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Creating an Exposure Hierarchy

article

Exposure therapy is a highly effective intervention for clients suffering from a wide range of conditions, such as phobias, panic attacks, social anxiety, and obsessive-compulsive disorder. But despite its proven track record and broad utility, exposure therapy remains underused by clinicians.

This guide offers an easy-to-follow roadmap for creating an exposure hierarchy, which is often the centerpiece of exposure therapy. Also known as a “fear hierarchy” or “fear ladder,” an exposure hierarchy is a list of scenarios that the client rates from least-distressing to most-distressing. Under the guidance of a therapist, the client works their way toward confronting their higher-level fears. While challenging, exposure therapy can be life-changing!

This guide assumes your client is sufficiently informed and motivated to begin exposure therapy. Our What is Exposure Therapy? infosheet is a useful introduction, while our Motivational Interviewing Guide is a helpful tool for gauging a client’s motivation.

Read on to learn how to create an effective exposure hierarchy.

Interview the Client

Before designing an exposure hierarchy, investigate the nature of your client’s fears, including their intensity and frequency.

Pinpoint Core Fears

Pinpointing a client’s most-feared scenarios is a crucial first step. Using the downward arrow technique, you can move from the client’s surface fear to the underlying core fear or belief. To do this, ask clients reflective questions such as “what would that mean?” and “why would that bother you?” Continue questioning until you arrive at the scenario or belief that most troubles the client.

Downward Arrow Example

Therapist: What troubles you most about using public restrooms?

Client: I’m afraid I might touch something that’s contaminated.

Therapist: Why would that be a problem?

Client: I could contract a contagious disease and get really sick.

Therapist: What would be the worst thing about that?

Client: I would miss work and maybe even die.

Therapist: Anything else?

Client: I could accidentally infect my daughter.

Therapist: What would that mean?

Client: That I'm a failure as a mother.

Downward Arrow Illustration

Fear of touching something "contaminated"

Fear of contracting an illness

Fear of infecting daughter

Fear of failing as a mother

Surface fear

Core fear

With the help of this technique, it’s clear that the client’s fears go beyond touching something “contaminated.” She worries excessively about infecting her daughter and feeling like a failure as a mother. It is important that the exposure hierarchy target these deeper fears.

Find Out What is Being Avoided

By the time clients enter therapy, they often have numerous avoidant behaviors that are severely impacting their quality of life.

The next step is to figure out which situations clients are avoiding due to their anxiety. This may seem straightforward, as in the case of a client with a spider phobia. Clearly, such a client avoids spiders! But it is important to discern what else the client has been avoiding to manage this fear. For example, the client may avoid entering certain rooms of their house where spiders have been seen. Or they may refrain from walking in nature or watching a movie without researching whether it includes spider scenes. By the time clients enter therapy, they often have numerous avoidant behaviors that are severely impacting their quality of life. Exposure therapy identifies and changes these behaviors.

Fears and Avoided Activities
Fear Avoided Activities
spiders right arrow
  1. Will not enter a room for days after seeing spider
  2. Will not walk or hike in wooded areas
  3. Will not watch movie without researching it
contamination right arrow
  1. Will not use a public restroom
  2. Will not shake a person's hand
  3. Will not take public transportation
social
situations
right arrow
  1. Will leave restaurants if crowded
  2. Will not attend large gatherings
  3. Will not stay in class if seat near exit is unavailable
accidents right arrow
  1. Will not leave house without checking stove many times
  2. Will not allow partner to use candles due to fire hazard
  3. Will not go on trips and leave house "unguarded"

Sometimes it is challenging to determine what clients are avoiding, perhaps because these behaviors have become part of their normal routine. At the beginning of therapy, consider inviting a client’s loved ones to offer their perspective on how fear is impacting the client.

Tips for discovering clients’ avoidant behaviors

Ask clients to keep a log of their behaviors when their anxiety is highest. This often reveals their avoidant pattern.

Challenge clients to imagine their lives without anxiety. What would they be doing that they are not doing now?

Have clients list their top-three values and then explore what keeps them from living according to those values.

Consider Exposure Types

Once your client has a list of avoided activities, you can evaluate which types of exposure exercises to use. Some of the common types are shown below:

Types of Exposure Therapy
Imaginal

The client vividly imagines their fears in the therapy session or at home using a script or audio recording.

In Vivo (“In Life”)

The client confronts fears in real life in a structured way, guided by the therapist.

Virtual

The client is exposed to their fears by confronting stimuli through a headset or screen.

Interoceptive

The client is exposed to fear-inducing physiological sensations until they no longer view them as a cause for concern.

ERP

Exposure and Response Prevention (ERP) involves exposing a client to their fears and then having them refrain from safety behaviors both during and after the exposure.

Combination

Many therapists use a combination of these exposure types depending on a client’s fears and needs.

In vivo exposures—i.e., real-life confrontations with clients’ fears—are typically the main focus of exposure therapy. But a combination of exposure types is often the most effective approach. Below are some to consider:

Imaginal Exposures

Imaginal exposure exercises are ideal for fears that are difficult to confront in clients’ daily lives, such as the fear of losing a loved one. To implement this, narrate a vivid description of the client’s most feared outcomes. Continue until your client’s anxiety reduces by at least half.

Interoceptive Exposures

Interoceptive exposures involve having clients confront physiological sensations associated with their fears, such as a rapid heartbeat or tight muscles. Over time, clients learn that these sensations are not a cause for concern.

Exposure and Response Prevention (ERP)

This exposure type is often used for treating obsessive-compulsive disorder. As the name implies, “exposure and response prevention” involves exposing clients to their fears while simultaneously ensuring they do not engage in any safety behaviors during and after the exposure.

For more guidance specific to OCD, see our OCD Treatment Overview.

Create the Exposure Hierarchy

Equipped with a list of your client’s avoided scenarios, you are now ready to create the exposure hierarchy. To assist you with this, check out our printable Exposure Hierarchy template.

Rate & Select Exposure Exercises

As a first step, ask clients to rate their listed scenarios using the Subjective Units of Distress Scale (SUDS) according to their anticipated level of anxiety. The scale ranges from 0 to 100:

Subjective Units of Distress Scale (SUDS)
100 extreme anxiety
75 severe anxiety
50 significant anxiety
35 moderate anxiety
20 low anxiety
0 no anxiety

Here are two examples of scenarios rated by a client (Maria) with arachnophobia and a client (Luis) with OCD-related contamination concerns:

Exposure Hierarchies
Maria Luis
Watch a short video of a spider 55 Stay 5 min. in filthy public restroom 95
Hike where there are spiders 85 Describe a dirty public restroom 55
Stand five ft. from a spider 70 Stay 10 min. in clean public restroom 70
Let large spider walk on arm 100 Record & listen to worst-case scenario 65
Watch a spider documentary 60 Stay 10 min. in filthy public restroom 100
Look at a photo of a tarantula 60 Read restroom horror stories 60
Sit next to spider in a terrarium 95 Touch stall door in public restroom 85

Determining how far to go with exposures and what constitutes acceptable risk can be tricky. Some therapists believe they should not ask their clients to do anything they would not do. Others argue that clients may need to exceed what a “normal” person would do in order to habituate to their fears and maintain treatment gains. If in doubt, consult with an experienced colleague.

Construct the Hierarchy

When adding items to the hierarchy, be sure to include a wide spread of SUDS ratings and avoid a disproportionate number of higher- or lower-rated items. When possible, utilize a variety of exposure types – e.g., combine in vivo exposures with an imaginal exposure. The hierarchy should feature around 10 to 15 items in total.

Arrange the items in descending order, with the highest-rated items appearing at the top of the hierarchy. Most experts advise not including items with SUDS ratings less than 20 or 30, so clients will typically start with an exercise rated around 30. The initial exercise should be challenging, but doable. Instruct clients to continue the exercise until their anxiety decreases by at least half the peak level.

Using these principles, this is what a hierarchy for the client Maria might look like:

Maria's Exposure Hierarchy
Exposure Activity SUDS
Let a tarantula walk on arms 100
Touch a tarantula 95
Sit next to several spiders in a terrarium 90
Hike a trail where spiders are common 85
Stand five feet from a large spider in a web 70
Watch a documentary about spiders 60
Watch a short video clip featuring spiders 55
Look at a close-up photo of a tarantula 50
Read a story about a spider infestation 40
Look at several cartoon images of spiders 30

Adjust & Tweak

Proximity and duration are common variables you can use to modify the exposure difficulty level. For example, Maria could move closer to or further away from a spider, and Luis could spend more or less time in a public restroom. As clients successfully habituate to the lower-rated exposure exercises, their SUDS ratings for the remaining hierarchy items may change.

Below is Maria’s updated hierarchy depicting changes in her SUDS ratings from week one to week four of her exposure therapy:

Maria's Revised Exposure Hierarchy
Exposure Activity SUDS (w1) SUDS (w4)
Let a tarantula walk on arms 100 100
Touch a tarantula 95 95
Sit next to several spiders in a terrarium 90 90
Hike a trail where spiders are common 85 90 up arrow
Stand five feet from a large spider in a web 70 60 down arrow
Watch a documentary about spiders 60 55 down arrow
Watch a short video clip featuring spiders 55 40 down arrow
Look at a close-up photo of a tarantula 50 0 down arrow
Read a story about a spider infestation 40 0 down arrow
Look at several cartoon images of spiders 30 0 down arrow

Maria downgraded many SUDS ratings, but increased the rating for “hike a trail where spiders are common” after realizing her anxiety is higher when she encounters spiders in nature.

To help gauge the need for adjustments, encourage clients to complete an Exposure Tracking Log. This details the content of the exposure exercise, its duration, the SUDS ratings at the beginning, peak, and end, and the client’s safety behaviors.

Maria’s exposure tracking log for the exercise “watch a spider documentary”:

Exposure Tracking Log
SUDS (0-100)
Date Length Start Peak End Notes
6/7/2022 65 mins. 50 90 25 resisted urge to turn away from screen

Be sure to check whether clients’ anxiety reduced by at least half of the peak level when they ended their exposure exercises. This may take as long as 60 to 90 minutes, especially when first starting therapy. But this period often shortens as clients make progress.

Tips for safety behaviors

Effective exposure therapy requires eliminating so-called “safety behaviors.” These include distraction and reassurance-seeking, among others.

Use our Exposure Tracking Log to monitor these behaviors throughout treatment. Be sure to check for mental rituals, such as counting or repeating a word or phrase.

Reinforce Treatment Insights

By confronting their fears, clients begin to see themselves through a more flexible and adaptive lens.

By confronting their fears, clients begin to see themselves through a more flexible and adaptive lens. They learn that worst-case scenarios rarely if ever happen. They learn that while anxiety is uncomfortable, it can be tolerated. And they learn that some level of risk and uncertainty is part of being human. While these truths may be difficult to accept, they open the doorway to the growth and meaning that clients are craving.

Despite its challenges, exposure therapy is a transformative intervention when implemented with rigor and attention to detail. If you need more guidance, consult with an experienced colleague or seek out formal training opportunities.

We recommend Exposure and Response (Ritual) Prevention for Obsessive-Compulsive Disorder: Therapist Guide for continued learning.