NOTE: Emotional Content- Mature Readers Only Please
Imagine intentionally telling yourself- again and again- "Maybe I’ll get sick and die.” Or, “I’ll have a sudden urge to kill someone." Or, “Maybe I blasphemed God and will go to hell." What if your therapist asked you to repeat these things to yourself? Does that sound like negative self-talk? A cause for grave concern? Not if they’re intrusive thoughts. If they are, in exposure therapy you would most likely learn to repeat these thoughts over and over.
Why in the world would I do that?
This can be hard to understand. It’s initially counterintuitive. There is a purpose behind what I'm sharing, so stick with me! In fact, the purpose is so distinctive and powerful, that for many people, entering willfully into sitting with scary content is the only thing that will help them overcome tremendous fear and consequent suffering.
I'm referencing the use of Imaginal Exposure.
Are you a newbie to what OCD, PTSD, Anxiety Disorders, CBT or Exposure Therapy is? You will want to understand these before trying to grasp Imaginal Exposure- which might otherwise seem strange, weird, harmful, or negative. Done well, it's none of these. To those of us who use it every day, it's a high horsepower beast of a tool that ages like a fine wine- with time, discipline, skill, and determination the end product typically is first-rate. By first-rate, I also mean clinically first line treatment (highly recommended with the best evidence) for Anxiety, OCD, Phobias, PTSD, Social Anxiety, and more. Let’s jump in.
Exposure Therapy, in a phrase, is the systematic and intentional triggering of fear while minimizing- and ideally eliminating- all pathological responses. Imaginal Exposure accomplishes this with thoughts and ideas. It is done in the context of addressing unhelpful/pathological responses to fear. Hear me loud and clear: fear is a healthy emotion in context- we need to honor it when we use it in a healthy way. Exposure, though, is about facing fears that are creating problems for an individual- pathological (disordered) fears.
Think of a TV set. Friends. Frasier. The Office. It appears so real- so NYC, Seattle, or Scranton. Have you ever seen behind the scenes? It's funny what effect a studio tour or footage has on the mind when you have the "curtain pulled back." Imaginal exposure capitalizes on the brain's creative ability. We’ve done this for even longer as humans through verbal storytelling. It's part of what makes us wonderfully human. From a threat preparedness standpoint, the ability to imagine and conceptualize problems (like children getting injured or killed from a safety hazard) helps us think through problems and find solutions, when done appropriately. Imagination can be wonderfully delightful (a good book, a child’s creativity), highly practical (designing safety procedures), it can also become nefarious (a traumatic memory, a panic inducing nightmare, constantly running worst case scenarios).
If you have a phobia of spiders, the average person may think along the lines of Fear Factor, that old TV show that threw people in a literal pit with their feared object in order to “face” their fears. Rarely would that work, if ever, if you have an actual phobia- without structuring it appropriately and having "buy-in" to the process. CBT and Exposure therapists use a treatment plan and usually stair-step their approach (through a hierarchy) to inhibit the learned fearful response. Here is a sample hierarchy with arachnophobia (1 is easiest, 10 most difficult):
1-6 are actually Imaginal Exposures. They don't involve direct confrontation. In-vivo (situational) exposure (7-10) implements exposures in a real life setting. E.g., if you pathologically fear you will get sick and die from touching a door knob and not washing, the situational exposure is to touch the door knob ultimately and experientially test the hypothesis of “what if I get sick and die?” Many fears in life, though, either cannot be accessed through in-vivo exposure or have a strong mental component to them. Common examples are:
Why would these responses lead to problems? Simply put- they reinforce fear, disgust, and other strong responses out of context. We call these either compulsions or safety behaviors (unnecessary anxiety based reactions). A person who gives into them consequently learns they need these responses to protect themselves. Enter the heightened level of disability that sufferers of OCD, Anxiety, and PTSD face.
Here’s the good news. Exposure lets you gain appropriate control. It is learning to play offense rather than defense. It is very active, and it can lead to a greater sense of confidence and acceptance.
How do I do imaginal exposure? The first thing we do besides good education and understanding exposure is gaining a strong assessment- it must underlie good exposure. Know what you’re working with. Make a list of your obsessions or bothersome thoughts. See a specialist. Get educated. Get to know your symptoms, your motivations for getting better, and start a running log (monitoring) daily. Once you have a tally of key examples, placing them on a hierarchy really helps to get a road map and be realistic and also to monitor progress (like the one above for arachnophobia).
Once you’ve got your hierarchy, we consider conceptualizing the core fear behind an uncomfortable thought or action. Start simple; don’t overthink it. Here’s a “downward spiral” vignette for a person who fears they might one day “snap” and kill someone.
Therapist: So what about that bothers you?
Client: I don’t have control.
Therapist: So what?
Client: This terrifies me.
Therapist: So what?
Client: It may just happen, I might just snap, so I
need to be hypervigilant all the time.
Client: Yeah yeah, I get it. I suppose it’s impossibly tiring; I will always have to be in a careful state to make sure I don’t harm someone.
Therapist: Anything else?
Client: I don’t think so right now.
Therapist: This is the core fear we will begin basing your exposures on: “I must always be hypervigilant to not harm someone.” This is the hypothesis we will be testing experientially.
Once you have hierarchy examples in which you've identified your compulsions or safety behaviors, along with core fears, determining the type of exposure (In-vivo, Imaginal, and/or even Interoceptive or Virtual Reality- see The Four Types of Exposure Therapy) is important. The best exposure seeks to maximize learning and go as far as is needed to eradicate pathological responses.
Let’s take an intrusive, unwanted thought like, “What if I jumped off this bridge?” When it is ego-dystonic, imaginal exposure would seek to respond with a strategy like writing/saying/hearing/reading something like the following: “What if I jumped off this bridge?” many times and over many minutes, all the while sitting with the feelings without compulsing. Once a person can tolerate facing their fear at a lower level, they can then move up the hierarchy and face higher and higher ones, in this example it might involve riding in a car over a bridge. At a later point, they would likely want to visit a bridge and walk across, getting as close to the edge as would be appropriate. Pairing an imaginal script with the situational would address any thoughts the person attempts to suppress, neutralize, or avoid. Here is a sample hierarchy (incorporating in-vivo, imaginal, interoceptive- bodily sensation exposure, and virtual reality):
A good summary of these steps I usually take in exposure therapy can be found in my guide, “Thriving Mental Health.”
Scripting is observation in its basic form. It’s taking what you already fear and calling it out.
Popular forms involve scripts/stories, videos, and audio tracks/loops. Creative ideas:
How does it work? Why does it work? People smarter than me call this the mechanism of change. You’re going to love this response: we don’t know exactly how exposure works. We can theorize. There are roughly 6 theories (some are often combined) as to how exposure therapy works:
Problem Solving & Tips. There are small and large nuances alike involved in imaginal exposure. Here is a list of some key tips, but remember that this is one of the key benefits of a specialty provider of exposure therapy. You can additionally look at “10 Tips for Effective ERP,” which covers important details related to all types of exposure.
Catch All Compulsions. Mental compulsions and avoidance are compulsions. Reassurance from others (including your therapist) is compulsive. Learn to get rid of all of it. Distraction from fear is avoidance. Gotta catch ‘em all!
Conceptualize Your Core Fear. Skipping your core fear conceptualization.
Face, don’t Escape. Use your script to face fear- NOT escape fear. Anything to relieve fear in the moment can lead to reinforcing fear.
Remember the Framework. Face fear by sitting with it and/or don't pathologically respond. It might seem like you're allowing something bad (in fact, that's almost a guarantee you will feel this way). Dig into your commitments and motivations to stick with challenging exercises. Our goal is to go as far as your fear/disgust/etc. makes you run. However, sometimes we do go further with an exposure than thoughts go. We must seek maximum disconfirmation of fear, which means pushing exercises further than you initially want (because seeking relief and comfort and perceived safety got us in this mess in the first place).
Get Messy. Expect to mess up exposure. It’s naturally mucky, and no one does it perfectly. However, those who stick with it and keep working on it are more likely to achieve better results.
Get Support! You are a complex being in an interconnected world. You will likely need to incorporate various supports in your life for long-term success. Involve your loved ones. I get it- it will typically feel very odd to get your family members involved in scripting with you- but often remarkably helpful when your system is healthy and supportive.
Hard to catch. Many clients exclaim that predominantly internal OCD themes are very challenging to work with because they are so difficult to catch. True, at first. But they can be treated just as successfully, and once you know how to work with them, they are very treatable. In a sense, covert obsessions (“Pure-O”) and mental rituals can be more difficult to notice and catch than overt behaviors and processes like washing. But to be clear, OCD in any form is no cake-walk, nor do folks who have more overt rituals have it better, per se. They are just different. Also, there is always a mental process behind overt behaviors, which also must be addressed in treatment. Last of all, though all treatment is on paper the same, everyone’s experience is personal to them; certain themes (like sexual, religious, etc.) can lead to tremendously higher amounts of shame, guilt, anger, or any number of feelings.
Matching game. Match the script to the actual content of your thoughts that you need to face to overcome and maximize your strength training. Make sure the content of exposures fit with the content of your obsessions.
Prepare. A healthy mind is not made in comfort. Prepare to feel uncomfortable. The inverse of taking on too hard of exposures is not pushing oneself enough. The reality of scripting is that it can seem monotonous. It can seem really scary. It does trigger at least some distress.
Proper Dosing. When we utilize medication, we often consider dosing. It’s not a foreign concept for many aspects of life. Applied to cooking we measure ingredients, in learning a new subject we stair-step difficulty and measure as we go along. A lot of people come to mental health with expectations that deeply rooted patterns and habits, behaviors and thoughts will somehow magically vanish. We’ve got to be realistic. The more severe a case, the higher the “dosing” is typically needed for therapy and exercises. I often point out that if you have 4 hours of compulsions/safety behaviors rituals per day, you will need to get to the point where this number is ideally zero. The “dosing” then of treatment is a lot higher than someone with 1 hour of these pathological responses.
Relapse Prevention Planning. When you’re feeling better, don’t just move on and say, “Thanks, it’s been fun!” Have a plan. Develop this with your team.
Strength Training. One of the most significant errors clients report to me prior to therapy was trying to “lift too much weight” consistently before they were ready. If you can’t face a level 3 on your hierarchy without compulsing, you’re not ready for a level 10. But as soon as you know how not to compulse or do a safety behavior in the face of fear, CONGRATS!! This is one of the greatest achievements, and now you can move the ball forward with other examples.
Type Matters. Remember that though we are discussing Imaginal exposure, it is usually best to make sure to do in-vivo exposures with things that you can face in real life. Though you can always pair imaginal with situational, you must go as far (or further) than your obsession goes.
Fin. Imaginal exposure may seem odd, counter-intuitive, and harmful at first. The reality is that it's just what the doctor ordered to start playing offense with problems and not be a victim of cycles of fear and relief. If you've made it this far, you've got some guts. I hope you've been encouraged. Let's do this.
This post is intended for Christians looking to deepen their faith and mental health and may not apply to my entire reader base.
“You need to pray about that.” “Resist those thoughts; they are from the enemy.” “Don’t think on such things.” I often hear confusion from Christians on how to engage- or not engage- with fear based thoughts, urges, and sensations. This led me to do a deep dive into Scripture to see if there are any differences between responding to fear vs. temptation. Spoiler Alert: there are. We must learn to face fear and flee temptation.
Joy* came in to see me because she was getting overwhelmed- having panic attacks and getting stuck in making decisions. Most of all, she was terrified of the doubt that she wasn’t walking with God. These are weighty things to carry. Joy is an incredible woman of faith. Loved ones agreed (though she’d never tell you this). Due to her obsessions and intrusive thoughts, she couldn’t stop compulsively asking God for forgiveness when feeling like she’d sinned, constantly evaluating things as small as the way she walked and the facial expressions she carried when around others. She would often have thoughts that went counter to what she believed: “Maybe your anger is just the same as wanting to kill someone.” “You’re not close to God- you don’t feel His presence.” “Are you sure you are living your life fully for Him?” “Your attraction to other men is lustful- you’re supposed to feel pleasure seeing your husband.” These thoughts and their consequent feelings led to a lot of avoidance- dodging men, running from ‘scary’ Scripture passages, avoiding going out in public.
It is impossible to read very far in the Bible without coming across some variation of “fear not!” It is the most common directive in the Bible- occurring more than any of the following “do nots:”
Growing up, I was involved in a Christian subculture that took an oft avoidant stance to things perceived as risky. I remember some varying examples from different people through the years: some condemning rock music and drums, dating, kissing before marriage, alcohol in any way, dancing, mental health medications, and playing cards. Of course, each Christian must develop their conscience and walk with Christ, so I am not here to make decisions for you on any of these topics. There are a lot of decisions in a lifetime that will necessitate flexibility and exhibit differences between believers- they are not all black and white (cf. Romans 14, Galatians 5), though some are. To understand why these often well meaning folks said what they said would require knowing the context. I know many times I have heard believers condemn alcohol for anyone it is out of themselves or loved ones having problems with alcohol- which would be one of the best reasons not to drink! However, we must be careful not to make a rule or law of conscience generalized to everyone that is not specifically laid out for all believers (check out TGC’s article on conscience). Unfortunately, I heard plenty of cautions from people rife with fear.
For Christians, hypervigilance as to spiritual matters is out of place. Vigilance is called for in the things we must be alert about. Hypervigilance is being on edge, fearful, shaky. Before Christ was crucified he prayed that his followers would be protected, but still present in the world (John 17:15). Healthy and spiritually mature individuals have developed discernment of separating good from evil while being present in the world (Hebrews 5:14)- part of growth requires learning how much focus and time to prioritize on any one thing.
Stick with me closely here: this is where I want to delineate between fear and temptation. I believe it’s a crucial difference- one that has led to a lot of personal growth and change along with that of many clients.
Let’s first view some key texts on temptation:
With a misappraised lens we might think God would have us constantly eschewing evil, always looking over our backs for sin crouching to get us (Genesis 4:7). Nope. Context is key. There’s a bigger picture.
Both in Bible reading and In CBT (Cognitive Behavioral Therapy) a key thing we do is to look at context- understanding one thing through the larger picture (i.e., for Bible reading, observing before interpreting; in CBT, we assess the larger connection between feelings, thoughts, and behaviors). Here is the broader backdrop for all the above Scripture passages:
There you go. I hope these key passages have helped identify a trajectory for facing temptation- knowing that hypervigilance or persistent fear is unbefitting God's will for believers.
What if something I fear is also a desire? Or becoming a desire? This is a common question I get when helping clients call out and lean into their fears in therapy.
As mentioned concerning the 2nd passage above (1 Corinthians 6:18), sometimes people run into things they simultaneously fear and are a risk at the same time (egosyntonic and egodystonic). Maybe it’s abusing substances for the addict, fear of harming a child while also having actual anger outbursts, or being scared by unwanted thoughts on suicide for the depressed person who sometimes contemplates suicide. This gets a little tricky, and I have to admit, makes the process in therapy a little more challenging. I like a good challenge! It’s important to do a little more assessment and separate out the two domains. On this topic, let me just say that’s what makes therapy all the more important. Get a professional outside of yourself who can help you separate the two and know how to address both sides of the problem- a mixed desire with simultaneous lack of desire to act on a behavior.
A final word. Deuteronomy 31:8: “ It is the Lord who goes before you. He will be with you; he will not leave you or forsake you. Do not fear or be dismayed.”
Being overcome with fear is not what God desires for His children. I myself and a lot of fellow Christians can be so torn up with fear when facing uncertainty or a perceived threat, forgetting that this fear itself is not from God.
Fear manifests in all sorts of ways- ways that are often overlooked and (sometimes applauded!) by fellow believers in areas such as perfectionism (think of the workaholic in a church setting), over-thinking and analyzing (the person who appears to study the Bible often but are obsessed with minute details and not relationship), and rugged self-reliance (not submitting to authority, relying on community, and otherwise being a ‘lone ranger’). We can often call these things high standards, thoughtful, and independent. Insomuch as any of these things lead to a lack of dependence and faith on God through fear, we have entered into another formidable foe in and of itself! Whether it comes from our brains (the flesh), other influences (the world), or the enemy (the Devil) (Ephesians 2:2-3).
Fear and temptation are two different things. Responding to them requires a different stance. However, they can easily be confused with the other. My prayer for you today, my friend, is that you would know the freedom and joy that is in Christ the solid rock, who will complete the work He has started in you (Philippians 1:6).
*Joy is not this client’s given name and is a composite of case information to protect patient confidentiality. There are thousands of cases very similar to this.
Every reference in this article is ESV.
In advance of the full episode of the OCD Stories podcast being released Fall 2020, Stuart Ralph released a special members only listen. I hope you'll check it out.
COMING SOON- the OCD Stories podcast episode with Stuart Ralph
This post is intended for Christians looking to deepen their faith and mental health and may not apply to my entire reader base.
When we recently moved to the house we are currently in, we got an extra bonus with some “smart home” features. Far from a ‘techie,’ I quickly got frustrated in the first week. When I didn’t know how most of it worked, I began to become irritable. This is not a growth, learning, or curiosity mindset.
This is a problem. Why do I expect to get everything on the first try? What leads to seeking accomplishment over growth? This is not who I want to be or what I want to impart to my wife or child or others. This is the way of the world. Busy. Hurried. Trying to do more and more. Have you also caught these moments where you have forgotten the powerful God we serve? Oh how we can fall into “The Hurried Spiritual Life” (click to see my blog post on the topic). Worth and value is so easily tied to performance and accomplishment. But with the Lord it is not so (here’s a couple kickin’ passages on the topic: John 9, Psalm 46:10).
2 Corinthians 4:18 reminds us to “look not to the things that are seen. For the things that are seen are transient, but the things that are unseen are eternal.” Prior to this in verses 16-17, we’re reminded not to lose heart while our earthly bodies are wasting away, and affliction creates a ‘weight of glory’ (an excellent C.S. Lewis book, fyi). Suffering and hurt is inevitable in this world- it will either break you or build you. Romans 8:18-19 reminds us, “For I consider that the sufferings of this present time are not worth comparing with the glory that is to be revealed to us. For the creation waits with eager longing for the revealing of the sons of God.” This is a growth mindset.
Getting the lights to work in my house isn’t significant suffering. First world problems. But the reality still exists: suffering exists in many forms, both extreme and small. I have experienced both, and I will experience more. My focus when I get frustrated over things not going my way is so often earthly- temporal. It’s results-driven, not growth oriented. It’s accomplishment over development. It’s the ‘click’ over the long road of growth. Becoming insta-famous over being faithful in the little things. So I will keep turning my eyes to Christ in each and every thing.
Prayer: Lord, I thank you for your unending love and longsuffering with us. I ask that you’d make me humble and open my heart to you- to what you are doing and continuing to do in the world and through me. I ask you to fill me with your Spirit to make known fruit so that I can be patient and gracious with others- who also suffer. I ask that you’d speak through me and that I’d listen as you speak through others. In Christ, Amen.
“Beloved, we are God’s children now, and what we will be has not yet appeared; but we know that when he appears we shall be like him, because we shall see him as he is” (1 John 3:2).
A Psychotherapists' thoughts on healthy living.
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