The 4 essential conditions of exposure and habituation As a practitioner, being able to spot any essential condition problems on planned and completed homework diary visually is important, as well as assisting the patient to draw out the habituation curve for each step as a visual indicator in review.
Graded: The first condition is that exercises are graded. This needs to be so there is enough
anxiety to habituate, but it is not too overwhelming and feels manageable. 50-60% is a good starting exercise, any lower and symptoms are not high enough for the fear cascade response and over learning and habituation to take place, any higher and the response is more likely to lead to a panic attack and disengagement.
Prolonged: The second condition is that each time the patient completes an exercise, that they
need to stay in the situation until their anxiety drops by 50% from the start of the exercise rating. They should complete the duration on the diary at the end of the exercise, once it is known how long this took. This is a measure of progress towards habituation and highlights any instances where it has not come down as quickly as expected, or may have come own too quickly, suggesting a problem with the way the exercise has been carried out.
Repeated: The third condition is that each step of the hierarchy needs to be repeated until it
no longer triggers a high level of fear. 4-5 exercises of exposure a week on average is needed to achieve over learning of the conditioned response. Some weeks the patient will need to a mix of steps if they habituate to one mid way through before their next session. They repeat each step of the hierarchy as an exercise until your anxiety drops to 40% or less before and at the start of the exercise at least once. Then habituation to that step has taken place and they can move to the next exercise. Remember each step will produce an increased level of fear as they work up the hierarchy and take more time to drop, although it often gets easier than predicted.
Without distraction: The final condition is that they need to be aware of any internal or external
distractions, even subtle things that can distract them while doing the exercise. These must be discussed with the patient and a clear rationale given for how they must experience the anxiety without any safety behaviours or anything to bring anxiety down artificially, including subtle internal and external avoidances.
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© Marie Chellingsworth (2020). The CBT Resource.
