OCD and Imaginal Exposures

by master isolated images freedigitalphotos.net

by master isolated images freedigitalphotos.net

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!


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14 Responses to OCD and Imaginal Exposures

  1. My biggest OCD fear was going to hell– which could not be duplicated in an exposure, of course– so I did imaginal exposures too! It gave me back my life! So grateful for the brilliant people who figured out this as an alternative ERP opportunity.

    • Thanks for sharing, Jackie, and that’s an excellent point. Who came up with the idea of imaginal exposures? So simple, yet so powerful….a really effective way to face our fears.

  2. mssarahashley says:

    I’m doing this now as part of my treatment. It really helps!

  3. 71 & Sunny says:

    I too have heard people say that they didn’t think their type of OCD could be treated by ERP. And I suspect that in their case, imaginal exposures were probably the key to their treatment. The best part is that they can be perfectly and exactly tailored to a person’s specific needs. I also think they can be a good adjunct to traditional physical ERP – as in my case with Hit & Run OCD. I can do the exposures like driving even when I don’t want to, and not turning around to check, but I can’t make accidents happen (well, at least I shouldn’t!) but I can work through an actual accident in an imaginal script.

    • Thanks for sharing your experiences with imaginal exposures, Sunny. I think that’s a great point, that these exposures can be specifically tailored for each person. As we know, there is no “one size fits all” when it comes to OCD.

  4. Before starting Imaginal Exposures I also thought my OCD was untreatable. But even when you realize it might help, and you really want to get better it might be very hard to accept the uncertainty that follows when not performing your compulsions. Like for Jackie Lea Sommers, there might be a chance she gets to hell. How to be able to live with this uncertainty for the rest of the life? Since you don’t see the benefits from exposing yourself to your anxiety at first sight it is mentally very hard to see to benefits of ERP even when you know rationally it will work. Of course, when you don’t spend time making sure you don’t go to hell anymore, the fear itself will also go away over time. So combined with mentally having the courage to do ERP, it is also crucial to start accepting that the world is chaotic and it is very rare you’ll find something that is 100% sure. But over time you’ll also realize that not being certain about things don’t prevent you from having control over your own life and the things that you care about, which hopefully is your way out of OCD 🙂

    • What a wise comment…..I love it! You hit on the very thing that fuels OCD – doubt and uncertainty. But your last sentence says it all: “But over time you’ll also realize that not being certain about things doesn’t prevent you from having control over your own life and the things that you care about, which hopefully is your way out of OCD.”
      Thanks for sharing!

  5. Char says:

    Would it truly be helpful to encourage myself to imagine these things when I already have a reel of mental gymnastics screaming scenarios and possible outcomes as a daily sermon when I force myself to “accept” that I have to wake up and deal with another day of digging through the garbage and trying to find a last minute outfit for the ~first day~? How could that work?

    • Hi Char, Thanks for your comment, and I understand what you are saying. I’m not going to give advice because I’m not a therapist, but I’ve heard from so many people who have found these imaginal exposures helpful. I hope you have or can find a good therapist to help you out with it!

  6. newtoblogs says:

    Hi Janet

    I don’t normally interact on the Internet or on social media, so I am hoping that this will reach you. I have never been prompted before to put comments anywhere but wanted to thank you for the refreshing articles you have provided. I have had OCD for about fifty years. The acuteness of it has varied over the years as have the treatments. All I wanted to say was a big thank you to you for taking up the cause of ocd and running with it in the way that you have. I stumbled across your articles and have fond them both empathetic and inspiring, addressing things I identify with but haven’t seen mentioned elsewhere, and providing interesting links to other information and resources. The concept of imaginal erp is another technique I will be looking into, thank you again! There is such a strong sense of hope in your writing that has made me feel more optimistic – thank you for caring enough to share your wisdom.

    • Thank YOU for your very kind words. You have made my day :)! And I’m so glad you’ve found my posts helpful. My guess is if you’ve had OCD for fifty years, you are quite the expert yourself! There really is so much hope for all those with OCD. At one point I thought I’d lost my son forever. Now he is living a happy, full life. If he can beat OCD, others can too. I wish you all the best as you continue your journey and would love to hear from you again!

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