Tag: <span>CBT</span>

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6 Ways to Tackle BFRBs Outside Your Home

Body Focused Repetitive Behaviors (BFRBs) can often make us feel like we have no control over our behaviors and that we’re at the mercy of an endless cycle.  We pick at our skin, pull out our hair, pick our nails, etc.  We tell ourselves we won’t pick or pull again and then end up falling into the same old habits and routines.  Cue the spiral of shame, frustration, guilt and helplessness. 

Understanding BFRBs

Body Focused Repetitive Behaviors include things like skin picking (excoriation disorder), hair pulling (trichotillomania), nail biting/picking, cheek chewing and more.  Unfortunately, due to the shame and embarrassment caused by these behaviors and the possible noticeable consequences (i.e., bleeding fingernails, bald spots, open scabs, etc.), they are often not reported or discussed.  Therefore, they are not as well researched as many other mental health disorders.  

However, there is enough research to suggest that these can be successfully understood and treated in most cases.  The process of a BFRB often starts with an urge to engage in the behavior.  This urge may result from internal or external triggers such as a sensory cue (itchy sensation), emotional cue (boredom or anxiety), cognitive cue (hair is gray/out of place, nails are too long, etc.) or others.  This is not always within the awareness of the person, making resisting the urge difficult to do. 

Treating BFRBs

When working with a mental health professional specializing in the treatment of BFRBs, the evidence-based treatment is the Comprehensive Behavioral (ComB) Model.  The therapist works to increase awareness of the individual’s internal and external triggers.  They come up with competing strategies to implement once they become aware of their urges.  After practicing these competing strategies, they learn that the urges and the sensations pass and they can successfully get through that experience without further engaging in their picking/pulling/biting.  These strategies might include learning new ways to respond to their emotions, finding other ways to “satiate” the physical sensation, or removal of external triggers (i.e., tweezers) from their view.  The more often they get through this, they experience less intense urges and sensations and more confidence that they can successfully manage their BFRBs.

For anyone who’s tried to get control of their BFRB in the past, they will probably say it’s quite the undertaking.  However, this can be much more challenging when we’re in settings where skills are not readily available.  The good news is that we can still set ourselves up for success even in less than ideal locations.

Choose Strategies You Can Implement

Here are 6 ways you can set yourself up to combat your BFRB outside of your home:

  • Place a visual cue to remind you to implement your strategies.  This could be a post-it note, a picture, a single word, or something else entirely that simply reminds you to use your skills.
  • Have a bag of items handy to serve as your competing strategies.  Perhaps you use a hairy squish ball to pull at, hair ties to pull your hair back, long sleeves to cover your arms or a pair of gloves making it more difficult to pick or pull.
  • Focus on mindfulness strategies, specifically attending to your five senses.  By doing this, you may be able to keep yourself out of “autopilot” and stay attentive to your actions.  Often times our BFRBs present with boredom, anxiety, distress or other emotions we’re experiencing when we aren’t being present.
  • Set aside a few moments to review your goals regarding your picking or pulling.  For example, maybe you want that bald spot to grow back in, or you want your cuticles or other scabs to stop bleeding, etc.  Maybe you just want to feel like you’re in more control of your body.
  • Ask for and use your support system.  This may come in the form of talking to someone who knows your struggles while driving home, putting on a podcast that helps you stay focused on your goals.
  • Put something that serves as a tactile stimulus in these locations. One might use a piece of velcro on the back of your steering wheel, or under your desk at work or school.  Using this strategy, you are providing yourself with a less destructive stimulation for your fingers.

Planning is Key

The cycle of any BFRB can be difficult to break, but with a solid plan in place and consistency in practicing your skills and strategies, it can absolutely be done.   

In order to come up with an effective plan, ask yourself these questions?

  • Am I willing to be uncomfortable and push through the urges in this setting?
  • What will I have access to use/bring?
  • Does someone there already know about my BFRB and support my treatment and strategies? If so, how can I use/ask them for help?

Like anything else worth achieving, it will be a process that will include both successes and mistakes.  If you are already seeking professional help, try adding these tips to your list of strategies.  If not and you’re finding yourself struggling to navigate these unwanted picking/pulling behaviors, seek out a professional who specializes in cognitive behavioral therapy for BFRBs.

*This blog was also published on the Anxiety and Depression Association of America website.

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Telehealth: We love it and you will too

Therapy can greatly help people, but it is a lot of hard work; telehealth can take some of that stress away and make it an easier process for all. Because therapy can be so challenging, we want to minimize the time required to make therapy work for you. This means that you will have more time and energy to pay attention to the things that matter to you. The ease and convenience of telehealth may be the answer we’re all looking for. This post will walk you through what is telehealth, the benefits of telehealth, and if it is right for you.

Telehealth explained

By this time in the pandemic, most of us are familiar with some form of telehealth. Telehealth is simply remote healthcare provided via phone or video conferencing. Telehealth rapidly gained popularity in 2020. However, it’s been around for over a century and has a substantial amount of research supporting its use across many fields. In addition to being backed by science, telehealth has greatly improved the accessibility of quality mental health care. Along with this, we’ve noticed it has many benefits for our patients. Below we’ll discuss what providers and patients love about telehealth and if it is appropriate for you.

What we (and our patients) love about telehealth

Telehealth services for most medical and mental health care were effective long before 2020. However, for insurance, privacy, and other reasons it either couldn’t be used by providers or there was a stigma against it. Now that telehealth has been widely used with patients for years, and science firmly demonstrated that it is just as good as in-person most of the time, we want to point out what makes it so great for us and those we treat. Telehealth:

  • Makes therapy more accessible
  • Therapy is more convenient
  • Allows for patients, both adults and children, to feel safer at home
  • Provides invaluable symptom information, as many symptoms present within the comfort of one’s home
  • Allows for more time and energy to be put towards other important areas of your life


First, and possibly most importantly, telehealth makes therapy more accessible. Not only is it more accessible for many providers, it is more accessible for many patients as well. For example, patients dealing with agoraphobia or trauma may have difficulty leaving their home. Remote appointments mean they don’t have to face their biggest fears just to make it to a session. Those who are physically disabled, chronically ill, or have chronic pain can access the care they need without bringing on a symptom flare. Individuals who are deaf/hard of hearing, have a learning or other cognitive disability can greatly benefit. Remote options allow for the use of captions, screen sharing, chat functions, and more. Remote therapy options (along with legislation like PSYPACT), means we can treat patients in over 30 different states. This provides access to effective care which might not be available in many areas. This list isn’t comprehensive, but you get the idea. Remote options make accessing mental health care possible when, in the past, it might not have been an option for many.


Second, telehealth therapy is more convenient. Even if you’re close to your provider’s office, getting to an appointment once a week can be quite the hassle. Parking, gas, traffic, delays at school or work can all impact getting to your session on time. If your child is the one in treatment, convincing them to go to the office after a long day at school could be a struggle. If you’re very busy, it might be hard to find a regular time that works with your demanding schedule. This is especially true if you have to factor in the additional time for commuting. For college students, scheduling therapy between classes allows opportunities to work on mental health without compromising school performance or social life.


Third, most adults and children not only feel safer at home. Home is often where symptoms are most frequently occurring. With the type of therapy we offer at AWCC, therapy within our patients home can provide invaluable information. Working with someone where they feel safe and experience the most symptoms provides therapeutic opportunities. This allows providers to address specific symptoms in ways that are much more difficult in an office setting. In the past, working with a patient in their home meant we had to charge for travel time. The more time we spend time commuting, the less time we have to see patients. Despite being a small practice, we are passionate about helping as many people as we can. Telehealth allows us to help more patients, across various settings, in ways that work for them.

Leaves time for other things in life

Lastly, as we already stated, therapy is hard. What you get out of therapy is directly linked to what you are willing and able to put into it. Telehealth options are often more accessible, convenient, and can allow for more targeted treatment. This means leaves you with more time and energy to put in the hard work to achieve your treatment goals. Because remote sessions are easier to attend and schedule, they also decrease the likelihood that someone will cancel or miss appointments. This means they won’t be set back a week simply due to scheduling conflicts. Remote sessions also mean that you can still attend an appointment when you otherwise may not have been able. For example, if you have to watch your kids or you’re not feeling well, you can usually get to your computer/phone while at home. Therapy is only effective if someone can engage, so whatever makes it more likely that you can make it to sessions and put in the effort will make it more likely that you will succeed and start to feel better.

Is telehealth right for me?

Do you or your family member deal with symptoms of an anxiety, obsessive-compulsive, depressive, sleep, or trauma disorder? Need help managing a chronic health condition, chronic pain, or an eating disorder? Have ADHD, struggle to keep organized, have trouble keeping up with work/school, or possibly have a hoarding problem? Find that fear or worry keep you from doing the things you want to do in life?

If you answered “yes” to any of the above questions, then you/your family member might be a good fit for telehealth at AWCC.

In addition to wanting help managing one of the many conditions we treat, telehealth requires access to a few things. First, you need a device, such as a smartphone, tablet, or computer, that has a working camera and microphone. Second, you need an internet connection that’s stable enough for video calls. Third, you need a private space to have the sessions in. This can be a home office, empty conference room, car, bedroom, or wherever you have privacy and feel safe. 

Telehealth is a fantastic option for almost all of the patients we see at AWCC. However, it isn’t appropriate for all diagnoses and in all situations. Sometimes, people with more severe symptoms, various disabilities, and/or children younger than 10 years old may require either in-person services or a hybrid option. People with symptoms or a condition that would prevent them from being able to effectively engage in treatment via a video conferencing format are similarly unlikely to be appropriate for telehealth.

All in all, telehealth therapy is a fantastic option for almost all of the patients we treat at AWCC. Time and time again, studies have shown that Cognitive Behavior Therapy, the primary treatment we provide at AWCC, provided via telehealth is just as effective as in-person treatment for the types of patients we see and conditions we treat.


All in all, telehealth can be a great option for most of the patients we see at AWCC. Telehealth can increase access and allow you to engage in treatment where you’re most comfortable. As fall approaches, getting your child to weekly appointments can be a nightmare with after school activities and evening traffic. Telehealth can also mean fewer missed appointments, more flexibility, and more time for you to focus on getting better rather than getting to session.  Telehealth can be the difference between being able to get care or having to continue to suffer without it. Patients with a history of trauma, suffering from conditions such as agoraphobia, who are physically or otherwise disabled, or in locations with few treatment options are prime examples of this.

Most importantly, telehealth mental health treatment is proven to be effective for most, if not all, of the conditions we treat at AWCC. We have seen this first-hand with many patients over the last few years. We would not offer it if we did not believe in it.

Everyone knows video calls can suck, but so can facing the hard stuff in therapy; why not do it in sweatpants?

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Sleep? Who has time for that?

The average human spends about one third of their life either trying to sleep or actually sleeping. By age 80, you will have spent about 26 years in bed. As humans we spend a lot of time sleeping. But, we still don’t fully understand why we need sleep in the first place. What we do know is that getting too little of it can have devastating consequences. We also know that people struggling with the following conditions report having difficulty either falling or staying asleep:

  • Anxiety
  • Stress
  • Depression
  • Chronic Pain
  • And many other health conditions

It’s Sleep Awareness Week and Dr. Antler has studied this necessity for almost a decade, so we thought it would be a great time to help you understand:

  • What is it
  • Why we think we need it
  • What happens when we don’t get enough of it
  • What we can do to improve it

What is sleep?

Sleep is defined as a naturally recurring state of altered consciousness during which we experience reduced muscle and sensory activity. Sleep impacts almost every type of system and tissue within the body. There are four stages that fall into two basic types of sleep: rapid eye movement (REM) and non-REM. Stages 1 through 3 are all non-REM sleep.

  • Stage 1: The first few minutes after you fall asleep; a light sleep with the slowing of your heart rate, eye movements and breath
  • Stage 2: Body more fully relaxes and brain activity slows. Most time is spent in this stage.
  • Stage 3: Deep sleep; body is most relaxed; brain slows further and it’s hardest to wake
  • Stage 4: REM sleep; starts about 90 minutes after you fall asleep; most dreaming occurs during this stage; eyes move rapidly and brain activity is close to waking levels; muscles become temporarily paralyzed (we don’t want to act out our dreams!); heart rate, blood pressure, and breathing increase

Usually, people pass through stages 1 through 3 before entering stage four and this cycle, which usually takes 1-2 hours, is repeated three to four times every night. There are many biological processes involved in sleep. Since we don’t have time to go into that here, if you are interested in learning about these processes, you can find more detailed information from the National Institute of Health. Now that we know what it is, let’s see why we need it and what happens when we don’t get enough of it!

Why do we need it?

Scientists still aren’t entirely sure why we need to sleep and research in this area is still an evolving field. That said, recent studies suggest that it may play a housekeeping role in the brain. This includes removing toxins that build up while you are awake, which promotes better functioning the next day. Other studies have found that sleep may be important to our ability to remember information. Specifically, it allows our brains to process and encode information we’ve taken in during the day. Then, helps us to store that information in our long-term memory for retrieval later. Have you ever struggled to remember things from the previous day after you didn’t sleep well the night before? Poor sleep might be the cause. Though we aren’t certain about why we need sleep, we know a lot about what happens when we don’t get enough of it.

What happens when we don’t get enough of it?

Many people think they must get 8 hours of sleep. However, the range most people fall in is more like 6-10 hours. When we’re younger, we tend to need more. Babies sleep as much as 16 to 18 hours a day, whereas children over 5 and teens need 8-11 hours a night. As we age, our need for sleep decreases, with people over 65 sometimes needing as little as 5-6 hours. Whatever our personal sleep requirement, when we don’t get enough of it we call that sleep deprivation. Sleep deprivation has been extensively researched and the impact it has on your health and functioning might surprise you. When we sleep just a few hours less per night for only a few nights in a row people:

  • Are less able to attend to information
  • Have less ability to complete puzzles or various tasks
  • Struggle to remember information
  • Have difficulty regulating emotions

Beyond just impacting your day-to-day activities, it’s also been shown that losing just a few hours of sleep repeatedly is associated with:

  • Cardiovascular issues and other physiological changes
  • Impairment in weightlifting performance
  • More susceptible to illness due to changes in immune markers

There are many studies that have demonstrated the negative impact of sleep loss, but luckily for us, there are also many studies that have looked at how we can make sure we get the sleep we need.

What can we do to improve our sleep?

Not only can improving our sleep help us to avoid the negative consequences of sleep deprivation, improving our sleep can have a positive effect on our mental health, physical health, and even our athletic performance. So what are some things that you can do to improve your sleep?

One is to practice sleep hygiene. Having good sleep hygiene means everything from setting up a good sleep environment to engaging in daily routines that promote healthy sleep patterns. Some simple things you can do to improve your sleep hygiene include:

  • Set and stick to your sleep schedule (both sleep and wake times)
  • Create and follow a nightly routine
  • Avoid activating things (i.e., large meals, bright light, exercise, caffeine, etc.) in the few hours before bed
  • Restrict in-bed activity to only sleep and sex
  • Ensure you have a comfortable mattress and pillow
  • Keep bedroom at a cool temperature (around 65°F)
  • Block out noise and light

Improving sleep hygiene can help some people improve their overall quality of sleep, yet research suggests that the most effective way to improve sleep quality is through cognitive behavioral therapy (CBT). By combining CBT techniques with mindfulness, relaxation, and sleep hygiene, we help patients to change the way they think about, engage with, and actually sleep. The end result is usually better sleep and better overall physical and mental health! In honor of Sleep Awareness Week, we challenge you to choose one of the sleep hygiene techniques above and implement it throughout this week. Sweet dreams!


The Magic Behind CBT

CBT?  What’s that?  And what do you mean, magic?

Cognitive Behavioral Therapy (CBT) is one of the most evidence-based, well-researched psychotherapies out there.  Honestly, if you search it, you will be bombarded with an insane number of results.  Having so much information available on such a life-changing topic is actually a fantastic thing!  However, it can be problematic for a consumer, as it might simply be too much.  It may be overwhelming to figure out where to start or what you even want to know about it.  That’s where this easy-to-digest piece on the basics behind CBT, what it is and how it works comes in.  

What is Cognitive Behavioral Therapy? 

CBT is a type of therapeutic intervention that focuses on thoughts, feelings, behaviors, and physiological sensations.  Any time we experience a situation, we have thoughts and feelings associated with it.  Then, we may also notice, or not, physiological sensations in response.  Once our body very quickly processes these pieces of information, we react/respond (behavior).  This sounds extremely simple because it really is.  It is not a complicated process once we understand it, but that does not mean that if we are stuck in a maladaptive cycle that it is easy to get out of it.  Let’s run through an example to give real-life context.  We will use the same situation and go through it with two different “people” to show just how much a person’s internal CBT cycle plays a role, even when the situation is the exact same. 

CBT Cycle in Action

The Situation
Someone is holding a dog in their arms.  Picture a dog in someone’s arms; there are no obvious signs of aggression and the dog is small enough that it is possible for their owner to hold it.  

Person A: Adaptive/Positive Experience
Person A sees this dog in the arms of its owner and has an automatic thought about it.  This thought could be something like Oh, look at that cute dog, Isn’t that sweet, or even I hope that dog is okay.  These thoughts will elicit some type of feeling, which could be happiness, joy, care, or others.  Along with these more positive emotions, Person A probably wouldn’t notice anything physiological; however, they’d likely have calm muscles, a normal heart rate, regular breathing patterns, etc.  Behaviorally, Person A may want to approach the dog/owner and ask to pet it or tell the owner they have a cute dog, but at the very least, they may have a slight smile (yes, that’s also a behavior).  Because they left this situation in a positive mood and mindset (and potentially positive feedback from the dog or owner), they are likely to repeat this cycle the next time they encounter a similar situation. Not a problem; there’s nothing wrong with this cycle.

Person B: Maladaptive/Negative Experience
Person B sees the exact same situation and their initial thoughts might be What if they put the dog down?, Did it try to hurt someone and that’s why they picked it up?, or It doesn’t look friendly.  Based on the nature of these thoughts, you can probably assume that they would likely have a different set of emotions.  Person B likely experiences fear and anxiety.  Based on this, they may notice physiological symptoms of an increased heart rate, sweating, muscle tension, upset stomach, etc.  It is highly unlikely that Person B will respond with the same behaviors as Person A. Instead, they may try to quickly walk past the dog/owner, cross the street if that’s possible for them, or even turn around and escape entirely.  When they leave this situation, they will no longer be experiencing fear or anxiety; instead, they will experience a sense of relief and safety.  Because they experienced this relief, they will also be more inclined to repeat this cycle when they encounter a similar situation. This, however, can turn into a problematic response if this happens every time they see a dog.

What’s wrong with escaping an anxiety-provoking situation?
It is sometimes encouraged to escape certain anxiety-provoking situations. In fact, there are absolutely certain situations that escape is necessary for survival! However, when our need to escape less threatening situations starts interfering with our lives, it becomes problematic and we need to learn how to respond differently. 

How does CBT help?

The whole idea behind CBT is learning how to respond differently, while challenging the negative thoughts along the way.  When we do this, we start to learn that our thoughts are not always facts and may or may be true.  We also begin to learn that those negative emotions and unpleasant physiological sensations we’re experiencing, don’t stay around forever!  Once this is understood and learned, a person becomes much more empowered and can look at various unpleasant situations through a new lens.  Not sure what I mean? Let’s get back to the example of Person B to show it more clearly.

Person B: Breaking the maladaptive/negative cycle
Person B will still see the dog and begin their initial thought process.  In turn, they will experience the distressing emotions and physiological sensations.  However, instead of running away or escaping, they respond differently and approach the situation.  At this point, Person B makes a conscious decision to go toward the dog/owner.  As they approach, their anxiety and fear may temporarily increase; however, if they stop to chat and/or even keep moving at a calm pace past the dog/owner, their anxiety will slowly begin to decrease.  Now, this might not seem like a big deal at all, but it was actually a great educational moment.  Instead of avoiding something they feared, Person B chose to actively approach it and they were able to learn a few things. 

  • Their emotions ebb and flow and they can tolerate those changes 
  • Their physiological symptoms ebb and flow as well 
  • They can respond in a different way
  • Their thought was just that…a thought! 

The dog didn’t get down, the owner didn’t “sick” the dog on Person B and everything turned out okay.  This would not have been experienced had Person B resorted to avoiding the situation like they usually do.  Instead, they are starting to put some cracks in the thought that this situation (and others like it) are threatening.  If they continue to use an approach strategy as often as they can, they will soon learn that their fears about this type of situation may have been exaggerated compared to the actual threat of a situation.  

That’s great, but what if something bad does happen? 
I won’t go into significant detail here, but I’ll do a quick explanation and example.  One could easily argue that driving in a car is dangerous and threatening, but most adults of driving age take that risk daily.  However, if we end up in a car accident (as many of us have or will), why don’t we stop driving?  After all, the danger was just proven to us and something bad did happen!  Well, for a few reasons.  One is that we have had many more times driving when we didn’t get into an accident, so we’re able to see that, although it’s possible, it does not mean it is highly probable.  A second reason is that we may lose our job, social life, family, etc. if we allow this anxiety to prevent us from driving.  Another reason is that we learned that, although it was unpleasant and uncomfortable, we tolerated it!  We were able to handle the situation, problem-solve as necessary and move forward with the understanding that what happened was the exception and not the rule.  So, if Person B experienced the dog getting down, barking at them, or even biting them, they would have learned that they can handle the situation, even if they didn’t like it.  Scary things happening to us doesn’t have to be a bad thing.  They are wonderful learning experiences, even when it’s hard to see that in the moment.  

So, where’s the magic? 
Well, that’s just it…there isn’t any.  We don’t need any magic wands or smoke and mirrors; rather, we simply need to make an adjustment in our actions to make the magic happen!  We are retraining our body and our brain by responding differently and approaching situations instead of avoiding them.  This process alone begins building new pathways in your brain, getting you closer to taking control of your anxiety and fear.  Even though it is a simple process, it can be difficult depending on the severity of the negative emotions and thoughts.  It will take time, patience and practice, but with those things, CBT can do wonders for making significant life changes toward a happier lifestyle!  My challenge to you is this: the next time you’re faced with a fear that you would usually avoid, try looking at it from a new perspective and approaching it instead of avoiding it.  Maybe it’s a phone call you’ve procrastinated, or an assertive discussion you’ve been debating, or even looking at a bug outside.  Whatever it is, see what happens if you approach it.  Good luck!