Take Control of Your Wellbeing.

GAD Program Lesson 4

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Facing Your Fears WWW.THISWAYUP.ORG.AU
Welcome and Lesson Overview
Welcome to the summary for Lesson 4! We hope that you are finding this Program helpful
and interesting!

So far in this program, you have learnt to identify and evaluate your thinking habits,
challenge unhelpful thoughts and beliefs that can keep anxiety going, and know when
to use which strategy to stay on top of your symptoms.

In this lesson you will learn about tackling habits and certain behaviours to help you
overcome your symptoms in the long run.

Don’t hesitate to contact us if you have any questions at any stage of this program, by email
or by telephone 02 8382 1437.

Good luck!

The Team from THIS WAY UP Clinic

www.thiswayup.org.au

Topics Covered In This Summary & Action Plan

Here is a list of the topics we will cover in this Summary. Tick these off as you go:

1. Behavioural Symptoms of GAD (page 3)

2. Facing Fears Gradually using Graded Exposure (page 6)
3. Creating Exposure Stepladder (page 7)
4. Your Exposure Stepladder (page 12)
5. Exposure to Thoughts and Feelings: Worry Stories (page 14)
6. Summary of Skills & Action Plan (page 15)

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1. Behavioural Symptoms of GAD
During the course, we have discussed the role of physical
symptoms of GAD (muscle tension, restlessness, fatigue,
difficulty sleeping) and the role of thoughts and beliefs in
maintaining symptoms of Generalised Anxiety Disorder
(GAD).

In this lesson, we will be discussing the role of behavioural

symptoms in maintaining GAD.

Safety Behaviours
What are safety behaviours?
Safety behaviours are things that people do to try and avoid physical and emotional
discomfort.

For example, imagine you were invited to a friend’s party and you didn’t know many other
people going. A few days before the party you started to feel anxious and thought “what if
nobody speaks to me.” As a result of these thoughts and feelings, you ask another friend to
come along with you and keep you company. In that situation, your friend’s presence eases
the anticipatory feelings of anxiety or nervousness. But the next time something like this
happens, and your friend is unable to come with you, you are likely to feel even more
nervous, and ultimately, you don’t learn that you can cope on your own.

The problem with safety behaviour is they are a short-term solution to a

problem, and utilising them keeps the symptoms of GAD going.

How do safety behaviours maintain my feelings of anxiety?

REMEMBER in the last two lessons we discussed how people with GAD tend to make two
errors in their thinking. They:

Overestimation of Threat Underestimation of Abilities

People tend to overestimate the People tend to under estimate

likelihood of something bad their ability to cope
happening

Safety behaviours only strengthen these unhelpful thinking patterns as they stop you from
learning that things can go better than you expected. Alternatively, if something bad did

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happen, safety behaviours stop you from learning that you could cope. In the example
above, you were worried that nobody at the party would talk to you. The presence of a
friend meant you did not have an opportunity to learn whether that was an accurate,
realistic or helpful thought. You also did not see whether you could cope in that situation.

Common safety behaviours:

 Difficulty saying ‘no’ to others

 Over planning

 List making

 Always having a ‘Plan B’

 Seeking / needing assurance from others

 Other __________________________________________

We can learn to tackle safety behaviours using exposure, but first let’s discuss the role of
avoidance behaviours.

Avoidance Behaviours
Avoidance is a very common symptom in Generalised Anxiety Disorder (GAD). When people
feel anxious they tend to avoid activities, situations or events that they fear or feel they
can’t cope with.
While avoidance seems helpful as it reduces your anxiety in the short-term, it can be highly
problematic and can be responsible for maintaining your anxiety in the long-term, just like
the safety behaviours we just discussed. This is because in the short term, avoidance of
anxiety-provoking situations can:

1. Prevent you from learning that your fears are unlikely to

come true and that you are overestimating threat.

2. Lead you to believe you wouldn’t be able to cope if

something bad happened.

3. Prevent you from learning that, although unpleasant,

symptoms are normal and rarely harmful.

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Let’s use a simple example to examine why avoidance and safety behaviours might be
problematic:

Imagine you were frightened of dogs. Every time you saw a dog, you
became anxious because you thought that the dog would bite you. Over
time, every time you saw a dog approaching you, you always walked
across the road to the other side of the street (you avoided going near
it). You also started avoiding places likely to have dogs such as parks, the
beach, or even going to friend’s houses who have dogs.

Avoiding dogs may seem helpful to you because it reduces your anxiety and helps reduce
your discomfort in the short-term. However, if you never walked on the same side of the
street as dogs, you would never have the opportunity to learn that:
 Not at all dogs bite, and most of them are actually friendly (that is, you never learn that
you overestimated the likelihood that something bad might happen).
 You could cope with the anxiety (you are underestimating your ability to cope).
Avoidance and safety behaviours contribute to people over-estimating the likelihood of
bad things happening and under-estimating their ability to cope. They also keep the cycle
of symptoms going.
Typical avoidance behaviours include:

• Avoid unplanned or unfamiliar situations.

• Avoid watching news, reading the newspaper or watching TV shows about my fears.

• Avoid difficult conversations or expressing my opinion.

• Only talk about positive feelings and avoid expressing any negative feelings.

• Procrastination.

Worrying itself is a form of avoidance. When we worry, we tend to jump between different
negative scenarios or possible outcomes in our mind, without actually thinking through an
entire scenario or event in detail. This likely happens, because we are actually avoiding
thinking about the feared event in detail. Worrying does not involve processing a whole
scenario, but instead avoiding anxiety-provoking thoughts or emotions associated with
that feared scenario.
Take a moment now to reflect on the role of avoidance in your life. You may come to realise
that there are particular situations you avoid due to anxiety or fear. These might include
situations such as social events, being assertive, going to work, driving and so on. When you

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are designing your own stepladders below, think of: situations, physical sensations,
emotions, thoughts, and tasks you fear.
In the last few months, I turn questions around to people
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2. Facing Fears Gradually Using Graded Exposure

Now that you have identified how avoidance interferes with your life and how it keeps the
symptoms of anxiety going, it is important that you practise fighting against avoidance!
Graded exposure is one of the most effective techniques to tackle avoidance and gradually
face your fears.

Graded exposure works to help you slowly build your confidence in your ability to cope with
the situations you have been avoiding.

When you confront a fear directly (by entering a situation which you're afraid of), the
experience triggers the fight-or-flight response. If you go into such a situation and you stay
there long enough, your anxiety will go down!

The graph shows that each time you confront an anxiety-provoking situation, your anxiety
will rise, but not quite as high as the time before. When you expose yourself to the situation
again and again, your anxiety will resolve quicker with each time.

This is called “gradual desensitization”. This is when your body and brain learn that what
you worry about does not actually happen, and if it did happen, it would not be disastrous.

 Each time you confront the situation, you are testing out your worry and whether
your prediction came true.
 However, it is important to remember that if
you have used a safety behaviour, you will not
have properly tested your worry. Remember:
safety behaviours are a form of avoidance, so
you are likely to think that the bad thing did not
happen because of your safety behaviour,
rather than because it was not going to happen
anyway.

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Exposure Tests
Exposure Tests are a way to gently expose yourself to the situations and sensations you fear
in order to test your predictions and gradually build confidence. We could just tell you that
your worries won’t eventuate, that you’ll be able to cope, and that you can overcome your
worry. But, you probably won’t believe us. Instead, you need to be able to experience this
for yourself.

That’s why we strongly recommend that you do Exposure Tests by using the Exposure
Stepladder. Graded Exposure is a very important part of treatment for depression and
anxiety.

Why are Exposure Stepladders Important?

 They help to learn that you can cope. Many people with depression and anxiety
feel overwhelmed by their symptoms, and feel that they can’t cope with
“anything”. But this isn’t true.
 Each step lets you really see what it is that worries you
and lets you identify exactly what you fear. So, rather
than just worrying about all situations, you can start to
understand what triggers your anxiety. This will help
you to start to gain control over your symptoms.
 The steps help you see that anxiety isn’t “all or nothing”. That is, by changing
aspects of the situation, such as the importance of a task, you can control how
much anxiety you might feel.
Remember, you don’t need to worry about the high level tasks for now – we are only listing
them here. Focus on the tasks that only cause a mild level of anxiety. If thinking about a
task makes you feel unpleasant inside, then it isn’t mild! And, we want you to start only
with mild tasks.

3. Creating an Exposure Stepladder

Now we’ve discussed the importance of exposure in managing and reducing avoidance and
safety behaviours, let’s create a stepladder together. In the last session, Julie helped Liz
develop her own exposure stepladder using the steps below:

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 How to create an exposure stepladder

Step 1: Write down your goal

Step 2: Create your own list of anxiety triggers (or a list of similar
situations that would trigger a range of anxiety levels from low to high,
with varying levels of difficulty).

Step 3: Rate or rank the tasks from lowest to highest.

Step 4: Pick a low level (easy) task to practise. Make sure you write
down what you predict will happen in the task before doing the task.
Then, do the task and see what happens.

Let’s have a look at an example stepladder created by Liz. Her goal was to reduce her over-
controlling of situations and to feel more comfortable with uncertainty. As you can see
below, each step is slightly more difficult than the previous one. She is slowly building up to
confront her greatest fear at the top.

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Liz found each time she completed or repeated a step from her stepladder, she felt more
confident in her ability to cope in new or unfamiliar situations. Her stepladder gave her
multiple opportunities to learn that nothing bad actually happened and that she could cope
with not knowing what might happen.

Tips for Successful Stepladders:

Pick a low anxiety task first - it is important you pick a task you will succeed at
Stay in the situation until the anxiety drops
Repeat the same task (of the Stepladder) again and again until it becomes
easy
When it has become easy, then you can move onto a higher level task
Expose yourself to the situation at least 3 times per week until you get used
to that level of anxiety.
Evaluate the task after you’ve completed it: did your predictions and
worries come true? What really happened? What did you learn for next
time?
The idea is that you do each task repeatedly, until it doesn’t cause you anxiety anymore and
until it becomes an easy task. Then you move on to the next one.

Ideas for steps on a stepladder:

TYPE OF FEAR POSSIBLE TASKS

HEALTH ANXIETY OR FEAR  Go to the hospital and sit in a general or specific department
OF CONTAMINATION waiting room
 Look at an internet article about a feared disease for a specific
time (e.g., 15 minutes)
 Eat foods that you would normally be afraid to eat
 Touch the ground or touch the toilet seat/bowl
 Only wash hands after going to the toilet or before preparing
food
 Reduce how often you are checking your body for signs and
symptoms of disease
SAFETY  Walk down an unfamiliar street
 Get on an unfamiliar form of public transport
 Go to a pub and order a drink or food that you have not tried
before
 Do things on your own

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 SOCIAL FEARS  Eat in public
 Wear odd clothes or alter your appearance and walk through
crowds
 Skip down the street
 Pretend to talk on your mobile phone really loudly about an
embarrassing topic, or laugh very loudly
 Ask for a refund on an article of clothing you’ve bought
OTHER WORRY TRIGGERS  Read the newspaper (from shop or online)
 Hop on the next bus without knowing where it goes
 Order something without looking on the menu (point to the first
thing you see)
 Go window shopping – go into a shop you normally wouldn’t go
into
PROCRASTINATION  Start an assignment/project/reading
 Write an email you’ve been putting off
 Arrange a meeting

EXAMPLE 1: EXPOSURE FOR REASSURANCE SEEKING (Goal: to learn to be

more comfortable with uncertainty/not knowing 100%)

SYMPTOM LEVEL TASKS

VERY HIGH  Leave mobile phone at home for 1 day.

 For one day, do not say sorry or pre-empt checking with anyone
unless there is clear evidence to do so.
 Delay responding to an email unless an emergency for 1 day.
 Don’t apologise for anything for a full day.

HIGH  Reduce pre-emptive checking in with people to once per day.

 Do not check the news for one day.
 Delay responding to emails for over 1 hour.
 Reduce checking mobile for text messages and missed calls to
once per day.

MEDIUM  Reduce pre-emptive checking in with people to 3 times a day.

 Reduce checking news to twice per day.
 Reduce checking mobile for text messages and missed calls to 3

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 times a day.

LOW  Reduce pre-emptive checking in with people to 4 times per day.

 Delay responding to emails and missed calls for 30 minutes.
 Reduce checking mobile for text messages and missed calls to 5
times a day.
 Reduce checking the news to 4 times a day.
VERY LOW  Reduce checking mobile for text messages and missed calls to 8
times a day.
 Delay responding to emails and missed calls for 10 minutes.
 Reduce checking the news to 6 times a day.

EXAMPLE 2: EXPOSURE REDUCING PERFECTIONISM

(Goal: to learn to cope with mistakes and not be so self-critical)

SYMPTOM LEVEL TASKS

VERY HIGH  Do not use a ‘To Do’ list for one day.
 Leave a mistake (e.g. a typo) in a report and hand it in.
 Leave yourself 15 mins to get ready before going out.
 Give yourself only one night to write a report or essay.
 Go out without checking yourself in the mirror.

HIGH  Reduce checking of work to 2 checks.

 Delegate a work task to a colleague.
 Leave yourself 30 min to get ready before going out.
 Send an email to a superior with a typo or spelling mistake.
 Reduce preparation for meetings to 5 min.

MEDIUM  Make an impulsive decision.

 Arrive at work 10 min late and leave 10 min early.
 Leave house untidy 3 times a week.
 Reduce checking of work tasks to 3 checks per day.
 Delegate small parts of an important job to a colleague.
 Leave the house untidy and invite guests over.

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 LOW  Miss one workout for the week.
 Give yourself 40 min to get ready before going out.
 Delegate a minor work task to a colleague.
 Send an email to a friend with a few typos or spelling mistakes in
it.
 Arrive at work 5 min late and leave 5 min early.
VERY LOW  Leave dirty dishes in the sink overnight.
 Reduce checking work tasks to 4 times.
 Send an email to a friend/colleague with a typo or spelling
mistake in it.

4. Your Exposure Stepladder

Now you’ve had a look at some different ideas for stepladders have a go at creating your
own on the next page. There are some ideas at each step or spaces for you to enter your
own steps.
What you should remember:
Your symptoms did not arrive overnight, so they won’t go away
overnight. If you need to keep working at your low anxiety level step for a
week or two, that is fine. Take as much time as you need and only move on
when you feel you are making progress.
It is not a race. Please don’t jump in the deep end. Your success depends
on working gradually and consistently, so start at the low anxiety tasks and
only move up when they become easy.
Don’t use safety behaviours! If you find yourself needing to use a safety
behaviour to get through one of your steps, you might have bitten off more
than you can chew. Break it down into less anxiety-provoking steps and
build your way back up from a lower anxiety level.
Practice, practice, practice. The Stepladder only works if you are willing to
give it a go with regular practice. It will not work if you only try it once. It is
a new skill that takes time and practice to become familiar with, so practise
regularly.
Reward your hard work! This is important - the Exposure Stepladder is not
an easy task so reward yourself for all the hard work you are putting in!

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REMEMBER: Once you have completed your stepladder, review what you predicted at the
beginning of the task to see whether this came true.

For a blank copy of the “Exposure Stepladder” go to

the extra resources after this lesson. EXTRA RESOURCE

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5. Exposure to Thoughts and Emotions: Worry Stories
At times, it may not be possible for you to complete exposure to overcome certain fears or
worries. For example, if you often worry your children will become seriously unwell,
this scenario cannot be turned into an exposure stepladder.
Instead, you could write a story about one of these fears. Worry stories involve facing
certain fears or worries by writing a detailed story about the feared situation or event. It is
important to write the story step-by-step in detail, including the feared consequences.
These stories can teach you that even though an event is unlikely, if it was to occur in the
future you could cope. By doing this you could also become
more tolerant of negative emotions and thoughts in the
process.
Let’s look an example of Liz’s. In the past few months Liz
found herself worrying increasingly about her husband having
an affair. Whenever she thought about this she become
extremely anxious, vulnerable and panicky. As a result, she
began checking her husband’s phone and reading his emails regularly. Liz completed a
Thought Challenging Sheet to challenge this worry and although she knew it was unlikely to
be true, she continued to feel anxious and distressed. She decided to write a worry story to
purposely expose herself to these worries and cope with the distress as it occurred.
Goal: To learn to cope with distressing thoughts about my husband having an affair.

STEP TASK
WHAT IS MY TASK?  Write a story about my husband having an affair.

WHAT DO I PREDICT?  I will get very upset and worry that my husband will cheat
on me. If I write it out, it’s more likely that it could happen.
I couldn’t cope with that.

WHAT WAS THE RESULT?  I did get upset at first, and wanted to destroy the story,
but I kept writing it out until I started to feel more
comfortable. The more I wrote, the more I thought that
the story would not come true.

WHAT DID I LEARN?
WHEN WILL I PRACTICE IT AGAIN
OR
AM I READY FOR THE NEXT STEP?
 These thoughts are just thoughts; thinking them does not
mean that they will happen. I can’t control the future, but
it is very unlikely that my husband would have an affair. I
might even be able to cope if he did. I can cope with this
thought and feeling upset.
 I will write this story out every day for the next couple
of weeks before I start a new story.

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Will writing a worry story really reduce my level of anxiety?
When completing worry stories, some people think “but I’m worrying about these things all
the time, doesn’t that count as a worry story? Why don’t I feel less anxious?”
Our approach of using worry stories involves actively scheduling a time to face your fears,
rather than just worrying about things at random times. It encourages you to follow your
worries to their logical conclusion, rather than jumping between worst case scenarios or
using safety behaviours when it becomes too confronting. This allows you to emotionally
process distressing thoughts, images and feelings to find out if;

1. The worry is realistic, helpful and balanced, and

2. You can cope with worrying thoughts, images and situations.

The aim of writing a story is not to make you feel good or to reassure you that nothing bad
will ever happen, the aim is to acknowledge that negative events do happen but that you
can learn to cope with them.
Generally we find after writing a story 5-10 times, the strong emotional reactions that occur
the first time start to decrease and you start to realise the coping skills and other strengths
you possess. Writing these stories also improve your ability to tolerate doubt and distress.

For more information and examples of worry stories,

download the “Worry Stories” resource after this EXTRA RESOURCE
program.

8. Lesson 2 Summary of Skills and Action Plan

Congratulations on completing Lesson 4!

Today you have learned to:

 Face your fears through graded exposure.
 Challenge your fears about the future and/or negative emotions.
 Check and reduce your safety behaviours.

Below is your action plan for the coming week. Make sure to schedule time to complete
each task, before you return to do Lesson 5.

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 LESSON 4: MY ACTION PLAN
 Create and complete my Exposure Stepladder.

 Write a Worry Story and re-write it until I notice my anxiety ease.

 Identify and evaluate my beliefs about worry: Are they realistic? Are they
accurate? Are they helpful?

 Test the accuracy of my beliefs by doing an experiment and evaluating its

outcome.

 Use Structured Problem Solving to help me with worries that are realistic.

 Continue noticing and reframing any unhelpful thoughts or thinking errors

using the Thought Challenging technique.

 Exercise at least 30 minutes per day 3 times per week.

 Use Controlled Breathing whenever I notice anxiety increasing.

 Use Progressive Muscle Relaxation when I notice tension building up in my
body.

 Reward myself for my hard work and persistence with learning new skills!

Good luck and keep up the great work!

The Team from THIS WAY UP Clinic

www.thiswayup.org.au

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