What is an imaginal exposure?

Exposure Response Prevention is the most effective treatment for Obsessive Compulsive Disorder.  Ideally, we support our clients in facing their fear in a gradual method, which builds up in difficulty as the client becomes desensitized to their trigger. 

The gold standard for exposures is “in vivo” exposures, which means that we recreate a fear in real life.  For example, we would have a client who is afraid of flying get on an airplane.  However, sometimes a therapist cannot set up in vivo exposures either in the therapy room or as homework.  Sometimes an in vivo exposure would be too dangerous, too extreme, or simply not viable.  In these cases, an imaginal exposure is the next best option.  

For example, our client could have a deep phobia of plane crashes.  While able to fly (a simple exposure), this person nonetheless experiences intrusive thoughts of the plane crashing during the flight.  It is not enough for this client to simply force themselves to fly – they must force themselves to confront their brain’s narrative of crashing. 

In session, we would write a story together wherein the client is the protagonist of their worst nightmare scenario.  We would have the client provide vivid details about how the crash would happen.  We would encourage the client to read it out loud in session, and even make an audio recording of the narrative to play on loop outside of the office. 

In an imaginal exposure you confront the story of your worst nightmare so many times that it actually becomes boring, and sometimes a bit funny!

The premise of this technique is the idea that resisting an idea causes it to persist! Although we are fearing a plane crash and having intrusive thoughts about it, our phobia prevents us from actually leaning into the fear and looking at it straight on.  When we carry out an imaginal exposure, we are actually able to desensitize ourselves to our fears and open new doors to experiences without the pain of anxiety.