I approach exposure from the perspective of learning as opposed to habituation (For further discussion, see Exposure Is About Learning, Not Habituation). From this perspective, the point of exposure isn’t to habituate to a stimulus but rather to learn something. It’s easy to conceptualize how this might work for an ‘in vivo exposure,’ in which you are actually doing something that was previously avoided, or that was previously ‘undone’ by a compulsion: Doing the previously avoided action without any compulsion to ‘undo’ it gives the person the opportunity to (1) learn that nothing bad happens, and (2) learn that any anxiety they experience is manageable and eventually resolves on its own.
But what about ‘imaginal exposure’?
If you believe that learning, not habituation, is the mechanism that makes exposure work, would you still use imaginal exposures?
If you would, would you do them differently?
This article discusses four different cases in which imaginal exposure could be helpful from a learning perspective; what the goal of the exposure would be in each case; and how you would do the imaginal exposure for each one. (It should be acknowledged that these types of imaginal exposure are quite different from the type of imaginal exposure that has been used historically, in which the goal was to think about something and thus habituate to it, because the latter approach doesn’t make sense from a learning perspective.)
The case: The patient is afraid to think bad thoughts. For example, they are afraid to imagine something terrible happening to someone they love or to think about something violent or sexual.
The goal: In this particular case, the imaginal exposure functions the same way as an in vivo exposure. What the patient learns from this type of exposure depends on what the fear was to begin with: If the fear was that thinking about the event could cause it to happen, then they can disconfirm that expectation, though perhaps not immediately; if the fear was that they would be tormented by having thought the bad thought, then they can learn that any feeling of discomfort will dissipate (if they don’t ruminate afterwards).
The method: As long as they’ve thought the thought that they were afraid to think, they’ve accomplished their exposure goal. No need to measure anxiety levels. No need to stretch out the exposure or try to feel it very intensely. The exposure could last just a second. Just make sure the patient doesn’t do any compulsions, including rumination, following the exposure.
The case: The patient ruminates or does another compulsion when they experience a distressing thought.
The goal: This type of imaginal exposure provides a lot of opportunities for learning. Specifically the patients can learn that (A) they have the ability to experience a distressing thought and not do anything about it; (B) they have the ability to disengage from rumination; and (C) when they don’t ruminate or do another compulsion, their fear resolves pretty quickly, on its own.
The method: This form of imaginal exposure requires that you have already taught the patient how to stop ruminating. The goal here is to practice getting triggered by a thought, or ruminating, and then moving on. Here is what the prompt might look like: “You know that you can eliminate rumination because we’ve done it together, but sometimes when you’re triggered by a distressing thought it’s hard to do it. Today we are going to practice getting triggered and then not ruminating, so that you have the confidence that you can do this when triggers come up outside of therapy.” There are several different types of exercise you could do, such as:
- Have the patient ruminate for an amount of time (e.g., 30 seconds) and then not ruminate for an amount of time (e.g., 2 minutes)
- Have the patient purposely think about a disturbing event for a moment, and then not ruminate
- Have the patient sit and not ruminate while you intermittently (e.g., every 20 seconds) provide distressing thoughts
As possible, check in about how anxious the patient feels following triggers in order to highlight that their anxiety resolves on its own, and resolves more quickly, when they’re not ruminating.
The case: The patient isn’t sure what their core fear is, or has trouble connecting the compulsion/avoidance to their core fear.
The goal: This exercise helps the patient learn how their symptoms connect to a broader core fear. There are several reasons that this is crucial to effective ERP, but that’s beyond the scope of this particular article.
The method: The goal here is to think. The initial prompt would be something along the lines of: ‘Tell me a story, as if it were happening to you right now, starting with not being careful enough (i.e., by doing something avoided, or not doing a compulsion), and ending with the worst possible outcome.” As necessary, use prompts such as: “Keep going, what’s the worst thing that could happen next?”; “Okay, and what’s the worst part of that? … And what’s the worst part of that?”; “I could see a few really awful parts of this situation; which is the worst one?” It’s not necessary that the patient experience fear or anxiety during this exposure, though they sometimes do.
The case: The patient lacks insight into how unlikely it is that doing something avoided or not doing a compulsion would lead to the outcome they fear. The patient has never thought through the series of events that would have to take place in order for the core fear to be actualized, and has also never thought through how they might be able to handle any of those events.
The goal: The goal here is for the patient to realize how unlikely it is that their core fear will actually come true, and to think through how they might deal with different eventualities. For example, someone might be so busy worrying about being fired from their job and ending up destitute that they have never thought through the sequence of events that would have to unfold in order for that to happen, nor thought through how they might handle those events if they happened. Needless to say, the goal here is not reassurance, nor would we want a patient to do this on a regular basis to reassure themselves; at the end of the day, we want the patient to accept the possibility that their feared outcome could come true, rather than to reassure themselves that it won’t. However, this exercise can help the patient gain some perspective on the level of risk they are taking, and gather the willingness to take that risk through ERP.
Note: Exercises (3) and (4) above can help a person to “get there ahead of the OCD” (to borrow a phrase from Dr. Yadin), such that when they are triggered, they can quickly identify what they’re afraid might happen if they ignore the OCD and how unlikely that would be, and thus make the decision to take the risk.
I hope this article will help therapists to select and implement effective imaginal exposures, and to articulate to their patients how those exposures work and why they are using them.