Imaginal Exposure for OCD and Anxiety

Imaginal exposure is a powerful treatment technique
for OCD and related anxiety disorders.

What is Imaginal Exposure

For many people struggling with OCD and related anxiety disorders, one of the most beneficial treatment tools is imaginal exposure. In order to best understand this technique, it is first necessary to understand the basic idea of Exposure and Response Prevention (ERP).

ERP is a specific type of Cognitive Behavioral Therapy (CBT) that has consistently and repeatedly been found by researchers to be the most effective treatment for OCD. Simply put, ERP is the “B” part of CBT. Using this technique, a client learns to become less afraid of fearful situations by challenging the behavioral compulsions that they employ in an effort to reduce their fear. The basic principle behind ERP is that, by repeatedly confronting their fear (exposure) without doing any compulsive anxiety-reducing actions (response prevention), the client will become less afraid when faced with anxiety-provoking situations. This process is known as habituation, which is really just a fancy way of saying that we become less afraid of things as a result of repeatedly being exposed to them.

For those who are afraid of touching doorknobs for fear of catching a disease, a simple ERP intervention would be to repeatedly touch doorknobs without washing their hands afterwards. Likewise, if they repeatedly check stove knobs for fear of causing a house fire, ERP would have them using the stove without checking the knobs afterwards. In other words, ERP focuses on changing the fear response by challenging the individual’s behaviors – i.e., their compulsions.

But many people with OCD struggle less with outwardly observable compulsive behaviors, and more with distressing, unwanted thoughts and mental images. This is especially true for those suffering with variants of OCD that are frequently described as Pure Obsessional OCD, or Pure O. Common sub-types of OCD that fall into the Pure O category include Harm OCD, HOCD, ROCD, and Scrupulosity. It is in these cases that imaginal exposure is most effective.

The simplest way to conceptualize imaginal exposure is that it is the writing and reading of short stories based on the individual’s obsessive thoughts. But these aren’t just any stories. These are stories based on the sufferer’s scariest thoughts – their deepest, darkest OCD thoughts, taken to the worst possible outcome. In other words, their worst case-scenario!

As you can imagine, many people with OCD are not too keen on the idea of writing stories about their worst-case scenario. It is not unusual for clients to break into tears, or even abandon therapy when we first broach the idea of writing and reading short stories based on their worst fears. For this reason, imaginal exposure stories should not be used until a client feels ready to face their scariest thoughts (or at least as close to “ready” as they are likely to get). Essentially, the client needs to feel safe enough with the therapist, and with the exposure process, to go to a place that feels inherently unsafe for them.

As suggested above, one key reason for using imaginal exposure is that it allows the client to be effectively exposed to obsessional thoughts for which there may not be any outwardly observable compulsions. There are three additional reasons for which imaginal exposures may sometimes be the best approach to exposure:

  • Standard behavioral exposures cannot always be easily created for some thoughts. For example, if someone with Existential OCD fears non-existence, it is virtually impossible to create a behavioral exposure that actually replicates not existing.
  • Some thoughts cannot be acted on for legal or ethical reasons. We cannot assign someone to kill someone or to molest a child. But we can assign them to write a story about those things.
  • For some people, certain thoughts provoke too much anxiety to face with standard behavioral exposures. Some clients are so overwhelmed with anxiety about a particular event, situation or thing that writing a short story about what they fear may be a good intermediate step that helps them to eventually face that fear more directly.

Regardless of the reason, if and when the client feels ready to write and use imaginal exposures, this technique can have a profound impact on their OCD.

Writing Imaginal Exposure Stories

Imaginal Exposure stories are written with the client’s active participation, and based entirely upon their actual obsessions. To be truly effective, imaginal exposure stories should have six specific characteristics that ensure that they will have the most impact:

  • Write in the first person – “I stabbed my girlfriend”, rather than “he stabbed his girlfriend”. These stories are not about some other person – they are about you.
  • Write in the present-tense – Don’t write it like it happened last year. Write it like it is happening now, or at least write it in such a way that the consequences are occurring now.
  • Keep it real – It must be based on an actual thought that is bothering you now. If the thought is not really bothering you, don’t waste your time writing about it.
  • Keep it realistic – Nothing too far-out. It has to feel believable to you.
  • Keep it succinct – No fluff and no soft-pedaling. This isn’t a creative writing class. For example, if you have obsessions about harming someone, then write a short story in which you act on that thought, and you pay the price.
  • Take it to the limit – Make it as bad as you can make it – your own personal nightmare – whether that is life in prison for murder, eternity in hell, or just having to spend the next 40 years living with the knowledge that you’ve sexually molested your own child!

Imaginal exposures stories should be relatively short and to the point – usually no more than ½ to ¾ page. Again, this is not a creative writing class, so nix the fancy adjectives and metaphors, and focus on sticking to the content in all its brutal glory. I have had clients who have written powerful imaginal exposure stories that were only one sentence long. Each situation will vary.

Once completed, the client should read the story repeatedly. Preferably out loud. I often recommend that they read their imaginal exposure stories a minimum of 30 times per day, which can be easily accomplished by reading it ten times before work, ten times at lunch, and ten times after work. And no speed-reading.  The goal is to feel the full impact of the story, not to get through it as fast as possible.

Another alternative is to record the story and to listen to it over and over and over again during your commute to work (both ways). Remember, it is just like any other exposure. Just as you will usually need to do behavioral exposures many times to reap the full benefit of ERP, you will likely need to read imaginal exposures many times in order to see significant results. The goal is to read the imaginal exposure story until it becomes much less threatening – until it becomes just a really boring story you have read far too many times.  Boredom is good.

Also, if a particular story no longer causes anxiety, but the same obsession remains, write a new story that is somehow even worse! And just as you may need to adapt your standard behavioral exposures to changing compulsions, you may need to adapt imaginal exposures to changing obsessions. When you suddenly find yourself facing a new obsession (and you will), write a new, equally anxiety-provoking story. The sooner you face the new obsession head-on, the less likely it is to get entrenched in your mind. During the course of therapy (and afterwards), you’ll gain the most if you write multiple stories that challenge your various obsessions. Be proactive.

I know all this sounds dark and scary. That is mostly due to the fact that, at first, imaginal exposures are dark and scary. But that is precisely what makes them so effective. By facing your fearful thoughts directly, you learn over time that they really aren’t as scary as you think. After all, you aren’t actually doing the things you fear – you are just allowing yourself to experience unwanted thoughts that don’t deserve nearly as much attention and anxiety as you have been giving them.

Examples of Imaginal Exposure Stories

Below are two examples of imaginal exposure stories. The first addresses a typical Harm OCD obsession, and the second addresses a common HOCD / Gay OCD obsession.  Either or both these stories may make you uncomfortable. These stories are not meant to be pleasant – they are meant to effectively challenge OCD, so they are direct and crude by design, with no sugar-coating.

If your obsessions are anything like those described in these stories, you may be triggered by them. That’s ok.  Life is full of things we don’t like, and avoiding those things doesn’t make them go away.  In fact, for those suffering with OCD and anxiety, avoidance of fear is almost always a far bigger problem than what triggers the fear in the first place.  So if your anxiety gets triggered by reading either of these stories, I encourage you to view that as an indication that this is exactly the type of story you need to write for your own recovery.

Here is the Harm OCD imaginal exposure story:

“I am sitting on the sofa with my sister. Suddenly, I grab the scissors from the desk, and lunge them into my sister’s right eye. My father grabs me and pries the scissors out of my hand, but the damage has already been done.  My sister is blinded and unable to continue with her profession. I am arrested and convicted of attempted murder and gross mutilation, which carries a sentence of fifty years in state prison.  My family cuts all ties with me, and my friends desert me.  After forty years, I am paroled, but don’t know a soul in the world.  My dream of raising a family is no longer possible. I spend the rest of my life living with the fact that I destroyed my sister’s art career. When I die, my soul is sent off to eternal damnation in hell.” 

Do you see how short and simple the story is? It has three very straightforward elements – the event (stabbing the sister in the eye), followed by the immediate consequences (arrest, conviction, and prison), followed by the long-term consequences (the client’s worst fear, in this case, eternal damnation in hell).

Now here is a story based on HOCD / Gay OCD.

“Lately, I have noticed that I find Bill attractive, and I notice that whenever I see him, I can feel a tingle in my crotch. One recent day after class, Bill suddenly reached over and kissed me. I really liked it and kissed him back. His tongue went deep into my mouth, and I started rubbing my body against him. We both were breathing hard, and I could feel his penis hardening against me. We ripped each other’s clothes off, and he started licking my penis. I felt the warmth and wetness of his mouth, and screamed as I came. After that I went down on him and he tasted so good. I realize now that this is what I have always wanted, and for the first time I realize how sex really should be. I finally have to admit to myself that I am gay, and I spend the rest of my life as a gay man.”

Note how this story follows the exact same structure as the first story – the event (sex with a person of the same gender), followed by the immediate consequences (“I like it!!”), followed by the long-term consequences (the client’s worst fear, in this case, having to accept that he is gay, and that he will live the rest of his life as a gay man).

These are simple examples of imaginal exposure stories for two very common sub-types of OCD.  This  technique can be used to challenge virtually any obsession experienced by those struggling with OCD, and is particularly helpful for treating the Pure O variants of this condition.  Imaginal exposures can also be extremely effective for addressing symptoms of other conditions that include significant levels of obsessional thinking, including Body Dysmorphic Disorder (BDD), Health Anxiety (Hypochondria), Social Anxiety, Panic Disorder, and phobias such as Emetophobia.  For each of these conditions, the imaginal exposure story should follow the same simple three-part structure, as well as the six characteristics noted in the first part of this article.

It is worth noting that imaginal exposure is not a simple one-size-fits-all approach. Each person’s response to imaginal exposure will vary depending on numerous factors, including:

  • Severity of obsessional symptoms.
  • Level of insight regarding the accuracy and legitimacy of obsessions.
  • Willingness to write exposure stories that truly reflect one’s deepest fears.
  • Commitment to reading the imaginal exposure stories repeatedly and consistently.

Furthermore, it is critical that sufferers understand that imaginal exposure is not in any way a silver bullet that provides a quick fix – it is just one piece of the puzzle required for effective treatment of OCD and anxiety. For imaginal exposure to be truly effective, it should be integrated into a cohesive treatment plan focusing on Cognitive Behavioral Therapy (CBT) that emphasizes Exposure and Response Prevention (ERP).

If you are struggling with OCD or a related disorder, imaginal exposure is one of the most powerful tools you can employ in challenging your anxiety.  It may seem overwhelmingly scary at first, but with consistent effort, you will likely see a significant reduction in your symptoms.  Don’t get fancy – just write about what really scares you and keep it simple and direct. Then read that story over and over again until it becomes less scary to you.  Better yet, read the story until reading it becomes an excruciatingly boring chore.  Boredom is the opposite of anxiety.  Boredom is good.

•Tom Corboy, MFT is the founder and executive director of the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related anxiety based conditions.  In addition to individual therapy, the center offers five weekly therapy groups, as well as online therapy, telephone therapy, and intensive outpatient treatment.  To contact the OCD Center of Los Angeles, click here.