CBT for Anxiety

Anxiety disorders are the most common mental health complaints.
If you’re feeling nervous, worried, or on edge, please know that you’re not alone.

It’s important to remember that anxiety is totally normal. Anxiety comes from our fight-flight-or-freeze response, which has evolved over time to keep us safe. In ancient times, humans encountered threats like predators (think mammoths and tigers) and warring tribes. That fight-flight-or-freeze response kept our ancestors safe in those situations by triggering a rush of adrenaline, rapid heart rate, sweating, and other physical symptoms. If humans didn’t have that response, we wouldn’t have survived.

Today, however, many of the threats we encounter are less visible. We worry about things that might go wrong in the future. We fear failure at work or school, disappointing others, the safety of people and animals we love. And yet our bodies still respond with that same fight-flight-or-freeze response. It’s the right response but it’s happening at the wrong time because the threats are in our minds, not out there in the world. Those physical symptoms can’t help us battle those threats.

ANXIETY DISORDERS

There are several different anxiety disorders, including generalized anxiety disorder, social anxiety disorder, specific phobias, and panic disorder and agoraphobia.

Anxiety disorders are characterized by symptoms like:

  • uncontrollable worry
  • feeling restless
  • irritability
  • difficulty sleeping
  • stress
  • feeling overwhelmed
  • panic attacks
  • overthinking
Although we don’t fully know why some people struggle more with anxiety than others, research suggests that both genetics and the environment play a role. Some researchers suggest that on average, about 30% of the variance in anxiety can be explained by heritable genetic factors. So while this means that anxiety disorders do tend to run in families, MOST of that variance is due to the environment (so if you have children of your own, take heart in knowing that the bulk of the factors that explain anxiety are modifiable).
Often early experiences leading to beliefs about uncontrollability and unpredictability, combined with a genetic risk, play a role. You may have had experiences growing up that caused you to believe that the world is inconsistent and that you don’t have control over what happens to you. In response, you may have developed perfectionistic tendencies, a sense of over responsibility, and strategies to try to control your world that just aren’t working any more.
We use primarily Cognitive Behavioral Therapy (CBT) and exposure and response prevention interventions for working with anxiety.

CBT is based on the idea that thoughts (cognitions), behaviors, and emotions all work together. To decrease anxiety, we work with clients on several different strategies to change negative thoughts, including developing a more flexible, realistic mindset, mindfulness skills to slow down and become aware of the impact of negative thoughts, and learning to tolerate uncertainty. We also work with clients to set behavioral goals to gradually face feared situations and decrease avoidance with exposure therapy. This helps our clients to get unstuck and move forward in living a life they love.

It’s important that our work in therapy is collaborative. We know a lot about CBT in general, but you are the expert on your own anxiety. In our initial work, you’ll develop a treatment plan and a shared understanding of your symptoms with your therapist. By combining your knowledge, you and your therapist will take general principles and strategies and start to understand how they apply specifically to you.

CBT for anxiety is an active, skills based treatment. It’s meant to be a time-limited intervention so each of your sessions is productive and focused on helping you develop new skills and strategies for dealing with anxiety. There will be information, in session practice of new coping skills, and homework and worksheets between sessions where you’ll get a chance to put the ideas you talk about with your therapist into action. Our goal is to teach you as much as we can about CBT so you can work toward being your own therapist.

Therapy for OCD

OCD

Obsessive compulsive disorder can cause a lot of distress and get in the way of you living the life you want. If you’re dealing with these symptoms, we know you’re struggling with a unique kind of misery.

We have an idea from mainstream media what OCD looks like. The typical example involves fear of germs or maybe having things arranged in a certain way or put in a specific order. But OCD can actually look really different from person to person.

The symptoms that define OCD involve both intrusive thoughts and rituals/ compulsive behaviors. OCD sets up a cycle of anxiety through obsessions (the thoughts) and behaviors done to cope with the anxiety (the compulsions) that comes from the obsessions.

The cycle starts with an intrusive thought. Intrusive thoughts are unwanted thoughts that pop into your mind and present some kind of negative outcome. The content of this thought can be anything. It might be about germs or getting dirty but it might also be about making a mistake or a worry that you said the wrong thing or that your partner doesn’t love you (or that you don’t love them) or that you did a terrible thing in the past. These thoughts are scary and bring up anxiety.
Compulsions or rituals are the behaviors (including mental rituals) that are done right after the intrusive thoughts to manage anxiety.

The typical example is cleaning or checking the doors or the stove. Other common behaviors are taking photos to have evidence that you did something, internet searching, and avoidance.

We also very commonly see mental compulsions/rituals.. When we talk to people who describe overthinking, many times what’s actually happening is a mental ritual. Rumination, worry, figuring it out, replaying past events, and self-reassurance are all examples of mental rituals. Rituals might involve trying to figure out why you have these thoughts, what they mean about you as person, if they’re true or not and how you can find out if they’re true.

If these symptoms sound like you, feel free to schedule your free 15 minute consultation.

Examples of common obsessions and compulsions

Some common obsessions include:

  • Fear of contamination from germs, bodily fluids, or household chemicals
  • Fear of losing control and acting on an impulse to blurt out something inappropriate or an impulse to harm someone
  • Fear of harming others through not being careful enough or being responsible for something terrible happening to others (fire, burglary, dropping something that might cause someone to trip and hurt themselves)
  • Fear of forbidden sexual thoughts (about incest, children, homosexuality, or aggression)
  • Fear of offending God or concerns about morality
  • Fear of developing a serious disease
  • Perfectionism, including fears of losing or forgetting things, indecision, and concerns about evenness

Some common compulsions/rituals include:

  • Washing and cleaning
  • Ruminating
  • Figuring it out
  • Internet searching
  • Mental review of conversations or interactions
  • Prayer
  • Counting or special numbers
  • Checking
  • Arranging things until they feel “right”
  • Repeating body movements (tapping, blinking)
  • Repeating routines (setting items down, getting in and out of chairs, going through doors)
  • Seeking reassurance from others
The gold-standard intervention for OCD is called exposure and response prevention (EX/RP).

This treatment has decades of research to support it and is the most effective strategy for decreasing symptoms of OCD. 

Exposure Therapy
Exposure therapy is designed to help you systematically confront things that you’re afraid, giving yourself a chance to learn that anxiety is temporary and the thing you’re most afraid of is unlikely to happen. Exposure is about getting out of old patterns so that new learning can occur. The second part of EX/RP is response prevention. This means working together to eliminate time consuming rituals.

With exposure therapy, you’re always in the driver’s seat. We are right there with you on the passenger side, giving directions, encouragement, and sometimes pushing you out of your comfort zone but you control the treatment process. We work together to develop exposure tasks to help you get the most out of treatment. We never suggest an exposure task that we wouldn’t do ourselves and whenever possible, we’ll do them together to start.

OCD in Children and Teens

Seeing your child struggle is one of the most difficult things a parent can deal with. If your child seems highly anxious and seems to get stuck in anxiety loops, they may have OCD.

Just like in adults, OCD in kids and teens shows up as scary thoughts and a set of repetitive behaviors done to temporarily reduce the anxiety associated with the thoughts. While it’s normal to have scary thoughts from time to time, kids with OCD may seem preoccupied with their fears and overly focused on preventing them.

Common fears or intrusive thoughts in kids include:

  • fears of getting sick or hurt
  • fears of loved ones getting sick or hurt
  • fears of germs
  • fears of being responsible for something bad happening
  • fears of making mistakes

Common rituals or responses to these thoughts include:

  • refusing to be around people, places, or things that might trigger the thoughts
  • checking doors, locks, appliances, or candles over and over
  • repeating certain behaviors until it feels right
  • repeatedly asking for reassurance that things will be okay
  • insisting that family members do certain things or avoid certain things in order to prevent their anxiety
You might also notice your child becoming highly anxious when confronted with a trigger, rigidity around routines or schedules and needing to know what’s going to happen next, having difficulty sleeping, or having more headaches or stomach aches than usual.
You may feel overwhelmed by your child’s anxiety and unsure how to help. We’re here to help. If your child is experiencing any of these symptoms and you’re concerned, please schedule an your free 15 minute consultation.

Social Anxiety in Teens

Intense anxiety in social or performance-based situations is the hallmark feature of social anxiety.

Some social anxiety is typical for children and teenagers. Increases in self-focus and feeling self-conscious at times is a part of normal development. However, if your child is extremely nervous about spending time with peers, going to school, parties, or practices, starting or maintaining conversations with other kids or adults, being the center of attention, interacting in small groups, or speaking in class, they may have social anxiety. Older teens may struggle with dating situations or finding a job.
Kids and teens with social anxiety often worry that they will say or do the wrong thing and embarrass themselves. They may worry for days or weeks in advance about upcoming events. They might have stomach aches or irritability ahead of time and freeze up, blush, sweat, or tremble during social situations.

Many kids with social anxiety also do whatever they can to avoid social situations.

They may complain of feeling sick and ask to skip the event or stay home from school. If they can’t avoid these situations, they endure them with a lot of distress. Your child may ask you for a lot of reassurance before attending these kinds of events, wanting to know who will be there and how long it will last or they may insist that you go with them to the event. While avoidance might work to alleviate anxiety in the short term, in the long term your child is likely missing out on important life experiences that are key for social development and maintaining anxiety.

CBT for social anxiety in kids and teens involves developing new skills and strategies for dealing with anxiety.

These skills might include learning to identify negative thoughts or expectations that are getting in the way, practicing relaxation techniques, and problem solving to start taking small steps toward facing fears.

If you think your child is struggling with social anxiety disorder, please schedule a free, 15 minute phone consultation with our care coordinator.

Health Anxiety

Health anxiety refers to excessive worries and preoccupations about physical sensations or symptoms and their meaning.

This type of worry used to be called hypochondriasis but now is called Illness Anxiety Disorder. Health anxiety feels like extreme anxiety as a result of physical sensations, including changes in heart rate, pains, headache, dizziness, shortness of breath, urgency to urinate, or other uncomfortable feelings. You may feel preoccupied by trying to figure out what the symptom means and where it came from. You may worry that you might develop cancer, have an aneurysm, or be diagnosed with MS. You might be distracted by continuously checking to see if the symptom is getting better or worse. You may be spending a lot of time on the internet, reading articles and message boards about your symptoms. You might find yourself asking others for reassurance that your symptoms are normal. While this might relieve the anxiety for a short time, a new or different or more intense symptom starts the cycle all over again, leaving you exhausted and miserable.
After ruling out the possibility of a health condition, we use CBT and ERP (exposure and response prevention) therapy to help you get unstuck from the health anxiety cycle.

CBT focuses on helping you change your thoughts and behaviors so that you can get back to living your life.

One of the biggest skills you’ll work to develop with your therapist is your ability to tolerate uncertainty. Human bodies are noisy. We all have changes in heart rate and breathing, pains, twinges, tingling, ringing in our ears, and other sensations. Most people are able to cope with not knowing what these sensations mean. They assume they mean nothing until more symptoms show up and then at some point they may get more information or talk to a doctor. People with health anxiety tend to look for meaning at the first sign of anything that’s different. What does this symptom mean? What could it be? Why is it happening? With your therapist you’ll learn how to cope with these symptoms without jumping to conclusions or needing to know more about them.

Another element of treatment for health anxiety is learning to change your behaviors. Often times people with health anxiety learn to temporarily soothe themselves with behaviors that only make things worse in the long run. For example, asking others for reassurance about symptoms (doctors or loved ones, for example) may make you feel better for a little while but over time you may come to depend on others. In therapy you’ll learn to cope with the anxiety on your own, without checking with other people (or google). You’ll also practice reducing avoidance of triggers so you can do the things you want to do and live a full and meaningful life.

Emetophobia

Emetophobia is an extreme fear of vomiting. Sometimes the fear involves anxiety about vomiting yourself, seeing others vomit, or both. You may also worry that you would be unable to leave a situation if someone vomited. If you have this fear, you may notice a lot of triggers in every day life that make doing your normal activities really difficult. Common triggers include hearing other people talk about being sick, hearing words that describe vomit, using words that describe vomit, and seeing or hearing vomiting on TV. For people with emetophobia, these triggers can result in strong physical reaction or a feeling of panic, as well as ongoing worry about the possibility of encountering future triggers.
If you have these fears, you may have coped by avoiding people, places, and situations that might involve a trigger. You might avoid eating out or situations where food is shared and might be contaminated. You might avoid crowded places or places where people might vomit, like amusement parks or hospitals. You might avoid drinking alcohol or other substances that change the way your body feels or might increase the chances of vomiting. It might be difficult for you to travel by car or plane to visit loved ones, for vacation, or for work.

For people with emetophobia, it’s also common to have developed another set of behaviors to deal with symptoms when avoidance isn’t possible.

These include body scanning or monitoring symptoms that might indicate that you (or someone else) is getting sick. You might engage in worry or trying to figure out if you or someone in your household is sick. It’s also common to engage in reassurance seeking, where you ask others to confirm that they aren’t experiencing symptoms or you check their symptoms (for example, using a thermometer or checking if they feel hot). Excessive washing or cleaning of hands, dishes, cooking utensils and preparation surfaces to avoid contamination that might cause sickness is also common.

If this pattern of symptoms and experiences describes you, you are not alone!

We frequently treat emetophobia can teach you skills and strategies for working with anxiety and living a full life, doing all the things you want to do. Our goal is to help you live a life where you make important decisions about where you go, who you spend time with, and the activities that you do—not your anxiety.

Panic attacks

Panic attacks are sudden and intense rushes of fear or physical discomfort. For many people, the attacks feel like they come totally out of the blue. For other people, the attacks are clearly triggered by something in the environment or by a thought or feeling. Panic attacks tend to reach their worst point after 10 minutes then start to gradually decrease.

Common symptoms of panic attacks include:

  • racing heart
  • tightness in your chest
  • difficult breathing
  • sweating
  • trembling or shaking
  • stomach or GI distress
  • rapid breathing
  • dizziness
  • tingling in hands or feet
  • feeling of derealization or depersonalization
  • fears of losing control, going crazy, or dying

Many people mistakenly think the symptoms of a panic attack are a signal that something dangerous is happening and go to urgent care or the emergency room. After a panic attack, you may start worrying about the possibility of having another attack. This worry may lead you to change your behavior in an effort to prevent another attack. If you had your attack in a certain situation, for example while driving, at work, or in a store, you may start to avoid those places. Over time, you may start avoiding other places out of fear of having the symptoms again. You may start to feel afraid of being alone or going places alone. It’s also common to start to rely on other safety behaviors, for example carrying your phone, water bottle, essential oils, medication, or other objects with you to prevent uncomfortable sensations or another attack.

Therapy for Panic Attacks and Panic Disorder

We use Cognitive Behavioral Therapy and exposure therapy to treat panic attacks and panic disorder. CBT teaches new ways of thinking about uncomfortable symptoms. Rather than interpreting these symptoms as a signal of danger, we work together to practice tolerating and allowing those uncomfortable sensations, realizing that discomfort does not mean danger. We also use a specific kind of exposure therapy called interoceptive exposure. Interoceptive exposures are focused on helping you learn to experience internal sensations in a more controlled way. We’ll practice generating some of your feared sensations on purpose so that your brain can learn a new way of responding to them. In addition, we’ll practice real life exposures to help you get back out into the world and doing the things that matter most to you, like seeing friends, going to a show, shopping, seeing a movie, and traveling.

Online Therapy

Online Therapy for Anxiety and OCD

Online therapy is more widely available now than ever before. If you live in Missouri, you can see any of our therapists online. If you live in another state, you may be able to work with one of our psychologists.

Benefits of Online Therapy

Meeting virtually is a great option in a number of circumstances. Online therapy can be more convenient than in person therapy. If you’re busy, meeting online allows you to meet before or after work, or during your lunch break without using extra time to commute to and from the office. If you work from home or are taking care of children, meeting online allows you to make time for yourself without having to arrange for childcare. If you’re feeling ill or the weather is bad, there’s no need to miss a therapy appointment.

Online therapy also gives you greater choice in finding the right therapist. If you live in a rural area it can be hard to find expert therapists who work with anxiety and OCD. Meeting online means you aren’t limited by physical location in choosing the best therapist for you or your child.

Meeting in your home also has advantages that may improve your treatment results. For many people, symptoms often occur at home. We’ve found that being able to work together in the environment where triggers occur naturally allows us to guide you through skills in a more hands on way. For some people, a fear of driving or other symptoms may make it hard to leave your house. With online meetings, we can temporarily bring therapy to you in your home or even in your car as we work on meeting your goals.

Online therapy is Effective

There is now a significant amount of research showing that online therapy works for a number of symptoms, including anxiety, depression, and PTSD symptoms. A meta-analysis from 2017 examined 19 studies and almost 3,000 participants to determine the effect of internet delivered CBT on anxiety depression. Their results showed that the treatment had a significant effect on decreasing symptoms ( https://pubmed.ncbi.nlm.nih.gov/27712544/). Another study in 2018 combined the results from 20 studies comparing online CBT to in person CBT for a broad range of mental health conditions. They found that overall there was no difference in outcomes for people who received therapy online or in person (https://pubmed.ncbi.nlm.nih.gov/29215315/ ). These studies tell us that we can be confident that online therapy works!

What you Need to Get Started
There are few things to keep in mind before your first online therapy appointment. First, test out your internet connection. Make sure you have a strong and stable wifi connection. If your wifi is shaky, connecting directly with an ethernet cable can make a big difference.
(https://pubmed.ncbi.nlm.nih.gov/29215315/ ). These studies tell us that we can be confident that online therapy works!
Privacy and Confidentiality in Online Therapy
Your confidentiality is top priority for your therapist. We use HIPAA secure messaging and videoconference software for our therapy meetings. Before your session, you’ll receive a link that takes you directly to the meeting. There’s no need to log in or download any additional software. For the meeting, it may be best to go to a room with a door that closes and ensure that other occupants of your living space are occupied so you can focus on your session. Using headphones or earbuds can help so that others don’t overhear what your therapist is saying. Interruptions happen, but if you wouldn’t bring your mail person, plumber, or roommate to an in person therapy session, it’s probably best to keep your online sessions private too.

Fees

We are considered out of network providers with insurance panels. Many people are not familiar with using out-of-network benefits and so we try to make the process as easy as possible. We can prepare the paperwork (called a superbill), and help you submit that to your insurance company. You can also use a Flexible Spending Account or Health Savings Account to pay for services, which are tax free funds and can also help to reduce the costs.

The fees for our clinicians range from $105  to $170 and are based on clinician education and experience. You will be responsible for the full session fee at the time of service and then your insurance company will reimburse you based on your out of network benefits.

Working as out of network providers allows us to dedicate more time to your treatment. Rather than trying to see as many clients as possible and spending hours on billing and paperwork, we’re able to focus on you and your treatment. We prefer to use that time to attend conferences, read and discuss new research, consult with colleagues, and ensure that we continue to provide cutting edge therapy based on the newest scientific findings.