:

  • Review of goals achieved and the fundamentals of the treatment model we have used
  • Ongoing review and application of treatment principals post-termination and review of relapse prevention: signs, goals and strategies
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© 2018 Robert Safion, LMHC

Treatment of Obsessional Spectrum Anxiety

6 Harris Street, Newburyport, MA 01950