Imaginal Procedures

Description of the Strategy

Imaginal procedures are primarily used in exposure therapies for children with anxiety problems but are also often used to assist in the development of coping skills for a variety of child problems through the use of role plays or imagery in relaxation training or cognitive restructuring. With respect to exposure therapy, imaginal exposure requires the child to confront the feared stimuli in a way that typically produces less anxiety than an in vivo or real-life exposure. Children are asked to imagine themselves at various degrees of confrontation with the feared object or situation. Typically, anxious children focus on threat in their environment. The anxious child overestimates the likelihood of threat, overestimates the consequences of the threat, and underestimates their ability to cope in the face of the feared stimulus. As a result of these interpretations, the child avoids the feared situation, and the anxiety is maintained, as the child is unable to experience evidence contrary to his or her beliefs. Imaginal exposure allows the child to, in a gradual way, face the feared stimulus. Imaginal exposure produces physiological reactions that mimic those experienced during in vivo exposure and hence is typically used as part of gradual exposure therapy. By repeatedly facing their fear, children learn that they are able to cope with the feared stimuli and their negative expectations are not as likely to occur as predicted. Consequently, children experience a reduction in their anxiety. Gradual exposure involves creating a list of ascending steps of exposure to the feared stimulus, beginning with the least fearful and culminating in in vivo exposure to the most feared situation or object. The exposure is repeated and prolonged until the child is less fearful of the situation. The aim is not to reduce all fear and anxiety completely, as some stimuli demand a degree of developmentally appropriate fear. For children, beginning the exposure hierarchy with an imaginal exposure allows them to practice their skills in a less anxiety-provoking situation than if they were to face the situation in real life.

Imaginal exposure differs somewhat from systematic desensitization. During systematic desensitization, the child imagines the feared stimulus (as described above) but does so following deep muscle relaxation. The purpose of this procedure is to pair the feared stimulus with the feeling of relaxation. In contrast, imaginal exposure requires children to experience anxiety when facing the feared stimuli. The children are provided with new information regarding their ability to cope in the face of anxiety and regarding their expectations of threat in the situation.

One of the benefits of imaginal exposure is the convenience of applying it in an office setting. The therapist and the child can conduct exposures within the therapy session in a controlled environment. For many childhood fears, direct exposure to the feared stimulus may be difficult or impossible. For example, in vivo exposure to death, trauma, cyclones, tidal waves, disease, violence, dentists, or electrical storms may prove expensive, impractical, or unethical. Using imaginal procedures, the therapist is able to allow the child to confront the feared stimulus when actual exposure is not possible.

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