ERP & Imaginal Exposures

I’ve written elsewhere on this blog about Exposure and Response Prevention therapy (ERP) and how different my life is after I underwent an intense 12 weeks of this type of cognitive-behavioral therapy.  ERP is exactly what the name says it is: you are exposed to something that will trigger your obsessions and then you are prevented from responding with a compulsion that will relieve your anxiety.

For example, someone who has contamination obsessions and hand-washing compulsions might be made to touch garbage and then is not allowed to wash her hands.  Instead, she sits with that anxiety, feeling it intensely.  If someone has HOCD obsessions and seeking reassurance compulsions, she might have to look through a Victoria’s Secret catalog and is not allowed to ask, “Am I gay?  Am I straight?”

So, what happens when you have Pure-O obsessions?  What if your obsession is that you will kill your newborn daughter and your compulsion is to stay away from her crib?  What if your obsession is that you’re going to blaspheme God and go to hell and your compulsion is repeating a prayer in your head?

Then what?  You can’t really kill your daughter (um, big DUH there, but you get it!) and you can’t really go to hell, so how in the world are you able to practice an exposure then?

"little sad song" by *TrixyPixie on deviantART

“little sad song” by *TrixyPixie on deviantART

Imaginal exposures, baby.  Brilliant and brutal.

In situations like these, what you might be expected to do is to write down all the ways you could kill your daughter, read it into a digital recorder, and then listen to it over and over.  Or maybe you’ll create a story in which you go to hell, where you’re forever condemned, and you read that story again and again.

If you’re an obsessive-compulsive, trust me, these imaginal exposures are going to FREAK. YOU. OUT.  They will be so triggering and so terrifying that your anxiety is going to spike, no problem.

Meanwhile, no compulsions allowed.

Meanwhile, ERP is re-wiring your brain.

Meanwhile, you’re stepping toward freedom.  And “all” you had to do was listen to a story.

This was my particular brand of ERP actually.  I had to listen to my recording for about 80 minutes a day until my anxiety levels (self-measured at the beginning, middle, and end) decreased by 50%.  For the first ten weeks or so, my anxiety levels were NOT dropping, and I very nearly gave up.  I mean, why put myself through this misery and terror every day if it was doing no good?

But then.

Sometime during week eleven, those anxiety levels started to drop.  I developed a whole new way of looking at my intrusive thoughts.  I tiptoed up to OCD.  I can still remember the day when I was listening (again) to that horrid recording, and instead of feeling anxious, my thought was, “This is getting so annoying.

And then I laughed … because … because finally.  You know what I mean.

40 thoughts on “ERP & Imaginal Exposures

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  2. I love this. I have to do imaginative exposures too. I’m in the early stages where it’s incredibly painful. But I’m hopeful that at some point, I will get better, and it will be easier.
    Hanging on.

    • Yes, hang in there, Kimberly! I can utterly relate to those early stages of huge pain. I HATED my exposures (I guess that’s the point, ha!). For me, it DID get better. There was this week when everything finally CLICKED into place … and my life has been so different for the last four years!

    • I am in this place right now. I did some “basic” in vivo exposures, and I didn’t think they could get better, but they are starting to.

      Now, I’m starting the imaginal exposure. it seems impossible that I will ever look at it as boring/annoying.

      It’s kinda scary, but I’m trying. (I’m also worried about mental compulsions.)

      I am glad things got better fvor you, jackieleasommers.
      I hope things worked out well for you, kimber.

  3. Oh my goodness. I know I need to do this. I am so terrified to do it. I’m terrified just to write them down. I feel like someone will find it and think I am crazy. Somehow though, I know this is where freedom is 😦

    • ERP is very counter-intuitive. If I’m not mistaken, my homework assignments were/are very similar to Jackie’s. I had to think/expose myself to the obsessive thought. I now vocalize it which sometimes weirds me out, but the more I do the exercise is done the less sensitive I become to it, almost like a mental callous. Definitely hang in there. At some point the words just don’t mean the same thing you originally thought they did. Essentially, one of many words strung together in a menu of thoughts of which you are not obligated to believe in or identify with.

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  8. Hi Jackie!
    I just came across your blog and I am so glad that I did! I don’t know if you’ll see this comment as this post was quite a while ago, but I just had a question for you. While you were doing your ERP, did you focus on the same subject matter the entire time? My obsessions tend to change after a few weeks. Did you experience that at all? Mine tend to jump between HOCD and POCD.

    • Hi Jessy!

      A lot of people do a variety of exposures with their ERP therapy. You create a “hierarchy” with your therapist (or on your own) and rate them from the one that would cause you the least anxiety to the one that would cause you the most. You start with the lowest rung and work your way up!

  9. Hi Jackie Lea,

    That was very insightful – thank you. It does seem so counter-intuitive to not ‘speak the truth’ over my life. But I see a deeper magic in ERP.
    I have managed to find a practitioner in my area – yay! Felt a bit more secure than just using the app. We are starting next Wednesday. I asked God about whether he was OK with me doing ERP. I think he said ‘face who you really are’ and I felt that the answer to that was ‘Anna who has OCD’ and he said ‘You’re gonna look the fear in the eyes and stare it down’. I’m sure I heard Aslan roar inside me 😉
    Please may I ask three questions?
    1. I started doing some desensitisation stuff. I read a headline that disturbed me so many times that in the end it was mostly just words. I think I’ll wait until Wednesday though to do more as it was very difficult. The question that arose is ‘is it normal for other, different obsessive thoughts to arise from situations like this?’ As I was reading, another disturbing obsessive thought came up as a result of reading it. I didn’t do many compulsions and didn’t block it and allowed it to be so but it is quite off-putting. If it’s part of what I can expect, I’ll just gird my loins and do it anyway.
    I couldn’t help thinking that if I hadn’t have read it then the thought wouldn’t have come up but I suppose the point is that you should be able to read anything and not need to panic if a thought comes up.

    2. Did you do one hourly sessions for 12 weeks plus the tons of homework or more sessions than that? It costs me $138 per session so I’m gonna have to dig deep!

    3. Like someone else mentioned, I might have several obsessive thoughts a day – do you do all 100 that you accumulate and put them all into the hierarchy (haha) or do you choose a broader heading for them such as ‘obsessive thoughts about harming animals’ for example?

    I understand if you don’t have time to reply.

    I’m a writer too – I won an official Harper Collins Agatha Christie writing award twice and write poetry also but I gotta say when I read your poetry – boom! It’s magic! 🙂

    Anna x

    • Hi Anna! I love connecting with other writers! 🙂

      1. Talk to your therapist about this! I’m not an expert or a professional in any way, and I’d feel much better deferring to an ERP expert!

      2. I did hourly sessions once a week for 12 weeks — plus daily homework. (I practiced my exposures for about 80 minutes a day.) I had really good health insurance though, so I only paid a co-pay each time.

      3. Again, talk to your ERP therapist about this. I think I grouped mine!

      Wishing you ALL the best, Anna! I wish I could answer more of your questions, but I really think it would be best for you to talk to your therapist!

  10. I’m not sure if I’m reading the wrong part and whether you explain somewhere else more clearly what you say as you’re recording – but that’s the bit I don’t understand. If you say something blasphemous into the tape recorder, then aren’t you doing it? (Sorry if this sounds stupid). Or do you say into the tape recorder something like ‘ok, imagine the sin’ etc.
    The reason I ask is that I live somewhere where therapists’ don’t have much experience of pure O and I could well imagine them trying to persuade me to do something that would be considered blasphemous.
    Thanks for reading.

  11. Most inspirational Jackie. I suffer from harm OCD and insanity OCD….not that they’re not related…..the insanity OCD …..fuels the harm OCD. I’ve had it since I was 24 and am now 47. It’s about harming my loved ones having gone insane and paranoid. Truth is I wouldn’t hurt a fly and would stand in front of a truck to protect them. Anyway….it’s flared up again recently, so I popped the 20mgs of prozac, and vowed to do imaginal ERP. Your blog was inspirational. I’m now in the process of scaring the hell out of myself….going as deep and revolting as it can get…..but your words ‘ERP is rewiring your brain’…..it makes it feel that I’ll see light at the end of the tunnel and can finally laugh at this thing. There was a positive moment this morning when I told my voice on the mp3 recording that he was a ‘dick’ ….. and I smiled. Long way to go but thanks so much for giving those of us who suffer from this a way forward. Back in 1995 when I was diagnosed there was so little understanding of the nuances of OCD, barely any books. Thankfully there are now more books, and more expertise. Cheers, Dave.

    • Bravo, Dave! Proud of you for doing the hard work of treatment! And I love that you’re starting to separate the voice of OCD from your own voice. I did the same and it was tremendously healing for me!

  12. Jackie thank-you. what kind of imaginal script would i write for ocd that is a bout real life events. like my guilt for putting a rescue dog down for repeated biting, i keep telling myself their were other options. I have had harm ocd and pure-o all my life with mental rituals

  13. Just found your website. Very helpful, hopeful, and informative. Love everything I’ve read so far… and I’ve found it very helpful already. I’ve had symptoms since 14, spiking to almost unbearable at times… never knew what “it” was until finally receiving a diagnosis of OCD about 8 months ago… just now really getting a handle on what ERP means and how to implement it. Thanks for all your honesty, transparency, and encouragement on this site. Keep it up!

    I’ve never made a tape and listened to it…. but read about the technique many times. What length of recording do you recommend for a zealous beginner?

    • Hi Adam! Love that attitude!

      As for me, I listened to an 18-minute recording four times a day for about 12 weeks. Sounds like a lot, doesn’t it? It was. But it was ultimately what made me get ANNOYED with my triggers and stole their power! 🙂 If you can’t do that long, try starting with a five-minute recording!

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  15. Hi Jackie,
    I have a very uncommon “version” of OCD for disgusting things. Like eating glass or sh**t or saliva or dirt in my mouth or the one of others. Or swallowing some sharp stuff. I haven’t found in literature any of these examples so I am not really sure whether I have OCD or not. Even though my therapist told me that the content is not important but how you react to it.
    My question is that I have not a single obsession (like being homosexual, or order) but it hopes from one to the other. So how can I do ERP? Do I have to do ERP for all of them in one session?
    Thanks for the great tips in your blog!

    • Claudio, are you wanting to avoid those things? Because that’s probably a pretty common version of contamination-related OCD.

      You probably won’t need to treat EVERY theme (I didnt!), but get a book like Dr. Grayson’s Freedom from OCD or Dr. Foa’s Stop Obsessing to guide you. Or else find an ERP specialist!!

      • Thanks Jackie. Yes I want to avoid this thing. But my compulsion are purely mental. I don’t wash my hands and mouth, I just try to modify this intrusive images for example substituting s*** with chocolate. Or like I have a barrier in my mouth preventing all this things to come in. And I am perfectly aware this are compulsions. Now I am much less prone to do them but I know it will be still a long way to eradicate the problem. It just seemed a little uncommon as OCD disturb. But yes most likely with the ERP I can go to the root of the problem without “fixing” every single obsession I have. Because as I told you the hoop for X to Y.
        Thanks for the tips!

  16. Hi Jackie!
    Just want to say that your posts on HOCD have been very helpful in making me feel like I’m not alone in this. Just for context, I’m a mid 20s woman – I was very tempted to tell my whole life story and then ask if it sounds like I suffer from HOCD like I suspect I do, but based on your posts and the other reading I have done, that would just be another means of seeking reassurance. I have come to a point where talking about my struggles doesn’t make me panicky or super emotional. I have a few questions though, one relating mostly to the process imaginative exposure and its role in ERP.

    Like many people who would post on here, for most of my life I’ve just felt… straight, except for the times when I’ve started obsessing. Then as I’m trying to self-help, I have days/weeks where I feel comfortable in my heterosexuality, and I also have times when I’m so confused and anxious I have to stay home. I’ve never had a problem with homosexuality/LGBTQ+ness. I have a sister who is queer (though she predominantly dates men) and friends and an uncle who are gay/bi/trans/what have you, and it was never a weird or uncomfortable thing to me. So of course the anxiety and discomfort I feel when I begin to obsess about my own sexual orientation makes me wonder – have I been secretly homophobic my whole life – and if so, is this because I’m actually a repressed homosexual? Does this mean I hate the LGBTQ+ people in my life, and myself if I am a part of that? Just wondering if this kind of thought ever occurred to anyone with HOCD.

    Another question – I feel on my good days/weeks that I’ve made a lot of progress by doing a sort of home-version of ERP(That I may, when I have time and enough money, seek actual professional aid with if I need). At the beginning, it would literally make me so anxious I would be SICK to think of myself being attracted to another woman, or having a relationship or sexual relations with them. But I persisted. After a couple of months of trying to habituate myself to imaginative scenarios, reading articles relating to LGBTQ stuff, and just trying to sit with the thoughts- all things I think bear semblance to what I’ve read of HOCD-ERP, It no longer makes me as anxious. I don’t feel as sick to my stomach. I have times where I’m feeling almost back to normal, just straight and happily attracted to men- But, despite the reduced anxiety, I still feel the obsessiveness sometimes, which triggers me to wonder if that means that I’ve been merely suppressing that I’m actually gay/bisexual/whatever and now just learning to accept it. I just want to know if this train of thought is at all familiar to anyone with HOCD – does this seem like a normal part of the process of ERP?

    I know these questions may be a compulsion, but I feel that hearing whether others relate to these struggles might help push me over a bit of an obstacle I’ve been experiencing in the process of my attempt at self treatment. If you take the time to read this- thank you!
    PS: My apologies for the excessively long comment.

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