Several of you have asked about doing imaginal exposure (exposing yourself to fear producing things only in your imagination), and since this is a very powerful way to fight obsessions using behavior therapy, I've put together this short description. A little background first, and then an example.

Let's talk about behavior therapy for OCD. This first thing to know is that all changes take time. Many of you have had your OCD for several years, and you can't expect to change all of your symptoms, habits, thoughts and beliefs overnight. That said, behavior therapy is the best road currently known to get to your destination of reduced (or eliminated) OCD symptoms.
The type of therapy best supported by the literature is Exposure and Response Prevention, or E & RP. Exposure means being exposed (or exposing yourself) to your anxiety-producing stimuli, the things you normally avoid or the things that you fear. Response prevention means inhibiting yourself from doing the behavior, or the ritual, that you normally use to temporarily reduce your anxiety. Sounds awful, huh? It sounds like asking you to face your dragons and taking away your sword and shield. For instance, someone with contamination fears may avoid touching the trash can, or may wash their hands several times after touching it.
With an E & RP approach, that person would be volunteering to touch the can deliberately, and then refrain from washing for at least an hour. Now this may sound intimidating, but we do this in the way that starts you out with something SMALL, that doesn't bother you very much, and work up AT YOUR PACE to the most difficult tasks at a rate you feel comfortable with. The best treatment for OCD is to pair these two strategies together. Now sometimes that's not practical. For instance if we're treating an obsession like "I'm afraid I might kill my kid," it may occur with a ritual like saying a prayer. Or it may actually occur alone without a ritual. In that case, we might use exposure alone by exposing the person over and over again to the obsession until it loses it's value. This is what others have called flooding, and what we call "Imaginal (not imaginary, because the anxiety is real) Exposure". We do this in a slowly increasing way, sort of like getting used to the water in a lake before just diving right in.
When we ask you to do the thing that normally increases your anxiety, and then ask you not to do the thing that normally reduces your anxiety, what do you think will happen? I mean, besides the formation of a lynch mob. Right, your anxiety will go up. And it seems like it won't go back down. What an awful situation; how dare we ask you to do something like that! Some of you must think we're joking. Well, we're not joking, but we're also not asking you to expose yourself to any more anxiety than you are ready for. From the beginning, you will have complete control over how much anxiety you experience, and if you don't feel ready to do it, then you simply won't have to do it. And it isn't true that your anxiety won't come back down. Let's diagram the situation. Let's draw time on the X-axis (going out to the right) going out to about an hour, and Y-axis (going up) we'll call anxiety. We'll be starting at your baseline level of anxiety, positive but not too high. Now a couple of minutes out on the X-axis you'll be exposing yourself to your anxiety-producing stimulus, and all of a sudden your anxiety goes up, to whatever the peak value is for you. What would normally happen is that your anxiety would peak, then you would do your ritual and your anxiety would come back down as it tapers back to baseline. Now what happens if we ask you not to do your ritual? Well, your anxiety will stay up; pretty scary thought, huh?
However, OVER A VERY SHORT TIME your anxiety starts to come back down, by itself, withoutdoing your ritual - all the way back to its original level. What this shows is really the basis of Exposure and Response Prevention - even if you don't do your ritual, your anxiety will eventually come back down by itself (MAJOR POINT OF BEHAVIOR THERAPY!!) With E & RP and with your hierarchies and with your repeated exposures we will be reinforcing that notion. We will in effect be training your brain to know that your anxiety will come back down after each exposure.
The principle tool of E & RP is called the hierarchy. You can't do this type of behavior therapy for OCD without it. The hierarchy is a graduated list of all the things that you do that make you anxious, that you think that make you anxious, or that you avoid because they make you anxious. You write these items down as short sentences, so that if you did these things as written, you would get anxious. For instance, one item might be touching the trash can without washing your hands, or touching the trash can without wearing gloves, or touching the trash can without using a paper towel. So you can see that I'm stating both the exposure and the response prevention in each item on the hierarchy, so there's no question about what the RP is going to be. Now we realize that with some items you won't be able to do this, as we talked about earlier. You may be only doing exposure, so you might write "having the thought that I might kill my child," and there wouldn't be any RP.
Now that we have a short list of anxiety producers, we'll apply a scaling system called the SUDs scale, or the Subjective Units of Discomfort scale. Subjective, because the amount of anxiety you feel is totally up to you; no one can tell you how much anxiety you are feeling. Units, because we have to have some way of measuring this. Discomfort because that's what we're really measuring, how bad you really feel. Now the most important part of this is the word subjective, because what makes me anxious may not make you anxious, and it certainly won't make us anxious to the same degree. The way you do this is that you find some item on your hierarchy that you absolutely could not do under any circumstances because it would make you too anxious. That would be your 100. Now there are things on your hierarchy that you could probably do, that would cause you a lot of anxiety but you could grit your teeth and last an hour with the anxiety. You wouldn't like it, but you could do it. These would be your 50s. And at the bottom end of the spectrum would be the things that might give you almost no anxiety at all, and these would be 10s. Suppose you have a contamination fear, and touching the trash can would be a 100, but only thinking about the trash can doesn't cause you too much anxiety. The idea of a 10 is that this creates almost no anxiety at all. Everything else fits in between as 20s, 30s, 40s etc. Now, once you have your hierarchy, hopefully you'll find that you have a continuum of numbers, from 10 through 100.
What if I have obsessions without compulsions? Here, we might simply have to use imaginal exposure. That might mean imagining a lower-level version of your obsession over and over, on a regular basis, either by reading out loud a story about your obsession, or by listening to a tape of yourself reciting it. It seems to make a big difference if you actually hear the words, probably because the brain processes things it hears differently from things you read or things you think. Your hierarchy would have to include many versions of your obsession, each representing different levels of anxiety for you. For instance, if your obsession is "I might harm my dog," one level might be imagining harming her under conditions where you know that she is safe in your mother's arms. Another higher level might be imagining harming her when you know she is safe in bed, but no one else is there to protect her. Another level is imagining harming her when she is there in front of you at a distance. Another level would be imagining harming her when she is on your lap. Each of these scenarios would be a different VERBALLIZED exposure assignment, each one doable one when you've gotten through the one before. Now all of you may experience your level of anxiety going up as I suggest this, since this is not a pleasant thought. For these types of situations it is important to remember that, for OCD sufferers, the things that we obsess about are the last things we are likely to do in real life. It kind of makes sense, doesn't it? These obsessions are horrific to us, and we worry so much about doing these things that we become hypersensitive to them. So, in effect, we are the last people who would ever really do these things. It sometimes helps to remember this if you're going through an exposure for an obsession. Of course, even this is rational reassurance, and we know that rational arguments don't often defeat irrational fears. So it might actually help others more than it would help you to know that you are the last person likely to act out on your obsessions.
We need to introduce one more tool that you can use to help monitor your responses to these assignments. This is called the anxiety log. Make yourself a form with headings across the top, and six columns going down the parge. On the left make a column for "Activity;" that basically means, which assignment are you doing? Then make columns marked "Before," "During," "Immediately After," and "1-2 hours later." These columns are there for you to write in numbers that describe your level of anxiety during different parts of the assignment. We use a different numbering system here, so that we don't get confused with the SUDs scale. The SUDs scale refers to levels of anxiety comparing one assignment to another, while this scale is just to compare your relative anxiety while you do a particular assignment. The scale we use is 0-8, with 0 being "no anxiety," and 8 being "highest levels of anxiety." So you might expect that before an assignment, you would experience a level of anxiety equal to, say, a 4 as you anticipate the exposure. During the exposure it might climb up to a 6, and drop to a 4-5 right afterward, finally dropping back down to a 2-3 in about an hour. The last column for comments is to note anything that is special about that particular occurrence (eg., if you had a bad day, if you just hada fight with your father, or if you were sick with a cold). Just about anything that might affect your score should go in that column.
Keeping the anxiety log will be most useful if you keep a separate sheet for each assignment, and make an entry on the sheet for each exposure. Keep the sheets together in a notebook with the dates listed at the top or on the side. Just doing them can help you see, in a measurable way, that your peak anxiety goes down with repeated exposure to the same assignment; that is, your numbers should drop over the course of the week, from the top to the bottom of the sheet. This will also give you a way to see that your numbers will also drop over time between assignments, that is, from sheet to sheet. This is true even though you will be doing harder assignments as you go. One other benefit of keeping the anxiety logs is that, if you have a bad day or a bad week, you have something to look back on to see that you have been making improvements. Remember that even though you will be continually improving overall, you might have a bad day or even a bad week from time to time. When you do, it's helpful to have something to look back on, something in numbers to show that it's just a bad week, that overall you're doing better and that your anxiety is going down and you're accomplishing more. The anxiety log is a great tool for exactly that.

Here's an example (adapted from a real-life group session) of an interaction between a client and therapist making an imaginal assignment:

Carol: I want to make sure I get a turn, so I'll go next. I have a couple of compulsions, a little washing and a little checking. But the thing that's been bothering me the most has been my obsessions. These are just driving me crazy (starts to cry). I just can't believe that I could even think of something like this.

Therapist: We'll ask you about your last assignment in a minute, Carol. What is it that's bothering you the most right now?

Carol: I'm kind of ashamed to talk about it, but that's why I'm here, right?

Group member, giving Carol a hug: That's why we're all here.

Therapist: Can you talk about your obsessions with us? If you want to leave out some of the specifics, that's OK for now.

Carol: Well, I'm afraid I might hurt my two little girls. I don't want to tell you how I might hurt them, but it's one of the most terrible things I can think of. I really need to work on getting my obsessions under control so I can move on. How can I do that?

Therapist: I can think of three things to suggest, and you can tell us what seems to be right for you right now. The first might be to check with your psychiatrist about your current medications. They may be able to be adjusted to lessen the power of the obsessions before you try to go after them with Exposure therapy. The second is to review some of the anxiety reduction techniques we taught in the other group, like diaphragmatic breathing and muscle relaxation, as well as the thought-stopping techniques like the rubber band and the thought contracting.

Carol: I'm trying to do all of those at different times, but they're hard to remember when I'm in the middle of an obsession.

Therapist: Then you might want to post reminder signs around your house, like "Breathe!" and "Five minutes off!" But the third and most powerful thing is to try Imaginal Exposure, where you write down an imaginary script of the obsession coming true in some ways and in graphic detail, read it into a tape recorder and listen to it over and over again for several minutes each day. This may seem terrible at first, but it will get easier, then laughable, then boring over time as you build up tolerance against it.

Carol: No, no, just the thought of doing that makes me want to crawl out of my skin. I can't even imagine doing that. I guess that's pretty close to a 100 for me.

Therapist: The whole idea here is that you would do this in a hierarchical fashion. Let's see if we can't create some version of that obsession that's a less anxiety-producing. For instance, how high would it be if you said out loud, "I might hurt my child," and left it at that?

Carol: That would be a 10, because I think that every day, and it isn't until I think about how I'm going to hurt them that the anxiety starts.

Therapist: What about saying, "I'm in a room alone, and I hear my husband and my two kids in the room next door, and I can't be sure that I didn't hurt one of them?"

Carol: That would be higher, because it's closer to what I experience, but I know that my husband would tell me if I had hurt them, so it wouldn't be too high; maybe a 25.

Therapist: Good, that might be a good one to start with. Simply write that down and recite it into a tape-recorder with a 30-second "endless loop tape," normal-sized cassettes like telepone message machines use, and listen to your own voice saying that at least once a day for a week. The anxiety will go down over time as you get bored hearing the same thing over and over. Then, we will go up on your hierarchy by changing the level to something just a tiny bit scarier, like, "I'm in a room alone, and I my husband and my two kids are in the room next door, and I can't be sure that I didn't hurt one of them BECAUSE I CAN'T HEAR THEM."

Carol: That seems too high right now, but the first one doesn't, and I know that the second one might seem different after I do the first. I think I can do that tape. Will this really help take away my obsessions?

Therapist: It won't actually take them away, but it will help reduce their power, and their "stickiness" in your brain, so that you'll not be so bothered by them, and they'll be easier to dismiss from your mind. It'll be important to write out your Imaginal Hierarchy before you start any exposures, so that you'll know what to expect, and to always write the specific item down on your hierarchy, if it isn't already there, before you do the exposure so you know it's in the right SUDs range.

Carol: OK, I'll do it. And I'll call my doctor about my medications, too, just in case.

I know this will raise questions about specifics, so please post them for me and I'll post them back as a learning process for everyone.

Good (imaginal) luck!

DrHat