3 Graded Exposure

Discipline of Behavioural Health
flinders.edu.au
One step
at a time
Graded Exposure
Content
Introduction and the 4I’s....................................................................3-4

Inspiration................................................................................................5-6
Problem statement, Goals & Values................................... 7-10
Lisa’s story .................................................................................11-13
Information.............................................................................................. 14
Learning about Anxiety & Depression ................................. 15
Anxiety and Graded Exposure............................................16-19
Guide for using Graded Exposure.....................................20-22
Implementation...............................................................................23-24
Lisa’s Graded Exposure worksheets.................................25-26
Graded Exposure worksheets............................................27-32
Into the Future........................................................................................ 33
Relapse Prevention Plan.......................................................34-37
Version 1.0.
ISBN 978-0-6480216-1-2
Copyright © 2017 Flinders University Discipline of Behavioural Health.

All images used were sourced and purchased, where appropriate, from two stock image
websites (www.shutterstock.com and www.pexels.com).
Discipline of Behavioural Health - Flinders University

Margaret Tobin Centre
Flinders Drive, Bedford Park SA 5042 AUSTRALIA
Phone: +61 8 8404 2323
Web: https://www.flinders.edu.au/study/health/behavioural-health
Authors: Dr Anthony Venning, Paula Redpath & Simone Orlowski

Acknowledgements: Professor Malcolm Battersby, Professor Sharon Lawn, Andrea Morello
& Tassia Oswald
2
Congratulations, you have committed to making
changes in your life by signing up to this program!
You have now met with your coach and received
this workbook. The hardest part is seeking help,
so you are already well on your way to making
changes. This guided self-help program is made
up of three major components: you, your coach
and this workbook.
The most important component of the program is

You. Your coach’s role is to guide and support you
to use the strategies in this workbook, to make the
most of this program.
This workbook contains information, worksheets

and resources to guide you through the program.
Making any change takes time and persistence.
Your willingness to give new challenges a go will
be an important factor in seeing the change you
want in your life.
Help yourself with

the right tools and
support....
Copyright © 2017 Flinders University Discipline of Behavioural Health 3

4I’S
This workbook is made up of the four sections we call the 4I’s:
• Inspiration - to help connect you with why you’re doing this.
• Information - to let you know what this is all about.
• Implementation - to direct you how to start.
• Into the future - to show you how to maintain the changes that have been made.
4
3
2 INTO THE
FUTURE
1 IMPLEMENTATION
INFORMATION
INSPIRATION
What’s next?
How do I start? • What worked for you?
What is this all about? • Read through Lisa’s • Think about tools and
activities to see how she resources that have
Why am I doing this? • Depression and anxiety used Graded Exposure in worked
everyday life to confront
• Take some time to • Information on Graded and overcome feared • Keep doing these
reflect on where you are Exposure: what it is, why situations, objects or
now, where you plan to it is beneficial and how it places • Look for signs of
be in the future and why can be used unhelpful thoughts and
you decided now is time • Talk to your coach behaviours
for change • DEFINE, DO & DISCOVER
guide • Make use of the tools
• Read through Lisa’s and resources you need
story to see how the
program helped her to • Talk with family and
make positive changes in friends about what you
her life are doing
4 Copyright © 2017 Flinders University Discipline of Behavioural Health

INSPIRATION

Inspiration
When you first met with your coach, you As you work through this program,
identified the main problem you are you will learn more about how anxiety
currently experiencing. You also talked and depression impact on your life.
about how your behaviours, feelings, and Sometimes it can be difficult to recognise
thoughts contribute to, and maintain, the progress you have made. You might
the problem. Now that you have started, like to come back to the pages in this
you and your coach will work together section as sources of inspiration and
to identify goals to work on. Fill out the motivation to see how far you’ve come
worksheets in this section of the book since you started.
based on what you discussed with your
coach.

Problem statement
Impact of the problem

Setting goals
Working out at the beginning where you hope to be at the end is useful for identifying clear and
meaningful changes. Together with your coach, you will work out some goals so that you are able
to determine if what you are doing is making a difference.
Treatment goals should be S.M.A.R.T.
Specific
what are you going to do, when
are you going to do it, for how
long and how often?
S
Measurable
how will you measure progress
toward the goal?
M
Achievable
needs to be a realistic activity or
activities for you
A
Relevant
should be related to the problem
you are working on
R
Time Limited
be clear about how long the
goal will take to complete
T
Goal 1
What will I do differently?
Where will I be doing it?
How regularly will I do it?
Currently, I can complete my goal
Goal 2
What will I do differently?
Where will I be doing it?
How regularly will I do it?

Values
Areas in my life that matter the most
and give me reason to change
e.g. being able to

complete my studies in
my field of choice (value =
following through on my
commitments)
Take some time to think about why What am I prepared to change so that my
making these changes is important to actions match what I care most about?
you.
e.g. going to family events and social
gatherings even though you don’t currently
‘feel’ like it (you eventually will!)

Lisa’s story
Lisa is an 18-year-old trainee vet nurse living at

home with her parents. She has had trouble dealing
with the sight of blood since a young age. She has
always had a love for animals and wants to care for
them as much as she can.
However, Lisa faints at the sight of blood and just the

thought of it makes her feel weak in the knees. She
tries to avoid anything that she thinks will involve
blood, including TV programs or conversations with
other students. Lisa worries that she will make a fool
of herself if she faints. This is a particular problem for
her at work/study, where she will frequently make
excuses to avoid being around blood. She prefers
not to watch her boyfriend play sport, and when he
recently sprained his ankle, she refused to take him
to hospital.
Lisa knows her fear of blood is getting worse and

she worries about her future in vet nursing. She
wants to be able to complete her studies as she
would love to be able to help animals in need. She
wants to deal with her fear of blood, so she can help
family, friends and animals when they are injured.
Lisa found out about the program and made a call. She met with a coach for an assessment, and she found
out that what she was experiencing was more common than she realised. With the help of her coach, Lisa
was able to identify her problem, put it into a statement, and rate the impact it was having on her life.

Lisa’s problem statement
When I see or think about blood.
I feel sick and like I’m going to faint.
I avoid any situation where I might see blood, hear about it, or talk about it.
This interferes with my study/work and social life.
Impact of the problem


The coach then helped Lisa to identify clear goals, to work toward them and to rate the level of difficulty associated with
achieving them right now.
Goal 1
What I will do differently?
To be involved in all trainee vet nurse activities.
Where I will be doing it?

At the vet clinic where I am currently training.
How regularly I will do it?

Every time I’m at the vet clinic.

After meeting with her coach, Lisa and her coach spoke weekly by phone for five weeks. Together, Lisa and her coach worked
through the Graded Exposure workbook, reviewing and re-visiting Lisa’s problem statement and goals. The activities and
regular contact helped Lisa see that she was making progress towards achieving her goals.

Where is Lisa now?
As part of the graded exposure

program, Lisa learnt how to use
exposure techniques to confront any
challenging situations involving blood.
As Lisa worked her way through the

exposure challenges, carrying out each
step multiple times, she occasionally
experienced anxiety, nausea and
feeling out of control. Each time she
carried out an exposure challenge,
Lisa was able to tolerate these feelings
better, got used to them, and she was
able to confront situations she never
thought she could.
Eventually, Lisa was regularly engaged

in all trainee vet nurse activities. She
has now finished her traineeship and is
working as a vet nurse, assisting with
surgeries daily.
The Implementation section of this

workbook will show you some of the
activities Lisa completed to get to
where she is now, and will be a space
for you to try your own!

INFORMATION

Anxiety and Depression
Anxiety is when you might feel Depression may be when you feel
overwhelmed, upset, or worried about consistently low for two or more weeks
things in your life. When this happens what and lose interest in the activities you used
you Do, what you Feel, and what you Think to enjoy. When this happens what you
impacts on how you go about your life. For Do, what you Feel, and what you Think
example, you may go out less, avoid seeing impacts on how you go about your life. For
friends, or continually take days off work. example, you may stay home more, stop
going to work and seeing friends, and stop
participating in activities.
When you are anxious; When you are depressed;
You might Do You might Do

Avoid the situation, keep to what’s safe.... Spend more time alone, enjoy things less....
You might Feel You might Feel

Tense, short of breath.... Flat, unmotivated, sad....
You might Think You might Think

I can’t escape, I can’t handle this.... It’s too much effort, I’m useless....
ith
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ANXIETY DEPRESSION
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“I

Understanding anxiety
Helpful anxiety Unhelpful anxiety

At one time or another we have all felt anxious about While anxiety is designed to help us respond to
things – having enough money to get by, having threats, it becomes unhelpful when it is triggered off
enough time to do what you want to do, and about in situations that we feel are threatening, but aren’t
the relationships that are important to you. Feeling actually as harmful or dangerous to us as we think.
anxious and on guard has been hardwired into us When this happens we tend to be caught in a cycle
so we can respond appropriately to threats in our of panic, escape and avoidance of the situations,
environment by being alert, aware and prepared. objects or people that trigger the anxiety.
Take a moment to consider the following situation: Take a moment to consider the following situation:
You are at the beach on a hot day, cooling-off in the You can’t find your wallet/purse. Immediately,
water. All of a sudden you find yourself further out you start to panic thinking that someone has
than expected, struggling to keep your head above stolen it and is now emptying your bank accounts.
the waves. You weren’t expecting the water to be Your thoughts are all over the place, your heart is
this rough and a wave knocks you off balance. At pounding, and you become short of breath. You
this point you don’t know which way is up, and you start to think the worst - that you won’t be able
start panicking. After what feels like a long period to pay bills, that you’ll have a huge debt, and that
of time, you manage to get to the surface, catch someone is stealing your identity. This panic then
your breath, and make your way back to the beach. prevents you from thinking rationally and looking
for your wallet. After 10 minutes, you see your
In a situation like this, you may have felt your heart wallet on the floor under where you usually keep it.
racing, short of breath, the tensing of your muscles,
and increased alertness. Anxiety served a critical In this situation, anxiety was not helpful. The panic
purpose in this situation - it prepared you physically that you experienced prevented you from searching
and mentally to respond to a dangerous situation. for your wallet/purse.

The fight, flight, or freeze response
Consider the situation at the beach - in this situation you responded with the flight response – this prepared
you to take action to do what you needed to do. In a different situation where you sense danger or threat
you may respond by fighting back. Sometimes, however, the danger or threat may seem so overwhelming
that your brain and body have neither the time nor strength to respond – in this case you may freeze and
not respond at all. These responses are all part of the way in which we protect and keep ourselves safe.
Release of chemicals
Flushed Face The brain releases chemicals
Caused by expanded (adrenaline, cortisol) to initiate your
blood vessels in the skin body’s reaction to increase focus
Increased Heart Rate

Rapid Breathing To pump blood and oxygen
Breathing increases to draw around your body faster to
more oxygen into the power your muscles
blood
Sweaty Palms and Body

Sweat cools you down. The
internal body systems have
generated extra body heat
Muscles Tense
To get the body ready to respond

Escape and avoidance
When you are faced with a situation, object or place As facing the situation becomes more difficult, you
you fear, you become anxious because you perceive may find that you are avoiding the situation, object,
a threat. Your anxiety gets to a point where you feel or place, entirely. You develop a learned escape or
as though you are unable to cope. To reduce your avoidance response that becomes reinforced over
feelings of anxiety, you leave the situation. If this time and harder to break. While it may work in the
occurs a number of times, you learn that escaping short-term, in the long-term responding in this way
from feared situations/objects/places is a way to can have a serious impact on your life.
manage your anxiety.
Habituation
Habituation occurs when you confront a feared situation, object, or place, stay there for long enough, and
find that the anxiety reduces on its own. The habituation process takes time, and although you experience
short-term discomfort, it will bring about long-term benefits as you continue to face up to anxiety provoking
situations. On average, it takes 30-45 minutes to experience less anxiety. The more you engage in exposure
the easier it will become to do the things that matter to you. The graph below shows how facing a situation,
object, or place that makes you anxious, over-and-over again, will ultimately lead to less anxiety.
100
Exposure challenge attempt 1

Anxiety level (%)
0
60
Time (mins)

Graded exposure
Graded exposure is one of the most effective ways of overcoming anxiety by helping you face situations,
objects or places that you have been avoiding, in a gradual way. Through this program you will learn to
overcome anxiety, without escaping or avoiding it.
Principles of graded exposure

Graded
People learn better when they tackle things in stages. When you start your exposure challenges, it is
important that you experience enough anxiety to be uncomfortable, but not so much that you can’t manage.
As challenges are overcome, you learn that you can face up to more than you thought was possible.
Focused
It is important to pay attention to your thoughts and feelings without distraction. Focusing on what happens
within you when you are facing the situation, object, or place that makes you anxious is important.
Prolonged
An essential aspect of graded exposure is to remain in a situation for long enough so that over time your
anxiety will eventually reduce on its own.
Repeated
People get better at things the more they do them, which means that repeated exposure to challenging
situations will ultimately lead to less or no anxiety.

A guide for using graded exposure in your own life
1 2 3
DEFINE DO DISCOVER
Identify:
Identify and list cues,
situations and triggers.
Rate:
On the worksheet, list the Discover what works
exposure challenges and rate for you:
the anxiety level (%). Talk to your coach
about what
Place the most difficult happened during the
challenge at the top, and the exposure challenge.
Identify the feared least challenging at the
situation, object, or bottom of the list. What worked well,
place. what didn’t?
Plan:
Together with your coach, What exposure
plan to carry out an exposure challenge will you
challenge from your list. do next?
Do:
Carry out the exposure
challenge.
Use the worksheet to record

what happened as soon as
you have completed the
exposure challenge.
Make sure you follow the

four principles of graded
exposure.

Take away
While anxiety is designed to help us respond to threats, it becomes unhelpful when it is triggered
off in situations that we feel are threatening, but aren’t actually as harmful or dangerous to us as
we think.
Escape and avoidance is a learnt behaviour that provides short-term relief from anxiety, but
negatively impacts your life in the long-term.
Graded exposure helps people overcome anxiety, using the four principles - graded, focused,
prolonged, and repeated.
Facing your fears is challenging – it takes time, practice and courage. With the support of your
coach and this workbook, you are on your way to achieving your goals.
Practice makes permanent.

Albert Einstein

Food for thought
A space to reflect on what I have read
and what it means to me....

IMPLEMENTATION

Making change
Now that you have identified sources of Inspiration to complete this program,
and have learnt valuable Information about how to make positive changes in
your life through Graded Exposure, it is time to Implement some strategies.
This section involves completing three activities:

(1) Defining your Exposure Challenges
(2) Completing your Graded Exposure Worksheets
(3) Using your Exposure Challenges Record
First, you will see how Lisa completed some of these activities during her program.
With the guidance of your coach, you will then have the opportunity to start
implementing them yourself!

Lisa’s exposure challenges
Together with her coach, Lisa listed her different exposure challenges. She then planned a time to carry out the
first exposure challenge (e.g. the anxiety trigger which causes the least distress). Before carrying out the challenge
she took some time to fill out the ‘Before’ section on her Graded Exposure worksheet (see next page), and
continued filling it out during the exposure challenge.
Level of
Anxiety trigger anxiety (%)
1.
Prick my finger to produce blood 100%

Assist in a 30 minute surgery at the vet clinic
2.
Hold a vial of blood 90%
Watch online video showing vet surgery
3.
Watch a video of someone giving blood 75%
4.
Look at a colour photo of a surgical procedure 50%
5.
Look at a black and white photo of a surgical procedure 40%
Look at surgical equipment

Lisa’s graded exposure worksheet
Describe the exposure challenge you plan to carry out:
Look at a black and white photo of a surgical procedure.
Doing Feeling Thinking Level of

anxiety (%)
Before I am fidgeting a lot. I feel nauseous and tense. How am I going to react 25%
to the photo? This is
hard.
During My hands were shaking, I Nervous. My heart was During the exposure 40%
was breathing fast. beating quite fast and challenge I was thinking
I felt tense. My palms that I could make out
were sweaty. some parts that looked
like blood and I could see
that the procedure was of
someone having stitches.
I could see the cut and
instruments with what
looked like dried blood.
I was thinking about
focusing on the picture
and not looking away.
Now I am breathing normally. I am now thinking that At the moment I am 10%
Sitting calmly. I can do the challenge feeling relieved. I noticed
again and I am ready to that my heart rate began
tackle the next exposure to slow down after about
challenge - the colour 20 mins and I was able
photo of a surgical to breathe normally. I
procedure. kept looking at the
picture for another 10
mins and was no longer
grossed out by the
picture. I actually feel
pretty proud of myself
and a bit surprised about
how I was able to manage
the exposure challenge. I
also feel hopeful.
In doing this exposure challenge, I have learnt that:
I can get used to seeing pictures with blood in them if I am exposed to them for long enough. I won’t
always feel like I’m going to faint. The longer I spend exposed to the blood, the less intense my feelings
of anxiety become.

Exposure challenges
Level of
1.
2.
3.
4.
5.

Graded exposure worksheets

anxiety (%)
Before
During
Now

anxiety (%)
Before
During
Now


anxiety (%)
Before
During
Now

anxiety (%)
Before
During
Now


anxiety (%)
Before
During
Now

anxiety (%)
Before
During
Now

Exposure challenges
Level of
1.
2.
3.
4.
5.

Exposure challenges record
Now that you have had practice defining your Exposure Challenges, and reflecting on them in-depth
in the Graded Exposure Worksheets, continue to monitor your progress with the use of this Exposure
Challenges Record sheet.
No anxiety Moderate anxiety Severe anxiety

0% 50% 100%
Date Challenge Level of anxiety (%) Comments
Before During After

INTO THE
FUTURE

Relapse prevention
Throughout this program you have been If your mental health declines for longer than
provided with information and an opportunity that, then you may be experiencing a relapse.
to apply skills. You have been encouraged to Relapse is when you return to the previous
learn more about yourself, and in particular, behaviours, feelings and thoughts which caused
how the interactions between what you do, the anxiety or depression in the first place, and
feel and think, impacts on you. At this point, we are causing significant disruption to your life.
hope you have made some important changes
to your life. Relapse is not inevitable and does not happen
without warning signs. The techniques you
Having experienced anxiety or depression can have learnt throughout this program can help
increase the likelihood of experiencing them you avoid or reduce the severity of relapse.
again in the future. If you notice changes to Your confidence will grow as you continue to
what you are doing, how you are feeling, and apply the techniques that you have put into
what you are thinking, that last anywhere from practice. Supported by NETTS and your Relapse
a few days to a week, you may be experiencing Prevention Plan (see next pages) you will have
a setback – this is common. A setback is when a clear plan to respond to any setback and get
unhelpful behaviours, feelings or thoughts back on track.
become more frequent. Responding to a
setback by using the techniques you have
learnt throughout this program can get you
back on track.

NETTS:
New skills and knowledge, Exploring opportunities, Traps and Triggers, Solutions
New knowledge and Exploring how these Traps and Triggers Solutions for when
skills you have learnt skills and knowledge that can disrupt your you feel you may
can be applied to other recovery be experiencing a
areas/situations in your setback or relapse
life
UTIONS
SOL
Knowledge
NEW SKILLS Symptoms

& KNOWLEDGE (physical)
& Places
Strategies/
SOLU ONS
SOLUTIONS
NETTS
Skills TRAPS &
TRIGGERS
TI
Signs
New (thoughts &
Situations behaviours)
EXPLORE
OPPORTUNITIES New Goals
SO
LUTIONS

Relapse prevention plan
Refer to the worksheet below to develop your RPP with the help of NETTS
New knowledge and skills I have learnt

What I have learnt about the problem:
What I have learnt about what works:
Exploring opportunities
How can I use this further in other parts of my life:
1. ...............................................................................................................................................................................................................................................
2. ...............................................................................................................................................................................................................................................
3. ...............................................................................................................................................................................................................................................
4. ...............................................................................................................................................................................................................................................
5. ...............................................................................................................................................................................................................................................

Traps and Triggers
What early warning signs, thoughts, and feelings I need to be aware of:
People and places that can disrupt my recovery:
Solutions
What’s next?
People and/or services I will contact if I need some additional support:
When will I schedule my routine ‘Wellbeing Check-in’ day and time?
• Developing your RPP is something that you will do together with your coach as part of this program.
• We recommend that you keep this resource and refer to it as you need.
• It may also be helpful for you to choose a routine ‘Wellbeing Check-in’ day and time every few weeks
to review your progress (e.g., by re-rating your initial problem statement and goals you recorded in the
INSPIRATION section of this workbook and adding in and rating any new goals that you have developed).

This guided self-help workbook is designed as an essential resource in the delivery of Low
Intensity Cognitive Behaviour Therapy (LiCBT).
CIRCOS No. 00114A

Copyright © 2017 Flinders University Discipline of Behavioural Health

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Discipline of Behavioural Health

Introduction and the 4I’s....................................................................3-4

Copyright © 2017 Flinders University Discipline of Behavioural Health.

Discipline of Behavioural Health - Flinders University

Authors: Dr Anthony Venning, Paula Redpath & Simone Orlowski

The most important component of the program is

This workbook contains information, worksheets

Help yourself with

Copyright © 2017 Flinders University Discipline of Behavioural Health 3

How do I start? • What worked for you?

4 Copyright © 2017 Flinders University Discipline of Behavioural Health

Copyright © 2017 Flinders University Discipline of Behavioural Health 5

6 Copyright © 2017 Flinders University Discipline of Behavioural Health

Impact of the problem

Copyright © 2017 Flinders University Discipline of Behavioural Health 7

Treatment goals should be S.M.A.R.T.

Where will I be doing it?

How regularly will I do it?

Currently, I can complete my goal

Where will I be doing it?

How regularly will I do it?

Currently, I can complete my goal

Copyright © 2017 Flinders University Discipline of Behavioural Health 9

e.g. being able to

10 Copyright © 2017 Flinders University Discipline of Behavioural Health

Lisa is an 18-year-old trainee vet nurse living at

However, Lisa faints at the sight of blood and just the

Lisa knows her fear of blood is getting worse and

Copyright © 2017 Flinders University Discipline of Behavioural Health 11

I feel sick and like I’m going to faint.

This interferes with my study/work and social life.

Impact of the problem

Where I will be doing it?

How regularly I will do it?

Currently, I can complete my goal

12 Copyright © 2017 Flinders University Discipline of Behavioural Health

As part of the graded exposure

As Lisa worked her way through the

Eventually, Lisa was regularly engaged

The Implementation section of this

Copyright © 2017 Flinders University Discipline of Behavioural Health 13

14 Copyright © 2017 Flinders University Discipline of Behavioural Health

When you are anxious; When you are depressed;

You might Do You might Do

You might Feel You might Feel

You might Think You might Think

Copyright © 2017 Flinders University Discipline of Behavioural Health 15

Helpful anxiety Unhelpful anxiety

16 Copyright © 2017 Flinders University Discipline of Behavioural Health

Increased Heart Rate

Sweaty Palms and Body

Copyright © 2017 Flinders University Discipline of Behavioural Health 17

Exposure challenge attempt 1

Exposure challenge attempt 2

Exposure challenge attempt 3

Exposure challenge attempt 4

18 Copyright © 2017 Flinders University Discipline of Behavioural Health

Principles of graded exposure

Copyright © 2017 Flinders University Discipline of Behavioural Health 19

Use the worksheet to record