OCD & Imaginal Exposures
As I’ve written many times before, exposure and response prevention (ERP) therapy is the front line psychological treatment for obsessive-compulsive disorder (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. Competent therapists can help those with OCD 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. And there will be plenty of anxiety! Eventually the anxiety subsides, 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 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. For example, a woman with OCD who has a debilitating fear of making wrong decisions might be helped by using imaginal exposures. She could make a recording or write a list of all the horrible things that might happen should she make a wrong decision, and listen to it whenever she goes shopping, or out to eat, or wherever she typically gets triggered. The script should include details of what is most upsetting to her about her fear (that she will cause harm to others, or be haunted by regret, for example). After continually listening to or reading her imaginal exposure, she will likely become more comfortable not only making decisions, but not dwelling on them, and this obsession will no longer have a significant impact on her life.
As many of us know, OCD can have a wild imagination. Through the use of imaginal exposures, however, those with OCD can confront the very things OCD desperately wants them to avoid. Now that’s a great tool to have in the fight against obsessive-compulsive disorder!
Woman thinking photo available from Shutterstock