Graded or graduated exposure is a traditional way of overcoming fears and phobias. The therapist helps the client to draw up a list of feared situations which are then faced in order of increasing difficulty. The traditional ‘rule’ for exposure was that the client was to be encouraged to remain in the feared situation until fear had habituated to some degree (often by about 50%). Graded exposure is helpful because its simple rationale tends to make it acceptable to clients leading to greater adherence. Graded exposure builds upon success: therapists can build upon positive feelings associated with successfully overcoming fears lower down the hierarchy.
Clinicians should note that modern approaches to exposure have de-emphasized the importance of hierarchies in favour of exposure schedules including tasks which violate the client’s expectancies, or which increase the variability of the exposure (Craske et al, 2014). For example, as an alternative to a traditional exposure setup a behavioral experiment may be conducted where the client expresses the belief “If I go near the spider it will jump on my face” and then tests that prediction. Varying the stimuli, durations, intensity, times, and contexts of exposure has also been demonstrated to increase the effectiveness of exposure and should be considered if clients are willing.
“One way of overcoming our anxieties is to confront whatever it is that we are afraid of. Have you ever heard of the phrase ‘facing your fears’? A really good way to do this is to draw up a list of the situations that make us feel frightened so that we know what we need to confront.”
Tips for therapists:
- Hierarchies do not always have be started at the bottom – the items here are often too simple and can be a less productive use of therapy time. Consider asking “Where should we start?”
- Make sure to positively reinforce exposure attempts. This worksheet includes space to colour-in items as they are attempted.
- Consider asking clients to rate how much each item frightens them, or to rate how much they expect a specific catastrophe to occur should they attempt that item.
- Consider encouraging clients to verbalise their emotions during exposure attempts (affect labelling).
- Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: an inhibitory learning approach. Behaviour Research and Therapy, 58, 10-23.