Counselling

How to Use Gradual Exposure to Treat Anxiety

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Avoidance is the behavioural hallmark of anxiety, and gradual exposure is an important part of overcoming it.

It’s normal for people to move away or avoid something that is threatening or scary. However, avoiding anxiety-provoking thoughts or situations can result in higher sensitivity. A person’s internal alarm may go off more quickly in anticipation, making them more rigid in their reactions to try to protect themselves.

Some people believe facing fears directly is the best approach. However, being thrown in the deep end of a pool doesn’t guarantee you’ll learn to swim. It’s just as likely you’ll sink, which could create a fear response.

This direct approach might lead to a lifelong avoidance of swimming or anything associated with pools or water.

The perception of threat is lessened by an approach that helps a person face the fear and approach the challenge gradually.

 

What is gradual exposure?

In contrast, learning to swim by starting out in the shallow end, receiving lessons, and using supports like water wings is a more gradual and effective approach. The perception of threat is lessened by an approach that helps a person face the fear and approach the challenge gradually with strategies and support. When working with anxiety, this approach is referred to as gradual exposure and is considered a key ingredient in anxiety treatment.

Clients can be encouraged to develop a systematic plan for gradually approaching challenging thoughts or situations. Rather than facing difficult situations in a way that triggers intense anxiety, clients identify small manageable steps they can take to approach the fear.

Building in aids such as social support, self-regulating strategies, and helpful self-talk can make it more manageable for clients to approach a source of fear. In some cases, for unrealistic or exaggerated fears, exposure can be done through imagination. In other situations, real-life exposure is ideal.

Clients can be encouraged to develop a systematic plan for gradually approaching challenging thoughts or situations.

 

Here’s how you can incorporate gradual exposure into your practice:

Invite clients to identify anxious thoughts or situations they fear and/or are avoiding.

  • If there is more than one concern, invite the client to rate these from low to high, creating a hierarchy of fears.
  • Encourage clients to start addressing fears on the low end of the hierarchy to minimize anxiety and create a sense of competence.

Help clients develop a step-by-step plan for approaching each feared situation.

  • Remind clients to use support, calming techniques, and helpful self-talk as they approach challenging situations. For example, if a client fears making a phone call, their exposure plan could include writing out a script for the call, practicing with a support person, using relaxation breathing to calm down, and creating a helpful coping thought.

Introduce a rating scale to help you and your clients track their arousal or distress as they face fears (0-10). I introduce the rating as SUDS – an acronym for subjective units of distress scale.

  • Remind clients to be aware of their arousal so they can maintain a low to moderate level of distress when engaging in exposure. Practice using SUDS with clients and help develop a plan to initiate rest and recovery techniques to de-escalate their anxiety.
  • Encourage clients to prepare for escalating anxiety by identifying a sensory object or grounding technique that works for them ahead of time. Slow breathing, cold water, relaxing pictures, a sprig of lavender, or a beach rock are examples of common things people use to feel calm.
  • Emphasize effort rather than outcome and celebrate partial success. Remind clients that any effort or movement toward situations they fear is success and should be reinforced through positive self-talk. Clients with disordered anxiety tend to be all-or-nothing thinkers. If the exposure plan does not work out perfectly, they may consider it a “failure,” and this labelling can reinforce anxiety and undermine willingness to engage in future exposure tasks.
  • Prepare clients for setbacks. Exposure doesn’t always happen smoothly or go as planned. It’s possible to make progress quickly in facing a feared situation and then experience extreme anxiety and retreat back to avoidance. This back-and-forth movement toward behaviour change should be explained and normalized.
Remind clients to use support, calming techniques, and helpful self-talk as they approach challenging situations.

While disordered anxiety is distressing and limiting, it also reveals important information about clients’ natural defences and abilities. Gradual exposure and other anxiety work helps clients make sense of their worries and cultivates their natural coping.

When people learn to manage anxiety problems, they often report that they feel stronger and freer than before the difficulties began. In a life dominated by anxiety, a lot of time and energy is spent on being preoccupied with threatening possibilities. With proper support and coping strategies like gradual exposure, people experiencing anxiety can better accept uncertainty and develop confidence in their abilities to face the challenges of life.


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Author

AnnMarie Churchill

PhD, RSW – Trainer, Crisis & Trauma Resource Institute

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