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Exposure Hierarchy Treatment Plan

We all experience irrational fears. You may let out a muffled screech any time you see a creature with half-a-dozen legs or more or feel claustrophobic in a crowded room. These anxieties and fears are normal. But when they begin to take over, it makes daily functioning difficult.

Exposure therapy can help people who struggle with irrational fears affecting their daily lives, allowing them to reduce their anxiety and fear reactions to a more manageable level. Exposure therapy takes many different forms. And it isn’t just used for treating anxiety and phobias — exposure therapy is effective for PTSD, OCD, and trauma-related issues. We’ll explain why exposure therapy works and the different methods therapists use to get results. To wrap up, we’ll discuss the importance of developing an exposure hierarchy and integrating it with a strong treatment plan.

Exposure Therapy Techniques

Exposure therapy is an umbrella that covers a broad range of techniques. The diversity of interventions gives therapists the flexibility to customize their approach.

In Vivo

This type of exposure therapy involves facing a feared stimulus in real life. Think handling a (non-poisonous!) snake or standing on top of a tall building. 


Imaginal exposure therapy involves bringing up memories of trauma or realistically imagining a feared stimulus. This intervention is commonly used on trauma survivors or those with PTSD, where recreating the stimulus in real life is not possible. 

Virtual Reality

The next best thing to in vivo therapy, virtual reality seeks to replicate a fear-inducing situation using VR technology. Example scenarios could include fear of driving or flying.

Interoceptive Exposure

This technique involves purposefully bringing on a feared physical sensation like an elevated heart rate. Someone with a panic disorder may fear this sensation as a harbinger of a feared anxiety attack. Raising the heart rate by running in place in the therapist’s office can help associate this sensation with a safe, non-threatening environment.

Prolonged Exposure Therapy

Most often used with clients with past trauma or a PTSD diagnosis, prolonged exposure therapy provides repeated exposures to the feared stimulus along with extensive education on symptoms, talk therapy, and techniques to control feelings of panic, fear, or anxiety.

Exposure and Response Prevention

For people experiencing obsessions and compulsions, exposure and response prevention reduce the intensity of connection between those obsessions and compulsions. In this type of exposure therapy, you would provoke the client’s obsessions and then ask them not to engage in their compulsion. 

Exposure Therapy Pacing

The pace at which fear or anxiety-producing stimuli are introduced can vary quite a bit. Here are the three main approaches to pacing.

Graded Exposure

Pacing for graded exposure begins with the exposure hierarchy. The therapist and client identify a stimulus that generates the weakest response and work on that first, gradually building to the stimulus that elicits the greatest response.


The opposite approach of graded exposure, flooding involves tackling the stimulus that solicited the most significant fear response first and working down the exposure hierarchy from there.

Systematic Desensitization 

This technique blends exposure to the stimulus with relaxation techniques. Systematic desensitization can make a feared stimulus easier to work through by interspersing stress-relieving activities. It also serves to build associations between a feared stimulus and pleasant activities. 

Why Exposure Therapy Works

This type of therapy has proven to be useful for treating a broad range of issues from phobias to PTSD. There are several reasons and ways it works. 


Repeated exposure to a feared stimulus tends to reduce the intensity of the reaction over time. 


As time passes, the connection between a feared stimulus and a bad reaction tends to lessen. The associations a client has learned to place on an object or situation are no longer strongly connected to a negative outcome. 


Exposure therapy builds confidence in clients, allowing them to believe they’re capable of facing their fears and effectively using various strategies for handling the difficult emotions that can come from fear responses.

Emotional Processing

By being exposed to feared stimuli, clients become more comfortable with the experience of fear and can build new, more accurate views about their fears.

How an Exposure Hierarchy Works in Exposure Therapy

An exposure hierarchy is a client-created list of situations that trigger fear or anxiety. Beside each event, the client ranks how severe their reaction is to that situation using a scale of zero to ten. An exposure hierarchy is a valuable tool that helps clients and therapists clarify which situations are priorities for treatment and find the best approach to use with each one.

How to Develop a Strong Treatment Plan that Includes Your Exposure Hierarchy

treatment plan is a roadmap you and your client use as you travel from where they are in the present to where they’d like to end up when therapy concludes. If you’re using exposure therapy to treat a client, integrating the information from the exposure hierarchy can make your treatment plan more effective. Here’s how to do so.

Problem Statements 

This section is devoted to presenting problems. What is your client currently experiencing that spurred them to seek therapy? If the anxiety or fear-producing events listed in the exposure hierarchy follow a theme or themes, list them.


Goals provide a big-picture view of what you and your client would like to accomplish with therapy. Use the data in the exposure hierarchy as a helpful guide as you discuss priorities. Create goals that address the core issues. The exposure hierarchy makes it easier to see what needs to be taken care of first.


Objectives are the incremental steps needed to reach a treatment goal. 


There are many exposure therapy techniques to help a client overcome fear or anxiety-triggering situations. You may choose to use a variety of them to address the goals of the treatment plan. There’s no one-size-fits-all approach. Customize the interventions to your client’s unique needs and what they hope to achieve. 

General Checklist

The general checklist is a series of questions that ensure the treatment plan is a custom-fit course of action that the client was involved in making. Questions include the following:

  • Was the treatment plan created to meet the client’s goals?
  • Does the treatment plan take into account the client’s abilities?
  • Does the treatment plan consider the client’s lifestyle, economic status, culture, career history, and educational background?
  • Are the client’s strengths thoroughly integrated into the treatment plan?
  • Were the client and any applicable family members involved in creating the treatment plan?

In Conclusion

Exposure therapy is one of the leading therapeutic interventions for helping clients overcome life-impacting fear and anxiety responses. A variety of techniques can be deployed to implement this type of therapy, and integrating the exposure hierarchy into a treatment plan makes the plan clearer and more effective.

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