Overcoming specific phobias: Graded Exposure

Satwant Singh Nurse Consultant in Cognitive Behavioural Therapy

CBT@GP Newham

Aims
To have an understanding what are the maintaining factors for phobias To have an understanding of the principles of graded exposure To carry out at least one exposure either in vivo or imagery within the session

Definition-Phobias
Phobia: A intense unrealistic fear which can interfere with the ability to socialise, work and activities of general living that is brought about an object, event or situation resulting in avoidance and development of complex coping mechanism which interfere with activities.

Key features
It is specific (spider etc) Not like panic attacks- sudden out of the blue but can have panic It has a long standing history of development (starts in early life) Extensive and elaborate safety behaviours including avoidances

Features..cont
Occurs at two levels Anxiety

Belief (the fear)

Simple model for phobia

Trigger Specific situation/object

Thoughts
Behaviour Anxiety

Anxiety curve

Simple model for phobia

Trigger Specific situation/object Thoughts Behaviour Anxiety

Safety behaviours Avoidances

Role of safety behaviours, safety seeking behaviours &avoidances

Used as coping mechanisms Prevent the disconfirmation of the fear Gradually makes the fear worst (contaminates the situation) Prolongs the anxiety Gradually affects the persons ability to function as it becomes more elaborate and extensive

Anxiety with safety behaviours

Principles for treatment- Exposure

Understand that anxiety does not increase to intolerable levels Discomfort reduces with exposures Graded (step by step) Repeated Prolonged Tasked clearly identified in advance

Graded Exposure
Draw up hierarchy to guide List all the avoidances and SB for each item Rate from the least to the most anxiety provoking Carry out exposure without the avoidance and SB Consistency Repeatedly

Anxiety reduction with exposure

Fear (Belief)
Determine the fear and prediction of what would happen Write down what would be confirmation information that the prediction has come true Carry out the exposure Record the outcome and data Re-evaluate the prediction and fear

Types of exposure

Real life (in vivo) Imaginable Exposure

Session Exposure
Look at your hierarchy list of your fears Pick one that we will carry out in the session using imaginal exposure List all the safety behaviours and avoidances Ask yourself if you were to face the situation what would the worst that could happen and how would you know it

Session Exposure. cont

Imagine the situation, object and rate your anxiety (rate 0-100%) Stay in the situation and be aware of any safety behaviours/avoidance (both overt and covert) Stay in the imaginable situation till the anxiety comes down around 10-20% Repeat it

Trouble shooting
If the anxiety does not come need to ask yourself what am I doing differently? What safety behaviours that I am carrying out and if there are any avoidances that I am using to cope with my anxiety You might be awfulising (it is terrible to feel like this etc) These maintain the anxiety up

Take away tips

Repeat the exposures even if the become comfortable (repeat it longer each time) Gradually work your way up the hierarchy Always address your prediction and fears by looking at the evidence for and against Normalise your anxiety When ready face the real thing use the same principles

Take away tips

If you are finding it difficult revisit the hierarchy Set small goals (easier to achieve) Recognise the time spent in exposure however long or short Record each exposure you undertake and recognise your achievement no matter how small Be kind to yourself, acknowledge the difficulty