Blogs Archives - Page 4 of 9 - Mountain Valley Treatment Center

The Work/Rest Cycle in Anxiety Treatment

Posted on May 15, 2023 by scottc

Mountain Valley interviewed its executive program director, Zack Schafer, MS, OTR/L, about how our clinical and residential team balance orthodox ERP with complementary modalities to accelerate and sustain treatment results. Zack’s expertise as a mental health occupational therapist helps him wed the efforts or our clinicians and our residential team in ways that make treatment more approachable, practical, and sustainable.

Mountain Valley: Zack, can you briefly describe what ERP is and what makes for an effective exposure?

Zack: ERP, or exposure and response prevention therapy, is a therapeutic intervention that aims to help someone more adaptively respond to their fear (or other emotion) so they can live with greater freedom and agency. In ERP, the premise is not that fear, anxiety, or other emotions are the “problem” per se, but rather that the challenges arise in our response to those emotions.

For example, let’s take someone who experiences social anxiety and responds to this anxiety by staying in bed and avoiding school, or only agreeing to go out in public if they can listen to music on their headphones. For this person, these attempts to reduce or avoid their anxiety—known as “safety behaviors”—are preventing them from fully engaging in their lives. Over reliance on safety behaviors will also lead to worsening anxiety over time—a kind of vicious cycle. The problem is not that they feel anxious, but rather that they react to that fear ineffectively, leading to increased anxiety and problematic avoidance.

ERP works by exposing someone to the things or situations that trigger their fear (Exposure) and coaching them avoid engaging in their maladaptive “safety” responses (Response Prevention).

To provide an example of ERP intervention, let’s go back to the example of above. For this person, an ERP session may look like having them go into a store without any headphones on or going into a store with the headphones and no music. The degree of challenge of the exposure depends on many factors, but the goal is always the same: we want this person to feel their anxiety fully while refraining from using their headphones or engaging in any other strategies that distract, avoid, or otherwise reduce the feeling of their experience.

There are many different schools of thought and theories about what the “goal” of ERP is regarding habituation, inhibitory learning, etc. At Mountain Valley, we use ERP to help residents experience their emotions and regain a sense agency in how they respond, so they can be free to meaningfully participate in their daily lives.

Mountain Valley: What other modalities, activities, and experiences do we employ here that you would consider either supportive of or complementary to ERP?

Zack: As a program we try to address anxiety from a holistic perspective, so we compliment ERP with psychoeducation, skill building, and an experiential milieu focused on decreasing anxiety, managing stress, and promoting adolescent health and well-being. This includes teaching in the moment anxiety management strategies such as breathing techniques, sensory strategies, and tactics to decrease distress. We educate around lifestyle factors and support healthy participation in self-care, diet, exercise, and sleep. We engage kids in restorative exercises, such as walking in nature, yoga, breath work practices, and journaling. We also seek to engage residents in activities that allow for them to center, contemplate, connect, create, and contribute – experiential principles recognized by occupational therapy as essential for hope, resiliency, and well-being.

Mountain Valley: So I know that strict ERP advocates leaning into a normally anxiety producing situation, fully engaging the feelings of distress it elicits, and doing so without engaging in any safety behaviors, i.e. any coping, self-soothing, or accommodation tactic designed to reduce distress. The idea is largely to develop distress tolerance and, in so doing, to indirectly reduce that distress over time, but as a byproduct of ERP, not as the main goal. When and why do we encourage what might be considered safety behaviors at Mountain Valley such as meditation, therapeutic breathing, ice baths, PRN anxiety medications, etc.? We are both athletes and you once described this relationship between ERP and other strategies using an athletic “work, recover, compete” analogy. Can you describe that again here?

Zack: Yes – that is an excellent point. In the traditional delivery of ERP, the goal is to have the person experience their anxiety fully and not engage in strategies to decrease their distress. However, although we are an ERP program, we also promote coping skills, stress reduction, and positive daily experiences. So, it can sound a little confusing and contradictory. But this is where that “athlete” metaphor comes into play.

In this analogy it’s helpful to think of ERP like “training.” The purpose of training in sports is to condition the body and mind to the demands of the task, build the skills needed to complete the task, and to “stress test” one’s limits. The goal of training in sports is to prepare the athlete for the game or event, just like the goal of ERP is prepare a resident for the “game” of life, where exposures and anxiety can happen anywhere. But in both activities, you have to alternative training with rest for the training to be maximally effective. Any elite athlete will tell you that the quality of your rest is just as important as the quality of your training.

That’s why we want make sure there is a balance between doing hard work and engaging in restorative practices. Making everything a challenge and trying to always increase distress as an “exposure” is not sustainable or realistic. However, always engaging in restorative or pleasurable activities, or always waiting for anxiety to go away before we engage in our life, is also not realistic.

Like many things, it’s about balance. Ultimately, we want to help our residents become more dynamic and adaptable so they can be free from the grip of their anxiety. We want them to feel empowered to embrace their anxiety when it is intense and we want to feel empowered to reduce their anxiety in adaptive ways should they need to – but at the end of the day, the goal is always to promote their ability participate and meaningfully engage in their lives.

Bring It On

Posted on April 19, 2023 by scottc

He who has overcome his fears will truly be free. -Aristotle

I woke up to a bright light and a loud roaring in my ears. I was hunched over, bouncing slightly in my seat. My face was pressed against something cold and hard. Where was I? How did I get here? I started to panic.

While I sat up and groped for my mind, for some clue to my situation, my chest began to heave like a sprinter and my normally sub-40 pulse banged out an urgent 200 BPM alarm in my head. I couldn’t form a thought and my body was clenched, holding on, trying not to fall any deeper into panic.

Even once I realized that I was on a 737 flying from San Francisco to Denver, I continued to grip my tray table as if it was the only thing keeping me from falling 30,000 feet to earth, or, worse, running down the center aisle screaming like a madman. For the rest of the flight I was absolutely gripped with fear, fear that I might spiral again into panic.

It wasn’t until much later that I was able to deconstruct the event, to connect the previous all-nighter in San Francisco and the two compensatory venti coffees slammed just before boarding to this very panic-worthy episode of falling asleep and waking up hyper caffeinated and completely disoriented. Now it all makes sense to me. At the time, though, and for many months later, the episode seemed random, out of the blue, and completely outside of my control. When, I wondered, might my mind and body betray me again.

***

Panic attacks are scary. They can also be self-perpetuating and invasive, insinuating themselves into new situations seemingly at random. Like the sumac we have here in New Hampshire, panic doesn’t always stay put once it takes root; it can send out secret subterranean tendrils which shoot up through the ground to claim random new territories.

Like sumac, the panic that started on that airplane began to generalize to other areas of my life: public speaking, overly formal business conversations, and even phone calls—anywhere I felt that a panic attack might have significant, if mostly social, consequences.

Panic entered my life, ironically, as I was approaching the pinnacle of my career as an elite adventure athlete. While I was calmly risking my life running hundreds of miles at a time in very dangerous places—the Sahara Desert, Taliban controlled parts of Tajikistan, -65°F arctic tundra—I was also developing a profound fear of airplanes, telephones, and everyday conversations. It did not make sense. My hard-won identity as a tough athlete—cool in the face of danger, a master of my own body and mind—was suddenly threatened by this outsized fear of everyday activities. So, who was I now? How might this unpredictable, episodic madness unravel my life and my career? I kept my struggles to myself, afraid that I might be losing my grip.

In order to remain employed and to continue my career as an athlete, I had to fly, I had to talk on the phone, I had to speak publicly. So I continued to muscle my way through these activities as best I could while trying, unsuccessfully, to manage the anxiety and stave off panic. My initial strategies included prescribed medication for public speaking or flying, breathing exercises, and—when possible—avoidance. None of these strategies worked. Some made things worse. Least helpful of all were my attempts to ignore or resist panicky feelings when they emerged. The more I fought those feelings, it seemed, the more they fought back and the stronger they became.

***

It wasn’t until months later that I bumbled into a concept that turned my white-knuckle experiences of flying and public speaking into something vaguely resembling actual exposure and response prevention therapy (ERP)—the clinical modality so successfully utilized by my colleagues at Mountain Valley Treatment Center. I was sitting on the floor of the Las Vegas International Airport failing to be hypnotized by a “fear of flying” hypnosis app I’d recently downloaded to my phone. Instead of dropping, as instructed, into a state of “deeeep relaxation” where the monotone hypnotist’s droll suggestions would insinuate themselves deep into my subconscious mind, I was wide awake, listening with my quite conscious mind, hoping this sleepy sounding guy would get to the freaking point before I had to board that damn airplane. Fortunately, he did.

As feelings of fear and panic approach, he suggested, invite them to come all the way to you. Lean into the feelings, experience them fully, consciously, and completely. Locate these sensations in your body, name them, feel them. Explore them with your mind the same way your tongue might explore the contours of a sore tooth. This guy was a nut, I thought. Invite panic? His approach makes no sense. So I decided to give it a try.

I boarded the plane, took my seat, and buckled my seatbelt. Right on cue, when the flight attendant started droning on about oxygen masks and exit lights and life preservers, the usual feelings of panic started to rise in me. But this time, instead of trying to push them back down, I invited them to join me, albeit a bit angrily. “Come on M#@$!* F#@!!!,” I mouthed silently, “bring it on! Let’s see what you’ve got. Okay, there you are, a tickle in my solar plexus, moving up my spine now. My head is filling with cotton and I’m getting dizzy. I’m handling this. Come on heart, you can beat faster than that. Is that all you’ve got? Bring it on!”

I wasn’t very nice to those feelings, but once I invited and engaged them, they proved less formidable than I’d thought. I did not fall from the sky. I did not run down the center aisle screaming like a madman. As I practiced this approach on subsequent flights and other high stress events, the feelings continued to show up, generally, when expected, but now they more or less moved along, they passed through me; I wasn’t there to block their path anymore. I stopped cursing my feelings and started engaging the feelings with calm, curious detachment.

As my sense of confidence and mastery over these feelings developed, it occurred to me that I had already been applying a similar mindset to other areas of my life for years. As an athlete, external challenges—a mountain, a race, a contest—elicited a sense of competition, of complete engagement, of “bring it on” defiance. But it had not occurred to me to apply that same mindset to “fear itself,” as Roosevelt put it, i.e. to an adversary that was fundamentally internal rather than external.

In the authoritative ERP training manual we use at Mountain Valley Treatment center, Exposure Therapy for Anxiety: Principles and Practice, by Brett J. Deacon and Jonathan S. Abramovitz, and Stephen P. H. Whiteside, this mindset is referred to literally as the “bring it on attitude.” During intentional exposures to highly distressing or triggering situations, the authors suggest that “instead of trying to resist or control unwanted or fearful emotions and experiences, patients should focus on better tolerating, accepting, and even welcoming these experiences…” This combination of exposure and full emotional engagement is at the core of exposure therapy. The “bring it on attitude” toward anxious feelings is the catalyst that activates exposures, making them therapeutic rather than simply unpleasant.

Once I recognized the connection between the challenges of adventure and the challenges of panic, my experience of anxiety actually began to shift from a threat to be avoided to an adventure to be engaged. A contest. Once I reframed them as adventures, my internal “anxiety expeditions” (what I now understand as “exposures”) became even more gratifying than my other expeditions, which were more dangerous but less scary. This, frankly, felt more badassed to me. When you successfully climb a mountain, it doesn’t make the mountain smaller. Instead, it makes you a mountaineer—freer to go where you want and to do what you want to do. That is the point of exposure therapy.

***

Several months ago, a very talented occupational therapist was considering a position at Mountain Valley. I knew that taking the position would move her from her high-level research and organizational work, back into the trenches of clinical care for highly anxious adolescents. It would be a huge change and a significant challenge, but her gift for clinical work was obvious and I hoped she would take the job. A few weeks after her initial interviews, I checked in with her.

“So, what are you thinking?” I asked.

“Well,” she answered, “honestly, I’ve been thinking a lot about it, Will. I’m just really nervous about the job.”

My heart sank. I understood her concerns but I was so disappointed. She would have been an incredible hire for Mountain Valley. While I tried to mask my disappointment and formulate a positive response, Kevi finished her thought.

“So I think I need to take the job.” In other words, bring it on!

For me, that interaction sums up the core of our philosophy at Mountain Valley: the evidence-based notion that engaging fear is the best way to flip it on its head, transforming anxiety from disability to ability, from enemy to ally. When our residents bravely engage in this work, as they routinely do, their personal Mount Everest of fear doesn’t necessarily get any smaller. Instead, they become mountaineers—confident and free to live the adventure they want.

Bring it on.

Dropping Anchor: Sitting With Distressing Thoughts and Engaging With the Moment

Posted on April 13, 2023 by scottc

At Mountain Valley, we work to incorporate strategies to help residents embody the “bring it on” ERP philosophy into their everyday lives. It is common for people to try to avoid, get rid of, or otherwise disengage themselves from their distressing thoughts and feelings. However, what you resist often persists. The counterintuitive way of managing these distressing thoughts and feelings is to lean further into the experience.

One of the tangible skills we use to teach this concept is “dropping anchor,” which stems from the Acceptance and Commitment Therapy (ACT) framework. Dropping anchor is used to help someone stay in the storm of their distressing thoughts and feelings so they can continue to engage in the moment. Rather than try to avoid or get rid of the thoughts and feelings, dropping anchor encourages one to lean into their experience – to name it, acknowledge it, feel it, and move through it.

ACE, or Dropping Anchor, in Acceptance and Commitment Therapy

Dropping anchor uses the acronym ACE to depict the steps one should take when trying to stay present with their emotions of the moment:

Acknowledge your thoughts and feelings – Try to be curious about what is coming up inside of you. What thoughts are you having? Can you say them aloud? What feelings are you experiencing? Can you name them?
Come back to your body – While acknowledging what is going on in your mind in regard to thoughts and emotions, also bring awareness to your body. Can you push your feet against the floor? Is your back up against a chair? Can you feel your hands or wiggle your fingers? Can you notice your breath?
Engage in what you are doing – Once you’re aware of your body, now become aware of your surroundings. Where are you? What do you see? What do you hear? What are you supposed to be doing? What’s the next step you should take?

Leaning into discomfort – naming it, noticing it, moving through it- is not an easy task. It takes practice, consistency, and the appropriate frame of mind mindset. It can be helpful to practice dropping anchor sporadically throughout the day, so it becomes more second nature during times of distress.

However, you engage with this concept, just remember, distressing thoughts, feelings, and emotions are meant to be embraced, not avoided – that’s the secret to turning fear into freedom.

How Sensory Integration Therapy Can Help Your Child

Posted on March 28, 2023 by scottc

Exposure and response prevention therapy, or ERP, is Mountain Valley’s core therapeutic approach. Often referred to simply as “exposure therapy,” this approach is largely what it sounds like—a systematic method of carefully but assertively exposing individuals to the everyday things that cause them outsized fear. Exposure therapy, when artfully implemented, essentially extinguishes the “fear of fear” that is at the core of most anxiety-based avoidance and dysfunction.

But to optimize and accelerate our use of exposure therapy, Mountain Valley utilizes a host of holistic, milieu-based approaches that are based on the highly practical orientation of mental-health occupational therapy. In this article, our executive program director, Zack Schafer, MS, OTR/L, introduces one aspect of this OT-informed program of care: sensory integration therapy.

Sensory integration therapy allows us to understand each resident’s unique sensory profile so that we can customize their exposures for maximum effectiveness. Our sensory work also provides residents with the insights and skills necessary to take charge of their own sensory processing and integration—i.e. their ability to understand and better regulate their own emotional responses. Since sensory processing difficulties predispose people to anxiety and related disorders, addressing these difficulties is a critical piece of the treatment puzzle at Mountain Valley.

What Is Sensory Integration Therapy?

Occupational Therapy (OT) has a long history with exploring the role of sensory system in human behavior. Dr. Jean Ayres, a clinical psychologist and occupational therapist, first founded Sensory Integration Therapy in the 1970’s. Her original theories, works, and practices have been applied, contested, and developed over the years. Nowadays, the use of sensory based strategies has become more prevalent in the treatment of a variety of psychiatric disorders. We see sensory strategies incorporated for emotional regulation in established therapy protocols, such as DBT TIPP skills. Occupational therapist, Tina Champagne developed her Sensory Modulation program which has been applied in a wide range of mental health institutions as means to reduce the use of seclusion and restraint. We even see sensory-motor approaches being applied in innovative trauma treatments, such as the Sensory Motor Arousal Regulation Treatment (SMART) approach developed in Bessel van der Kolk’s trauma center, by Elizabeth Warren and Andrea Koomar.

Sensory strategies have even gone “mainstream” and seem to be gaining popularity within the general public. We see fidget spinners in the classroom, pop-it’s on every kids back packs, and cozy weighted blankets advertised on Amazon.

But what exactly is sensory processing? How do sensory based interventions work? And what is the practical application of this knowledge for people who struggle with anxiety and OCD?

What Is Sensory Processing?

Let’s start by getting on the same page with a few “simple” definitions. Sensory Processing is one’s ability to perceive, modulate, and organize sensory input to create an adaptive response to one’s environment. In Jean Ayer’s original theory, she referred to this as Sensory Integration. She used the word integration to highlight the fact that we are always receiving a multitude of sensory stimuli, and our brain is engaged a very complex process of organizing this information effectively so we can engage with our environment adaptively. Although sensory integration was the original language used by Ayers, over the years the term sensory processing has become more common. You will often hear this the term used in ways such as “they have a sensory processing challenge,” or you may even hear that someone has a “sensory processing disorder” (*It’s important to acknowledge that despite how often you may hear the terms ‘sensory processing disorder” this is not a formal a diagnosis acknowledged by the American Psychiatric Association [APA]).

Sensory Discrimination & Sensory Modulation

For those who have sensory processing challenges, they often have challenges with two main components of sensory processing: sensory discrimination or sensory modulation. Sensory Discrimination is one’s ability to accurately perceive, identify, and conceptualize sensory input. Examples include one’s ability to accurately recognize their name when it’s called, locate a particular pair of socks within a crowded drawer, or decipher between the taste of something that is cinnamon or mint. Challenges with being able to accurately discriminate sensory information can impact one’s capacity to function in their daily lives.

Sensory modulation refers to one’s capacity to respond to and engage with sensory input in an adaptive manner that promotes self-regulation. This includes one’s ability to attend to certain stimuli while ignoring other stimuli (i.e. focusing on your teacher while the birds chirp outside). It also includes how you regulate your arousal level by either engaging with or avoiding sensory stimuli (i.e. listening to music to help you focus or turning off your TV when trying to read).Within Ayres model of sensory modulation there is the concept of:

Sensory Over-Responsivity:

The individual has a low threshold for sensory input; they are hyper aware of sensory information in their environment, or they experience sensory input to higher degree than others.

Sensory Under-Responsivity:

The individual has a high threshold for sensory input; they may not notice and respond to certain relevant sensory input in their environment.

Sensory Seeking (or Craving)

The individual requires a high intensity or frequency of input in order to maintain an optimal level of self-regulation.

Sensory Avoidant

The individual often has a sensory over-responsivity and thus seeks to reduce the amount of sensory in order to maintain an optimal level of self-regulation.

Sensory Processing & Anxiety and OCD

Now how common are sensory processing challenges in people with anxiety, OCD, and related disorders? In a research article published by McMahon et al. (2019), findings showed significant links between early childhood sensory processing challenges and development of anxiety related disorders later into adolescents and adulthood. Children with sensory processing challenges were much more at risk for developing lifelong anxiety related disorders and the relationship between these two variables was mediated by the individuals capacity for emotional regulation.

In 2022, Houghton et al. (2022) conducted a critical review of available evidence on sensory processing and anxiety and OCD. The results found a high prevalence of sensory abnormalities in children with OCD and anxiety related disorders. Finally, in a recent paper published by Cervine (2023), findings showed a high correlation between sensory processing challenges and those with anxiety and OCD. Interestingly, the study highlighted a unique connection between sensory processing challenges and the specific OCD dimension of symmetry/ordering and the specific anxiety dimensions panic and social anxiety.

All this to say, sensory processing and sensory modulation patterns are a critical component to consider in the treatment of many psychiatric disorders, especially those with OCD and anxiety. In addition, occupational therapists and their expert knowledge of sensory processing are in a unique position help integrate the sensory processing framework within current best practices for the treatment of anxiety and OCD (i.e. ERP, CBT, etc.)

Sensory Processing at Mountain Valley Treatment Center

So what does all this mean for how we approach our care at Mountain Valley? How is sensory processing incorporated into individual and comprehensive milieu-based treatment? Read about how the 3 “powerhouse” senses can help with self-regulation here. And stay tuned for next month’s newsletter, where I will discuss in further detail how integrate sensory processing theory into our OT informed milieu.

Sources Cited:

Cervin, M. (2023). Sensory Processing Difficulties in Children and Adolescents with Obsessive-Compulsive and Anxiety Disorders. Research on Child and Adolescent Psychopathology, 51(2), 223–232. https://doi.org/10.1007/s10802-022-00962-w

Houghton, D. C., Stein, D. J., & Cortese, B. M. (2020). Review: Exteroceptive Sensory Abnormalities in Childhood and Adolescent Anxiety and Obsessive-Compulsive Disorder: A Critical Review. Journal of the American Academy of Child & Adolescent Psychiatry, 59(1), 78–87. https://doi.org/10.1016/j.jaac.2019.06.007

McMahon, K., Anand, D., Morris-Jones, M., & Rosenthal, M. Z. (2019). A Path From Childhood Sensory Processing Disorder to Anxiety Disorders: The Mediating Role of Emotion Dysregulation and Adult Sensory Processing Disorder Symptoms. Frontiers in Integrative Neuroscience, 13. https://www.frontiersin.org/articles/10.3389/fnint.2019.00022

Sensory for Anxiety: The 3 “Powerhouse” Senses for Self-Regulation

Posted on March 7, 2023 by scottc

After reading here about sensory processing and its relevance to the treatment of anxiety, OCD, and other mental health disorders, lets get practical with some basic sensory strategies that can support self-regulation. When most people think of their sensory systems, they think of the five main senses: touch, smell, taste, hearing, and sight. However, through decades of research, occupational therapy acknowledges three additional types of sensory input: proprioceptive, vestibular, and interoceptive.

Additional Sensory Inputs

Proprioception

One’s awareness of their body in space. Each person has tiny receptors in their muscles and joints that are responsible for sending messages to the brain about where one’s body is in space. Thus, proprioceptive input involves applying deep pressure, resistance, or movement to particular joints and muscles.

Vestibular sense

One’s awareness of their relationship to gravity. This includes our sense of movement, balance, and posture. Vestibular input involves any input that moves the head and/or engages the bodies balance system.

Interoception

One’s awareness of their internal body functions. This includes one’s ability to sense their own heart rate, respiration rate, blood pressure, digestion, etc. Interoceptive input involves any input that increases one’s awareness of their internal functional and processes.

Why is this important? Early occupational therapy literature points to 3 main sensory systems that are the critical point of intervention when trying to support one’s self-regulation. These three systems are Prospective, vestibular, and tactile systems. Below is an outline of these systems along with practical “hacks” for engaging these systems as means to manage anxiety and emotional regulation:

Sensory System Type of Input Strategies

[table id=5 /]

“It’s The Thought That Counts”…But Is It Really?

Posted on February 20, 2023 by scottc

For many people who experience challenges with anxiety and OCD, they have limited control over the content of the thoughts that run through their head. In fact, some of the newer neurobiology research suggest that persons with OCD may have a functional impairment in the structures of the brain responsible for “gate keeping” which thoughts reach their conscious awareness.

The problem is, we live in a society that reinforces this idea that “it’s the thought that counts.” We are made to believe that we are responsible for the thoughts in our head, and many people begin to identify themselves with their thoughts or may mistake their thoughts for “truth.”

For example, someone may have a “bad” thought about someone and began to label themselves as a “bad person.” Or someone may be worried about what other people think and truly believe that other people are thinking negative things about them.

In Acceptance and Commitment Therapy (ACT) this concept is called cognitive fusion and is described as the phenomenon of getting “attached” or “entangled” with the content of your mind. This is where typical CBT strategies, such as cognitive restructuring, can be counterproductive to address the anxious thoughts. In ACT, one is encouraged not to try to change, fight, or avoid the thought, but rather acknowledge and observe the thought is happening.

Rather than being the thinker of the thought, one should aim to be the observer who is watching thoughts come and go in their mind. After all, if you are aware that you are thinking something, are you the one thinking it or are you the awareness that’s watching yourself think?

This concept of noticing the thoughts in your head and choosing to observe them rather than engage them, is called cognitive defusion. This ACT based skill is incredibly effective for helping people manage their anxious thoughts in a functional and effective way. With cognitive defusion, the purpose of the skill is to teach people how to live with their distressing thoughts, rather than try to make it go away.

So next time you experience some anxiety, try to defuse yourself from the thoughts. You can do this by stating “I’m noticing that I am having the thought…” creating some space for the notice of the thought. You can also use imagery, such as imagining your thoughts like clouds in the sky passing by or hanging around for awhile. But most importantly, the goal is noticing your thoughts, stay present in the moment despite their presence, and engage in activities that align with your values.

After all, “it’s not the thought” that counts… it’s the way we respond to them.

Hikikomori & The Future of Anxiety Disorders

Posted on February 15, 2023 by scottc

In the 1990s, when I was the young president of an international college with campuses in Tokyo and Osaka, Japan was a country under pressure. There was profound political division, a looming recession, and a surge in crime and terrorism – including the Sarin subway attack of 1995. Despair was so ubiquitous that I was late to work about once a week due to suicide by train – and that was just on my subway line. This social and economic uncertainty increased the perceived necessity to attend a prestigious university, driving admissions standards and tuition costs to unattainable heights. For college-oriented families, failure to gain admission to a preferred college meant, simply, failure, and even academically talented young people were folding under the pressure.

Hikikomori

By almost all measures, the world seemed pretty scary to many Japanese youth in the ’90s, and the resulting fear elicited a number of different reactions.

My high achieving students at Keio and Tokyo University, where I was an adjunct professor, doubled down on their pursuit of safe, traditional corporate jobs. To gain admission into these elite schools, they had forgone high school sports, extracurriculars, and leisure time in favor of grueling and expensive “cram schools,” where they prepped for college admissions exams after school and on weekends until well into the night, often seven days a week.

The quirky kids at the small, funky college I ran – a “kokusai daigaku” with transfer agreements to S.U.N.Y and other American and European universities – came to class wearing pajamas, neon hair, gyrary makeup, and other clear but harmless symbols of their rejection of, and rejection by, mainstream Japanese culture. They enrolled at the daigaku to escape Japan. While I enjoyed my high achieving Keio and Todai students, I loved my funky gakusei – an eclectic crew of smart, sweet, anxious, “square pegs” who refused to give up on themselves just because their society did. They would be okay, I knew, because they were still trying, still fighting. They were still fighting, I suspected, because someone close to them – a parent, grandparent, teacher, aunt-believed in them and would not let them give up.

Another group of Japanese youth also wore their pajamas all day, but as an act of retreat, not rebellion. These young people were termed Hikikomori, by famed psychiatrist Tamaki Saito. The Hikikomoris’ response to a scary world was to avoid it completely. These young people opted out of society by the hundreds of thousands, simply refusing to leave their bedrooms.

The American School-Refusal Epidemic

Now, twenty years later, the U.S. is experiencing similar pressures and a phenomenon not unlike Hikikomori. Like 1990’s Japan, the U.S. is experiencing intense political division, a looming recession, an increase in crime and terrorism, a spike in despair and suicide, and extreme college admissions pressure. Add to all this a pandemic, and we now have our own pajama crisis.

Our version of Hikikomori, aka school refusal, is an epidemic of anxiety-based withdrawal from a scary world. Prior to the COVID pandemic, the National Institutes of Health estimated that as many as 5%, or 2.5 million young people refused school and were, as a result, homebound. According to research conducted jointly by Stanford University and the Associated Press, another 230,000 students never returned to school after the pandemic, and that’s just in the 21 states that provided data.

Japan’s Hikikomori crisis of the 90s and America’s school refusal crisis of today share another common feature – cultural accommodation. Rather than aggressively addressing Hikikomori as the public-health crisis that it was, many in Japan chose to view the massive withdrawal of youth from society as just a modern manifestation of the ancient Japanese ancestral desire for solitude. In other words, they found a way to explain away Hikikomori as a cultural phenomenon. As such, Hikikomori has been rationalized and normalized and, as a result, has gone largely unchallenged.

Similarly, America’s school refusal epidemic coincides with a cultural movement toward safety, protection, and accommodation. These safety responses are not limited to objectively dangerous phenomena, but to any perceived threat, whether physical, emotional, or social. Hyper-protective safety behaviors* are increasingly promoted as culturally evolved safeguards against previously underestimated threats.

Our media and social media provide constant, inescapable reminders of the dangers of daily life, magnifying these dangers to the point that sticks and stones may break my bones, and words, differences of opinion, and microaggressions can also really harm me. Our response to these often-exaggerated threats is to accommodate retreat through safe spaces, school withdrawal, social avoidance, and staying home. Compounding these social forces is the fact that our terrified youth now have the perfect camouflage for their retreat, as homebound behaviors have become suddenly and profoundly normalized post pandemic. The pandemic also provided massive accommodations for retreat through the proliferation of home-based services like video conferencing, distance learning, food delivery, telehealth, and remote therapy.

The 2030 Problem

The problem with extreme accommodation is that it perpetuates and magnifies our fear of objectively harmless phenomena. Uncontested, avoidance responses are self-reinforcing, isolating our youth and decreasing engagement, self-efficacy, and resiliency. Since Japan has a twenty-year jump on this problem, Hikikomori provides us with a window into how this problem might evolve in the US.

Now, two decades after its emergence, Hikikomori has become what the Japanese are calling the “2030 Problem.” Because Hikikomori has gone largely unchallenged, many of the pajama-clad legion from my days in Japan are still homebound. Their parents, many now approaching their eighties, won’t be around much longer to take care of them. What then? To many Japanese, the situation seems hopeless.

The Hope

Assuming, however, as I do, that Japanese Hikikomori and American school refusal are just anxiety-disorders on an epidemic level, the situation for both countries is actually far from hopeless. Clinical research and practice make it clear that anxiety and related disorders are highly treatable; in fact, anxiety is among the most treatment-responsive of all mental-health problems. With clinically significant anxiety, as with most mental-health challenges, it is critical for loved ones and mental health practitioners to begin their intervention by meeting the sufferer where she is. But it’s equally critical not to stay there. In the case of bedroom-bound hikikomori and school refusers, we meet them where they are so that we can leave together.

It is this “leaving together” that is the most important but challenging aspect of effective anxiety interventions, especially in a culture that values comfort and perceived safety above all else. In fact, the most research – supported treatment modality – exposure and response prevention therapy, or ERP – is downright counterculture. ERP is predicated on the simple but profound notion that the only way to overcome disabling fears is to face them, which is easy to say but hard to do. This approach requires enormous courage; courage that we, as caregivers, must first cultivate in ourselves so that our children and our clients can borrow it from us until they are able, through a combination of challenge and support, to develop it in themselves.

The only way to avoid our own “2050 Problem” is to actively challenge the cultural trend toward accommodation and withdrawal. In the fight or flight equation that so often defines anxiety, this constitutes a commitment to fight. We must fight the “two lies of anxiety,” as described by Dr. Ellen Hendriksen in a recent New York Times article: first, that our children’s fears are actual threats; second, that our children are too weak to face those fears. Rebutting those lies requires that we believe in our children’s innate strength, resiliency, and self-efficacy in ways that have become, tragically, counterculture.

I saw this fight twenty years ago in my pajama’d gakusei. I see it today in our Mountain Valley residents and their brave parents. Most of these bright, sensitive people would not describe themselves as fighters or as brave, counter-culture rebels. But that’s exactly what they are. And it will save them.

Mountain Valley’s Narrative Approach

Posted on January 12, 2023 by scottc

CEO Will Laughlin discusses Mountain Valley’s new phased approach to treatment with Executive Program Director Zack Schafer.

Will: Can you tell me how you are using a narrative approach to structuring treatment at Mountain Valley?

Zack: Yes, of course. There tends to be a typical arc to how residents progress through treatment at Mountain Valley. Sort of organic stages that they pass through and benchmarks of progress and growth that are thematically typical but that also vary, of course, per resident. Our assessment of a given resident’s passage through those stages, however, tended to be subjective in nature. So, we have applied a narrative reasoning approach to provide a structured overlay to our program; it consists of three stages, or phases, that more specifically define and sequence the experiences, skills, and competencies that make for a successful Mountain Valley experience. This allows our inputs- both clinical and milieu based- to be more intentional while also making our assessment of progress more objective and concrete. Every resident’s experience here unfolds as a unique story; using a narrative reasoning approach allows us to track and measure that story.

Will: There are three stages, or phases, to this narrative structure. Can you describe each one?

Zack: Sure. As I mentioned, the overlay is informed by the burgeoning body of research called narrative psychology and, more specifically, narrative reasoning- an approach used extensively in the field of occupational therapy. While there are many ways we could have structured our program phases, we borrowed from Joseph Campbell’s hero’s journey because it aligns so well with our foundational modality of exposure and response prevention, or ERP. Specifically, the hero’s journey supports the ERP concept that if you face things you are afraid of, you’re likely to come out the other side a better person and/or more true to who you are and were always meant to be. The way our website states it, facing fears is the best path to “finding the person you’ve always been.”

We call our first phase The Departure. This is when a resident leaves home to come here. It’s a time to settle in and build a foundation for the treatment experience. During the phase, we help residents get used to a new routine, new environmental factors-like the absence of tech, a different sleep/wake cycle, dietary changes, et cetera. Also, before they can do deep therapeutic work, they have to build strong trust and rapport staff, including their assigned clinician. So, trust and rapport building is a real emphasis now and is why there is more accommodation during The Departure than there will be later in the program. This is also the phase in which we establish an initial treatment plan.

The second phase is called The Adventure. In this stage, you’ve settled in and now you are ready face some hard things. This phase is all about facing challenges and actively seeking out opportunities for growth, which is crux of a resident’s therapeutic experience. Typically, our residents encounter one or more turning points during this phase; usually these come in the form of a particularly challenging moment. It’s these moments that often provide our residents with a revelation that allows them to change the way they relate to the world and their own anxiety. This can take the form of a primary event, whether in the form of a planned exposure or an organic, unplanned stressor. It shows up as one big event for some residents and a few smaller crisis points for others. It’s these “adventures” that really help push the resident forward.

The third phase is called The Return. This is less a reference to your literal home than it is to returning “home” to the person you’ve always known yourself to be. It’s also about preparing for whatever home will be after Mountain Valley. For some residents that might be college, for others it’s boarding school or a step-down treatment program, and for many it’s the home from which they came to Mountain Valley. This phase is about planning for what’s next and preparing to bring your new skills and confidence with you.

Will: So, just as a resident’s “return” is really a return to who you most authentically are, the “departure” is a departure of old ways of being.

Zack: Yes. You’re departing from familiar and unhelpful patterns of engaging, or disengaging from, a world you’ve come to fear.

Will: What are you most excited about in implementing this new program overlay?

Zack: Because there are defined skills, experiences, and assessment tools built into each phase, this approach helps us focus clinically and more objectively monitor progress. That helps us ensure consistent quality and allows us to pace the program to match a resident’s capacity for change. Also, it gives residents a clearer sense of their own growth; they sometimes express fear that maybe they’re not progressing or that they’re not progressing fast enough. The phases help ground them and see and celebrate their progress. It uses ceremonies to mark and celebrate progress all along the way, not just at the two most obvious big events of arriving and graduating. Finally, and perhaps most importantly, this approach helps bring our therapists into the milieu where their psychotherapeutic work can inform- and be informed by- the work of our residential and milieu staff. This sort of activates our psychotherapeutic work by grounding in real-life experiences.

Will: How did background as a licensed psychotherapeutic occupational therapist inform your approach to this program structure?

Zack: Two big things. First, the narrative reasoning approach. There is a whole field of narrative psychology that has recently gained popularity among researchers and practicing psychotherapists. But narrative reasoning has always been at the core of what we do as OTs. We ask: what’s the story of this individual and how do we weave that story into their therapeutic process? Using story is something that comes naturally to OTs from how we write up our clinical notes to how we implement the therapeutic process.

The second thing is what we call activity analysis and activity breakdown. OTs are really skilled at this process of breaking down an activity into its component parts; we are very strategic about how we deconstruct a life skill so that we can construct a clear and sequential strategy for learning. With something as seemingly simple as brushing your teeth, for example, an OT might ask “what range of motion do they need in their elbows, shoulders, and knees? What kind of sensory tolerance is required? What kind of visual strength is indicated?” Whether a physical, social, or emotional task, we seek to understand every little component, what does it take to do this activity. Our narrative program overlay, therefore, takes the big overarching goal of graduating from Mountain Valley and breaks it down into a step-by-step process. OTs are good at designing a practical, manageable path to achieving things that might otherwise seem very abstract, philosophical, or just really hard.

Will: By the time a resident completes the phases and is ready for The Return, what should they be able to do?

Zack: By the time a resident leaves Mountain Valley, they should be able to do ERP on their own. They now see challenges as opportunities for self-directed exposures and growth. Like, when I’m in Starbucks today can I push myself out of my comfort zone to say something to a stranger? Can I challenge my own fear of judgment? By this point, our residents have rewritten the narrative about their relationship to anxiety. They may have arrived at Mountain Valley thinking, “I hate my anxiety; it takes everything away from me.” They return home knowing, “my anxiety is there to serve me; it’s there to call me to things that are challenging and if I can answer that call, I’m going to come out stronger on the other side.”

Come Into The Cold

Posted on January 10, 2023 by scottc

The Holidays: Exposed

Posted on December 13, 2022 by scottc