Exposure Therapy and Hierarchies

Social anxiety graded exposure and hierarchies

Sometimes known as fear ladders, these involve creating a list of anxiety-provoking situations, ranked in order of increasing difficulty. It is common for people with social anxiety to engage in avoidance and safety behaviours to minimise the anxiety they feel. Behaviours such as distracting yourself with a phone or avoiding a social event altogether can give immediate relief. However, avoidance and safety behaviours may mean that social anxiety does not improve and can become worse.

People with social anxiety can usually identify situations where they feel relatively mild anxiety to those that are much more challenging. With therapy, or self-help, most are able to begin some easier challenges right away. However, with more intense anxiety-inducing situations, it makes sense to build up gradually. Graded exposure and social anxiety hierarchies can help organise anxiety provoking situations as a step-by-step process. Through this method, confidence and skills can be built in a structured and steady way rather than social anxiety sufferers jumping into the deep end.

Hierarchies are a pivotal part of CBT and behaviour-based therapy. The first step is to create the list of the situations that provoke your social anxiety. The next is to give each situation a score for how much anxiety it produces. For example, someone’s going to a pub hierarchy might look like the image to the right.

Each step is scored 1-100 :

0 – You are perfectly relaxed
25-49 Mild: You can still cope with the situation
50-64 Moderate: You are distracted by the anxiety, but are still aware of what’s happening
65-84 High: Difficult to concentrate, thinking about how to escape
85-100 Extreme: The anxiety is overwhelming and you just want to escape from the situation

Next the situations are arranged on a hierarchy with the easiest tasks first and the hardest task last.

Remember each situation should be broken down further into a series of manageable steps that can be faced. Each step should be listed as specifically as possible, for example, the setting, the number of people around and the time of day.

Some people might feel very anxious about attending an evening social event at a bar with people they are unfamiliar with. In order to build up to doing this, the situation can be broken down into the following steps:

The number of steps in the hierarchy can differ for every individual. The number of steps can also differ for each different situation. Each step of the ladder can be attempted multiple times until the individual becomes confident and is ready to proceed to the next step.

The intention of social anxiety hierarchies

The intention of social hierarchies is to try and gradually manage the fear felt in anxious situations, starting from easier tasks and building up to harder tasks. Skills for managing anxiety can be built over time and the hope is to end up with a more confident mindset towards the fearful scenario.

Sufferers of social anxiety can use techniques such as breathing exercises, mindfulness and focusing outward rather than inwards to help with the physical symptoms of anxiety during every task. See our page on grounding techniques to help calm yourself. Working through steps gives you time to challenge negative thoughts that may have built up around a given situation.

By facing anxious situations gradually, we aren’t overwhelming ourselves by jumping in at the deep end. We are creating momentum and applying skills step-by-step to eventually face a situation that was previously very anxiety-inducing.

It’s suggested that individuals don’t rush, and ensure they become comfortable and relaxed at each stage before progressing to the next. If a step becomes too overwhelming, they can return to a lower step to build on their skills of managing their anxiety. Steps can be repeated and practised multiple times. The number of repetitions varies from person to person.

Benefits

With gradual and repeated exposure, anxiety and fear can decrease over time
Those who have social anxiety can learn that some situations don’t pose a threat
People with social anxiety can explore and understand their fear and replace their fear response with more helpful thoughts and beliefs in a gradual way
Eventually they can start to believe in themselves and think that it is possible to manage their social anxiety

Things to consider

Doing steps in the social anxiety hierarchy may be challenging and uncomfortable
Some anxiety should be expected but it might be helpful to remind yourself that anxiety, including social anxiety, is a complex physiological response (see fight or flight) and it takes time to find the solutions that works best for you.
Remember to focus on engaging with social or public situation, the conversation, whatever needs to be done – rather than your feelings inside.
Try not to use safety behaviours or alcohol to reduce the anxiety.
Remember the exposure therapy and hierarchies can be challenging as social situations are often dynamic. People can unexpectedly join or leave a planned exposure situation – your focus and plans may to adapt.
Celebrate each step you work on and treat yourself with patience and kindness

Coping with setbacks
Being able to cope with setbacks is an important part of getting better with social anxiety. Even as you begin to make progress there will be times when things are difficult. Getting better is usually a journey and there tend not to be quick fixes.

Even a well planned behavioural experiment may be scuppered by unexpected circumstance e.g. you suddenly feel more anxious than expected, you find the person you are dealing with is difficult or in a bad mood, or an unexpected or challenging individual joins your well planned interaction. Even when you have been making good progress, setbacks and even recurrences of intense social anxiety may still occur. Coping with setbacks, allowing time to pass and trying again are all parts of the journey to getting better.

Remember

Overcoming social anxiety is not quite as simple as just “Face your fears and they’ll go away”. We, as people with social anxiety, have constantly faced our fears – we’ve had to – and often the fear remains. Getting better works best as part of a comprehensive cognitive-behavioural approach.