Avoiding fears is the surest way to increase their power. That’s why the treatment for anxiety is to move toward rather than away from the source of the fear.
Therapists do this by helping clients confront their fears in real life, which is an approach called in vivo exposure. For example, a client with contamination OCD is encouraged to use a public restroom and touch multiple “dirty” surfaces. A client who dreads public speaking is challenged to give a presentation to a local group.
These real-life exposures are powerful therapeutic interventions, but they aren’t always possible. When that’s the case, imaginal exposures are an effective way to confront fears and phobias. This technique works by helping clients imagine their worst fears coming true in vivid detail. When done correctly, imaginal exposures take the wind out of clients’ fears, allowing them to reclaim their lives.
Why it Works
Imaginal exposures work by purposely elevating anxiety for long enough to allow clients to learn that they can tolerate it without something catastrophic happening. This helps them develop new, more positive associations with their fear, gradually rewiring their old ways of thinking. Known as inhibitory learning, this process along with habituation are the likely mechanisms of action when doing imaginal exposures (de Jong et al., 2024; Frank & McKay, 2019; Sauer & Witthoeft, 2022).
To do this effectively, you need to expose clients to all aspects of their fear. You also need to do this long enough for clients to learn that they can handle their fears without using avoidance, distraction, or compulsive behaviors. In some cases, clients will begin feeling less anxious (habituation) when undergoing exposure therapy, but this isn’t the main goal or measure of success.
Considerations
Ideal uses
Imaginal exposures are best suited for clients with OCD, phobias, or generalized anxiety disorder, particularly when their fears cannot be adequately confronted in real life.
For example, clients with OCD who fear “going crazy” or who worry about harming someone they love are unable to fully confront these fears through in vivo exposures. In such cases, imaginal exposures are an opportunity to play out feared scenarios in a safe, but effective way.
Imaginal exposures can also be used to complement in vivo exposures. For example, a client with arachnophobia may benefit from first confronting this fear through an imaginal exposure. They may then feel motivated to do in vivo exposures that require facing their fear in the real world (e.g., touching an actual spider).
Contraindications
Imaginal exposures are not for everyone. Some clients do not feel anxious enough when they simply imagine confronting their fears.
Imaginal exposures are also not indicated for clients with a history of psychosis, borderline personality disorder, or PTSD. Regarding the latter, exposure therapy can be an effective intervention, but it requires a different protocol from the one described in this guide.
Preparation
Uncovering fears
The first step is to determine what clients are most afraid of. The general theme may be obvious, but it’s important to identify the specific fears that lie beneath the surface. The downward arrow technique can help you do this, as the following example illustrates:
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Surface fear: “What if I go crazy?” |
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Use the downward arrow technique to explore deeper fears. Ask your client:
“If you really did go crazy, what would happen?” |
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Deeper fears: “I’ll end up alone.” “I’ll lose all control.” “I’ll no longer be myself.” “I’ll be locked in a mental hospital.” “I’ll never get better.” |
Clients with the same surface fear can have different underlying fears. It’s critical to understand these fears so you can tailor an imaginal exposure effectively. This means learning what clients’ worst fears are, what triggers the fears, and the consequences of the fears coming true.
Tip: Motivated clients with good insight can use our Imaginal Exposure worksheet to carry out an imaginal exposure on their own. The worksheet supports them in drawing on their firsthand knowledge of their fear and then incorporating these details into an exposure script.
Preparing a story
Once you’ve learned as much as possible about your clients’ fears, the next step is to weave these details into a convincing story. Your role as the therapist is to help clients imagine their worst fears coming true in vivid detail.
Triggers are the situations that bring clients closer to their fear (the lead-up) while Action is the actual moment when the fear comes true. Outcome refers to the meanings and consequences of the fear coming true.
To prepare for an imaginal exposure, you need specifics on each of these elements.
Here’s how this might look for a client with a needle phobia (trypanophobia) who worries about getting fatally sick from an infected needle:
| Triggers | Action | Outcome |
| (lead-up to the fear coming true) | (the fear coming true) | (consequences of fear coming true) |
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To create a story, you piece together these components, making the narrative as visceral as possible. You can write the story in narrative form (usually a couple of pages suffices) or just write bullets of the main points or details.
There’s no one right way to create an imaginal exposure story, but there are some key guidelines to follow:
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Use the present tense. Keep the client engaged in a story that’s unfolding in real time. |
Use vivid, sensory-rich language. Focus on triggering sights, sounds, and smells to build tension. |
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Make the fear come true. Work up to describing the client's worst fear becoming reality. |
Magnify and exaggerate outcomes. Dwell on the worst-possible consequences of the fear coming true. |
Preparing the client
It’s normal to feel intimidated by this intervention! Imaginal exposures are an aggressive approach to working with ingrained fears.
To build motivation, talk to clients about the power of finally standing up to fears they’ve been trying to avoid for months or even years. Being willing to experience a short-term increase in anxiety is the price for meaningful change and growth.
Once you have clients’ buy-in, agree on when you’ll do the imaginal exposure so you both can prepare.
Implementation
Key elements
Set aside a full session for an imaginal exposure.
Keep these points in mind when doing the intervention:
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Ask clients to close their eyes. This helps activate the imagination and minimize distractions. |
Improvise the details. Use your own imagination and intuition to piece together the key story elements. |
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Prompt clients for reactions. Keep asking what clients are feeling and thinking as the story unfolds. |
Refrain from reassurance. Offering reassurance or comfort defeats the purpose of an exposure. |
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Track clients' anxiety level (1-100). This gives you an objective measure of how clients are doing over time. |
Record the exposure. If clients consent, record the session so they can practice at home. |
Use case
Now let’s look at a client for whom an imaginal exposure would make sense:
A client with OCD is terrified about hitting someone with her car.
Even small bumps in the road make her panic that she may have hit an animal or person. When this happens, she stops and carefully examines the road and her car. The next morning, she scans the police report to check for hit-and-runs, worrying that she may have killed someone, but repressed the memory.
Her anxiety is consuming her life and making it more and more difficult to leave the house.
This client’s therapist plans an imaginal exposure to help the client confront the scenarios that frighten her.
Let’s look at some key moments in the imaginal exposure:
| Dialogue | Skill |
|---|---|
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Clinician: “Picture yourself driving home from work along the usual route. You suddenly hear a loud thud, like you may have hit something.” (pause)
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One of the client's triggers is mentioned. Present tense is used to make the story feel real. |
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Clinician: “Given what’s happening, how would you rate your anxiety?” Client: “Around an 80 out of 100.” |
Client’s anxiety level is checked to ensure it’s high enough (70+). |
The story slowly increases in intensity, with regular pauses and prompts for the client’s reactions. The story eventually culminates in the worst-case scenario:
| Dialogue | Skill |
|---|---|
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Clinician: “As you scan the road, you notice a lump in the distance. You walk closer and discover to your horror that it’s a body.” “Blood is pooling all over the pavement. You check for signs of life, but it’s clear that the person is dead. Their body is mangled and broken.” “Your worst fear has come true: You’ve killed someone.” (long pause)
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The client’s worst fear is described in graphic language (the action). Vivid sensory details are mentioned. |
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Clinician: “How are you feeling as you realize the gravity of what you’ve done?” Client: “Horrible. Like I’ve done something unforgivable.” Clinician: “What emotions are coming up?” Client: “Guilt. Panic. Despair. I don’t know how I’ll live with this.” |
The narrative is paused at the moment of maximum intensity. The client is encouraged to feel and linger with their emotions. |
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(long pause) Clinician: “So here you are, standing next to an innocent person you mowed down. Their loss will be mourned forever by their loved ones. What does this say about you as a person?” Client: “That I’m a monster. That I don’t deserve to live.” |
The client is asked to say what their fear means about them as a person. |
At this point, the consequences of the fear coming true are explored in detail, drawing on what was learned in the preparation phase:
| Dialogue | Skill |
|---|---|
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Clinician: “The police eventually take you into custody, handcuffing you and pushing you into the back seat of one of their cars. What do you think is going to happen next?” Client: “I’ll be convicted for murder and will spend the rest of my life in prison.” |
The consequences of the client’s fear coming true are explored in detail. |
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Clinician: “So, you’ll live out the rest of your days in a tiny cell. What will that be like?” Client: “Terrible. Everyone will judge me for what I’ve done. My family will abandon me.” (long pause)
Clinician: “That sounds horrible. What will that feel like?” Client: “I’ll be lonely and crippled by guilt until I die.” |
The client is asked to participate in the narrative, describing not just what happens but also how they feel. |
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Clinician: “You’re doing great. Stay with those emotions, just allowing them to be there.” |
The clinician encourages the client to feel their emotions fully, giving them adequate time to do so. |
The therapist continues exploring all consequences the client fears, such as being sentenced in court, facing the loved ones of the person they killed, enduring hardships in prison, and missing out on milestones in their family’s lives.
As the exposure progresses, the client may experience significant anxiety reduction, but sometimes this doesn’t happen right away. Remember that the treatment goal is not to eliminate anxiety, but to help the client learn that they can endure it.
Troubleshooting
If you notice a client going beyond what they’re able to tolerate at that moment, you can use these strategies to help them:
Pause and ground
Take a break from the exposure story and ask the client to tune into sensations in their body until they feel able to resume. The trick here is to help the client ground without actively reassuring or comforting them. In other words, your goal is to help them stabilize—not relax—so they can continue the exposure.
Break the story into parts
If the client is still finding things too intense, praise them for their bravery and suggest an adjustment: Instead of doing the entire story at once, you’ll do one piece at a time to make it more manageable.
Using the example of the client with a fear of needles, you might devote one session to describing what they see, hear, and smell when waiting for a blood draw (the triggers). The next session might focus on getting their blood drawn with an infected needed (the action). Finally, a third session could then address contracting a fatal illness and its consequences (the outcome).
This method allows you to reach the same goal more incrementally, similar to how it’s done when creating an exposure hierarchy for OCD.
Wrapping Up
You should begin wrapping up around ten minutes before the end of the session.
To do this, stop the storytelling and praise clients for their bravery in confronting their fears. Direct their attention to what they’re feeling in their body or use another grounding technique to help them regain equilibrium.
A common treatment scenario is for the imaginal exposure to become a little less provocative each time it’s repeated. You can reinforce this process by recording the exposure (with consent) and asking clients to listen to it between sessions, tracking their progress using our Imaginal Exposure worksheet.
Remind clients that they’re making progress every time they directly face their fear.
For a deeper dive into imaginal exposure, check out these books:
