Introduction
The terms exposure therapy, behavioural challenges, behavioural experiments, graded exposures and hierarchies are closely linked.
Behavioural challenges (or behavioural experiments) are individual activities used to test and challenge negative beliefs or assumptions through real-world activities. A behavioural challenge might be saying hello to a stranger or returning something to a shop. It can also relate to the dropping of safety behaviours that you might usually use e.g. avoiding eye contact or staying on the edges of a group to avoid too much attention.
Exposure (and exposure therapy) are based on principles of habituation and work therapeutically by reducing anxiety through repeated exposure to a feared stimulus or activity. However, in the case of social anxiety is not quite as simple as just “Face your fears and they’ll go away”. Progress requires a more complete understanding of what social anxiety is, alongside new ways of thinking and behaving within the situations you find difficult.
For more information on what keeps social anxiety going – see our page on the social anxiety maintenance cycle.
Hierarchies
Hierarchies, also known as fear ladders or graded exposure, involve a systematic approach to more difficult tasks that are best broken down into smaller components. They involve creating a list of anxiety-provoking activities, ranked in order of increasing difficulty. They are a pivotal part of CBT and many other social anxiety therapies.
The intention of social anxiety hierarchies
The intention of social anxiety hierarchies is to try and gradually manage the fear felt in anxious situations. 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.
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.
Creating a hierarchy of steps to achieve a “Goal”
Firstly, create a “goal”. The goal is the challenging “end task” that you want to achieve e.g. doing a presentation to colleagues at work or to go to lunch with a large group of people in a busy café.
Note: the image is just an example – we know many social anxiety hierarchies will involve far less busy or challenging environments.
The important point is to set a goal that has meaning to you. The goal may seem distant and difficult at first but by breaking it down into small more achievable steps we develop a plan and structure to eventually achieve the goal.
Each step is scored by level of difficulty 0 -10 (10 being the hardest).
Remember each step should be listed as specifically as possible, in our example: the setting, who you are with, the number of people, the time of day.
The number of steps in the hierarchy can differ for every individual or goal. Each step of the ladder can be attempted multiple times until the individual becomes confident and is ready to proceed to the next step.
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.
Link to a blank worksheet to create your own hierarchy (step ladder):
Step Ladder (Worksheet).pdf
See these step ladders examples:
Step Ladder (Example 1).pdf
Step Ladder (Example 2).pdf
Please also see www.cci.health.wa.gov.au – Module 4 – Behavioural-Experiment-Stepladders.pdf
Strategies to help you work through the steps
www.cci.health.wa.gov.au – Module-6 – The-Role-of-Attention.pdf
Challenging Negative Thoughts and Beliefs
Conversation Skills
Grounding Techniques to help calm yourself (In Situ)
Mindfulness and Social Anxiety
Things to consider
- Doing steps in the social anxiety hierarchy may be challenging and uncomfortable at times
- 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 and steps that works best for you
- Remember to fully focus on engaging with the people, the social or public situation – rather than the anxiety feelings inside (see www.cci.health.wa.gov.au – Module-6 – The-Role-of-Attention.pdf)
- Try not to use safety behaviours or alcohol to reduce the anxiety. Safety behaviours may stop you getting the full benefit of the challenges you are trying to work through e.g. looking at your phone to avoid having to speak, drinking excessively for confidence, avoiding eye contact because you think people will see your fear and judge you.
- Remember you use your new skills new skills (see strategies section above), just doing what you have always done may not work without new ways of thinking and behaving
- Remember exposure therapy and hierarchies are not simple to arrange or guaranteed to go smoothly. Social situations are often dynamic. People can unexpectedly join or leave a planned exposure situation – your new skills and plans may need to adapt
- Celebrate each step you work on and treat yourself with patience and kindness
Coping with setbacks
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.
If setbacks and even recurrences of intense social anxiety occur, try not to dwell on them. Being able to cope with setbacks is an important part of getting better with social anxiety. Getting better is usually a journey and there tend not to be quick fixes.
If there are particular issues or lessons to be learnt from a particular step or challenge these are best listed on a worksheet like https://socialanxietyalliance.org.uk/wp-content/uploads/PDF-Behavioural-Experiment-Worksheet.pdf .
Setbacks may be a chance to review your hierarchy of steps and challenges and go back to easier challenges if you need. Its also a chance to reconsider the ideas and strategies listed within this article.
Conclusion
Overcoming social anxiety is not quite as simple as just “Face your fears and they’ll go away”. It often requires a fuller understanding of what social anxiety is alongside new ways of thinking and behaving learnt through self-help, online resources or therapy.
Please see related resources at www.cci.health.wa.gov.au :
www.cci.health.wa.gov.au – Module 4 – Behavioural-Experiment-Stepladders.pdf
www.cci.health.wa.gov.au – Info Sheet 11 – Situational-Exposure.pdf
www.cci.health.wa.gov.au – Worksheets 12 – Situational-Exposure-Building-Steps.pdf
www.cci.health.wa.gov.au – Worksheet 13 – Behavioural-experiment.pdf
Please also see these links to other websites:
https://www.verywellmind.com/what-are-anxiety-hierarchies
https://www.anxietycanada.com/Examples_of_Fear_Ladders.pdf
www.betterhelp.com/advice/anxiety/anxiety-hierarchy-treatment-for-anxiety-disorders/
https://www.healthline.com/health/systematic-desensitization#examples
