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Licensed Psychologist

Imaginal Exposure vs. In Vivo Exposure for OCD

Use imaginal exposure to address OCD based around catastrophic feared outcomes.

Use imaginal exposure to address OCD based around catastrophic feared outcomes.

As I’ve talked about in numerous posts, overcoming OCD involves learning to co-exist with doubt and uncertainty. This idea can be a bit counter-intuitive at first, as many people initially expect OCD treatment to reduce uncertainty.

One therapeutic approach that helps with this process is exposure and response prevention (ERP) for OCD. Not surprisingly, ERP consists of two parts: 1) exposure, and 2) response prevention.

An exposure is when you do something on purpose to provoke an anxiety spike. By definition, exposures are not accidental; rather, they are pre-planned, deliberate offensive strikes against your OCD. Exposures are designed to help you build up your tolerance to fear-producing situations. Exposures are often completed according to an exposure hierarchy, meaning that people typically complete lower level exposures (i.e., less distressing exposures) before gradually working up to higher level ones.

Response prevention refers to the idea that after the exposure, you will allow your anxiety to naturally decrease on its own without artificially forcing it to decrease prematurely through rituals. Response prevention is most effective when one resists ALL rituals, including both behavioral and mental rituals. Behavioral rituals may include things like washing, checking, or rearranging; whereas mental rituals may include self-reassurance, thinking “safe thoughts”, praying, or mental review. Avoidance is also considered a ritual.

Exposures come in two forms: in vivo exposure and imaginal exposure (also referred to as “scripting“).

In Vivo Exposure for OCD

When we think about exposure therapy for OCD, we often think first about in vivo exposure. In vivo ERPs involve directly exposing yourself to feared situations in real-life. For example, a person with contamination OCD might develop a hierarchy of in vivo exposures that involve purposefully touching “dirty things” like doorknobs, light switches, trashcans, animals, or even toilets. The goal of these in vivo exposures is to face the fear directly without ritualizing. This means that after touching these contaminated objects, the person would refrain from washing their hands, using hand sanitizer, getting reassurance, mentally reviewing reasons why it’s okay to not wash, or doing anything else to neutralize the perceived danger of the situation.

Likewise, someone with harm OCD might develop a hierarchy based on putting themselves in feared situations. These feared situations should evoke the fear directly or present opportunities for the person to act on the fear. For example, someone who is afraid of stabbing their spouse might expose themselves to situations such as sitting near a plastic knife, sitting near a sharp knife, using a knife alone, using a knife to cut vegetables near their spouse, pointing a knife at their spouse, etc. Response prevention would involve holding the knife while accepting (and not neutralizing!) whatever thoughts might present themselves. This means resisting urges to reassure yourself, resisting urges to replace bad thoughts with good thoughts, resisting urges to analyze whether or not you might act on your thoughts, etc. This can be very intense at first, but ultimately, practice and persistence make the process easier.

How to Develop a Good In Vivo Exposure

In general, good in vivo exposures include: 1) fear-eliciting triggers or scenarios; and 2) opportunities for the fear to come true. The first factor is pretty straightforward, as by definition exposures must include components to elicit fear. However, the second factor may be a little less obvious. It is no less important, though, as this is the means by which we inject elements of uncertainty into the exposure.

For someone afraid of contracting a deadly illness, touching a doorknob at home would meet criterion 1 (if the person is fearful about cross-contamination from other household members) but it might not fully meet criterion 2. Touching a doorknob in a public place would probably meet both criteria 1 and 2.

Similarly, for someone afraid of stabbing a loved one, holding a knife while alone in your apartment might meet criterion 1, but it would not meet criterion 2. Holding a knife while cooking in the kitchen with your spouse would meet both criteria 1 and 2.

It’s okay to complete exposures that meet only criterion 1, especially in the context of doing hierarchical exposure. Just know that ultimately, you will also have to complete exposures that meet criterion 2.

Regardless of whatever type of OCD you have, there is always the need to do some type of in vivo exposure. In my opinion, in vivo exposure is always relevant — at least to some extent.

However, there are also many types of OCD in which in vivo exposure is insufficient and must be supplemented with imaginal exposure.

Imaginal Exposure for OCD

Imaginal exposure (or “scripting”) involves directly confronting feared thoughts and feared consequences using your imagination. In scripting, people practice writing out their worst fears and then expose themselves to these scenarios over and over again in their minds until the intensity of their anxiety response is diminished.

Regardless of the type of OCD you might have, imaginal exposure can be a particularly important technique to include in your toolkit. Exposures may be imaginal-only (e.g., listening to your script at home alone in your bedroom), or they may have combined imaginal/in-vivo elements (e.g., for harm: listening to your script while sitting near someone you’re afraid you might harm; or, for contamination: listening to your script while touching a contaminated object). This parallels the criteria we discussed earlier related to in vivo exposure. Good imaginal exposures should also include: 1) fear-eliciting triggers or scenarios, and 2) opportunities for the fear to come true.

When you are developing an imaginal exposure script, it is important to expose yourself to the imagery/content of even the most unwanted thoughts. Imaginal exposure exercises should be vivid and should incorporate specific details (e.g., sights, sounds, smells, textures, thoughts, feelings). This level of detail can help you face your unwanted thoughts in a direct and non-avoidant way. Scripts are usually written in the first-person using present tense verbs. It can often be helpful to record your imaginal exposure on a loop tape, smart phone, or digital recorder so that you can listen to it for extended periods of time. Many people find that, at first, they must sit with a single imaginal exposure script for up to an hour or longer before their anxiety begins to habituate. However, a willingness to sit with the uncomfortable feelings elicited through imaginal exposure (without escaping or ritualizing) eventually gives way to less anxiety.

Some imaginal exposures end at the point of some unwanted event occurring or shortly thereafter when the person is horrified in the knowledge of what has happened (e.g., after the person has contracted AIDS; after the person has killed their spouse). However, it is also sometimes necessary to push imaginal exposure even further down the road. In these types of scripts, the individual exposes themselves to what happens after the dreaded event. For example, after you contracted AIDS (or committed the murder), what would happen in the next second… Over the next ten seconds… Over the next five minutes… Over the next hour… Over the next week… Over the next few years…?

Because these scripts extend further into the future, they are able to incorporate other feared consequences that shorter scripts might omit. For example, if you have unwanted sexual thoughts about pedophilia, your feared consequences might involve much more than simply harming a child. You might be afraid of what your family might think of you, having your picture in the newspaper, going to jail, losing the respect of everyone you know, and/or living out the rest of your days as a social outcast. Sometimes these feared consequences can evoke emotions that are even stronger than the emotions linked to the feared act itself. If you don’t expose yourself to these consequences in at least some of your scripts, your imaginal exposures may be of limited benefit.

When writing these imaginal exposures, you should continue to write in as much detail as possible. What was the expression on your spouse’s face when s/he found out? What did s/he say? What was it like the first day you walked into prison? What did your daughter say to you on visitor’s day?

Here a two sample imaginal exposure scripts (used with the permission of the writers). If you’re not looking to read something potentially triggering, feel free to jump ahead.

Contamination Script

That sticky, red substance that I stepped on in the parking lot was most certainly blood. Microscopic blood particles got stuck to the bottoms of my shoes when I walked by, and now these particles have been tracked everywhere I have walked. At this point, blood globules have spread throughout my car and throughout my house. I don’t know whose blood it was, but knowing my luck, they probably had AIDS or Ebola. When I itched my leg earlier, I probably transferred blood particles to my nose and mouth. These viruses are now probably coursing through my bloodstream infecting my organs and permeating my tissue. Every cell in my body is probably infected at this point. I’ll probably die a slow, horrible death and infect my family so that they get sick too. When they’re lying in their hospital beds, they’ll look at me accusingly and say, “How could you do this to me? I loved you.” I’ll apologize, but it will be too late to do any good. They’ll be dead, and I’ll be a murderer.

Serial Killer Script

I am a serial killer, and I’m going to slit my wife’s throat tonight. I’ll wake up in the middle of the night, creep downstairs to the kitchen, and pull out the big knife from the butcher’s block. I’ll walk silently upstairs and then slip into the bedroom. She will be sleeping peacefully on her side, and I’ll be able to hear her even breathing over the sound of the ceiling fan. Before she knows what is happening, I will grab her hair with my left hand and pull tight. Then I’ll slit her throat with my right hand. Crimson blood will spray all over our white sheets. She will scream but then the scream will turn into a gurgling sound as the blood oozes from her throat. She will thrash around trying to get free, but I will hold her down until she stops struggling. She will stare at me with a look of confusion, horror, and betrayal. Then the life will leave her eyes.

I will smile and walk away, finally knowing for sure who I really am.

Notice that in the first script, we include some examples of feared consequences. This imaginal exposure script is short and doesn’t delve into more far-off feared consequences, but it does a good job of highlighting this person’s fear of being irresponsible and unintentionally harming others.

The second script was used by someone who engages in a lot of mental rituals, including “figuring out” rituals, self-reassurance, and mental review. Because of these rituals, this person proactively built response prevention into their script. Specifically, the last statement of this script involves the person actively agreeing with their own worst-case scenario.

Response prevention during imaginal exposures is just as important as it is during in vivo exposures. If you don’t practice good response prevention, your imaginal exposures will be unhelpful. During these exposures, resist all the mental rituals associated with your OCD. Don’t analyze your thoughts or argue with them. Don’t try to figure out how likely they are, or what factors might make them more likely to occur. Don’t come up with an action plan designed to prevent these situations from coming true. Overall, sit with the uncomfortable thoughts and embrace uncertainty.

It is also important to be wary of avoidance behaviors that can creep in when you begin doing imaginal exposure. For example, if your scripts focus on the fear of harming a loved one, you might have mixed feelings about the prospect of spending time with those you care about. Although spending time with them might be uncomfortable at first, do not indulge the urge to avoid. If these relationships are important to you, it’s critical to work on building closeness and quality of life with those you care about even when your OCD makes it more difficult to do so.

Similarly, if you are scripting about touching contaminated objects and then getting sick, you MUST continue to interact with these objects without engaging in washing or cleaning rituals. If you script and then avoid these objects, your fear will increase. This is yet another example of how it is important to combine exposure to triggers with opportunities for the fear to come true.

It can be difficult to sit with extended imaginal exposures but doing so can give you power back.

OCD does not want you to know that you can reach a point where these possibilities hit you less hard and affect you less.

If you do these exposures, you may feel panicky, desperate, anxious, and nauseous at first. You may sweat, cry, and feel like your head will explode. However, I would encourage you to see it through and ride out the wave. At times, the experience of exposure can be extremely emotional, which is why it’s sometimes important to have a therapist to guide you through it. However, you can stack the deck in your favor by choosing an exposure that meets you at the right level. You should begin with an exposure that has a SUDS (i.e., “Subjective Units of Distress Scale”) rating of about a 3 or 4 (on a 10-point scale) and gradually work your way up to the harder stuff.

When you do reach the point where your scripts are causing less anxiety, OCD will probably try to trick you by saying, “Aha! See, these scripts don’t even make you anxious or disgust you much anymore. This is proof that you’re callous and that you’re capable of doing terrible things!” It will imply that a lack of anxiety means that you want to act on your thoughts.

This just isn’t so.

If your anxiety begins to lessen in response to your scripts (and yes, I mean those terrible, disgusting, graphic scripts that you wrote), you have begun to establish a healthier emotional distance from your thoughts. You are beginning to short-circuit an emotional button that OCD has been pressing over and over again to its own advantage. This is a good thing, despite the fact that OCD will paint it as a bad thing (i.e., the “backdoor spike”).

If I was your therapist, I would ask you to incorporate planned, deliberate exposures in which you purposefully face your thoughts head-on and use scripting as a technique to habituate to your fears. If you did this, your relationship to your thoughts would begin to change. Most individuals set aside at least an hour a day to work on their scripting. To be effective, scripting exposures may be prolonged (as long as it takes for your anxiety to decrease significantly) and you must actively resist ALL rituals.

The goal of exposure is to allow yourself to feel the anxiety you are experiencing without turning away from it (i.e., without neutralizing, reassuring, distracting, or undoing). This is often first practiced in-session with a therapist who can help shape your technique…however, it then becomes a strategy that you can replicate on your own. Make sure that you don’t avoid self-directed exposure. If you are only doing exposures with your therapist, you may be using your therapist as a source of reassurance (i.e., using your therapist as a ritual).

Exposure does work, and like any exercise, the best form yields the best results.

Questions?  Comments?  What has been your experience in using in vivo vs. imaginal exposure?  Any success stories worth sharing? Any tips or tricks for your fellow scripters? Sound off below.

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