Confronting Phobias: Creating a Fear and Avoidance Hierarchy
Behavior/Prolonged Exposure Therapy
The conventional treatment for anxiety disorders is Cognitive Behavior Therapy (CBT). This article focuses on the behavioral aspect of this therapy.
The theory behind behavior therapy or prolonged exposure is simple. If anxiety is caused by a fear of something terrible happening in a given situation, being in that situation without something bad happening should ease that anxiety. For example, if someone has a fear of flying, every time that person is in an airplane and it does not crash or experience any problems should serve to lessen that person’s fear. Each subsequent flight would cause this individual less anxiety as his or her fear of crashing would not be realized.
By exposing oneself to the anxiety-producing stimuli over a prolonged period of time, anxiety should lessen as the feared consequences never happen.
Of course, someone who is severely afraid of flying would not be able to take that step and get on a flight for the first time. Instead, an individual going through this type of therapy would be placed in a situation that created low levels of anxiety and slowly work up from this point. Since a phobia differs from person to person, a therapist will work with each individual to pinpoint the situations that cause anxiety and order them based on intensity from lowest to highest. This is the creation of a fear and avoidance hierarchy.
Constructing a Hierarchy: Phobias
When creating the hierarchy, anxiety-provoking situations are assigned a score on a scale of 1 to 10 (one being little; ten being a lot) for fear and for avoidance. A situation may cause a patient a lot of anxiety but not be avoided because of necessity. Conversely, a low level item on the fear scale could be constantly avoided because it is easy to do so. The shape an individual hierarchy takes is dependent upon the particular anxieties of the patient in question. With highly specific phobias, the hierarchy will most likely consist of steps approaching the feared item.
To continue with our example, the fear of flying may take many forms. A patient may experience little anxiety when seeing planes in flight but balk when attempting to enter an airport in order to fly, with each step in the process of boarding producing more and more anxiety. In this case, the lowest level of a fear and avoidance hierarchy may consist of entering an airport lobby. Subsequent steps could be waiting in line for check-in, checking in baggage, going through security, waiting at a gate, entering the ramp to the plane, sitting on a stationary plane, and then actually flying on the plane. Someone who has a more severe phobia may experience anxiety at the sight of any plane. A lower step on this individual’s hierarchy might be looking at a picture of a plane or watching a video of a plane in flight.
Constructing a Hierarchy: Social Anxiety
The fear and avoidance hierarchy for overcoming a specific phobia is rather straightforward. The object of fear is gradually approached at a speed dependent upon the strength of that fear. With social anxiety disorder, however, the hierarchy can be a bit more confusing. It is difficult to break down the approach to a social situation. You are either engaging in one or not. Furthermore, social anxiety is based on the fear of being judged, which is a risk you take simply by being a part of society. One would think that simply being social would ease the anxiety of a patient suffering with the disorder, but that is often not the case.
When I first sat down to create a fear and avoidance hierarchy to deal with my social anxiety, I was a part of a group class that dealt with specific phobias. I was the only person in the group with social anxiety disorder (and let me tell you, just going to the group would have gone on my hierarchy. When my therapist first suggested it, I was not happy). In earlier classes we had already shared our phobias and practiced breathing exercises to remain calm in the face of anxiety. Now we had to figure out what made us anxious.
I could easily see how everyone else would go about constructing a hierarchy. Some had a fear of doctors’ offices. Some had a fear of flying. But I had a fear of being judged, and I did not know how to go about putting that down on paper. I experienced that fear every day when I interacted with anyone at work, but my anxiety was not diminishing. I asked the leader of the class if she had any suggestions. What I got was this: “What if you wore only one earring to work?”
This suggestion did not sit well with me, because I did not see the point. Yes, I would be placing myself in a position to be judged (my mind immediately supplied that this was “stupid” or “ridiculous”), but I did not see how it would apply to everyday life. And, yes, I do realize that the reason I found this to be a terrible suggestion is because my anxiety demanded that I not purposefully place myself in a position to be judged (is it just me, or are all perfectionists closet sufferers of SAD?).
Nonetheless, I declined to take the second stage of the class, as I was unsure how to continue. In order to make progress, I would have to know what to do next, and I required a hierarchy to do this. It was not until I joined a group class for people with generalized or social anxiety that I understood how to fill out my hierarchy. I had to focus on finding general situations in which I felt judged rather than on creating new situations to invite judgment. Suddenly it was a lot easier to complete my hierarchy.
Here is a portion of my hierarchy. Again, take note that the levels of fear and avoidance do not always match. I am more likely to avoid returning a call or asking a question of a stranger (activities that cause a low level of anxiety) than I am to avoid going on a job interview. Even though it is the hardest thing for me to do, I would not avoid an interview if I were offered one. Of course, I am not offered many chances to interview given that I am likely to avoid applying altogether. Unlike a hierarchy for a specific phobia, the only way to order the activities in intensity is by the score I assign them. The progression in a hierarchy for a specific phobia would be clear from the activities themselves, but another person might take my activities and order them differently based on their own experiences.
Making CBT Work for You
The key to success in this treatment is to experience each given situation on your hierarchy with little to no anxiety. Even if nothing bad happens during a session, if anxiety is present, the very act of feeling anxious will exacerbate the situation further. The key to lessening anxiety is to relax as much as possible and pause at its first sign, allowing the anxiety to lessen before continuing.
Even if this therapy is attempted without the help of a trained psychologist, it should not be attempted alone. Someone should be with the patient to monitor levels of anxiety and make sure the patient feels safe during all steps of the process. Ultimately, it is up to the suffering individual to seek help and treatment, but the support of others is crucial as well.