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Exposure Therapy for Obsessive-Compulsive Disorder
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In the last section, we discussed techniques to help an OCD client reduce anxiety during exposure. These techniques included: "Worry Time"; "Helpful Phrases"; and "Paradoxical Thinking."
In this section, we will examine effective cognitive behavioral therapy strategy number six: "Imagined Exposure" through four key concepts that I ask my clients to keep in mind. These four concepts include: sensory experiences; emotional responses; internal physiological reactions; and thoughts and ideas. Listen to this section and think about your own imagined exposure sessions with your clients. What would you change? What would you keep the same?
4 CBT Concepts Regarding Behavioral Strategy
♦ #1 Sensory Experiences
The first concept is sensory experiences.
Stacy, age 32, suffered from a fear of toilets and doorknobs. To begin her imagined exposure therapy, I asked Stacy, "How would the external setting of this scene affect you if this were a real situation? Think about all your senses. For example, what are you seeing? What can you smell? What do you hear? What do you feel or touch? What do you taste?"
I asked Stacy to record her senses in her journal. She stated, "I can see the toilet. It’s white porcelain, stained slightly off white over the years. The bathroom smells like my flowery soap, jasmine, which my grandmother gave me a long time ago. The toilet is running. I’ve just used the toilet and it needs to be flushed. The handle is slightly cold to the touch."
Think of your Stacy. Can you think of any other sense that he or she should be mindful of during his or her exposure? How would you frame these questions differently?
♦ #2 Emotional Responses
The second concept is emotional responses. I feel that this concept most directly addresses with the toughest part of exposure therapy. Do you agree?
I explained to Stacy, "After we’re done with imagining exposure, the time will come when you must directly expose yourself to your fear. Emotional responses will no doubt be the most overwhelming. Consider the feelings that arise while you’re imagining this scene. For example, you might experience fear, anxiety, guilt, anger, surprised, or any combination of other emotions. You might also feel pride or gladness for having overcome such a huge roadblock. Acknowledge and allow yourself to experience all of your feelings. After the negative emotions have subsided, write down the strongest of them in your ritual journal."
A few days later, Stacy read aloud to me her emotional responses. She stated, "At first, I felt panic. Extreme panic, more vivid than I thought an imagined exposure would incite. But I continued to through with the scene until I no longer felt like I was having a panic attack." What other emotional responses do you think your Stacy should be mindful of? Are there other factors involved with his or her OCD?
♦ #3 Internal Physiological Reactions
In addition to sensory perceptions and emotional responses, the third concept is internal physiological reactions. I feel that asking the client to concentrate on her body’s physical reaction is key to understanding the severity of her reaction in a real exposure session. What do you think?
I told Stacy, "Pay attention to what happens to your body as you face the situation. Your heart may start to beat faster or your muscles might tense. Sometimes certain emotional responses affect the way our body expresses stress. For example, if you felt anxious, did your facial muscles tense up?" The next session, Stacy stated, "I could definitely feel my face muscles contract. It actually hurt. My jaw clenched and I could feel my forehead crinkling up." Think of your Stacy. Would you emphasize emotional or physical responses?
♦ #4 Thoughts and Ideas
The fourth concept is thoughts and ideas. I ask clients like Stacy to concentrate on the spontaneous thoughts or ideas that might arise during the imagined exposure session and to write them in their journal.
I stated to Stacy, "Think about what goes through your mind about what is happening. This could be linked to the meaning the situation has for you. For instance, you have a fear of the toilet because of the germs it harbors. You’re really afraid of becoming sick and dying. Is your root fear a fear of death? If the thought of becoming sick does jump into your mind, let it become part of the scene. If in your imagination, you become sick, imagine yourself sick, but do not allow yourself to perform any rituals. No cleaning. No washing. No disinfecting. I want you to get used to your fear of death and eventually it will subside."
The next session, Stacy stated, "I did envision myself becoming sick. I got pneumonia from the toilet handle. I went to the hospital, but the infection was already too far along for them to do anything about it. I vividly remember talking to my parents and saying goodbye to them for the last time. When I broke out of my trance, on the other hand, I sort of laughed at myself. It was so cheesy, like something from a bad film." Here, Stacy has just begun to face her fear of sickness and death through humor.
Think of your Stacy. Would playing this section for him or her be beneficial? Would you change anything in the methods I have just described?
In this section, we discussed effective behavioral strategy number six: "Imagined Exposure" through four key concepts that I ask my clients to keep in mind. These four concepts included: sensory experiences; emotional responses; internal physiological reactions; and thoughts and ideas.
In the next section, we will examine effective behavioral strategy number seven: "Reducing Rituals." For this strategy, I use three different smaller techniques. These three smaller techniques include: Ritual Restriction; Gradual Selective Ritual Prevention; and Response Delay.
Peer-Reviewed Journal Article References:
Barrera, T. L., McIngvale, E., Lindsay, J. A., Walder, A. M., Kauth, M. R., Smith, T. L., Van Kirk, N., Teng, E. J., & Stanley, M. A. (2019). Obsessive-compulsive disorder in the Veterans Health Administration. Psychological Services, 16(4), 605–611.
Benito, K. G., Machan, J., Freeman, J. B., Garcia, A. M., Walther, M., Frank, H., Wellen, B., Stewart, E., Edmunds, J., Kemp, J., Sapyta, J., & Franklin, M. (2018). Measuring fear change within exposures: Functionally-defined habituation predicts outcome in three randomized controlled trials for pediatric OCD. Journal of Consulting and Clinical Psychology, 86(7), 615–630.
Conrad, R., Bousleiman, S., Isberg, R., Hauptman, A., & Cardeli, E. (2020). Uncontrolled experiments: Treatment of contamination OCD during a pandemic. Psychological Trauma: Theory, Research, Practice, and Policy, 12(S1), S67–S68.
Newhouse-Oisten, M. K., Kestner, K. M., & Frieder, J. E. (2016). An evaluation of modified exposure therapy for a child diagnosed with obsessive compulsive disorder and pervasive developmental disorder–not otherwise specified. Behavior Analysis: Research and Practice, 16(3), 147–155.
Reid, A. M., Guzick, A. G., Balkhi, A. M., McBride, M., Geffken, G. R., & McNamara, J. P. H. (2017).
The progressive cascading model improves exposure delivery in trainee therapists learning exposure therapy for obsessive-compulsive disorder. Training and Education in Professional Psychology, 11
Stewart, E., Frank, H., Benito, K., Wellen, B., Herren, J., Skriner, L. C., & Whiteside, S. P. H. (2016). Exposure therapy practices and mechanism endorsement: A survey of specialty clinicians. Professional Psychology: Research and Practice, 47(4), 303–311.
What are four concepts that clients should keep in mind during imagined exposure? To select and enter your answer go to .