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
An editor for the American Counseling Association reached out to me about OCD from a Specialists' perspective. (I was so proud of them for doing their research with multiple specialists!!). The following are excellent questions that may help inform their ACA magazine article in February 2020. Whether they utilize any of these or not, I hope they are helpful for you as they cover important questions to consider with regard to treatment.
"What presenting issues might bring these clients into counseling?"
"What are some “red flags” for counselors to listen for that might indicate OCD in a client who came in for something else (anxiety, ADHD, etc.)?"
If a counselor begins hearing the exact same things, worded or behaved in similar ways, this is a good indicator to watch out for. Many of my clients are good at exactly quoting themselves on what they've said before. Obsessions are repetitions on a theme; if you get good at catching the theme, you can usually spot an obsession miles away.
At its core, it's not remarkably difficult to identify criteria in OCD (in most straightforward cases) if a counselor brushes up on what they're looking for (dust off that DSM-5!).
Furthermore, if a client isn't improving from certain methods (especially things like Cognitive Restructuring in CBT), this is "Getting Stuck 101" and needs further assessment. Most of my clients have had prior experience with a counselor who had no idea how to treat OCD from an evidence based way and approached the same as regular old automatic negative thoughts. This is not typically helpful.
"What counseling methods/techniques can be helpful when working with clients with obsessive behavior and/or OCD? Please explain how this/these method(s) work well for this client population. If possible, please talk about a case example (without identifying information) who worked with you and showed improvement. What were his/her presenting issues, what methods did you use and what issues did you focus on in counseling sessions?"
Exposure and Response Prevention (ERP) is the GOLD standard treatment (which is a very specific subset of CBT). It is indicated as the starting point for all OCD treatment. This is a strong statement, but it is backed by the research (the most RCTs by far) and organizations like the IOCDF, APA, and so forth. SSRI (and Clomipramine, a TCA) medications are also first-line psychopharmacological treatments, though with less effect on average than ERP. Both combined can be helpful, though may not necessarily increase the overall benefit of just ERP alone. Another first-line treatment for OCD (though not the "gold standard") is Cognitive Therapy with Behavioral Experiments. Along with medications, it is seen as sometimes a more agreeable option for those who are hesitant to engage in exposure therapy (which intentionally and repeatedly provokes distress in order to respond differently- i.e., without compulsions).
Adjunct therapies, medications, and treatments are utilized. In the interest of brevity, research has discovered the integration of Acceptance and Commitment Therapy (ACT), Motivational Interviewing (MI), and other techniques can be helpful to provide well-rounded treatment and/or facilitate the practice of ERP.
To share a classic example [identifying factors changed to protect confidentiality- this type of case is remarkably common], one woman came to me with severely distressing thoughts about harming her children (no history of harm or abuse). She knew it was irrational, yet it felt so real to her; the more these intrusive thoughts continued to appear, the more difficult it was for her to determine her intent from confusing feelings and "impulses" to stab her kids. Upon receiving a diagnosis of OCD, I thoroughly assessed history with symptoms, and educated on the CBT model for understanding OCD treatment with a rationale for CBT and ERP. We discussed medication options, to which the client was willing to pursue with their Psychiatrist. The client was very cooperative due to a high willingness and intrinsic motivation to be able to engage at home with her two children and spouse. As can be very typical, the stress also took a toll on most every area of life, making work difficult. Once we began ERP, we started with doable exposures while learning how to stay present with triggers and distress- without compulsing. Upon successful practice of more manageable triggers on their hierarchy, they- with the incredible support of their spouse and church and loved ones- made a jump in their exposure work that began with "scripts" (imaginal exposure stating/writing distressing thoughts and quickly progressed to holding knives and stating these feared thoughts aloud) and transitioned to practices situationally at home, holding knives and saying scripts aloud (in separate rooms appropriately not in front of their young children). The incredible support around this client, along with a sense of strong purpose, helped facilitate (this is part of ACT) the integration of ERP into daily life. They would be considered recovered at this point, scoring so low on the Y-BOCS (gold-standard assessment in rating severity) that their symptoms are sub-clinical. In relapse prevention planning, they understand the chronic nature of OCD and the necessity of staying on top of their good progress, with the plan to follow-up at occasional intervals for "booster sessions." I gain so much joy from stories like these.
"People with an OCD diagnosis may be taking medication and seeing other professionals (psychiatrists, psychologists). How could a counselor work in tandem with these other professionals? Please include a case example, if possible."
Coordinating care can be difficult, but worth it for the best client care! Although seamless communication and record exchange between providers is likely ideal, it just rarely happens in real life. Working within the space and limits that exist, I have found that outside of those very few therapists and Psychiatrists I can have near immediate communication with, it is still very helpful and feasible to at least request/give one way communication to a provider. In complex cases, it is almost unheard of for me to not outreach another provider that is connected somehow to shared treatment concerns. I think we need to be realistic about other providers' schedules and communicate what we can- how we can. This often looks like me leaving a Psychiatrist a voicemail after release is given- and not hearing back- but at least they have the information. It may be coordinating with another therapist who is treating other concerns. Early on, I used to welcome other counselors working at the same time on separate diagnostic concerns. Though I may work with someone now who is seeing another professional for something like, say, Depression, it is usually quite imperative that I make known to the patient and also the other provider the pitfalls of feeding compulsions through reassurance, ruminating, and so forth. This is a great opportunity for education of those who are not specialists in OCD. But OCD being as debilitating as it is (2 out of 3 people experience severe impairment at some point in their life), I need to work hard upfront to educate especially the patient about how hard they will need to work (and not undermine) their exposure therapy. Also, many other comorbidities can often improve significantly just by treating the OCD first.
"How, particularly, are counselors a “good fit” for helping clients with obsessive behaviors? How can they help people with OCD differently than a psychologist would?"
It has been my personal experience that my colleagues who are counselors (Master's level, typically), bring to the table incredible creativity and "outside the box" thinking. Many of the hands-on resources, videos, blogs, and social media that exist to help the sufferer of OCD often come from Master's level clinicians. I believe there is great flexibility many of my counselor colleagues have (which is a positive and a weakness all at the same time, sometimes lacking the rigors of adhering to the evidence based treatment protocols).
There are actually quite a few more Master's level clinicians than Psychologists, and there is a great need for more clinicians offering great treatment. Counselors can help fill this gap.
"As a practitioner who specializes in working with OCD, is there anything else you would want counselors who don’t specialize in this area to know?"
For many reasons, I love work with clients who have OCD. I have found they are some of the kindest, hardest working, conscientious individuals on this planet. This is where I believe many of their personality strengths arise once moving through pathology. It is a joy every day to see recovery, growth, and maturity bloom out of suffering.
"Any main take-aways to share?"
OCD Treatment can be so rewarding! It has very effective treatments for most, very clear evidence, incredible improvement that can be witnessed in a short period of time, and there are wonderful opportunities to get invested in this world with a community of professionals, sufferers, and supporters who are incredible.
~Justin K. Hughes
Those who know me know that I see people as individuals and hate to make generalizations. However, it seems to me that those suffering from OCD are among the kindest and most understanding people I have ever met.
This video and guide below were specially formulated to help you be mindful in an "Exposure-Friendly" way.
This one's a bit different from the average mindfulness practice you might be familiar with. The reason it's called "Exposure-Friendly" is that it is specially designed to help a person be mindful of whatever they are experiencing, not just attempting to feel better. This is a hallmark of exposure therapy: being able to tolerate distress without engaging in pathological responses (rituals, safety behaviors) that negatively reinforce fear. Distractions and relaxation when facing our fears can backfire (see the research at the end of the Guide). So if we need a different set of tools to face fear, here's one of them. I hope it helps.
Music: As Leaves Fall
In Vivo Exposure
Directly facing feared objects or situations, examples include:
Getting on a flight, touching a doorknob that feels “contaminated,” not going back to check a lock, or going to a social gathering.
Good exposure attempts to match the content and detail of a person's fear as close as possible. So, for example, if a person fears “going crazy” in a social setting, the best exercise will be working up to facing that, not just exposing to the thought or word. On the other hand, if the fear is that a person will have inappropriate impulses (to harm, sexually, etc.), sitting with the intrusive thought and being present will serve best.
Imaginal exposure involves accessing the content of fears and anxieties through cognitive means. For example, a fear that someone will fail, make the wrong decision, harm someone, die, or choose the wrong relationship are not accessed by activating these life occurrences. They are addressed imaginally.
There are many ways to practice Exposure imaginally, but the most common are writing scripts, stories, listening to recordings, watching videos, or using visualization.
To be clear, Imaginal exposure often is the most confusing and hardest to grasp of exposure practices, as it seems to be creating negative thoughts or “bringing” unrealistic and negative thoughts on- the seeming antithesis of most of psychology and cognitive therapy. But what is really done here is only facing what a person is already experiencing, thinking and feeling.
Intentionally bringing up physical sensations that are feared, such as:
Heart racing, shortness of breath, sweaty palms.
Ways to do this when a person's health allows are breathing through a cocktail straw, breathing rapidly, or sitting up quickly.
Virtual Reality (VR) Exposure
With the advent of new technology, we have a recently emerging type of exposure. Some may class Virtual Reality into imaginal exposure, but it can be seen as a cross between in vivo (situational) and imaginal. This is especially helpful with treating disorders such as Flying Phobia, where the access to an actual plane and flight to practice can be cost-prohibitive and difficult.
What is Exposure Therapy?
Exposure therapy is a psychological treatment that is practiced in Behavioral and Cognitive Behavioral Therapy (CBT). It is indicated as a first line treatment for a number of disorders such as
Exposure therapy helps clients to systematically confront fearful stimuli along with changing fearful responses. This relearning increases confidence and decreases disruption in life. Over time, discomfort and fear typically decreases through active engagement rather than avoidance, suppression, neutralization, or ritualization.
The evidence base is very strong for its use and effectiveness, though it is currently only applied a minority of the time in clinical settings.
How Do You Do Exposure Therapy?
The principles of exposure may be simple, but the specifics- personalized to any one individual- involve many working parts.
A Psychotherapists' thoughts on healthy living.
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