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.
The Guide above is provided entirely for free to newsletter subscribers.
One of my first questions to a professor in my earliest IOCDF BTTI (Exposure Therapy training) at Massachusetts General Hospital was, “What happens if someone actually gets sick after a contamination exposure?” I haven’t forgotten the simplicity of the answer that went something like this: “People get sick all the time. Yes, that might create some additional hesitancy to face exposures at first, but you have an incredible opportunity for learning.” Life involves not only facing bad things that don't happen, but also bad things that do.
Exposure Therapy involves the systematic confrontation of fearful triggers while reducing and eliminating fearful, pathological responses. In the end, it can relieve a lot of suffering.
During this global pandemic of COVID-19, people actually are getting sick. One might not think the principles of exposure therapy would apply (i.e., "Don't you do exposure therapy for risks that don't happen?"). Quite the contrary. I believe exposure therapy provides one of the best evidence-based ways forward, helping us stand up to fear we need to squarely face. So today, whether you have a disorder or not, there is an opportunity for learning and growth in the face of COVID-19.
This guide, "Thriving Mental Health Alongside COVID-19," is dedicated to my clients and the IOCDF and provides a thorough summary of the main steps of Exposure Therapy with me, with key tips for general mental health. May you be enriched by this!
Whether you have a mental disorder or not, there is an opportunity for learning and growth in the face of COVID-19 (SARS-CoV-2). Now, more than ever, we need stable footing to stand on. People go to every extreme. You don't have to. Mental health is about being grounded in reality, insomuch as we can grasp it.
Getting sick will happen. Yes, people die. Relationships break up and fail. Businesses go under. We might get it wrong. However...many people can experience health. Some people live with purpose and to the full (which is not the same as perfect). Relationships can be incredible. Businesses can thrive. We can get things right.
When I utilize the method of Exposure Therapy in counseling (a subset of Behavioral and Cognitive Behavioral Therapy), it involves the systematic confrontation of fearful triggers while reducing and eliminating fearful, pathological responses. It is Gold Standard treatment for OCD & Phobias, and is a first line treatment for all Anxiety Disorders and PTSD. What we think happens is that relearning occurs, which for most increases confidence and decreases disruption in life when they follow the treatment. Exposure, then, gives us two opportunities:
2. To learn we can face it anyway.
Its principles connect us to some of the best of life: face the thing you have reason to face; gain the opportunity to live more fully.
This guide is a very brief summary of the main points of the exposure therapy process with me, particularly with clients who have OCD and Anxiety. Many of my clients actually are faring better in this crisis than people I have talked to and seen in the general public- and why wouldn't they?! They've been training and learning- and now it's game-time.
Click "Read More" for a Summary
A Psychotherapists' thoughts on healthy living.
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