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,Graded Exposure,Tackling Avoidance in Feared Situations. Graded Exposure is an evidence based treatment used to tackle avoidance. of feared situations activities or objects due to anxiety It works through a. process called habituation a gradual reduction in the physical sensations of. anxiety This is achieved through identifying feared situations or objects. and gradually exposing ourselves to them whilst following four conditions. When we fear certain situations objects or activities we either avoid or leave the situation in order to. reduce our anxiety Although this may be helpful in reducing our distress in the short term avoidance. can help to maintain this pattern of fear and anxiety Therefore each time we go into a feared. situation we experience the same high level of anxiety time after time. Habituation, As shown in the above left graph when we leave a situation our anxiety immediately reduces. however the next time we enter that situation our anxiety becomes just as high As in the past we. have found relief in leaving this is what we often continue to do to reduce the distress we experience. The anxiety we experience is part of the fight or flight response a biological system to prepare us to. respond to frightening or dangerous situations However physiologically we cannot remain at this high. level of anxiety so by exposing ourselves to the situation and remaining in it our anxiety naturally. reduces this is the process of habituation, Graded exposure works by gradually exposing ourselves to the feared situation beginning only with. situations that we feel we are able to tolerate this can be seen in the graph on the right This allows. the process of habituation to occur in order to reduce our fear and reduce our anxiety response in the. 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. Common distraction techniques and safety behaviours. Listening to music Sitting next to your partner,Taking a friend Alcohol. Carrying a bottle of water Being near the exit, Talking on the phone Planning your route beforehand. Routine and checklists Medication,To complete Step 1 use Worksheet 1. Fill in the worksheet with activities that provoke anxiety. WORKSHEET ONE,Identifying anxiety provoking situations. Anxiety Provoking Situations,Developing a hierarchy. Having identified a specific fear to work on the second step of Graded Exposure is to rank. the situations identified in Worksheet 1 in order of the level of anxiety you experience. Ranking activities from least anxiety provoking to most anxiety provoking means that. Graded Exposure can be carried out gradually without experiencing levels of anxiety that. are overwhelming, Activities are ranked from those that would provoke the highest level of anxiety to those that provoke. less intense feelings It is useful to think about the situation that would be easiest to remain in first. and the situation that would be the most difficult and then fill in situations in between This process. can seem very daunting or overwhelming at first therefore this stage of developing a hierarchy is very. important Sometimes it can be difficult to think of what would be more or less anxiety provoking. therefore it is useful to,Rate predicted anxiety levels. It can be helpful to mark on Worksheet 1 next to each situation how much anxiety it would provoke. from 0 100 This will then make it easier to place the situations or activities in a hierarchy from the. lowest to the highest percentage,Break it down, Sometimes it is difficult to come up with several different variations of the same situation especially. as the feelings it causes are so overwhelming By thinking of what where when and with whom each. situation occurs we can then break down the situations into many variations that cause different. levels of anxiety The box below gives some examples of this also see example sheets at the back. Breaking down your fears,Different times of the day Watching a video. With safety behaviours and without Larger or smaller locations. Looking at a photograph Alone or with a friend,To complete Step 2 use Worksheet 2. Rank the activities in order of how much anxiety they provoke. 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. 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, 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, 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. WORKSHEET THREE,Planning exposure,Date Duration Exposure Anxiety Rating Comments. Time Before During After,0 25 50 75 100, No Anxiety Mild Anxiety Moderate Anxiety Severe Anxiety Panic. 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. Tesco Express 55,Local Caf at a busy time Saturday morning 50. Local Caf at a less busy time 40,Corner shop 35,Least anxiety provoking. EXAMPLE WORKSHEET THREE,Planning exposure,Date Duration Exposure Anxiety Rating Comments. Time Before During After, Wednesday 45 minutes ASDA 60 75 40 This was a bit scarier than I thought. 1 3pm quite hard, Friday 55 minutes ASDA 55 60 30 Better than the last time. Saturday 30 minutes ASDA 50 65 90 Got very busy in the shop and. 3 10am somebody hit me with their trolly so,I left wish I hadn t. Sunday 65 minutes ASDA 55 50 30 I m starting to feel the anxiety. 4 2pm really going down now, Tuesday 70 minutes ASDA 40 30 15 Found it really easy got a coffee in. 5 4pm the caf after my shopping,0 25 50 75 100, No Anxiety Mild Anxiety Moderate Anxiety Severe Anxiety Panic.
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