An example of how you can start situational exposure. Situational exposure, in contrast to imaginal exposure, is what you do practically. A combination of both types will work best. However, some cues may not be possible to do it practically. Hence, imaginal exposure will be more suited. The first step to starting ERP therapy is to brainstorm all thoughts and compulsive rituals that distress you.
Write down as many as you can and highlight next to them, classifying the symptoms as mild, moderate or severe. Mild symptoms cause less than 30% distress; symptoms causing 30-60% are classified as moderate, and over 60% distress are classified as severe.
Use a tabular column under the headings mild, moderate, and severe and tabulate your symptoms according to their severity. You could have a list of symptoms of increasing distress to start with. For example., if you are having intrusive images of contamination and getting infected by touching things around you, you might want to grade the thoughts according to distress like below:
Grade 1: Touching a napkin which has touched a door knob.
Grade 2: Using door knobs and handles of bedroom and lounge.
Grade 3: Bringing food from outside without washing hands first.
Grade 4: Touching the toilet door handles and was once or delayed the washing.
Grade 5: Use the toilet at home and wash once only.
Grade 6: Touching door knobs and not washing hands till eating or cooking.
Grade 7: Touching door knobs of public toilets.
Grade 8: Using public toilets.
Start with Grade 1 and perform the exposure a few times daily. You can maintain a log for the same. You might be very distressed, so we begin with Grade 1. Remember, ERP is a gradual process. It’s essential to avoid any compulsive rituals or reassurance-seeking or safety behaviours. Keep repeating the grade 1 imaginal exposure till you learn that it is safe to have an intrusive thought that is distressing, and understand that it is safe to experience panic. You can still function if you are distressed or panicked. This new learning, known as inhibitory learning, is critical to the success of ERP as a therapeutic strategy.
Only move on to the next grade once you have completed grade 1, even if it takes a few weeks. ERP is like exercising a muscle, gaining strength, and learning a new skill. It can be a life skill to learn. We have now seen an example of how you can conduct imaginal exposure in a graded fashion. In the next blog, we will see an example of how you can conduct a combination of imaginal and situational exposure, which is critical to a successful ERP programme.
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