Types of Exposure in Exposure and Response Prevention Therapy
Jessica Bell
Oct 26, 2022
OCD (obsessive compulsive disorder) is a debilitating condition that affects millions of people worldwide. It is marked by individuals struggling with obsessions and compulsions. Obsessions are intrusive, unwanted, distressing thoughts, images, or urges that cause anxiety or distress. The body's alarm system activates, our anxiety grows, and the person wonders what that intrusive thought must have meant. Compulsions are repetitive behaviors or mental acts that a person feels compelled to do in order to relieve OCD-related anxiety or distress. A person's obsessions may focus on intrusive thoughts about harm to themselves or others, sexual intrusive thoughts, contamination fears, relationship based thoughts, morality/scrupulosity based thoughts, and more. Compulsive behaviors and mental acts may look like checking, mentally reviewing, mentally rehearsing, excessive hand washing, thought neutralization, etc.
One common approach with significant treatment outcomes for anxiety management and obsessive compulsive disorder is exposure and response prevention (ERP), a type of Cognitive Behavioral Therapy (CBT). ERP involves gradually exposing clients to their feared stimuli in order to help them overcome their anxiety and learn to tolerate situations without engaging in compulsive behaviors or avoidance behaviors. ERP aims to have patients habituate (gradually reduce their anxiety over time) and also learn to manage the distress around anxiety provoking situations. Exposure exercises will be done in session with your therapist and clients will also have a practice exposure for outside of session, while engaging in ritual prevention. Even though exposure therapy is often the intervention used to treat OCD symptoms, it can also be done with those experiencing other types of anxiety related disorders and mental health issues (social anxiety disorder, panic disorder, generalized anxiety disorder, post traumatic stress disorder, etc.)
If you haven't experienced an exposure treatment before, you may be unsure of what this looks like. The types of exposures in ERP are imaginary, in vivo, and interoceptive exposures.
In Vivo Exposure
In vivo exposure involves facing distressing situations related to one's obsessions in real life. Even though this involves directly facing fears, this can also be done gradually. For example, if someone has contamination based OCD with fear of contracting an illness, this exposure may involve directly touching a doorknob that someone fears may be contaminated. Gradually increasing the difficulty of this exposure would look like touching a doorknob at home, then at a public restroom at a location where a few people go to, and then touching a doorknob at a location where many people may have access to the same doorknob. While doing this, it is very important to engage in response prevention (not engaging in compulsions). For someone who has harm OCD and has intrusive thoughts regarding harm and driving, an exposure may look like driving a parking lot, then driving on a busy road, driving on a highway, and driving over a bridge.
Imaginary Exposure
Imaginary exposure involves visualizing the feared situation in your mind. This can take the form of creating an imaginary script or verbally hearing or saying statements related to your intrusive thoughts and core fears. An imaginary script may be written by the therapist, on your own, or collaboratively with your therapist. The script is similar to the mindfulness practice of "guided imagery," where you are directly envisioning the script in your mind, as if this is currently happening. This could also involve the therapist asking someone to describe what they envision the tiny, microscopic germs on the doorknob may look like. This could also involve mimicking what some of the obsessive thoughts would naturally say when you are exposed to a trigger, such as, "what if you do get sick?" For harm OCD, this may look like statements that mimic similar obsessive thoughts, such as, "what if you drove off the bridge?" You may also create a script that access the core fear around the harm and driving that you envision happening while sitting in session.
Interoceptive Exposure
Interoceptive exposure involves experiencing the physical sensations that are associated with the fear, such as feeling one's heart racing or feeling like one is about to vomit. For someone with contamination OCD, this may look like creating a physical sensation that we fear could be a sign of being sick or contaminated. You might run in place to get your heart rate up or do an activity to create a tingly sensation in the body.
Conclusion
These are examples just around contamination OCD, but will look very different based on the type of obsessions and compulsions the individual has. Even if contamination OCD is what you currently struggle with, your exposure sessions should and will look different as well because they should focus on your core fears and situations/items that are triggering that are unique to you.
An exposure can be done individually, but can also be done in combination with another type of exposure. Some clients with obsessive compulsive disorder may find that one type of exposure is particularly effective for them, while others may need to incorporate multiple types in order to effectively manage their OCD symptoms. Incorporating multiple types can be more anxiety provoking than the ones done individually, but may also more closely mimic what happens when someone is triggered in their day to day life. Often we may come across an in vivo exposure (we touched a doorknob in a public restroom) and then we have the imaginary exposure (intrusive thoughts, such as, "I think I felt something on the doorknob. What if that was body fluids that could be harmful and get me sick?"), and the interoceptive exposure occurs (maybe our hand starts pulsing because we are anxious and we are unsure if this is a sign that we did come in contact with a contaminant). Exposure and Response Prevention (ERP) is a powerful and proven treatment modality. Treating obsessive compulsive disorder with these repeated exposure can help individuals learn to cope with and manage their OCD symptoms over time.
If this is something that may be helpful for you, please reach out to Mosaic Minds Counseling, LLC. Mosaic Minds is a group private practice with therapists that understand ERP treatment. The international OCD foundation (IOCDF) also has a wide range of resources to begin your treatment journey, as well.