Graded Exposure: The Ultimate Method To Tackle Fears

Graded exposure is a method used to tackle conditions like obsessive-compulsive disorder (OCD), phobias, post-traumatic stress disorder (PTSD), and anxiety disorders, such as social anxiety disorder. With the right workbook, anyone can use graded exposure to tackle their fears and anxieties on their own. This article contains such a workbook.

 

Graded exposure follows a pretty simple premise, to expose yourself to increasing levels of severity of the thing(s) that cause you fear or anxiety. You do this by taking a step-by-step approach, creating situations from least to most fear or anxiety-inducing situations. Then you work your way through those situations until the fear or anxiety is extinguished or at least becomes manageable.

 

 

Evidence For Graded Exposure

 

A study conducted by Rothbaum et al. (1995a) used graded exposure to treat acrophobia (fear of heights) using virtual reality. The study was conducted on 20 college students who screened positive for substantial fear and avoidance of heights. Of the 20 students, 12 were put into a virtual reality treatment group. By the end of the study, the students who received the virtual reality treatment all reported improvements in attitudes to heights and reductions in fear-arousal around heights.

 

This means that virtual reality can be effective in treating acrophobia, making it a useful step you could add to your graded exposure workbook. However, this was conducted on a small sample of college students, which means you have to take the results with a pinch of salt.

 

The same team of Rothbaum et al. (1995b) also conducted a case study on a single student to investigate acrophobia using virtual reality. The participant had a fear of heights, particularly elevators, and had five treatment sessions over three weeks. This study produced the same results as their other study (Rothbaum et al., 1995a).

 

However, this study also had a small sample, a sample of one, and both these studies were conducted by the same team as well. Furthermore, it would have been more useful to do this case study as a qualitative study, focusing more on the personal experience of the client’s acrophobia and the treatment. This would have allowed it to complement their other small sample study.

 

Another virtual reality study was conducted by Wiederhold et al. (2002) which looked to tackle a fear of flying using graded exposure. This study comprised 30 student participants, which are still on the small side, with a DSM-IV confirmed diagnosis of a fear of flying. These participants were split into three groups to compare two virtual reality treatments (no physiological feedback and with physiological feedback) to an imaginary-based treatment approach.

 

The results of the study found that three months later, 80% of the participants from the vertical reality group who didn’t have the physiological feedback and 100% of the participants who did have physiological feedback reported that they were able to fly without medication or alcohol. Whereas, only 10% of the participants who had to imagine flying rather than experiencing it through virtual reality reported they could. 

 

Again, Wiederhold et al. (2002) is another example of a small study, and which used students again, but the three studies together are starting to paint a picture. These three studies show how useful graded exposure is for treating fears and anxieties. It also shows how applying virtual reality can improve outcomes as well.

 

The use of virtual reality and graded exposure has been investigated in the treatment of military personnel with PTSD. One such study was performed by Wood et al. (2009) who did a case study on a single female active military personnel who’d done three combat tours. The participant met the diagnostic criteria for chronic PTSD and underwent 20 90-minute treatment sessions.

 

According to the study, the participant’s PTSD symptom severity decreased from diagnostic levels to non-diagnostic levels at a 10-week follow-up assessment. It would have been nice if this study had also had a qualitative aspect to it or more participants. However, it still adds to the pool of studies that show graded exposure to be effective, as well as virtual reality.

 

 

If you’ve read my work before, then you’ll be aware that I have intrusive thoughts whereby I think I have ground-up cockroaches and stuff like that in anything I eat. Well, this study reflects that issue I have. Berle (2007) did a case study on an elderly male participant who had an aversion to cockroaches, which the participant claimed was due to disgust, rather than fear. I’m just going to say it. Isn’t that a normal response?

 

Anyway, this client didn’t have a clinical diagnosis of any related mental health condition. The participants used steps of increasing intensity to get used to cockroaches, starting with a black-and-white picture of one, then seeing a dead one in a plastic container, with the final step being that he held a dead one in his hand. At the five-month follow-up, there was a reduction in the client’s disgust of cockroaches, which indicates that this method can be effective in non-clinical clients. Although again, this is just a single-participant study, which also didn’t add a qualitative component.

 

The last study I thought I’d share with you is one by O’Brien and Johns (2013), which is another case study, but this time on a participant who has schizophrenia and suffers from distressing visual hallucinations. The participant had phobic anxiety about the content of their visual hallucinations.

 

The participants received 20 sessions of CBT, 12 of which focused on graded exposure. The treatment allowed the participant to reevaluate their visual hallucinations as being non-threatening, which caused a decline in their fear of them. As a result of their decline in anxiety over having hallucinations, the frequency with which they experienced these visual hallucinations decreased. 

 

Summary

All the studies were either performed on small samples or conducted as single-participant case studies, therefore they might not be a useful indicator alone. However, collectively they add weight to the effectiveness of graded exposure as a useful tool in overcoming fears and anxieties. It can also be applied to anything that is capable of being broken down into a series of increasingly difficult steps to reach the desired goal.

 

 

My Experience With Graded Exposure

 

I developed two anxiety conditions that could trigger psychotic episodes, because of one event in my life that involved a cocktail of drugs and a distortion of my reality. As a result, I would experience multiple daily psychotic episodes for over a decade. Every single antidepressant I tried would just trigger more intense psychotic episodes, as my body became extremely sensitive to its homeostatic state.

 

This was my life, daily battles with hallucinations caused by my psychosis that affected all my senses. But then I came across graded exposure while I was studying for my undergraduate degree as a mature-ish student. Using this strategy on myself, with the help of my partner, lead to changes in the frequency and intensity of such episodes, which had quite a dramatic impact on my quality of life.

 

I wasn’t able to go out or travel across the city without drinking alcohol. There were three key steps in my application for graded exposure. The first was that I got used to going to new places with my partner every time we meet up, so I could get used to going to unknown places. When I started to get more comfortable with that, I wouldn’t drink before I left my place and instead would drink on the way. The last major step was travelling and leaving my place without drinking at all.

 

These three steps and the changes they eventually brought did more for my mental health than any mental health support I’d gotten through the NHS. I was even doing graded exposure on myself while I was receiving schema therapy for my anxiety disorders: schema therapy hadn’t helped me at all. Therapy can be extremely helpful, but so can engaging in self-help, if you’re applying the right interventions.

 

 

Graded Exposure Workbook

 

Graded exposure is a cognitive behaviour therapy method used to help extinguish fears and anxieties through incremental exposures to the sources of those fears and anxieties, which this workbook will help you achieve. The graded exposure workbook has been split into three main worksheets: Fears and Anxieties; End Goal; and Progress.

 

Fears and Anxieties

This worksheet is designed to list the fears and causes of your anxiety that affect your quality of life. It also has a section for your safety behaviours because they can help in the short term but hinder long-term progress. The idea is to stop engaging in your safety behaviours as you tackle your fears/anxieties.

 

1. Write all your anxiety triggers and fears in the first column you’d like to work on, in any order, they come to you.
2.  In the second column, rank them in order, with 1 being the worst sliding up to 10 (the least bad one in the list).
3. List all the safety behaviours you engage in to help soothe your feelings of fear and anxiety.
4. Once you’ve filled in this worksheet, move on to the ‘End Goal’ worksheet.

 

Things you fear or trigger your anxiety	Rank (1-10)	Safety behaviours
Going shopping on my own	10	Doing my shopping with my partner, going when I think it’s least busy, using the self-checkout
Doing a presentation at work	1	Biting nails, doing the presentation sitting down, avoiding eye contact, constantly checking notes beforehand, don’t ask if there are any questions

 

End Goal

This section uses the ‘Fears and Anxieties’ worksheet by getting you to pick a fearful situation, breaking it down and combining it with your safety behaviours to create several smaller steps to complete. Once completed, you can then go to the next fear/anxiety ranked in your Fears and Anxieties list.

 

One of the essential parts of achieving your goal of extinguishing your fears and anxieties is knowing when you’ve achieved each step you’ve set for yourself.

 

1. In the top box (end goal), write down the goal you’re hoping to achieve based on your fear and anxiety triggers.
2. Write down all the steps you can take to reach that goal, starting with the easiest and smallest step you think you’ll be able to do, then create subsequent steps with increasing fear and anxiety invoking situations and behaviours.
3. Once you’ve completed writing down your steps, think about how you’ll know you’ve completed each step so you know when you’re ready to move on to the next step. Remember to keep them realistic and something you’re comfortable with.
4. Move on to the ‘Progress’ worksheet.

 

GOAL To be able to go to the supermarket on my own

Steps	How will you know you’ve completed this step?	Achieved
Go to the local shop on my own	When my heartbeat no longer races at the thought of going to the local shop	yes
Going to the local shops when I know it’ll be busy	When I don’t give it a second thought about what time it is when I go to the shop

 

Progress

Lastly, this worksheet takes your steps from the ‘End Goals’ worksheet and allows you to track your progress and tick off your achieved steps on the ‘End Goals’ worksheet once you believe you can move on to the next step.

 

1. Transfer one of your steps to the progress worksheet.
2. When you attempt the step, you transferred to this worksheet, write down when you did the task in the Time/date column and write down how long you were able to do it. Improvements in duration are a good sign of progress, and in some cases, the day and time can be equally important, for example, being on a train during rush hour.
3. Use the comments section to note down how the experience made you feel, which will help you notice a change in yourself and allow you to make adjustments to increase your outcome success further.
4. If you don’t feel you’re ready to move on to the next step from the ‘End Goal’ worksheet, then repeat the same step as many times as needed, noting down the time/date, duration, and any comments.
5. If you feel you’ve mastered this step, then tick achieved in the last column on the ‘End Goal’ worksheet and transfer the next step to the ‘Progress’ worksheet and go through the ‘Progress’ worksheet stages again.
6. Go through this process until you’ve completed all your steps from the ‘End Goal’ worksheet and have ticked them all achieved. Then return to the ‘Fears and Anxieties’ worksheet and pick the next ranked fear and anxiety, starting again at stage 1 of the ‘End Goal’ worksheet and work and go through the process again.

 

Time/date	Step	Duration	Comments
11/09/2020 11.15	Went to the local shop	5 minutes	My heart was racing, but I managed to walk around the shop on my own even though my mind and body were screaming for me to leave
13/09/2020 11.27	Went to the local shop	9 minutes	My heart was still racing, but I was able to check out a couple of items

To download the workbook, click here. Alternatively, you can visit my Resources page and download it from there.

 

As always, leave your feedback in the comments section below. Also, feel free to share your experiences of anxiety, phobias, and trying graded exposure in the comments section below as well. If you want to stay up-to-date with my blog, then sign up for my newsletter below. Alternatively, get push notifications for new articles by clicking the red bell icon in the bottom right corner.

 

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References

Berle, D. (2007). Graded Exposure Therapy for Long-Standing Disgust-Related Cockroach Avoidance in an Older Male. Clinical Case Studies, 6(4), 339-347. Retrieved from https://www.researchgate.net/profile/David_Berle/publication/244916152_Graded_Exposure_Therapy_for_Long-Standing_Disgust-Related_Cockroach_Avoidance_in_an_Older_Male/links/543fa5b70cf27832ae8bbaf1/Graded-Exposure-Therapy-for-Long-Standing-Disgust-Related-Cockroach-Avoidance-in-an-Older-Male.pdf

O’Brien, P. & Johns, L. (2013). A Graded Exposure Intervention for Distressing Visual Hallucinations in Schizophrenia. Behavioural and Cognitive Psychotherapy, 41(4), 495-459. Retrieved from https://doi.org/10.1017/S1352465812001130 and https://www.researchgate.net/profile/Louise_Johns2/publication/235749525_A_Graded_Exposure_Intervention_for_Distressing_Visual_Hallucinations_in_Schizophrenia/links/54add6850cf2213c5fe41aca.pdf

Rothbaum, B. O., Hodges, L. F., Kooper, R., Opdyke, D.,  Williford, J. S., & North, M. (1995a). Effectiveness of Computer-Generated (Virtual Reality) Graded Exposure in the Treatment of Acrophobia. The American Journal of Psychiatry, 152(4), 626-628. Retrieved from https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.454.2666&rep=rep1&type=pdf

Rothbaum, B. O., Hodges, L. F., Kooper, R., Opdyke, D., Williford, J. S., & North, M. (1995b). Virtual Reality Graded Exposure in the Treatment of Acrophobia: A Case Report. Behavior Therapy, 26, 547-554. Retrieved from https://doi.org/10.1016/S0005-7894(05)80100-5.

Wiederhold, B. K., Jang, D. P., Gevirtz, R. G., Kim, S. I., Kim, I. Y., & Wiederhold, M. D. (2002). The Treatment of Fear of Flying: A Controlled Study of Imaginal and Virtual Reality Graded Exposure Therapy. IEEE Transactions on Information Technology in Biomedicine, 6(3), 218-223. Retrieved from https://www.researchgate.net/profile/Brenda_Wiederhold/publication/11079623_The_treatment_of_fear_of_flying_A_controlled_study_of_imaginal_and_virtual_reality_graded_exposure_therapy/links/5b64ea28a6fdcc94a70c14d5/The-treatment-of-fear-of-flying-A-controlled-study-of-imaginal-and-virtual-reality-graded-exposure-therapy.pdf

Wood, D. P., Webb-Murphy, J., Center, K., McLay, R., Koffman, R., Johnston, S., Spira, J., Pyne, J. M., & Wiederhold, B. K. (2009). Combat-Related Post-Traumatic Stress Disorder: A Case Report Using Virtual Reality Graded Exposure Therapy With Physiological Monitoring With a Female Seabee. Military Medicine, 174, 1215-1222. Retrieved from https://www.researchgate.net/publication/5461927_Combat_related_post_traumatic_stress_disorder_A_multiple_case_report_using_virtual_reality_graded_exposure_therapy_with_physiological_monitoring.