13. Imaginal Exercises

There are several ways to do imaginal exercises with Exposure and Response Prevention. Here we outline two of them which we employ in our practice with adults.

1. Brief imagination exercise.

This exercise would more than likely be used near the beginning of exposure treatment. The clinician asks the patient to imagine a vomiting scene, beginning with the lease frightening such as an animal vomiting, or a person who is not contagious vomiting. We would ask for an SUD level before and during this exercise. As with all exercises, if the patient’s SUD level is below 8 then we would ask “can you tolerate this anxiety without doing anything to try to control it or lower it?” Normally the patient answers in the affirmative. Sometimes level 8 is tolerable. 9 or 10 probably is not (but we would still ask). If the SUD level goes to 9 or 10 (a panic attack), then slow breathing, relaxation of muscles, and a calm steady voice of the clinician may be warranted.

Sometimes this imaginal exercise works well and sometimes it is not the least bit frightening to the patient.

2. Visualization writing exercise.

This exercise would likely be employed nearer the end of ERP. The clinician asks the patient to write out their absolute “worst nightmare” scenario. It can be typed. The patient then reads the scenario aloud. It can be done for homework, not necessarily in session. Again, SUDs are tracked. If the number is not tolerable then slow breathing, relaxing or even distraction may be used. However, the patient must go back and read the scenario again until it does not illicit any feelings of fear. Once the patient is literally bored with reading the scenario they may be asked to visualize themselves being very calm and acting in a “normal” way during the scene. This follows the principles of sports psychology where one envisions the perfect play, hit or shot. It is done over and over again until it becomes an automatic thought in the patient’s mind.