by Martin M. Antony, PhD, and Heather Hood, MA
Exposure is a critical element of cognitive behavioral therapy for most anxiety disorders and, for some phobias, a single prolonged session of exposure to a feared object or situation can lead to significant and lasting improvements. Gradually confronting feared stimuli and situations allows clients to learn that many of their fears are unrealistic. The client gains the confidence to manage the anxiety and remain in the feared situation, and learns that anxiety gradually decreases over time.
To begin exposure therapy, work collaboratively with your client to develop an exposure hierarchy. Have your client generate a list of ten to twelve situations that represent progressively more difficult encounters with the feared object or situation. Difficult situations can be broken up into smaller, more manageable steps, or with variations of themes that contribute to one’s anxiety (e.g., duration, distance, use of coping strategies). If the client is having trouble generating specific items, try a behavioral experiment to discover the focus and intensity of the client’s fear. Each item on the hierarchy should be specific and detailed so that the parameters for each exposure practice are clear. Next, have the client rate each item on a scale of 0 (i.e., no fear or anxiety at all) to 100 (extreme fear). Arrange the hierarchy with easier items at the bottom and the most difficult situation at the top. Exposure practices should be challenging, but manageable, so start with items lower on the hierarchy so that client's sense of mastery grows with each successful exposure practice!