During initial treatment planning in EX/RP, the therapist and patient collaboratively develop a hierarchy of exposures that will trigger the patient’s obsessional distress. Many persons who have been suffering from OCD start treatment with a myriad of symptoms that encompass a broad spectrum of obsessions and compulsions. For example, an individual with scrupulosity concerns might avoid numbers associated with the Devil, repeat ritualized prayers, avoid saying certain words, and repeat actions if performed while thinking of the Devil.
Such an abundance of rituals can seem overwhelming and insurmountable to the patient, as well as to the therapist, whose task is to help patients make sense of their condition and to offer them effective treatment in a manageable timeframe. Therefore an important part of the therapist’s job is to identify the “core fear” that often underlies all of the OCD-related concerns. The individual with scrupulosity OCD, for example, might have a core fear of going to hell. If the items on the exposure hierarchy are approached only at their face value (e.g., exposing the patient to the number “6”), the patient may do well on those items and be able to reduce ritualizing when confronted by those particular triggers. However, since the underlying obsession unifying all of the ritual presentations has not been identified and developed into an exposure, treatment is likely to proceed slowly. Furthermore, it is possible that new avoidances and/or rituals will replace the ones eliminated through the EX/RP exercises.
To achieve a faster, more generalized therapeutic effect and improve prognosis for relapse prevention, it is essential to identify early on in therapy the underlying core fear that may be contributing to the abundance of ritual presentations. Some common examples of the obsessional “well” that can feed the sufferer’s fears are: being responsible for harm, going “crazy,” being a bad or immoral person, contracting a fatal disease, dying, suffering, being an outcast, or going to hell. It is crucial to identify the precise core fear, which may not be apparent at first. For example, one patient with obsessions related to the possibility of being gay was not very distressed by an imagined scenario of having a torrid gay love affair; rather, his core fear was that he would realize he was gay, come out to his family, and as a result would lose the people in his life that he loved the most.
For many core fears, the use of imaginal exposure to the worst-case scenario (in combination with in vivo exposures and ritual prevention) yields the best results. Patients imagine that a disastrous event happens because they failed to perform their rituals; after repeated use of these imaginal exposure techniques, patients are better able to tolerate the distress associated with the imagined disaster. As a result, they are able to give up behaviors that artificially neutralize their distress or prevent their feared consequences from happening. Additionally, as discussed above, imaginal exposure provides a major opportunity for disconfirmation of patients’ belief that thinking about terrible outcomes can make them happen (thought-action fusion). An example of an abbreviated imaginal exposure script about responsibility for harm is found in .
Abbreviated imaginal exposure script about responsibility for harm
Patients can also be encouraged to assess whether other avoidances or rituals are being sustained by the same imagined worst-case scenario; habituation to the feared consequences can facilitate the elimination of such avoidance and rituals. Many patients report that once they are able to tolerate the distress that comes from exposures to the underlying core fear (e.g., going to hell), their reduced distress generalizes downward to triggers (e.g., the number “6”) that are emanating from the core fear. As a consequence, patients are able to relinquish their rituals more easily. Thus addressing the core fear improves the efficiency and effectiveness of the therapy, and maximizes potential for maintenance of gains and relapse prevention.
It is important to point out that not all patients require imaginal exposure to feared consequences. Indeed, for some patients there is no identifiable feared disaster—for example, among OCD patients who report that a lack of order “just doesn’t feel right” or who are afraid of damaging their personal possessions without any deeper or longer term fear. For these and similar patients, in vivo exposure is likely to be sufficient.