As we know, exposure and response prevention (ERP) therapy is the psychological treatment of choice for OCD. Basically, the person with OCD is exposed to his or her obsessions, feels the anxiety, and refrains from engaging in rituals to reduce the fear. It’s pretty straightforward for many types of OCD.
I hear from many people with OCD who say that while they understand what ERP therapy is, and even how it could be helpful, they don’t think it would work for their type of OCD, and therefore they don’t pursue treatment. I’m not a therapist, but as I understand it, ERP can be used successfully to treat all types of OCD.
Recently I received an email from a reader who wondered how ERP therapy could possibly help her. Her obsessions involved horrible things happening to those she loved; obviously she was not about to create a car crash, or whatever other intrusive thoughts she was having. How then could the exposure part of ERP ever take place?
Enter imaginal exposures, which are based on imagining something as opposed to it actually happening. In this recent post on his blog, Dr. Seth Gillihan talks about how therapists can properly use these types of exposures within the framework of ERP therapy. Typically, the therapist works with the person with OCD to verbalize his or her obsession and then makes a recording of it, which can be played over and over again. So plenty of exposure there! The response prevention comes in when the person with OCD refrains from engaging in any compulsions to neutralize the anxiety created by the imaginal exposure. Eventually, the anxiety will subside, and the more the recording is listened to, the less power it will have.
Imaginal exposures can be written as well. When our son Dan spent time at a residential treatment program for OCD, I remember seeing papers someone had taped to a wall that said “I have cancer” written on each line. I didn’t understand what that was all about at the time, but now realize this is also a type of imaginal exposure. Whether we think horrible thoughts, talk about them out loud, or write them down, we can’t make them happen, or not happen. Once again, it all comes down to accepting the uncertainty of life.
While imaginal exposures are typically used when “real life” ones can’t be, they can also be used in conjunction with actual experiences. In this blog post, the writer explains how she uses imaginal exposures to help her with her debilitating fear of making the wrong decisions:
“The key was finding what gave me the most unease about an OCD fear, and directly addressing that in the script, putting it out there, rather than running from it. Yeah, I might choose the “wrong” item and feel my face go hot, and a panicky ache in my chest. I might really screw up, and be haunted by regret about my poor decisions and never have any peace from the obsessing about obsessing.”
She made a recording on her iPod about all the horrible things that might happen should she make a wrong decision, and listened to it whenever she went shopping. She gradually became more comfortable making decisions and not dwelling on them, and was able to continue on with her life.
While OCD might have a wild imagination, we can always “one-up” it by using imaginal exposures to confront the very things OCD desperately wants us to avoid. What a great tool to have in the big ‘ol OCD toolbox!