What is graded exposure?

Graded exposure is a technique that psychologists use to help people to change their behaviour. Basically it works by taking a behaviour that someone finds very hard to do, and breaks it into smaller steps. You might have heard of this approach – the tricky part is figuring out which steps will help you reach your goal and to watch out for safety behaviours. See the end of this article for help with this…

The reason why it is hard to change most behaviour is because of avoidance. By making a list of behaviours that you are avoiding, and then working from the easy to the hard tasks, it becomes easier to change your behaviour.

For example: Let’s say I am trying to become more assertive. I know I should say “No” more often but I just can’t seem to.

• First I would make a list of lots of different things that I am avoiding that have to do with assertiveness.
• Then I rank them from easy to hard.
• After that I would start with the easy tasks and work up.
• Completing each task will boost my confidence that I can speak up and be assertive during the next task.

Graded exposure involves:

1. Figuring out which behaviour you would like to change (e.g., assertiveness, being more social, less reassurance seeking with others, learning to deal with panic attacks etc.)
2. Making a list of things that you avoid that are related to your goal.
3. Starting with easy tasks and working up the list.

However, there are two commons problems to watch out for: figuring out the right steps and safety behaviours. At the bottom of this post are a few example lists that you can check so that it is easier for you to figure out what to put on your list. The basic idea is that you do the steps that create an emotion that is hard for you to tolerate. Then, instead of acting on the feeling and doing what it tells you, you do the opposite behaviour of what the feeling urges you to do.

For example: If you practice speaking up or saying No you will probably feel fear or guilt. The feeling might normally cause you to stay quiet or apologise a lot. The opposite behaviour would be to speak your opinion more often or to not apologise.

The second issue is safety behaviours. Safety behaviours are ANY behaviour that we use to get rid of difficult feelings. They are like a crutch that we might use when we have a broken leg. At first we need to use a crutch but as we get better it is important to let go of the crutch so that we can return to living at its best. Here is a list of common safety behaviours to phase out as you get better at graded exposure.

• Taking someone with you to do difficult tasks
• Not making eye contact
• Pretending to be engrossed in your mobile phone when you feel uncomfortable
• Using other objects to avoid interaction
• Leaving when you feel too uncomfortable
• Using drugs/alcohol before, during or after tasks to calm down
• Apologising
• Not speaking your truth / speaking in half-truths / sugar-coating what you say
• Re-assurance seeking with others
• Overworking or keeping very busy so that you don’t have to feel difficult feelings like loneliness or loss

Here are some lists of ranked tasks for common goals people have:

Symptom Level	Assertiveness Tasks
Very high Extreme anxiety – I can barely stand it	£ Discuss your feelings about an important issue with a work colleague without making apologies £ Discuss your feelings about an important issue with a family member without making apologies £ Ask someone to stop a behavior that is annoying you (i.e. a flat mate who doesn’t clean up) £ Speak up in a meeting or social event £ Say no to a task at work
High Really unpleasant – My heart is racing	£ Go into a store and try on items but don’t buy anything. Just ask for help from the clerk. (Tip: Leave your wallet at home) £ Discuss your feelings about a non-confrontational issue with a colleague £ Discuss your feelings about an important issue with a close friend
Medium Unpleasant – I really don’t want to be here	£ Ask a store attendant for a discount on a non-sale item in a store £ Politely decline a request from a friend £ Discuss your feelings about a non-confrontational issue with a family member   £ Write a critical post on an internet discussion board
Low Mild Anxiety – I am aware of my tension, but I can handle this	£ Politely postpone a request from a friend £ Ask an attendant in a store to tell you more about a product £ Pay for something in small change £ Say to someone who makes a request of you “I don’t know, but I will get back to you” even if you will do it anyway
Very low A bit of tension – I’m fine, this just feels a bit odd	£ Politely ask a favour of a friend £ Ask a store attendant to show you where an item is in the store £ Ask someone unfamiliar the time or for directions

Symptom Level	Tasks For Reducing Re-assurance Seeking
Very high Extreme anxiety – I can barely stand it	£  Leave mobile phone at home for 1 day £  Do not say sorry or pre-empt checking with anyone, unless there is clear evidence to do so, for 1 day £  Delay responding to an email, unless in emergency, for 1 day £  Don’t apologise for anything for a full day
High Really unpleasant – My heart is racing	£  Reduce pre-emptive checking in with people to once per day £  Do not check the news for one day £  Delay responding to emails for over 1 hour £  Reduce checking mobile for text messages/missed calls to once per day £  Don’t apologise for anything for half a day
Medium Unpleasant – I really don’t want to be here	£  Reduce pre-emptive checking in with people to 3 times a day £  Reduce checking news (on TV, radio or the internet) to twice per day £  Reduce checking mobile for text messages/missed calls to 3 times per day
Low Mild Anxiety – I am aware of my tension, but I can handle this	£  Reduce pre-emptive checking in with people to 4 times per day £  Delay responding to emails/missed calls for 30mins £  Reduce checking mobile for text messages/missed calls to 5  times a day £  Reduce checking the news (on TV, radio or the internet) to 4 times a day
Very low A bit of tension – I’m fine, this just feels a bit odd	£  Reduce checking mobile for text messages/missed calls to 8 times a day £  Delay responding to emails/missed calls for 10mins £  Reduce checking news (on TV, radio or the internet) to 4 times a day

Symptom Level	Tasks For Learning to Cope with Panic Attacks
Very high Extreme anxiety – I can barely stand it	£  Walk up and down steps quickly for a minute, then try and control your breathing while breathing in and out of a paper bag for 1 min £  Wear an extra layer of clothing and then spin on the spot for 30 sec and don’t sit down immediately £  Drink coffee and try any of the high tasks
High Really unpleasant – My heart is racing	£  Wear 1 extra layer of clothing to simulate feeling hot, and breathe through a straw for 1 min holding your nose £  Wear 1 extra layer of clothing to simulate feeling hot and put cotton wool in the cheeks of your mouth to simulate a dry mouth
Medium Unpleasant – I really don’t want to be here	£  Breathe in and out through a straw for 1 min to simulate breathlessness £  Combine wearing an extra layer of clothing with spinning on the spot for 30 sec £  Drink coffee and combine with any of the low or very low tasks
Low Mild Anxiety – I am aware of my tension, but I can handle this	£  Spin on the spot for a 30 sec (to simulate feeling dizzy) £  Breathe in and out of a paper bag for 1min to simulate feeling of hyperventilation £  Hold breath for 30 sec £  Put cotton wool in the cheeks of your mouth to simulate having a dry mouth
Very low A bit of tension – I’m fine, this just feels a bit odd	£  Seated, shake head from side to side to simulate dizziness £  Wear 1 extra layer of clothing doing housework to simulate feeling hot or flushed £  Hold a “tense” position (a push up position, a sit-up position) for 1 min to simulate complete body tension