Facing Fears - BEHAVIOURAL EXPOSURE

Facing Fears:

BEHAVIOURAL EXPOSURE

 

An important step in managing anxiety involves facing feared situations, places or objects.  It is normal to want to avoid the things you fear.  However, avoidance prevents you from learning that the things you fear are not as dangerous as you think.

 

The process of facing fears is called EXPOSURE.   Exposure involves gradually and repeatedly going into feared situations until you feel less anxious.  Exposure is not dangerous and will not make the fear worse.  And after a while, the anxiety will naturally lessen.

 

Starting with situations that are less scary, you work your way up to facing things that cause you a great deal of anxiety. Over time, you build up confidence in those situations and may even come to enjoy them. This process often happens naturally.  A person who is afraid of the water takes swimming lessons every week and practices putting feet and legs in the water, then the whole body and, finally, diving underwater.  People with a fear of water can learn to love swimming.  The same process occurs when people learn to ride a bike, skate, or drive a car.

 

Exposure is one of the most effective ways of overcoming fears.   However, it takes some planning and patience. 

 

Doubts about the helpfulness of exposure?

You may have tried exposure in the past and found that it did not work. However, you may have tried to face something too scary too soon, which can be overwhelming.  Or, you didn’t have the chance to practice repeatedly in order to get the benefits of exposure.  If done correctly, exposure can be VERY effective for overcoming fears.  Be willing to try again!  Follow the steps below to get the most out of exposure!

 

 

HOW TO DO IT!

 

Step 1. Make a list

  • Make a list of situations, places or objects that you fear.
  • For example, if you are afraid of dogs, the list may include: looking at pictures of dogs; standing across the park from a dog on a leash; standing in the same room as a dog on a leash; standing a few feet from a dog; or petting a puppy.  If you are afraid of social situations, the list may include: saying “hi” to a co-worker; asking a stranger a question; making small talk with a cashier; or calling a friend on the phone.

 

Helpful Hint:

  • Group Fears Together. Some people have a lot of different fears, so it can help to group similar fears or specific fear themes together. For example, you may have a fear of bugs, as well as a fear of heights.  Make different lists for different fear themes.

 

 

Step 2. Build a Fear Ladder

  • Once you have made a list, arrange things from the least scary to the most scary. You can do this by rating how much fear you have for each situation on the list from “0” (No fear) to “10” (Extreme fear).  Once you have rated each situation, use the “Fear Ladder” form to make a final list.

 

Helpful Hints:

  • When making a fear ladder, identify a specific goal (such as having a meal in a restaurant), and then list the steps needed to achieve that goal (e.g., go to a restaurant and get a coffee to go; have a coffee at the restaurant and sit near the door; have a snack at the restaurant and sit near the door; have a snack at the restaurant and sit at a table in the middle of the room; have a meal at the restaurant and sit near the door; have a meal at the restaurant and sit in the middle of the room). See “Examples of Fear Ladders” for some ideas on building your fear ladder.
  • If you have a lot of different fears, build separate ladders for each fear theme.

 

 

  • Each ladder should include a whole range of situations. The ladder should include some steps you can do now with mild anxiety, some that you can do now with moderate anxiety and, finally, the steps you find too difficult to do now. It is important to start really small and take gradual steps. 
  • Some steps on the ladder can be broken up into smaller steps. For example, if you are afraid to talk to co-workers, this could be broken up into a number of steps such as saying “hi” to a co-worker, asking a quick question, and then talking about your weekend. 
  • Because it is sometimes difficult to come up with steps on the fear ladder that cause only moderate anxiety (that is, somewhere between a little and very scary), you can consider other factors that might make it easier or harder for you to do.  Some examples include:  

                       o   Length of time: for example, talking to someone for 30 seconds is probably less scary than talking for five minutes.

                       o   Time of day: for example, driving over a bridge in the middle of the afternoon versus evening rush hour.

                       o   Environment: for example, swimming at a local pool versus swimming in a lake.

                       o   Who is with you: for example, going to the mall with your spouse versus alone. 

  • See “Examples of Fear Ladders” for some ideas about building your fear ladder. 

 

Step 4. Facing Fears (Exposure)

  • Starting with the situation that causes the least anxiety, repeatedly engage in that activity (e.g., saying “hi” to the bus driver everyday) until you start to feel less anxious doing it. If the situation is one that you can remain in for a prolonged period of time (such as standing on a balcony), stay in the situation long enough for your anxiety to lessen (e.g., standing on the balcony for 20-30 minutes).  If the situation is brief, try “looping” it, which involves doing the same thing over and over again for a set number of times (e.g., repeatedly driving back and forth over a bridge until you start to feel less anxious or making consecutive phone calls until you feel more comfortable doing it).
  • If you stay in a situation long enough (or continue engaging in a specific activity), your anxiety will start to come down.  This is because anxiety takes up a lot of energy in the body, and at some point it “runs out of gas”.  The longer you face something, the more your get used to it, and the less anxious you will feel when you face it again.

 

Helpful Hint:

It can help to track your fear level during exposure exercises and to try and remain in those situations (or continue engaging in a specific activity) until your fear level drops by about 50%.  For example, if you rated holding a needle as a 6/10 on the fear scale (remember that “0” = no fear and “10” = extreme fear) then you want to continue holding the needle until your fear level drops to a 3/10.

 

  • It is important to plan exposure exercises in advance; that way you feel more in control of the situation.  Identify what you are going to do and when you plan to do it.

 

 

Remember - Exposures should be planned, prolonged, and repeated!

 

 

  • Make sure to track your progress. See the “Facing Fears” Form, which will help you identify how anxious you were before and after facing the feared situation, and what you learned. Make copies and fill one out each time you face a fear.
  • Once, you are able to enter a specific situation without experiencing much anxiety on several separate occasions, you can move on to the next thing on the list.

 

 
 

Helpful Hints:

  • Don’t Rush! It can be very scary facing the things you fear. Be patient and take your time. Go at a pace that you can manage!

 

 

 

 

 

 

 

 


Step 5. Practice

  • It is important to practice on a regular basis.  Some steps can be practiced daily (e.g., driving over a bridge, taking an elevator, saying “hi” to a stranger, touching doorknobs), while other steps can only be done once in a while (e.g. giving a formal presentation to a large group or taking a plane trip).  However, the more often you practice the faster the fear will fade!
  • Don’t forget to maintain the gains that you have made!Even if you have become comfortable doing something, it’s important to keep exposing yourself to it from time to time, so your fears don’t creep back.  For example, if you have overcome a fear of needles, you should schedule routine blood tests or donate blood every six months so that your fear of needles does not return.
  • Re-rate your entire fear ladder every once in a while; that way, you can see the progress you have made, and identify the steps on the ladder you still need to tackle. 

 

 

Remember, you will experience anxiety when facing fears - this is normal.

 

 

Step 6. Reward Brave Behaviour

  • It’s not easy facing fears.  Reward yourself when you do it!
  • It may be helpful to use specific rewards as motivation to achieve a goal. For example, plan to purchase a special gift for yourself (DVD, CD, book, treat) or engage in a fun activity (rent a movie, go to the movies, go out for lunch or dinner, plan a relaxing evening) after you reach a goal.
  • Don’t forget the power of positive self-talk (e.g., “I did it!”).

 

TIP: Don't be discouraged if your fears start creeping back. This can happen from time to time, especially during stressful periods or transitions (for example, starting a new job or moving).  This is normal.  It just means that you need to start practicing using the tools – plan some exposures!  Remember, coping with anxiety is a lifelong process.

 

For more information on how to maintain your progress and how to cope with relapses in symptoms, see “How to Prevent a Relapse”

 


Examples of Fear Ladders

 

Specific Phobia (dogs): Cassandra’s Story

Cassandra is afraid of dogs.  She refuses to walk around the neighborhood without her husband for fear of being attacked by a dog.  She tends to avoid places where there are dogs, such as parks or hiking trails (even though she used to enjoy hiking).   She will cross the street if she sees someone walking with a dog and will refuse to enter a store if a dog is tied up out front.

Goal: To be able to be near dogs without excessive fears.  Click here to see Cassandra’s Fear Ladder.

 

Step

Situation

Fear Rating

12.

Petting a larger dog off leash

10

11.

Petting a larger dog on a leash

9

10.

Holding a puppy

9

9.

Petting a puppy that someone is holding

8

8.

Standing beside, but not touching, a dog on a leash

7

7. 

Standing 4 feet away from a dog on a leash

6

6.

Standing 8 feet away from a dog on a leash

5

5.

Standing across the street from a dog on a leash

4

4.

Looking at a dog through binoculars across a park

3

3.

Looking at a dog through a window

3

2. 

Watching a film with dogs in it

2

1. 

Looking at photos of dogs

2

*Once Cassandra has completed the fear ladder and can tolerate being around dogs, she can start a new ladder tackling other fears she may have.

 

 

Specific Phobia (Needles): Cam’s Story

Cam is VERY afraid of needles.  He tends to avoid going to the doctor as he worries he’ll have to get a needle.  Cam’s health has not always been good and he is worried that if he doesn’t overcome his fear he is putting his health at risk. 

Goal: To tolerate having needles (In this case, the goal is not to feel completely comfortable getting needles -- as most people aren’t -- but to be able to tolerate them).  Click here to see Cam’s Fear Ladder.

 

Step

Situation

Fear Rating

11.

Having blood drawn from a vein

10

10.

Getting a shot in the upper arm or fleshy part of leg

9

9. 

Slightly pricking one’s skin with a needle

8

8. 

Watching someone else get a needle

7

7.

Resting needle against vein

7

6.

Resting the needle against one’s skin

6

5.

Rubbing an alcohol swab against one’s skin

5

4.

Holding a needle

4

3.

Watching an apple being injected

3

2. 

Watching video clips of someone getting a needle

3

1. 

Looking at a picture of a needle

2

*If Cam has a history of fainting when he gets needles, he should read the module on Applied Tension Technique, which can help Cam avoiding fainting. 


Panic Disorder: Fin’s Story

Fin is afraid of having a panic attack while driving over a bridge.  As a result, he avoids crossing bridges whenever he can.  When he does have to drive over a bridge, he insists on carrying his cell phone and prefers to be accompanied by a friend.  This way, help will be available if he does have a panic attack.

Goal: To be able to cross bridges without excessive fears of panic attacks.  Click here to see Fin’s Fear Ladder.

 

Step

Situation

Fear Rating

11.

Driving over the long bridge in heavy traffic without friend or cell phone.

10

10.

Driving over the long bridge in heavy traffic without friend

9

9.

Driving over the long bridge in heavy traffic with cell phone and friend

8

8.

Driving over the short bridge in heavy traffic without cell phone or friend

8

7. 

Driving over the short bridge in heavy traffic without friend

7

6.

Driving over the short bridge in heavy traffic with cell phone and friend

6

5.

Driving over the long bridge in light traffic without friend

6

4.

Driving over a long bridge in light traffic with cell phone and friend

5

3.

Driving over the short bridge in light traffic without friend and cell phone

5

2. 

Driving over the short bridge in light traffic without friend

4

1. 

Driving over a short bridge with cell phone and friend

3

*Once Fin has completed the fear ladder and can tolerate driving over bridges, he can start a new ladder tackling other fears he may have due to panic (such as being in crowded places). It will be important for Fin to tackle his fear of the physical symptoms associated with panic attacks.  See the module on Panic Disorder for more information about exposure to feared physical sensations.

 

 

Social Anxiety Disorder: Sarah’s Story

Sarah is worried about giving a presentation at work. She is also worried about asking and answering questions during meetings.  She is worried that if she doesn’t get over her fears, she will be passed over for an upcoming promotion. 

Goal: To be able to give presentations and participate in meetings at work. Click here to see Sarah’s Fear Ladder.

 

Step

Situation

Fear Rating

10.

Giving the prepared presentation during a staff meeting and answering questions

10

9.

Giving a short update of a project during a meeting

9

8.

Answering questions during meetings

9

7.

Asking questions during meetings

8

6. 

Asking the supervisor a question after the meeting with other co-workers present

7

5.

Giving an abridged version of the presentation to a few co-workers and having them ask questions

6

4.

Making a comment during a meeting

5

3.

Giving the prepared presentation in the boardroom with a few close co-workers present

5

2. 

Giving the prepared presentation in the boardroom. Only close colleague present

4

1. 

Giving a prepared presentation in the boardroom after work. No one present

2

*Sarah is also afraid of meeting new people. After she completes this fear ladder, she can start developing a new ladder to help her overcome her fear of meeting new people (which may include: saying “hi” to strangers; asking a stranger a questions; introducing herself to someone at a party; making small talk with an unfamiliar cashier; etc).

 

 

Social Anxiety Disorder: Sahl’s Story

Sahl gets anxious around co-workers and has not been able to develop any friendships even though he has been working for the same company for 3 years.  He tends to avoid the staff room and will only discuss work related things with co-workers.  He would like to be able to make new friends and feel comfortable interacting socially with co-workers.

Goal: To interact socially with co-workers.  Click here to see Sahl’s Fear Ladder.

 

Step

Situation

Fear Rating

11.

Attend staff party

10

10.

Share personal information about self with co-workers

10

9.

Go out for lunch with a group of co-workers

9

8.

Ask a co-worker to go for coffee after work

7

7. 

Eat lunch in the staff room and make small talk with co-workers

7

6.

Eat lunch in the staff room

6

5.

Sit in the staff room during coffee break and make small talk with a group of co-workers (e.g., talk about the weather, ask them what they did on the weekend, etc.)

5

4.

Sit in the staff room during coffee break

4

3.

Ask a co-worker what they did on the weekend

4

2. 

Ask co-workers questions about how to complete tasks at work

3

1. 

Say “hi” to co-workers

2

*Once Sahl has made some new friendships at work, he can start tackling some of his other fears (such as talking to persons in authority, such as his boos).

 

 

Post-traumatic Stress Disorder:  Wen’s Story

Wen was in a serious car accident a year ago.  She was rear-ended by a large truck while trying to make a left turn at an intersection.  Since the accident, she has stopped driving and feels very anxious when she is a passenger in a vehicle.  She tries to avoid walking near busy roads and avoids traveling by car whenever she can.  She also feels scared when she hears loud noises, such as car horns, or hears about accidents.

Goal: To be able to ride in a car.  Click here to see Wen’s Fear Ladder.

 

Step

Situation

Fear Rating

13.

Drive by scene of accident

10

12.

Make a left turn at a busy intersection alone

9

11.

Make a left turn at a busy intersection with husband present

8

10.

Drive down major road alone in heavy traffic

8

9.

Drive down major road alone in light traffic

7

8.

Drive down major road with husband

6

7.

Ride as a passenger on major roads

5

6.

Drive around the block alone

5

5.

Ride as a passenger in a residential neighborhood

4

4.

Listen to news reports about accidents

4

3.

Cross the road at a pedestrian crosswalk

4

2.

Stand on the sidewalk by a busy road and listen to traffic

3

1. 

Drive up and down the driveway

3

 

 

 

Obsessive-Compulsive Disorder: Chris’s Story

Chris is worried about germs and tends to avoid touching things he thinks are “dirty.” He is so concerned about coming into contact with germs that he tends to avoid going to public places, such as malls.  He washes his hands whenever he thinks he has come into contact with germs.  He is washing so frequently that his hands are dry and red.  He also changes his clothes whenever he returns home after being out as he worries that they are contaminated. 

Goal: Touch objects in public places (such as a mall), without worrying about germs.  Click here to see Chris’s Fear Ladder.

 

Step

Situation

Fear Rating

13.

Use toilet at mall

10+

12.

Use hands to open and close stall door

10

11.

Touch counter and taps in mall bathroom

9

10.

Touch doorknob to mall bathroom

9

9.

Touch garbage can in the mall

8

8.

Use public phone at mall

8

7. 

Use hands to push open doors to mall entrance

7

6.

Touch table in the food court

7

5.

Sit on bench at mall and touch bench with hands

6

4.

Touch railing at mall

6

3.

Touch items in a store

5

2. 

Sit on a bench at mall

4

1. 

Walk around public places, such as the mall

3

*If Chris washes his hands and changes his clothes after he comes into contact with “germs,” it will be important for him to complete all the steps without washing his hands or changing his clothes. Chris should only wash his hands before meals and after using the bathroom, and should only change clothes before bed. Refer to Self-Help Strategies for Obsessive Compulsive Disorder for more information about response prevention.

 


Sample

Fear Ladder

 

What is my goal?                   Touch objects in public places (malls)                                                                                                                                                                                                                                                  

 

1  –  2  –  3  –  4  –  5  –  6  –  7  –  8  –  9  -  10

  No Fear                     Moderate Fear                 Extreme Fear

 

STEP                                                                   FEAR RATING

13

Use toilet at mall

 

10+/10

12

Use hands to open and close stall door

 

10/10

11

Touch counter and taps in mall bathroom

 

9/10

10

Touch doorknob to mall bathroom

 

9/10

9

Touch garbage can in the mall

 

8/10

8

Use public phone at mall

 

8/10

7

Use hands to push open doors to mall entrance

 

7/10

6

Touch table in the food court

 

7/10

5

Sit on bench at mall and touch bench with hands

 

6/10

4

Touch railing at mall

 

6/10

3

Touch items in a store

 

5/10

2

Sit on a bench at mall

 

4/10

1

Walk around public places, such as the mall

 

3/10

 


Fear Ladder

 

What is my goal? __________________________________________

________________________________________________________

________________________________________________________

 

1  –  2  –  3  –  4  –  5  –  6  –  7  –  8  –  9  -  10

  No Fear                     Moderate Fear                 Extreme Fear

 

STEP                                                                   FEAR RATING

 

 

 

    /10

 

 

 

    /10

 

 

 

    /10

 

 

 

    /10

 

 

 

    /10

 

 

 

    /10

 

 

 

    /10

 

 

 

    /10

 

 

 

    /10

 

 

 

    /10

 

 

 

    /10

 

 

 

    /10

 

 

 

    /10


Sample

Facing Fears Form

 

Example: Specific Phobia: Driving

Date:               January 12th             

Exposure Exercise (What fear am I facing?):             driving in a residential area                                                                                                                                                                                                                                                                                                                       

 

Fear Rating:       

 

1  –  2  –  3  –  4  –  5  –  6  –  7  –  8  –  9  -  10

  No Fear                     Moderate Fear                 Extreme Fear

 

Start:                   6                                               End:                         3           

 

Length of Time of Exposure:            30 mins           

 

What did I learn?             I was scared at first.  It did get easier as I kept driving.  My anxiety was less this time than yesterday when I did the exposure exercise.                                                                                                                                                                        

 

Example: Social anxiety

Date:               June 27th             

Exposure Exercise (What fear am I facing?):              Asking strangers questions (asked for directions to the post office).                                                                                                                                                                                                                                               

 

Fear Rating:       

 

1  –  2  –  3  –  4  –  5  –  6  –  7  –  8  –  9  -  10

  No Fear                     Moderate Fear                 Extreme Fear

 

Start:                   8                                               End:                         4           

 

Length of Time of Exposure:            35 mins – asked 12 people during that time           

 

What did I learn?             My anxiety did drop and by the end I wasn’t that anxious.  Most people were pleasant and helpful – only one person was rude and did not help – so I guess asking for help doesn’t necessarily annoy others.                                                

 


Facing Fears Form

 

Date: ________________

Exposure Exercise (what fear am I facing?):___________________________ ______________________________________________________________

____________________________________________________________________________________________________________________________

 

Fear Rating:       

 

1  –  2  –  3  –  4  –  5  –  6  –  7  –  8  –  9  -  10

  No Fear                     Moderate Fear                 Extreme Fear

 

Start: ________                                   End: _________

 

Length of Time of Exposure:                            

 

What did I learn? _______________________________________________

____________________________________________________________________________________________________________________________

 

 

Date: ________________

Exposure Exercise (what fear am I facing?):___________________________ ______________________________________________________________

____________________________________________________________________________________________________________________________

 

Fear Rating:       

 

1  –  2  –  3  –  4  –  5  –  6  –  7  –  8  –  9  -  10

  No Fear                     Moderate Fear                 Extreme Fear

 

Start: ________                                   End: _________

 

Length of Time of Exposure:                            

 

What did I learn? _______________________________________________