Michael A. Tompkins, Ph.D.
Co-Director of the San Francisco Bay Area Center for Cognitive Therapy
Imaginal exposure involves the client imagining the feared object or situation to evoke fear and anxiety. Research has demonstrated that direct in vivo exposure to feared objects or situations is more effective than imaginal exposure to the same circumstance. However, the combination of both exposure strategies has produced excellent outcomes and, at times, imaginal exposure is the only exposure strategy therapists can use to treat a specific fear, such as a client who fears dying from a toxic substance at some unknown and distant date in the future. At other times, therapists can use imaginal exposure when in vivo exposure is not practical, such as a client who fears that the plane he is on will crash, but he cannot afford to fly frequently enough to treat the fear through in vivo exposure. At other times, imaginal exposures are effective “warm-up” exposures prior to the client participating in in vivo exposures.
The first step in implementing imaginal exposure is to develop a hierarchy of fear-evoking scenes arranged from least anxiety evoking to most anxiety evoking. The next step is to construct the scenes themselves. Imaginal scenes are vivid movie-like images that the therapist guides the client through to evoke anxiety and discomfort. The scenes include descriptions of sensory elements (sound, sound, smell, taste, touch) as well as descriptions of the setting and the client’s actions. The final step is to implement the imaginal exposure. The therapist instructs the client to sit in a comfortable chair, close his eyes and to “be in the movie” rather than observing it as if he were in the audience watching the movie. The therapist then describes the elements of the scene while asking the client to describe what he sees, hears, touches, smells, feels emotionally, feels physiologically, and thinks. The scene is recorded on an audiotape for the client to listen as homework. The recorded scenes can be brief. Often 2-5 minutes is good. The client listens to the recording three to five times and then rates his anxiety (0 to 10, where 10 is extreme). The client then returns immediately to the recording and repeats this process. In addition to these basic guidelines, I recommend therapists attend to the following when conducting imaginal exposures with clients.
Include response prevention in the imaginal scene. Response prevention is an essential strategy in the effective treatment of any anxiety disorder whereby the therapist blocks the avoidance strategy, either actions such as a compulsion, or thought actions such as mental reassurance, analysis, or internal checking. For example, the therapist treating a client with germ obsessions who washes his hands after touching a doorknob would instruct the client to touch a doorknob but not wash his hands. Similarly, a therapist might instruct a client with generalized anxiety disorder who fears something terrible will happen to her husband during his commute, to not call him as she usually does when he arrives at work. It is essential that therapists block mental safety behaviors during imaginal exposures in order that clients experience a full and effective exposure. For this reason, I recommend therapists include response prevention in imaginal exposure scripts. For example, a client with contamination obsessions that cause him to feel dirty and uncomfortable when he touches most anything and who then washes his hands for 30-40 minutes, would listen to an imaginal audiotape that describes him touching a counter and feel the contamination coating his hands, climbing up his arms and spreading across his face. The therapist includes the response prevention piece in the script by adding, “You go to the bathroom and wash your hands, like you usually do. But this time, the feeling of contamination does not decrease but continues to grow and grow. You desperately continue to wash your hands, but again and again you leave the bathroom with the feeling of contamination growing and growing.”
Block self-reassurance. Therapists are likely familiar with anxious clients who repeatedly seek reassurance from their partners, family members, physicians, and therapists. They ask, “Do you think it’s okay if I don’t wash my hands right now?” or they check with them whether the feared disaster has occurred, “I heard that feeling flush and nauseous is one of the first signs of food poisoning. My face doesn’t look flush does it?” Similarly, clients engaged in imaginal exposure can fall into a pattern of reassuring themselves as they listen to the audiotaped scene. They might think, “I know this isn’t really happening. I’m just listening to a tape.” Or, “My therapist must not think this would ever really happen or he wouldn’t have asked me to imagine this scary scene.” I recommend therapists check with clients whether they are doing this, particularly if the client tends to over-analyze events or if they have sought reassurance aloud from the therapist. When clients admit to reassuring themselves, review with them the importance of listening to the scene as if it is really happening and to counter these reassuring thoughts with phrases such as, “Well, I can’t be sure that I won’t get sick and die. My therapist can’t be absolutely certain, now can he?” If the problem continues, again remind the client that if the exposure scene is too anxiety-evoking for him to hold fully in their awareness without reassuring themselves, they can drop down in the hierarchy and try a less fear-evoking scene or modify this one so that it is more manageable.
Block cognitive avoidance. At times during imaginal exposure, clients will distract themselves to a neutral image to avoid fully interacting with the fear-evoking scene. I recommend therapists ask their clients whether they are doing this, particularly if they observe that the client has reported little or no anxiety as they listen to the imaginal exposure recording. When therapists encounter this problem, explain to clients the importance of making every imaginal exposure count and remind them that if this exposure is too anxiety-evoking for them to hold fully in their awareness they can drop down in the hierarchy and try a less fear-evoking scene or modify this one so that it is more manageable.
Consider imagery training. Many clients are poor imagers, particularly clients who suffer with generalized anxiety disorder, and will require imagery training in order to benefit fully from imaginal exposure. Imagery training involves instructing clients to imagine pleasant scenes that tap into all five senses. For example, a therapist might ask a client to imagine sitting by an open window through which the sun is shining and gentle breeze blowing. The client is to imagine the feel of the warmth of the sun on his cheek. He is instructed to imagine the feel of his hair moving across his forehead as a gentle breeze enters the window. The client is instructed to imagine the sounds of birds and the low hum of a plane as it flies overhead. The client then imagines that he looks out the window and watches a man cutting the grass and smells the fragrance of cut grass. The client imagines nibbling a piece of cinnamon toast and imagines the salty taste buttery cinnamon. The therapist instructs the client to rate the vividness of the scene from 0 to 10 (where 10 is extreme vividness). Imagery training continues until the client can imagine the scene vividly. The training continues with other pleasant scenes until the client reports vivid scenes, regardless of the content. Once the client begins imaginal exposure, I recommend therapists ask the client to rate not only their anxiety at various points in the exposure but the vividness of the scene as well. If the client reports low vividness ratings, I recommend additional imagery training.