Anxiety Treatment Tools – Exposure Hierarchies

What is a Hierarchy?

Hierarchies are commonly used in cognitive behavioural therapy for treating anxiety. They structure incremental exposures to a feared stimulus one step at a time. By gradually facing feared situations, hierarchies aim to help us slowly learn to tolerate and overcome stress associated with them.

Hierarchies can be used to tackle any experience that causes you distress. Lets say you have identified that your fear of driving is really disrupting you day-to-day life. An exposure hierarchy can help you tackle this fear in a manageable way.

How do They Work?

This technique is based on the fact that anxieties are perpetuated by cycles of avoidance. Naturally, this is understandable. Evolutionarily it makes sense to avoid the tallest cliffs and the most dangerous predators. However, many of our fears may now be less adaptive and can even interfere with our daily lives.

If we continually avoid things that make us anxious, we never give ourselves a chance to learn that our fears are unfounded.

Hierarchies can help us decrease anxiety by showing us that the dangers we anticipated are rarely as bad as we think they will be. Fear often causes us to over-estimate risk and under-estimate our ability to cope. Exposures give us a safe environment to become more confident in our ability to navigate situations we once found frightening and can make us more willing to approach them in the future.

Building a Hierarchy

1. Choose a long-term goal 

What situation would you ideally like to conquer that you currently find frightening? You might have more than one in mind (I know I do…) but pick one at a time that can be broken down into smaller steps. You can always come back and make another fear ladder for different stimuli.

Let’s use the driving example again. Maybe your ultimate goal is to drive on your own.

2. What variables affect the difficulty of this task? 

You may find that many factors contribute to your ultimate challenge. While exposures should always be conducted in a safe environment with necessary preparation, many things about the situation can influence the difficulty of the exposure.

Consider the timing, duration, who’s with you, the location, your mood, external circumstances etc.

For example, you could decide that your ultimate goal is to drive alone, through the city at nighttime. (Maybe something you’ve always wished you could do).

3. Rank each task in difficulty

Set the most daunting task at difficulty 100%, depending on how much anxiety it will generate.

Continue to tweak the circumstances of the situation to develop a range of exposures that will pose different levels of challenge.

It can be helpful to next consider the easiest first step you could take that still offers a little stress (i.e. 10%).

Maybe merely sitting in a car is a 10%.

And 20% – being a passenger driving with someone you trust in an empty parking lot.

(You get the idea)

Here is a fillable worksheet you can print out to help in the construction of your hierarchies.

What you Need to Know

A – Don’t leave an exposure too early

When conducting an exposure to a phobic situation from your hierarchy you need to give yourself enough time to allow your anxiety to reduce by at least 50%. A rather arbitrary number I know… Consider it to feel like you have experienced partial relief or that you now have some sense of control over the situation.

Depending on the circumstance this can take upwards of an hour or more. Be conscious to reflect on your experience of fear while doing the exposure to be sure you don’t stop too early. Ending a trial before your anxiety has reduced may actually worsen your fear by suggesting that leaving was the only way to quell your distress.

B – You should habituate to each level of your exposure before moving on the the next one.

Each step in the hierarchy can be thought of like a “behavioural experiment”. You will feel anxious during each initial exposure however, with repeated trials of the same thing, you will eventually begin to notice that your discomfort lessens. Once you feel more confident with a situation you can decide to increase the level of difficulty by moving on to the next step.

It can take several trials to become comfortable with a single step on your hierarchy but that’s okay. Take note of how your experience changes over time to ensure that you progress at a safe and challenging rate.

C – It’s hard, but it gets easier. 

Deliberately putting yourself in frightening situations is exhausting. At first, when you are facing a fearful stimulus and your anxiety is building it might feel awful. That’s why we do the prep work beforehand.

Remember that physiologically, anxiety cannot continue to rise forever. With time, it will reach an inevitable peak. After which, it will start to fall again. Beginning an exposure can often cause high levels of anxiety that last for prolonged periods of time. BUT, with each repeated experience it will become easier. Every time you confront a challenge you are getting stronger, even if it doesn’t feel like it at the time. With continued practice it is totally worth the feeling of being able to look back and truly appreciate how far you’ve come.

Remember why you’re doing this. Perhaps you are tired of letting your life be dictated by anxiety and rules. Maybe you want to prove to yourself that you are capable of facing your fears. Being able to navigate these situations might prove to significantly better your quality of life. You deserve to have freedom from restrictive fear.

D – It takes patience and practice 

Each step in the hierarchy may take several tries to become habituated to and that’s okay. Don’t rush through. Give yourself time and self-compassion as you work through this difficult process. Don’t forget to go back and re-try the steps lower on the ladder that you’ve surpassed to reinforce your new confidence.

It can be helpful to review some coping skills that you can use during these exposures. Consider progressive muscle relaxation, deep breathing, mindfulness/meditation, or grounding through the senses etc.

Choosing to challenge yourself in this way is incredibly brave. Not many people can appreciate the work that goes into this process. Remember that the reason you are doing this is to make your life better. Reward yourself for your efforts.

 

 

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