How to Build an Exposure Hierarchy With a Client

What is an exposure hierarchy?

An exposure hierarchy is a list of feared situations, ordered from least to most difficult, that a client works through during exposure therapy. It is also called a fear hierarchy or an exposure ladder. The list turns a broad fear, such as "I can't handle social situations," into specific actions the client can plan and practice one at a time.

Exposure means repeatedly approaching what a person fears instead of avoiding it. Craske and colleagues describe it as a mainstay of cognitive behavioral therapy for anxiety, delivered in different forms: graduated or intense, brief or prolonged, and imaginal, interoceptive or in real life. The hierarchy is the planning tool for the graduated form.

Does exposure work for anxiety?

Exposure-based CBT has good research support for anxiety and related disorders, although not every client benefits.

• CBT for anxiety outperforms placebo. A meta-analysis of 41 placebo-controlled trials with 2,843 patients found moderate effects of CBT on target symptoms (Hedges' g = 0.56). Interventions that mainly used exposure had larger effect sizes than those using cognitive techniques, though that difference was not statistically significant.
• It is part of guideline care for OCD. NICE guidance on OCD recommends CBT including exposure and response prevention (ERP) for adults.
• Results are not universal. Craske and colleagues note that a substantial number of people fail to benefit from exposure, or find their fear returns after treatment. Their paper sets out practical ways to strengthen it, several of which shape how you build and use a hierarchy.

How to build an exposure hierarchy with a client

Build the hierarchy together in session, starting from the client's own avoidance rather than a standard list.

1. Explain the rationale. Walk through how avoidance brings short-term relief but keeps the fear going. Use an example from the client's week.
2. Name one target fear. Keep the hierarchy to one fear or theme, such as speaking in front of others, rather than everything the client finds hard.
3. List what they avoid. Ask which situations, places, objects or sensations they stay away from, and what they do to get through them when they cannot avoid them.
4. Rate each item. Ask how anxious the client expects each item to make them, or how hard it would be to do. A rough rating is enough to sort the list.
5. Order the list. Arrange items from easiest to hardest. If the gap between two neighboring items feels too big, add a step in between.
6. Write down the expectation. Before each practice, ask what the client is most worried will happen and how likely it seems. In Craske's case examples, clients rate this likelihood on a 0 to 100 scale.
7. Practice and review. After each practice, ask whether the feared outcome happened, how the client knows, and what they learned. Use that to choose the next step.

What should go on an exposure hierarchy?

The items should be concrete actions the client could do this week, with details that make each one easier or harder. Vague items such as "be more social" are hard to practice and hard to review.

For a client who fears speaking up at work, a hierarchy might look like this:

• Ask a coworker a work question in person.
• Make one comment in a small team meeting.
• Ask a question in a larger meeting.
• Share an opinion that others might disagree with.
• Present a short update to the whole team.

You can change the difficulty of an item by changing its details: how long it lasts, who is present, where it happens, and whether the client brings anything they rely on for comfort. Those details are also useful later, when you vary practice on purpose.

Do clients have to complete the hierarchy in order?

No, a strict easiest-to-hardest order is not required, though starting low remains common. Traditional exposure moves from one item to the next and repeats each item until anxiety falls. Craske and colleagues describe an alternative, variable exposure, where items are taken in random order. They note that it usually still begins with the least anxiety-provoking item, to avoid the client refusing treatment.

The research behind this is early. In an experiment with 50 undergraduates with high contamination fears, a gradual, constant approach and a random, variable approach both reduced subjective fear, with no significant difference between them. The authors concluded that the traditional method is sufficient but not necessary. They also noted that their behavioral and physiological findings were limited, and that the sample was not a clinical group.

A related finding matters for pacing. Craske and colleagues report that how much fear drops by the end of an exposure does not predict fear at follow-up. So you do not have to wait for anxiety to fall before moving on. The focus is what the client learned: did the feared outcome happen?

What are safety behaviors in exposure?

Safety behaviors are actions a person takes to prevent, escape or reduce a feared outcome or the distress around it. Blakey and Abramowitz define them this way and note that research consistently links them to the development and maintenance of anxiety disorders.

Craske and colleagues list the presence of another person, therapists, cell phones, and food or drink among the common safety signals and behaviors for clients with anxiety.

Traditionally, safety behaviors are removed during exposure. Blakey and Abramowitz point out that the evidence on their effects during exposure is limited and mixed. Craske and colleagues prefer removing them straight away if the client is willing, and suggest phasing them out gradually only to reduce dropout. In practice, list the client's safety behaviors alongside each hierarchy item, and agree in advance which ones they will drop.

Using this with clients

Most exposure practice happens between sessions, so it helps when the client has a clear plan and a simple way to record each attempt.

• Start with the Exposure Therapy for Anxiety Disorders mini course. It covers how avoidance keeps anxiety going and how graded exposure works, and asks the client which safety behaviors they could let go of.
• Build the hierarchy in session with Build an Exposure Ladder. The client names the fear they are working on and five steps, from easiest to hardest.
• Assign Perform an Exposure for each step you agree on. It records the planned exposure, anxiety at the start and end, whether the client stayed without checking, avoiding or seeking reassurance, and what they noticed.

Treat the anxiety ratings as information for planning, not a pass or fail score. The more useful question is what the client expected and what actually happened. If clients struggle to complete practice, our guide to therapy homework engagement covers common barriers, and decatastrophizing can help you explore the feared outcome before an exposure.

You can assign all three tools to a client in Offload in one click and review each attempt before the next session. Start your 30-day trial.