Graded Exposure Therapy Worksheets, Exercises of Cognitive Psychology

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Graded

Exposure

Graded Exposure

Graded Exposure is an evidence based intervention for the treatment of anxiety and phobias.

This workbook can be used either alone or with the support of your Psychological Wellbeing Practitioner.

How to use this workbook.

Graded Exposure has three steps. It is important to work through one step at a time, only

move on to the next step of Graded Exposure once you are comfortable with using the

previous step. It is key to follow all three steps of Graded Exposure in sequence.

It can take some time for an intervention to become effective and to show improvement. It

is important to allow enough time for the intervention to be effective.

Helpful Resources;

Exposure and Habituation cedar.exeter.ac.uk

Facing Your Fears www.anxietybc.com

An Introduction to Coping with Anxiety, by Brosan and Hogan www.cpft.nhs.uk

www.overcoming.co.uk

Coping with Anxiety, Brosan et al www.cpft.nhs.uk

www.talkplus.org.uk

STEP ONE

Identifying anxiety-provoking situations

The first step of Graded Exposure is to identify all the activities that cause you anxiety and are therefore either avoiding, leaving or distracting yourself. It may be that you have a number of different feared situations, objects or activities, it is then important to separate these fears into different lists and select one specific fear to tackle at a time.

Avoiding or leaving a situation are just two things we might do to make ourselves feel safer and to reduce our anxiety. There are often more subtle ways in which we avoid fully experiencing anxiety in situations. These include distraction and safety behaviours, see the box below for examples, to help identify the subtle behaviours we use to minimise distress. Engaging in distraction and safety behaviours also maintain our fear of the situation in the long term, much as avoiding or leaving it does. Therefore it is important to include these in our list, for example going shopping with a friend instead of alone so we feel safer and experience less anxiety.

Be specific Whilst making the list of anxiety provoking situations, include when we distract ourselves, it is important to be specific. Include in the list what, where, when and with whom each situation occurs. It may be that there are a number of similar situations that cause anxiety, for example going shopping with a friend at 8am or going shopping with a friend at 4pm, due to the fact that these small differences cause different levels of anxiety.

Listening to music Taking a friend Carrying a bottle of water Talking on the phone Routine and checklists

Sitting next to your partner Alcohol Being near the exit Planning your route beforehand Medication

To complete Step 1 use Worksheet 1****.

Fill in the worksheet with activities that provoke anxiety.

Common distraction techniques and safety behaviours.

WORKSHEET ONE

Identifying anxiety-provoking situations

Anxiety-Provoking Situations

WORKSHEET TWO

Developing a hierarchy

Most anxiety-provoking % Rating

Least anxiety-provoking

STEP THREE

Planning exposures

The third step of Graded Exposure is to begin exposing yourself to feared situations, starting with the least anxiety-provoking. When planning exposures it is important to make a specific plan to exposure yourself based on the four conditions of Graded Exposure. These conditions are Graded, Prolonged, Without Distraction and Repeated. When planning exposure in the diary be specific about what, where, when and with whom you will carry out the exposure. Rate your level of anxiety, from 0-100% before, during and after each exposure to monitor reductions in your anxiety levels. There is a space to make any comments or record any reactions during each repeated exposure. Graded Facing fears can be a very difficult and overwhelming challenge, therefore it is important to start by exposing yourself to a situation which causes a level of anxiety but is not too much. This is achieved by using the hierarchy developed in Step 2. In this way you can move up the hierarchy only when you feel confident enough to do so. Prolonged It is important that we remain in the feared situation for long enough until anxiety naturally reduces through the process of habituation. This process can take anywhere from 5 minutes to 2 hours. It can be difficult to stay in the situation for this length of time, however if you leave before beginning to feel a reduction in anxiety you will continue to avoid the situations, and use this unhelpful strategy in the future. Without Distraction Engaging in safety behaviours or distraction whilst in an anxiety-provoking situation means we do not fully experience the symptoms of anxiety. Habituation cannot occur if we are reducing our anxiety in other ways, therefore it is important to plan your exposure to ensure you are not distracted in any way. It may be that to start with it is too anxiety-provoking not to use any safety behaviours that you might have been using for a long time. In this case you can begin exposing yourself with these behaviours, and then gradually reducing them. Repeated In order for habituation in a specific situation to occur we need to repeatedly expose ourselves. It is recommended that an exposure to one situation is repeated 4-5 times in one week. This may be difficult to achieve if the situations you are exposing yourself to are expensive, rare or involve others. In these cases it is important to be creative, e.g. watch a video, and try to carry out as many exposures as possible.

To complete Step 3 use Worksheet 3****.

Plan in your weekly exposures and rate your levels of anxiety.

EXAMPLE: WORKSHEET TWO

Developing a hierarchy

Fear of crowded places

Most anxiety-provoking % Rating

London Trafalgar Square 100%

ASDA alone 80%

ASDA with my partner 75%

Farnborough shopping centre 70%

Cinema 60%

Tesco Express 55%

Local Café at a busy time (Saturday morning) 50%

Local Café at a less busy time 40%

Corner shop 35%

Least anxiety-provoking

EXAMPLE:

WORKSHEET THREE

Planning exposure

Date &^ Time

Duration

Exposure

Anxiety Rating

Comments

Before

During

After

1

Wednesday3pm

45 minutes

ASDA

This was a bit scarier than I thought –^ quite hard

2

Friday11am

55 minutes

ASDA

Better than the last time

3

Saturday10am

30 minutes

ASDA

Got very busy in the shop andsomebody hit me with their trolly soI left

-^ wish I hadn’t

4

Sunday2pm

65 minutes

ASDA

I’m starting to feel the anxiety really going down now

5

Tuesday4pm

70 minutes

ASDA

Found it really easy

-^ got a coffee in

the café after my shopping

No Anxiety

Mild Anxiety

Moderate Anxiety

Severe Anxiety

Panic