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Expert view: graded exposure

What is graded exposure and what does it look like in practice? Watch Dr Melissa Snaith explain more.
What we know about anxiety is it doesn’t carry on forever. It tends to go up in a curve, and it peaks, and then it drops off again. The problem is that because anxiety feels horrible, most people try to get out of the situation or avoid the situation in some way before it peaks and drops off. Therefore, they kind of don’t learn not be afraid. So if you have fear say, of spiders, your fear is what we’d say paired with the spider. And that spider triggers it. When we talk about exposure, what we’re helping people to do is to stay with the fear until it peaks and comes back down again so that the link between fear and spiders is broken.
What we want to do is help somebody to sit through their fear where it peaks and calms down, but that has to be manageable. And it tends to come in waves, so the first thing you do is make– we’d call it a hierarchy, but it’s grading the difficulty. So if someone was afraid of a spider, you wouldn’t start by getting them to hold a spider. You might show them a cartoon picture, and then a photograph, and then a small spider in a clear box, something like that, and gradually build it up. And it’s very individual and different for different people.
The most important thing is that it’s agreed for that person that ordered that you do it, and that they’re in control of the process. In my experience of working with using graded exposure, one thing that comes to mind is a young girl who couldn’t have her vaccinations at school because of her fear of needles. And with that, we also had to learn a technique, because you can sometimes faint when you have a fear of needles or blood and injury. So we learned the technique first by applying tension to stop her fainting. And then in that situation, we worked through the same grading of difficulty, starting with a picture of a needle, and then bringing syringes into the session.
She’d practise touching them, taking the lids on and off, that sort of thing, and working up to the point where she was able to actually have injections with me there, and then being able to go off to school and have her vaccinations.

Graded exposure is, in brief is, a psychological technique developed to help people come face to face with their fears. It helps to break the kinds of vicious cycles we’ve been introduced to in this session (ie when fear leads to avoidance which subsequently results in increased fear).

Graded exposure provides the opportunity for patients to expose themselves to the things that they fear (and thus avoid) within a safe environment. The therapist’s role is to help support the patient and to encourage them to tolerate the thing they are frightened of. It is essential for there to be a high degree of trust and confidence between the therapist and patients before they start to use graded exposure.

Graded exposure as part of CBT has shown to be a helpful part of treatment for a range of anxiety problems, including specific phobias, panic disorder and social anxiety disorder.

Watch this video where CBT therapist Dr Melissa Snaith (Senior Clinical Tutor at the Charlie Waller institute), gives an overview of the rationale for graded exposure and how it has helped one of her patients. Try to think about the following:

  • What does ‘normal’ anxiety look like?

  • What do people with anxiety often expect will happen to their anxiety levels when confronted with the thing they are frightened of?

  • How does this compare with what we know about the ‘normal’ course of anxiety?

  • How does graded exposure help to educate a patient about their anxiety?

  • What does the ‘graded’ refer to in graded exposure?

In the next Step, we’ll learn more about the different ways in which graded exposure can be carried out.

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Understanding Anxiety, Depression and CBT

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