Graded Exposure – self reflection on a CBT intervention

When learning to carry out therapeutic interventions or treatments, it’s important to understand the mechanisms of the task in detail, and what better way to get to the bottom of that than by using the technique on yourself? Here I practiced a standard CBT intervention for anxiety, Graded Exposure, and reflected so that in the future I can improve the experience for clients in the future.

What is the background to the intervention you practiced?

I practiced Graded Exposure, which has its foundations in cognitive behavioural therapy. Cognitive Behavioural Therapy posits that our thoughts and behaviours can affect how we feel emotionally and physically, and that by modifying our behaviour and cognitions, we can help improve our physical and emotional wellbeing (Beck, 1979). Graded Exposure focuses on the behavioural aspect of this cycle and suggests that when people are feeling anxious, they may avoid doing things which cause them anxiety which in turn can maintain the fear cycle (Richards & Whyte, 2011). The intervention itself encourages individuals to identify activities which expose them to a related anxiety provoking situation, in increasing levels of difficulty and to remain in the situation until they witness their anxiety reduce naturally, without avoidance. With repetition, the individual habituates themselves to the feared activity or object and the fear response stops (Richards & Whyte, 2011). There is a large evidence base for exposure treatment of anxiety disorders (Hofmann & Smits, 2008; Norton & Price, 2007), many with a large effect size (Cox et al. 1992).

What did you find easy?

I found using the materials quite straight forward, the ladder or hierarchy of fears was simple to use, and once I had rated the anxiety level for each situation it was easy to put into order, to choose which one to do first and so on.

What did you find difficult? 

It was difficult deciding on an anxiety provoking situation that I was motivated to work on, particularly as in our Clinical Skills Supervision in service we were asked to consider a fear which was more complex (i.e. not spiders)

It was also difficult creating the individual steps of the ladder, as I had to be quite creative but also realistic as to what could be realistically simulated or set up within normal life limitations and resources

In addition, because the activities that I had chosen for the steps of the ladder were not situations that I had experienced in life before it was difficult to estimate the anxiety levels that they would produce

Carrying out the activities I chose took a lot of resources, time, a room, someone else to support me and I felt reluctant to carry this out because of these difficulties

Doing the activity was OK itself except it was hard to carry it out for long enough for the anxiety to reduce by 50%

Keeping going with the rest of the activities on the ladder was difficult because it took time, and keeping motivated for subsequent weeks was challenging

What parts were a learning experience for you and how will this guide future practice?

I learnt that this task is challenging because it can take a lot of organisation and motivation on the part of the client. In this way I would change my practice by:

  • encouraging clients to develop exposure options which are as easy as possible
  • talking about motivation tips
  • problem solving with the client in-situ if needed
  • scheduling the task in a diary to aid adherence to plan
  • reviewing progress each week and planning next week with client to keep momentum

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