Dr. Pence offers weekly cognitive behavior therapy services to both children and adults suffering from anxiety disorders. Sessions are 60-minutes or 90-minutes depending on severity of symptoms, comorbidity, & environmental circumstances. A diagnostic evaluation is assessed before starting sessions to determine diagnoses and evidenced-based treatment plans. 


Diagnostic Psychological Assessments:


A two-hour comprehensive research-supported psychological evaluation is provided to all new patients. The purposes of this extensive assessment are to develop an initial rapport with patients, to determine accurate diagnoses, and to provide patients with an evidenced-based treatment plan. As part of the initial evaluation, patients are assessed for all psychological conditions, psychological comorbidity, as well as information about their medical, developmental, biological, social, family history and educational background. The impact of the stressors or traumas on the developmental and/or maintenance of anxiety or other symptoms need to be thoroughly assessed. Dr. Pence assesses all patients based on DSM-5 criteria and utilizes appropriate assessment tools as needed. Lastly, the comprehensive psychological assessment is helpful in tracking patient progress. 


Evidence-Based Treatment Modalities:

Cognitive Behavior Therapy (CBT)
Exposure and Response Prevention (ERP) 
Habit Reversal Training (HRT, Tics, Trichotillomania, & Excoriation Disorder)
Cognitive Restructuring 
Behavioral Activation
Supportive Psychotherapy

Cognitive-Behavior Therapy: (CBT)

Cognitive-behavior therapy is a type of psychotherapeutic treatment that helps patients understand the thoughts and feelings that influence behaviors. CBT is a class of interventions and techniques with wide application and demonstrated efficacy in treating many psychological disorders including phobias, addiction, depression and anxiety. Cognitive-behavior therapy is generally short-term and focused on helping clients deal with a very specific problem. During the course of treatment, people learn how to identify and change destructive or disturbing thought patterns that have negative influences on behavior. In cognitive therapy, clients learn to solve problems such as distinguishing between thoughts and feelings, and becoming aware of the ways in which their thoughts influence their feelings in ways that are not helpful. CBT is effective in evaluating critically the veracity of their automatic thoughts and assumptions and developing the skills to notice, interrupt, and intervene at the level of automatic thoughts as they happen.

Can Cognitive Behavior Therapy Really Change Our Brains?
http://www.bbc.co.uk/science/0/23590545


Exposure and Response Prevention (ERP):

ERP is one of the most effective and highly researched modalities for the treatment of anxiety disorders. This includes both behavioral and cognitive techniques. Exposure involves intentionally confronting situations that you know are likely to increase your fear and anxiety. Ritual prevention involves choosing to sit with your anxiety (without resisting it) and letting go of the unhelpful strategies (rituals) that are maintaining the cycle. When you do this, you will naturally feel more anxious at first. However, with time, repetition, and practice, your fear will decrease. Because fear is what maintains your symptoms and causes your attention to lock onto your physiology, decreases in fear will lead to decreases in your symptoms.Treatment starts with exposure to situations that cause mild to moderate anxiety, and as the patient habituates to these situations, he or she gradually works up to situations that cause greater anxiety. The individual gradually challenges all of his/her symptoms and learns healthier productive methods of coping with anxiety. The time it takes to progress in treatment depends on the patient’s ability to tolerate anxiety and to resist compulsive behaviors. Over this time, the individual becomes desensitized to previously anxiety-provoking situations and thoughts, and the obsessions and compulsions are eliminated or significantly reduced in frequency and magnitude.

 The ritual or response prevention component involves instructions for the patient not to engage in compulsions or rituals of any sort. This is important because patients perceive that the rituals prevent the occurrence of a feared outcome. Only by stopping the rituals do patients learn that rituals do not protect them from their obsessional concerns.

 In Vivo Exposure:

This has demonstrated to be effective in reducing obsessions and related distress. This technique involves repeated and prolonged confrontation with situations that cause anxiety. Exposure sessions vary in time. The immediate goal is for the patient to remain in the situation long enough to experience some reduction in anxiety and to realize that the feared "disastrous" consequences do not occur. With repeated exposures, the peak of the distress as well as the overall distress decreases over sessions. Thus, the patient habituates to upsetting stimuli in two ways, within the session and between sessions. exposure is gradual and the patient begins by facing objects and situations that result in only moderate levels of anxiety. Constructed in collaboration with the patient, the list of distress-evoking stimuli are placed in a hierarchical manner, beginning with the least distressing stimuli and gradually proceeding to more distressing ones. A rating scale is used to rate the expected amount of distress associated with each item. After an item from the hierarchy is confronted in session, the patient then practices self-exposure to the same item as daily homework. Once mastered, the patient faces the next progressively more distressing object or situation. The patient learns that the feared consequence will not occur, to better tolerate anxiety, and that anxiety diminishes over time even without performing the rituals.

Imaginal Exposure:

Situations especially appropriate for an imaginal exposure are those in which the patient fears he may change in a fundamental way. For example, shifting in sexual orientation or becoming a serial killer, cause a distal catastrophe, or that the outcome of failing to do a ritual is far in the future. To conduct an imaginal exposure, Dr. Pence and the patient develop a detailed scene together based on the patient's worst fear. The story will describe a catastrophe befalling the patient and/or loved ones as a direct result of the patient's failure to perform rituals. Dr. Pence may say this verbally and then have the patient do the same, ideally in the present tense to make the events seem more real. Ratings are taken at various points throughout the narrative to assure that the story is evoking enough anxiety to be productive. The exposure is typically recorded to facilitate repeated listening as homework. Imaginal exposure is effective when it evokes the same distress in a person as the actual obsession. A person with OCD typically fights the obsession because they believe that if they entertain the ideas, the feared outcome will be more likely to occur. However, fighting the obsession only strengthens it. By repeating the distressing ideas in the form of a narrative, the person with OCD habituates to the fears and also learns that dwelling on the thoughts does not make them occur. The person gains a new perspective on the fear and is able to attend to it more objectively.

Habit Reversal Training:

Habit reversal training shows excellent results for the treatment of disorders like tics, trichotillomania (hair pulling), and excoriation (skin-picking) disorder.

Habit reversal training involves a few steps:
Awareness Training: clients identify situations, persons or places in which symptoms occur and in which symptoms worsen or subside as well as preceding sensations (urges) to the problematic action (i.e., tic, hair pulling, picking etc.).

Relaxation Training: clients learn and practice different relaxation techniques (e.g., diaphragmatic breathing).

Competing Response Training: clients learn a specific response pattern that is incompatible with the problematic symptom (i.e., tic, hair pulling, picking etc.).

Generalization Training: practice on how to control symptoms in everyday situations.

Behavioral Activation:

Behavioral activation can be an effective treatment approach for depression that emphasizes structured attempts at improvements in thoughts, moods, and overall quality of life. Patients can create a hierarchy of reinforcing activities that are ranked by difficulty and progress can be tracked by utilizing such measures as The Beck Depression Inventory-II (BDI-II). This approach utilizes the relationship between actions and emotions in which patterns of dysfunctional coping strategies and triggers are identified and then replaced. Rumination is an avoidance behavior and is central to the behavioral activation model in which the inactivity and withdrawal is considered a coping mechanism to avoid environmental circumstances. The goal is to decrease the avoidance behaviors and increase positive reinforcement. A goal can be for the patient to evaluate the rumination and attend to the experience assessing the function of their behavior. Patients can emphasize relationships between environment, mood, and activity. 

Cognitive Restructuring:

Cognitive restructuring, a component of CBT, challenges the specific thoughts you experience during anxiety. For example, if you have an elevator phobia you might say that you will die if you get on an elevator. Cognitive restructuring examines that thought for the evidence that supports or refutes it. The goal of this process is to get you to experience more accurate and beneficial types of thinking than the fear-based thinking you currently use.

Weekly Cognitive Behavior Therapy

Services & Treatment in Oakland County, Michigan