Fear hierarchy worksheet
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If you’re a mental health therapist looking for a fear hierarchy worksheet to share with clients, you’re in the right place.
This guide to exposure hierarchy worksheets gives therapists an overview of exposure therapy and the benefits of using a fear hierarchy worksheet. You can also download a free exposure hierarchy worksheet PDF to save to your electronic health record (EHR).
What is an exposure or fear hierarchy?
Cognitive behavioral therapy (CBT) is an effective treatment for anxiety and other mental health disorders.
Exposure therapy is a component of CBT that can be used to treat anxiety, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD).
By helping clients confront fears, fear hierarchy worksheets can help them break negative thoughts or patterns by providing the right environment to expose them to their fears safely.
Exposure therapy and the use of exposure hierarchy worksheets can help with various phobias, like those of inanimate or living things, particular activities, or specific situations.
Exposure therapy may involve:
Direct exposure
Also called in vivo exposure, direct exposure is a therapeutic process that involves directly exposing a client to their fear-inducing stimuli in real life. By doing so, the client can face their fear in a safe environment or controlled setting.
For example, a client who is afraid of spiders may be asked to face their fear by holding or facing a real spider.
Virtual reality
It's possible to confront some fears in a virtual environment.
For instance, a client who is afraid of flying may use virtual reality (VR) to simulate a flight in their therapist's office.
Imagined exposure
The therapist may ask the client to imagine they are confronted with the object or situation they fear, and then directed to recall specific details of the imagined experience.
Interoceptive exposure
This involves creating physical sensations that the client fears.
For example, someone terrified of having a heart attack may perform an activity (like jumping up and down) to raise their heart rate.
There are also different ways to pace exposure therapy, such as:
Systemic desensitization
In systemic desensitization, exposure is combined with relaxation exercises to make the experience more tolerable and to associate the fear with feelings of relaxation.
Flooding
A fear hierarchy worksheet, or a fear ladder worksheet, is used to list fears in order of severity. Treatment begins with targeting the most challenging fear first.
Graded exposure
Graded exposure involves using an exposure hierarchy worksheet, but treatment targets the least challenging fear first.
Benefits of using an anxiety ladder or anxiety hierarchy
Research shows exposure therapy is an effective first-line treatment for:
- PTSD
- Prolonged grief
- Phobias
- OCD
- Panic disorder
- Social anxiety disorder
- Generalized anxiety disorder
The benefits of exposure therapy include:
- Improved self-efficacy: Clients demonstrate they’re capable of confronting their fears and managing their feelings, which improves their self-efficacy and confidence.
- Desensitization: Through gradual exposure to fears, clients lessen strong associations with their fears and feared outcomes.
- Cognitive restructuring: Desensitization and CBT can help to build more adaptive thoughts about fears.
- Increased control: By ranking their fears in a fear hierarchy worksheet, clients choose the order of exposure, enhancing their sense of agency.
- Reduced avoidant behaviors: Through gradual exposure, clients can no longer avoid feared situations.
- Enhanced self-awareness: The exposure process helps clients gain insight into their cognitive triangle (the connection between their beliefs, thoughts, and behaviors).
- Clearly defined path of treatment: Fear hierarchy worksheets clearly outline the treatment process, making it easier for clients to set and achieve their goals.
How to use the fear hierarchy worksheet
Therapists can use the fear hierarchy worksheet to:
- Identify and rank fears in order of severity using an exposure hierarchy worksheet
- Provide detailed descriptions of the fear, including thoughts and feelings associated with it
- Identify, teach, and practice coping strategies
- Create a target sequence or approach to exposure, such as graded exposure, which starts with the least challenging fear first
- To reflect on and track progress, such as recording the client’s response to treatment and decreased fears over time
Sources
- American Psychological Association. (2017). What is exposure therapy?
- Curtiss, J. E., Levine, D. S., Ander, I., & Baker, A. W. (2021). Cognitive-Behavioral Treatments for Anxiety and Stress-Related Disorders.
- Moses, K., Gonsalvez, C., & Meade, T. (2021). Utilisation and predictors of use of exposure therapy in the treatment of anxiety, OCD and PTSD in an Australian sample: a preliminary investigation.
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