May 2, 2019

Exposure Practice Sheet

Introduction

In the videos, we discussed that anxiety disorders can be considered a conditioned behavior. And that recovery is based on Behavior Modification. While it might feel comfortable to fear or avoid specific situations, you will need to face your fears in a real situation and begin to turn specific trigger situations into a positive experience. Let’s call this “Exposure Practice”.

Some people might encourage you to tackle your biggest fear first – to “jump in the deep end” and get it over and done with. However, I always suggest that we approach any exposure, as well as all practice in “small, manageable steps”. We are not trying to scare ourselves or make things worse, rather we are trying to give us an opportunity to experience higher than usual levels of anxiety, but still completely manageable, and learn to work within those levels. Proper “exposure practice” consists of structured and repeated exposure to anxiety-provoking trigger situations. These are presented in levels of difficulties, starting with the situation that provokes the least amount of anxiety and moving towards more challenging situations.

HOW DOES SITUATIONAL EXPOSURE WORK?

Exposure gives you the chance to disconfirm your fears. People with anxiety in various trigger situations often think that the likelihood of a disaster happening is very high, and will likely continue to control or even avoid these situations. Taking the first step might feel the hardest. At first, the anxiety might feel uncomfortable, but by staying in the situation you can learn that what actually happens is not so bad after all. And we will become desensitized to the experience, as well as create a new behavioral response to the situation.

Exposure gives you the chance to use your tools. Feeling comfortable in these situations is not instantaneous. First of all you need to approach the situation ready with tools. It is only when you are in the actual trigger situation that you can learn to implement the tools and learn to “look away from the fear”.

Exposure gives you the chance to get used to being in your trigger situations & learn to manage your thoughts. By continuing with more and more exposure tasks, repeatedly confronting situations in which you had previously felt overwhelmed with anxiety, you will become used to them. And you will feel more confident in using your tools doing so. It might not feel like it at first, but it does happen. By entering into these trigger situations, in a planned and proper way, your body will respond more calmly. After a while these situations will lose their power to bring on as much anxiety as they had before. And ultimately you will become desensitized to the specific trigger(s).

Exposure gives you the chance to improve your confidence & build empowerment in your trigger situations. If you plan these steps carefully, you will build up on your confidence and this will allow you to take further steps forward. With increased confidence, you will be able to confront your fears, build a new behavioral response to the triggers, and create recovery.

Beginning Practice

We can now start building a stepladder of exposure situations that you can begin to climb. Remember that by taking a step-by-step approach you can get through the smaller challenges, which will in turn help you feel more confident to expand your practice and your exposure levels.

If you are finding the tasks particularly difficult or are concerned that you will find this task particularly difficult, you should consider revising the exposure to be more manageable. Or you can even consider enlisting the help of a friend, family member or someone you trust.

1. SITUATIONS THAT YOU FEAR AND AVOID
First of all, let’s look at the trigger situations you tend to feel higher levels of anxiety in, or possibly even avoid. You can list these on the next page. You may not have thought much about the kinds of trigger situations that you experience, so this exercise will increase your awareness about them.

To give you an idea, below are some examples of trigger situations that many people suffer with. If you see any that seem familiar to you, you can rephrase them on your list, so that they are more relevant to you.

  • Social Phobic
  • Public Speaking
  • DrivingHeights
  • Leaving the house
  • Going to large/public places
  • Pets / Animals
  • Elevators
  • Escalators
  • Parking Garages
  • Crossing Roadways
  • Speaking on the phone

 

Write down a list of your trigger situations: You can write as many as you like. But the idea is to start working on one of the less severe triggers that you have to start with.

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2. SUDS: SUBJECTIVE UNITS OF DISTRESS
This stands for Subjective Units of Distress Scale (SUDS). The SUDS scale is a numerical rating from 0-100 that indicates your level of distress and anxiety in a specific trigger situation. These ratings will help you to track changes over time. To practice using the scale, read through the following guide, then try to think of an example of when you’ve felt that level of distress and anxiety.

SUDSRating Description Can you think of a situation when you’ve felt this way?
 0 You feel absolutely no distress, you are calm and relaxed. Eg laying in the bath, having a massage, watching a funny movie.  
 1-3 You feel a mild level of anxiety but you can still cope with the situation. You might feel like you’re more alert or a little nervous. Eg. Athletes before a competition, and even confident speakers before a public presentation.  
 4-5 You feel a moderate level of distress that is becoming difficult to cope with. You might be distracted by the anxiety, or behaving in ways to avoid anxiety eg avoiding eye contact, sitting quietly, but still attending to what’s happening.  
 6-8 You feel a high level of distress that is really difficult to cope with. You’re more concerned with your anxiety and how to escape, and less able to concentrate on what’s happening around you.     
 9-10 You feel a severe to extreme level of distress and you think you cannot cope. Your body response is so overwhelming that you think you can’t possible stay in the situation any longer.    

Use this guide to rate your level of distress in the situations that you have listed in the previous list.

Use any number between 0 and 10 to represent how much distress you would feel in the situation.

Now that you have identified a number of situations that cause you higher levels of anxiety and possibly avoid, how do you build an approach to practice? First of all, let’s take a look at where it is that you do want to get to by planning your goals. After that you can start thinking about the steps you’ll need to take to reach those goals by exposure practice.

It’s important to be specific when it comes to building your plan and working towards your goals. Many people who have used this type of exposure have found that small, specific steps helps them feel comfortable with the situation by knowing what’s coming up. It also means that you’ll be able to make sure the steps are small enough to take, but big enough that you believe you’re heading in the right direction.

3. PLANNING GOALS
Let’s think about how you can turn those trigger situations that you fear and possibly avoid into specific goals that you would like to achieve. When you’re planning goals for exposure you can follow the acronym PRAMS: Personal, Realistic, Achievable, Measurable, Specific.

Personal: Choose the situations you listed that are most relevant to you at the moment. For example, if you feel anxious about eating in public and your avoidance of that situation is interfering in your ability to enjoy the company of your family or friends, then you might set a goal in that area.

Realistic: For example, expecting not to feel any anxiety is not realistic, as we all feel some anxiety at times, and sometimes it can even help our performance! Generate goals that are possible.

Achievable: Similarly, write goals that are achievable for you at the moment. Perhaps singing a ballad at a friend’s wedding is an unreachable expectation for most people, let alone for you right now. Generate goals that are probable.

Measurable: Make sure your goals can be easily measured. “Speaking to people with confidence at a party” might be difficult because “confidence” is hard to measure. Action based goals are easier to measure: “Speaking to someone at a party for at least 2 minutes” allows you to accurately assess whether you’ve reached that goal.

Specific: As the above example shows, goals also need to be specific. So, if the situation that you avoid is

“Eating out in public” then your specific goal could be “To eat a meal in a restaurant”. If the situation is “Talking at meetings” then your goal might be “To comment on an agenda item at a monthly team meeting”.

To start with, you might want to just choose just a one of your trigger situations to turn into a goal, rather than trying to do multiple all at once.

Choose trigger situations that you would like to change first, maybe one that impacts your daily life to start with, rather than planning goals that are not very important to you.
Choose a trigger situation that you can more easily approach in terms of beginning practice with lower levels so that you can set some easier, less distressing goals, but at the same time you don’t exclude the more difficult, distressing goals. Building up from lesser levels to higher levels can take time, but you want to have the opportunity to do so as needed.

Based on the situations that you listed, write down the specific goals you would like to achieve below. It is also useful to rate your SUDS level for each goal as it may have changed from when you were thinking of it as a general situation.

In situational exposure it is important to determine how you can reach your goals. You need to break down each goal into smaller, manageable steps so it is a little like climbing a ladder towards your main goal. Try to think of a set of exposure tasks that start with less anxiety provoking situations, then build up in intensity until you reach your main goal. The number of steps depends on how much distress is associated with the particular goal. A high-challenge exposure situation (SUDS: 8+) will need more steps than a medium-challenge exposure situation (SUDS: 4-6).

Perhaps you avoid driving as an example. Your specific goal might be to eventually drive around the block, or other type of short distance. This might be quite a difficult goal, with a SUDS rating of 8. So breaking the larger goal down into smaller, more manageable steps can make it easier. Maybe just sitting in the car is the first goal. Followed by additional smaller goals of starting the car, moving the car, driving for a short distance on the street. If you have a “practice partner” to assist in the process you can even use their presence in various steps. You may want them to drive first with you as a passenger for exposure. Then you can drive with the practice partner as a passenger in the front seat. Eventually moving to the back seat but still speaking. A goal may be to have the practice partner in the backseat and sit silently while you drive. Ultimately the final goal is with you driving alone. You need to think of situations that can act as steps that will still help you to climb the ladder to your goal. Below is an example of building a stepladder. On the next page is some space for you to complete the steps for your own goal.

EXAMPLE:

GOAL:  Driving around the block by yourself  SUDS (0-10)
8

 

  STEP SUDS
1 Sit in the car, parked in driveway, engine off and stay for 10 minutes 3
2 Start engine and sit in driveway practicing tools and stay for 15 minutes 4
3 Move car in driveway just a very short distance, maybe for 5 minutes 5
4 Have someone sit in the passenger seat as you pull out into the street 6
5 Drive down to the corner and park the car, w/ passenger 7
6 Drive around the block completely on your own 8

 

Remember, the amount of steps you have to help reach your goal will vary depending on where you are starting. Each of us have to find a starting point that is manageable for us to work with. We want to be able to feel some higher levels of anxiety, but not so much that we frighten ourselves or force us to struggle through a practice period. You can add as many steps as needed, there is no rush in trying to speed up this process. If one step is too easy, then you may want to adjust your exposure to find a more challenging place to work in. The length of time for each practice can vary as well. The length of time should be just enough to reach your optimum level of anxiety for practice and stay there for a period of time, and then end it on a positive note. Exposure practice should never be frightening or make you very uncomfortable. If a session is too difficult, the follow session should be a smaller, more manageable situation. Each of us have to find our starting point, and learn to work from there in a very consistent manner.

Module Summary

One of the ways to start turning your thoughts into actions is through “graded exposure”, or “situational exposure”. This means that you begin to confront your fears in a step-by-step approach
Situational exposure is helpful because when you enter the specific trigger situation(s) that usually cause higher levels of anxiety and/or avoidance, in a planned and proper way, your body will react more calmly and you will experience less anxiety. After a while these situations will lose their power to bring on as much anxiety as they did. Ultimately you will become desensitized to the situation.
Building situation stepladders is part of a process
Identify the trigger situation(s) that you feel anxious in and/or tend to avoid
Use SUDS (Subjective Units of Distress Scale) ratings as a gauge of how much distress you feel in particular situations, from 0 – 10. This rating scale will help you to plan your situation stepladders, and it will help you to track changes in level of anxiety over time.
Plan specific goals that give you something to aim for. When you’re planning goals for exposure you can follow the acronym PRAMS: Personal, Realistic, Achievable, Measurable, S
Build a practice schedule, or list of goals by breaking down each goal into smaller steps. Use the SUDS scale to plot the order of steps so it is a little like climbing a ladder towards your main goal. You can make each step easier or harder as needed to optimize the practice session.

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