Graded Exposure

Graded exposure is a technique employed by mental health professionals to assist clients cope with anxiety-provoking situations (or “triggers”). This technique is particularly useful to assist clients suffering from anxiety disorders.

The anxious response

When a person has experienced anxiety in a certain place or situation previously, they are more likely to anticipate the anxiety recurring under similar circumstances. This can lead to avoidance, which further reinforces the anxiety and its association with the particular place or situation where the anxiety initially occurred. The decrease in anxiety, when the situation is avoided, tells the person that avoidance is a useful strategy.

Unfortunately the anxiety will remain whenever the person is faced with this situation, and it is likely that the number of situations in which the anxiety is anticipated will increase. Therefore, rather than avoiding the anxiety provoking situation, exposure to it can be used as a more effective long-term strategy in reducing the anxiety associated with the particular situation(s).

Graded Exposure with Anxiety Disorders

Exposure simply involves remaining in the situation long enough for the anxiety to eventually subside. If choosing to use exposure, it is particularly important to ensure that the exposure is graded whereby the client is incrementally introduced to the anxiety provoking situation in well thought out measured doses. Respite from the specifically graded anxiety provoking situation is only permitted once the anxiety has decreased significantly. If the person does not remain in the situation until this occurs, they will negatively reinforce the avoidance behavior instead.

The client also needs to be prepared for the exposure through being skilled up in key coping strategies such as slow breathing, muscle relaxation and straight thinking. Using these strategies in the time of exposure will help the client learn different ways of dealing with their anxiety when it heightens. It is important that the client practices these skills outside the context of the anxiety provoking situation first, to ensure they feel confident in their ability to apply the strategies in their time of distress while being exposed.

Grading the exposure is important to ensure the client gains experience of the anxiety without avoiding it and to practice the skilled responses learnt. The exposure is graded by establishing a hierarchy to order levels of exposure from small levels of anxiety provoking stimuli to larger doses of the anxiety provoking stimuli as a way of grading the exposure from less intense to more intense over time. For example a person with a fear of lifts might follow the hierarchy of graded exposure below:

1. Stand in front of a lift – until the anxiety subsides
2. Stand inside the lift with doors open – until the anxiety subsides
3. Stand inside the lift with doors closed accompanied by a friend – until the anxiety subsides
4. Stand inside the lift with doors closed alone – until the anxiety subsides
5. Take lift to first floor accompanied by a friend – until the anxiety subsides
6. Take lift to first floor alone – until the anxiety subsides

The person continues to practice each step until it no longer evokes excessive anxiety. They then repeat the same process with the next step. In this manner, the association between the situation and the anxiety is weakened. It is important that the client works the grades with the therapist rather than the therapist being too prescriptive. This because it is the client who will know the specific things that will evoke their anxious responses and the order of intensity in which they would fall.

Individuals with blood injection injury phobias would need to begin graded exposure lying down to avoid fainting or to avoid injury if fainting. Exposure would increase to more difficult situations including watching blood being taken and finally having his or her own blood taken.

Systematic desensitization

This is a similar process to graded exposure however it uses visualization instead of actual exposure to the relevant anxiety provoking situation. As with graded exposure, the client is taught relevant coping skills, like progressive muscle relaxation, and then develops a graded hierarchy. Only this time the hierarchy is of imagined scenes. The client then uses progressive muscle relaxation to keep their anxiety to a minimum while visualizing the anxiety provoking stimuli.

While systematic desensitization has a demonstrated efficacy in reducing anxiety (Curtis, Nesse, Buxton, Wright, & Lippman, 1976) studies suggest that graded exposure is preferable (Barlow, 1988). Systematic desensitization is often used when real world exposure would be difficult, for example overcoming anxiety related to flying.

Imagined exposure is slower than graded exposure but is a useful way of creating small steps towards all-or-nothing activities. Systematic desensitization that is done in real life rather than imagined is often referred to as in vivo systematic desensitization which is really just another term for graded exposure. Graded exposure can begin with imagined scenarios and then progress on to in vivo or real life.

Source: Anxiety Disorders CE Course