"50 CBT tools for panic and anxiety are divided into several categories: general skills, initial relaxation training, initial cognitive restructuring, advanced mindfulness training, advanced cognitive restructuring, and exposure treatment."
An imaginal exposure is facing a fear in your imagination. This isn't effective for everyone because some people do not get anxious when just thinking about a fear. However, others experience anxiety when imagining a fear although it is usually not at the same level as if they were confronting it directly. For those who do not get anxious this method can still be beneficial as a practice exercise to prepare them for when they do confront the fear.
The process of an imaginal coping exposure is first to write out in detail the feared situation. Keep in mind that even writing a description can be an exposure so it is important to be prepared to use your coping methods, either cognitive or behavioral, to manage the anxiety that occurs. The description of the feared situation by itself is an imaginal exposure. However, this method is to create imaginal COPING exposures. The difference is that you add in throughout the description how you can cope with the anxiety.
For example, I once treated a young boy who had panic attacks related to a fear of heights. He wanted to be able to climb a nearby lookout tower like his younger brother could. The tower had seven or eight flights of stairs separated by platforms. In his therapy session I had him describe to me walking up to the first platform. He described the simple metal railing and the type of stairs and the platform. He also described how he expected to feel as he walked up to the first platform. I had him imagine walking up the stairs to the first platform and sitting down on the steps. I then had him imagine using his anxiety coping skills and self-talk to calm himself. I wrote down his description of the feared situation and how he coped with it. Then I gave it to him to take home, record it, and listen to the recording.
What I just described is the imaginal coping exposure. However, it is often combined with an actual exposure. In this case, once his anxiety level no longer increased while listening to the recording his parents took him to the tower and he was instructed to do what he had done in the recording: walk up to the first platform, sit on the step, and bring his anxiety down using his coping tools. We did this process about three times (up to the third platform) and the next time he came to see me he excitedly shared, “I went all the way up to the top!”
The concept of the imaginal coping exposure is that it prepares you with how to cope with the situation each step of the way as you experience anxiety symptoms. It is mental preparation. Often people tell me that they are able to use the methods to relax fairly well but when faced with a spontaneous panic attack they are unable to use the skills they have learned. This method helps them to gradually face a feared situation while preparing their brain to use the coping skills rather than avoidance.
The imaginal coping script should be written from an “I” perspective and consists of four components: the feared situation, the symptoms, the coping methods and review.
1) Feared Situation. First, write a detailed description of the feared situation. Be sure to include specific thoughts you may have about the situation. This can be fairly unpleasant because it can create anxiety. It may even need to be done in sections or with therapeutic assistance.
2) Symptoms. Re-write the script adding in your prediction of the anxiety level you expect to experience and a description of the specific anxiety symptoms. Indicate when the symptoms are likely to occur and when your anxiety level increases.
3) Coping Methods. Re-write the script again adding in specific coping statements where they are appropriate. Particularly, you need to challenge any irrational ideas that are included in your description. Also, indicate when you need to use relaxation methods such as deep breathing. These coping methods should be inserted throughout the script not just at the end.
4) Review. Once the script is written it needs to be reviewed frequently until the anxiety level no longer increases. The review can be done by reading it. However, I find recording it and listening to it can be particularly effective.
You may notice that each step of the process involves confronting the anxiety. Therefore, each step is an exposure and the anxiety needs to be addressed by using the anxiety management methods that are most effective for you. Also, I recommend writing the script by hand rather than on a computer. By doing so you are repeatedly being exposed to the imaginal feared situation each time you re-write it whereas just inserting changes on a computer can allow you to avoid the full imaginal exposure.
The difference between the above imaginal coping exposure and an imaginal exposure is that the imaginal exposure does not include the coping strategies. The goal of the imaginal exposure is to develop a tolerance of the feared situation and the anxiety. The more you can develop tolerance of the anxiety symptoms, the more you are likely to be able to handle unexpected events that cause anxiety. For many people it may be necessary to do coping exposures first before they are ready to focus on this method of tolerating the anxiety.
Learning to tolerate the anxiety while thinking of a feared situation involves a process of mindful awareness. It is being aware of the situation and the anxiety symptoms while putting aside the need to get rid of the anxiety. Giving yourself permission to feel the anxiety and tolerate it changes your perspective of the anxiety. It helps you to think of the anxiety as an unpleasant experience that you can tolerate rather than a horrible experience to avoid.
The steps of doing an imaginal exposure are almost identical as the steps described for the imaginal coping exposure above except step 3 would not be included. You would still write out a script describing the feared situation including your thoughts and symptoms but you would not include the coping strategies. Once you have written the script you would review it until your anxiety level no longer increases.
Once you are no longer reactive to an imaginal exposure you may be ready for the actual situation. However, you may still need to do some repeated exposures to the actual situation before you are no longer reactive.
A coping exposure is sort of a combination of the gradual desensitization and the imaginal coping exposures already described. The idea is to deliberately “walk through” the situation while following a plan for coping with the irrational thoughts and the anxiety that occurs. This can be done with assistance such as having a therapist coach you with using the coping methods. However, it may also be done alone depending on the specific goals of your treatment.
The difference between a coping exposure and an exposure is the practice. Many people in treatment find that they can face a situation when prepared but have difficulty with the spontaneous situations that occur. It is common to report “I didn't think of using my skills. I was too anxious.” I see coping exposures as helping to develop a more automatic coping response when faced with those unexpected situations.
For instance, you could do a hierarchy of driving exposures such as driving to the corner, driving around the block, driving to the store, etc. With repeated exposures you will likely get used to these situations and your anxiety will decrease. However, not everyone generalizes, or transfers, this change to other situations. In other words, until they actually do the exposures to the various situations they may be fearful of that situation occurring.
However, coping exposures focus on the coping methods during the exposure rather than the exposure itself. The purpose is to repeatedly practice those strategies so that when a situation occurs they are more likely to remember and follow through with the coping skills. The exposure is just the vehicle for the practice.
So the exposure might still be driving around the block but the focus is to use the cognitive and behavioral coping methods to manage the anxiety. The repeated practice then is likely to create more automatic skills that then can be applied during the next exposure on the hierarchy. Thus, when a person has completed the hierarchy and is able to drive again, if an unexpected situation occurs, they are more likely to respond by using the coping methods. This, in turn, increases their confidence in being able to handle the anxiety in any type of situation.
Some people who have Panic Disorder also have a socially anxious component of the anxiety. For instance, they are fearful of others seeing that they are anxious and worried about what others might think. Commonly this occurs most often with people who have perfectionistic demands of themselves. They believe that they must be perceived as perfect and that having anxiety is a flaw that they must hide from others.
As described above in the cognitive methods, this irrational style of thinking needs to be challenged. However, it can also be challenged through exposure. Mistake practice is a particular type of exposure method in which you deliberately engage in “mistakes.” Keep in mind that what one person may consider a mistake may not be considered a mistake by others.
The first step of this method is to create a list of “mistakes” that would cause you anxiety. For example, I have had clients who were anxious if their hand was shaking while handing money to a cashier. They were afraid that the shaking would draw attention to their anxiety. For others, it might be telling someone that they are anxious or asking others for help.
Once you have created a list you would put the list in order as described previously from easy to hard. The next step is to actually engage in the behavior. For instance, if you are fearful of someone seeing your hand shake, you deliberately create that situation. Coping skills can be used during these situations depending on the particular needs and goals of the individual.
Mistake practice usually accomplishes several things. One is that you are likely to find out that people aren't paying as much attention to you as you might think. The second is that if people do notice it may not be a negative reaction—it could be neutral or even positive such as showing concern. The third is that even if people react negatively it doesn't have to be a catastrophic event. Other people's reactions are a reflection of them, not of you. READ MORE: page 16