PTSD Professional Perspective: Coginitive & Behavioural Therapies, Part 2
Friday, May 28th, 2010 • PTSD Guest Post: Professional Perspective •
Last week Adrian Soden gave us an introduction to Coginitive Behavioural Therapy. This week he continues his explanation with a detailed look at Graded Exposure. Just another tool in your reduce-PTSD-symptoms healing kit!
Graded Exposure
When treating an anxiety problem with exposure the trick is to remain in the presence of the fear-evoking stimulus, to maintain the anxiety caused by that stimulus and to do this effectively you need to follow three cardinal rules, Exposure tasks must be:
1. Graded — that is at a level, which is distressing but not so distressing that you are not able to endure — use subjective units of distress as a measure for this step (0=no anxiety up to 8=the highest level of anxiety you can imagine) .
2. Prolonged — that is you must stay in the presence of the fear-evoking stimulus until such time that your level of anxiety has fallen by at least 50% of the initial rating without the use of any safety behaviours or distraction whatsoever. This, basically, means that you must be prepared to remain in the exposure task for up to one hour.
3. Repeated — that is once is not enough to habituate to the fear evoking stimulus — you must repeat each and every graded step until you can honestly say that the level of anxiety is reduced by at least 50% on your approach to the fear-evoking stimulus as compared to the first time you approached the fear-evoking stimulus. First steps are to compile a list of every situation that causes the anxiety response, no matter how trivial this appears. Then to compile a list of what you do and what you avoid doing to help you cope with the fear.
The next thing to do is to create an exposure hierarchy; this is achieved by rating the fear-evoking situations in order of severity and putting them in order from least difficult situations to cope with to the most difficult.
Following that you then undergo the exposure task (aim for an initial rating of approximately 5 out of 8 subjective units of distress or S.U.D.). Remain in situ until you experience at least a 50% drop in anxiety (for up to one hour) without your usual safety behaviours and distractions. Repeat this task several times until your S.U.D. rating is at least 50% lower on initial contact with the fear-evoking stimulus than it was the first time you attempted this graded step.
Then move onto the next graded step in your exposure hierarchy.
Habituation occurs when you no longer feel anxious in the presence of the fear-evoking situation.
Adrian Soden originally qualified as a Registered Nurse (Mental Health) in August 1995 and has worked in a variety of mental health settings, including Acute Admissions, Forensic and continuing care. He commenced Specialist Psychotherapy training (incorporating ENB650) in September 2000 at the Sheffield Hallam University and graduated with honours as an Adult Behavioural Psychotherapist. http://www.astconsultancy.co.uk/index.html
The opinions in this post are solely those of the author. To contribute to ‘Professional Perspective’ contact Michele.
Tags: Graded exposure, ptsd, symptoms
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I am “sold” on CBT, but I am having a hard time agreeing with Adrian and the suggestion to stay in a fear evoking situation – longer than you feel comfortable. Of course I am paraphrasing. But if I read this article on exposure before I began to face my fears, I’m not sure I would have been able to even begin trying. I have been taught by my therapist not to force myself – at all. First I learned about self-talk and how to view my fear evoking experiences before I even began exposure. When I felt reasonably prepared, I entered my feared place, and only stayed as long as I could feel somewhat comfortable (on my S.U.D. it would be a two or two point 5). Then I would retreat and re-enter if I was able to. I had to do this many, many, many times – over a period of a couple of years. I got better at it, but I never ever pushed myself through. The only pushing I did was to decide that I wanted to eventually conquer my fears. The wonderful result is that I am now able to enter into several of my fear/phobic situations and only have a cognitive memory that whatever I was doing used to freak me out.
Probably if Adrian and I were to talk this through we would find more common ground. After reading this I felt like it is important to know that you can overcome fear inducing situations without having to experience even 50% of what you once felt. For me, 50% would have too high – too scary
Hello Erin,
The main trick is to appropriately “grade” the situation- if you are too uncomfortable to remain in the situation then you are probably too high on the exposure hierarchy and would benefit from taking a step (or two) down. as regards the 50% that is at which point habitiuation is said to occur- so if your initial rating was a S.U.D. of 4 you would aim to remain in the situation until it fell to a SUD of 2 (at which point you have achieved in situ habituation). You would then aim to repeat this step of the hierarchy until on first approach you would rate no higher than a S.U.D. of 2.
Exposure can be very uncomfortable as you are voluntarily facing your fear, but if applied correctly not only do you habituate but also you learn that anxiety does not last forever and it will go away even if you don’t perform your usual safety behaviours, distractions and/or escapes, despite the presence of fear evoking situations.
Hi Adrian,
Thank you for clarifying your method for me. I was imagining 50% of a ten! 50% of a S.U.D of 3 is manageable and reasonable. I faced my phobic situations with S.U.D. of 2/3 for a very long time. I hope people understand that it is not a race to achievement (and I know you were not saying that).
If one thinks like that, as I did initially, they will find themselves more triggered and uncomfortable than needed.