Flip the Script- A Guide To Imaginal Exposure

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 OCD, PTSD, Anxiety Disorders, CBT or Exposure Therapy? 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. 1. 1. Say the word “spider”
      2. Write out a story with a spider in it
      3. Look at a picture of a spider
      4. Look at a picture of a spider that looks threatening
      5. Watch an educational video of a spider
      6. Watch a video portraying a spider bite
      7. Visit a spider display at the zoo
      8. Watch someone hold a live spider
      9. Hold a live spider at an exhibit for 5 seconds
      10. Hold a live spider for 5 minutes- repeat in mixed contexts

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:

• Fear of killing oneself
• Fear of going crazy, “snapping,” losing one’s mind, psychosis and Schizophrenia
• Fear of becoming a pedophile
• Fear of harming someone (hit with a car, abuse, negligence)
• Existential concerns such as “What if I don’t exist?”
• Going to hell for thinking a blasphemous thought
• Fear of losing a relationship or choosing wrong
• Fear of being or being a sexual pervert
• Fear of getting attacked in public

Therapy, of course, would never have you pursue these things as outright exposures, just like the fear of getting sick would not be treated through the means of having you contract a disease (that’s unethical and known to be harmful). That’s not exposure. Remember, Exposure is confrontation of the pathological fear, while reducing and abolishing pathologically fearful responses. With the above examples, if it is assessed that the fear is ego-dystonic (or values-inconsistent), the following would be fear reinforcing compulsions, safety behaviors, and/or avoidances:

• Plugging one’s ears or suppressing thoughts when hearing the word ‘suicide’
• Constantly checking one’s experience to see if they might have heard or seen something that wasn’t there or asking other people to verify ‘reality’
• Looking or walking away from children when in public or at a park
• Avoidance of driving
• Emotional checking and hyper-awareness to determine if reality “feels real”
• Compulsively seeking reassurance, going to confession, or prayer
• Asking reassurance from one’s partner or compulsively comparing their qualities (or one’s own) to someone else
• Physiological checking and “testing” to see if you’re aroused seeing a picture of an animal
• Avoidance of public places

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.
Therapist: And….
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):

1. 1. 1. Write a paragraph story with the details that occur in you mind involving jumping off a bridge.
      2. Read the level 1 exercise while running outside and sweating.
      3. Ride with someone who drives over a bridge, with the doors locked.
      4. Ride with someone who drives over a bridge with doors unlocked (and/or windows down).
      5. Watch a movie where someone jumps off a bridge
      6. Play a V.R. video game where you jump off a bridge.
      7. Walk across an actual bridge, away from the edges.
      8. Write out a detailed story of jumping off a bridge.
      9. Say/write a detailed story of jumping off a bridge while riding with someone else driving, doors unlocked and windows down.
      10. Going to a bridge, up against a railing by the edge, saying “What if I jumped off this bridge?”

A good summary of these steps I usually take in exposure therapy can be found in my guide, “Thriving Mental Health.”  You can get it by joining my list, FREE!

Practices

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:

• Script script script!!!  Write down key phrases, words.  Vary it up by highlighting, writing in cursive, coloring.
• Write a story of the fear occurring.  Spare no detail when you are able to face it.
• Listen to audio recordings of yourself or others reading your script.
• Watch movies/tv/youtube that feature the content you fear
• Have loved ones trigger you with key words and phrases you may be working on tolerating.
• Sample words and key phrases might be the following:
  • Sick
  • Die
  • Responsible/Irresponsible
  • Pedophile
  • Kill
  • Murder
  • Hit and run
  • Contaminated
  • Anxiety
  • Never ending
  • Hell
  • What if?
  • Maybe
  • Pedophile
  • Are you sure?
  • Did you check?
  • How can you be certain?
  • What do you feel?
  • Are you being completely honest?
  • Is that true?
  • Deviant
  • Sex
  • You’ll never know
  • Neverending
  • You’ll always be anxious
  • Maybe you’ll never get over this
  • Maybe it’s not OCD/Definitely not OCD
  • How can I know?
  • Something bad will happen if I don’t figure it out.
  • Wrong relationship
  • Law breaker / rule breaker
  • Blasphemous
  • Devil / Satan
• OCD Coloring Books (click to see one here by my friend and colleague, Amanda Petrik-Gardner, LCPC), flash cards, and other creative ideas abound
• Imaginal exposure has an unlimited number of applications, limited only by, well, your imagination.

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:

1. Habituation– repetition of experiencing a stimulus typically leads to a decreased response.
2. Emotional Processing– a faulty fear structure can be processed and learned differently through different interactions with a stimulus, response to it, and presumed meaning.
3. Inhibitory Learning– when facing a feared stimulus in the absence of a fear response, a person experiences “expectancy violation” whereby new learning can occur.
4. Extinction– conditioned responses (like fear and avoidance) are weakened by exposure to the conditioned stimuli (spiders or bridges, etc.), in the absence of the original unconditioned stimulus (like negative event or association with spiders or bridges).
5. Self-Efficacy or Psychological Flexibility (as in the Acceptance and Commitment Therapy model)- emphasizing skills and training in the midst of anxiety and stress rather than focusing on reducing a fear response.
6. Cognitive Model– disorders significantly involve negative interpretations and unrealistic, distorted thoughts.  Targeting irrational beliefs can thereby decrease obsessional beliefs which then impacts functioning.

Any of these models may apply to a given situation, or none.  They are still theoretical, but they can help frame our understanding and give direction.

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.

The Power Of Counterintuitive

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.