Exposure hierarchy

Exposure remains a cornerstone technique of the more behavioural approaches to CBT. It is based on a simple principle: the more we avoid situations that we are frightened of the more frightening they become. And not only that, but our fear is likely to become more general, meaning that there are more and more situations that we avoid, making life restricted and increasingly unhappy. And the opposite is also true: the more we face our fears, the less frightening they become.

This principle is known as habituation: the more habituated we get to situations we once found frightening, the more the reflex fear that we experience, or anxiety in anticipation of going into those situations, is diminished until it becomes either negligible or entirely extinguished. Rather than fanning the flames of fear and anxiety we aim to put out the fire at its source.

Habituation is a form of learning that takes place simply by exposing ourselves to frightening situations, letting ourselves experience the fear that they produce and remaining in the situation until the anxiety has reduced to at least half. It is usually done best in a graded fashion. That is, we make a list of situations that we avoid (or endure with great distress) and rate each situation for the level of fear or trepidation that they produce in us. We usually rate situations out of 100, where 100 is the very worst fear we could imagine.

Start your hierarchy by coming up with an example of a situation you avoid. Then, rate your example for the level of fear that you imagine you would feel if you were to go into that situation. If, for example, you have a phobia of dogs, you might rate looking at a picture of a bull mastiff as slightly alarming, say a 10 out of 100. Being left alone in a small room with the same dog would probably be 100. Being in the same room as a small dog who is on a leash and being held by its owner might rate a 65. You get the idea. Try to create 10 examples that cover a range of feared situations. When you start your exposure you'll be starting at a level that elicits some anxiety but not such an overwhelmingly high level that you can't stay in the situation until you feel more comfortable.