Anxiety Hierarchy Treatment: Coping With Fear Through Exposure Therapy

Therapists often use anxiety hierarchies as tools to help clients understand and overcome their fears and sources of anxiety. When used in therapy, an anxiety hierarchy can provide structure and a clear pace for the treatment. Although anxiety hierarchy treatment usually shouldn’t be attempted without the help of a licensed mental health professional, creating your own anxiety hierarchy may help you gain deeper insight into how your fears affect you. Practicing various relaxation techniques may also prove helpful. If you’re interested in trying anxiety hierarchy treatment, consider scheduling a session with an in-person or online therapist.

Exposure therapy: Using hierarchies to overcome fear

Exposure therapy is usually at the heart of modern psychology's approach to specific phobias. It has also been used effectively to treat generalized anxiety disorder, post-traumatic stress disorder, and obsessive-compulsive disorder. Exposure therapy can be highly adaptable and can be adjusted to fit any level of anxiety, from mild to severe. In clinical settings, therapists typically design a specific treatment that is paced with their client's unique needs. There can also be multiple approaches to initiating exposure based on the client's needs.

The first step to exposure therapy is often developing an exposure fear hierarchy, also known as an anxiety hierarchy or exposure hierarchy. An exposure hierarchy can be thought of as a core feature and fundamental tool a client and their clinician use to structure exposure therapy.

Developing your list of fear-provoking experiences for the anxiety hierarchy treatment

On the surface, an anxiety hierarchy usually isn’t difficult to develop. It can simply be a list of ways you could be exposed to your fear, along with the intensity of the distress for each situation. In clinical settings, anxiety hierarchies are often discussed in clinical terms. They can be used as treatment plans and often provide a valuable structure that can keep therapy on track.

However, anxiety hierarchies may serve another useful function inside and outside clinical settings. Anxiety hierarchies may allow you to analyze your fear critically, and the insight gained from developing your hierarchy may be useful. Here are a few examples of what you might learn from your anxiety hierarchy:

• Whether your fear is consistent across different settings
• Whether your fear is consistent across different emotional states
• Which situational factors mitigate your fear or increase it
• The level of impact your fear has had on your life

There are usually worksheets available to assist you in creating your anxiety hierarchy. You may discover that your fear has had a much more significant impact on you than you initially realized. If that is the case, consider working with a therapist to address your fears safely and productively.

Using exposure therapy and anxiety hierarchies to cope with the fear of social interactions

Examples of how anxiety hierarchy treatment is used for obsessive-compulsive disorder

A person who experiences intense anxiety related to obsessive-compulsive disorder (OCD) might experience anxiety surrounding fears of contamination and the need for cleanliness. Their hierarchy might look something like the following:

1. Thinking about touching a doorknob or surface that is considered dirty 
2. Seeing someone else touch a doorknob or surface that is considered dirty 
3. Watching a video about germs or contamination 
4. Touching a surface considered slightly dirty with one finger 
5. Touching a doorknob or surface considered dirty with one hand 

Many people create longer and more detailed hierarchies based on their unique experiences. The goal of writing out an anxiety hierarchy is usually to help the person experiencing a phobia establish what situations cause them to experience fear the most. Once a hierarchy is established, the person can avoid high-anxiety situations and begin treatment in situations that don't produce a strong fear response.

Techniques for overcoming difficult situations and disorders like obsessive-compulsive disorder or anxiety

In most cases, the goal is to slowly and steadily increase the amount a person is exposed to their fear or anxiety triggered by their mental state, like having obsessive-compulsive disorder or GAD, or different experiences in the past, although there can be other approaches. In clinical settings, for example, the exposure hierarchy essentially becomes the treatment plan for addressing a client's phobia. Some common techniques used in exposure therapy are listed below.

Graded exposure - the simplest form of exposure therapy

Graded exposure may be the simplest implementation of exposure therapy. The client generally starts at the least anxiety-provoking situation described in their anxiety hierarchy and slowly increases their exposure as they move forward. As they progress, their therapist normally provides support and helps them address specific concerns that may arise.

Systematic desensitization

Systematic desensitization typically combines graded exposure with relaxation exercises to make the exposure more manageable and recondition the source of the fear to be associated with relaxation, not anxiety. Systematic desensitization can be commonly confused with exposure therapy itself, but it represents only one type of behavior therapy and may not be suitable for all situations.

An example of how systematic desensitization can be applied in overcoming fear of heights:

• The person visualizes standing on a low step or viewing a picture of a tall building.

• Next, the individual might climb a small hill and stay on top for a few minutes.

• Finally, they progress to standing in higher locations or joining activities that involve heights like ziplining.

Exposure-response prevention for managing fear and anxiety in people with obsessive-compulsive disorder

Exposure-response prevention usually focuses on preventing specific behavioral responses to fear-inducing stimuli. It tends to be most used in the treatment of obsessive-compulsive disorder to reduce a client's compulsive behavior. However, it has also shown utility in treating specific phobias, and researchers continue to examine behavioral approaches to fear responses other than relaxation.

Flooding

Flooding tends to be the least-used technique in exposure therapy, but it can be effective in certain circumstances. In flooding, the client usually jumps immediately to the most anxiety-inducing end of their anxiety hierarchy. Imagine a person with a specific phobia of spiders. After consulting with a therapist, the therapist may bring a trained, defanged tarantula to the next session. The therapist may inform the client that the tarantula is harmless and remove it from its enclosure with the client's consent.

The therapist may then spend the session helping the client remain calm in the presence of the tarantula and may even encourage the client to touch or handle the spider. In this case, the therapist "floods" the client with their fears. If all goes well, the client may leave the same day with little to no fear of tarantulas. However, flooding is not often used because it typically carries a higher risk of worsening fear or anxiety than a gradual process.

Using exposure therapy techniques at home

Successfully completing exposure therapy normally requires the guidance of a qualified and licensed professional. For severe or intractable fears, the training and experience of a therapist or other mental health professional can be necessary to establish treatment plans, guide your anxiety hierarchy, determine the pace of exposure, and address underlying concerns that may arise.

While you generally shouldn't attempt to initiate a course of exposure therapy without the help of a professional, becoming aware of the techniques and skills learned from this therapy can be a proactive step. There are several techniques found in the therapy that can be used at home as effective self-care techniques for fear or anxiety. 

Using relaxation techniques - a critical component in systematic desensitization

Relaxation techniques can be critical to systematic desensitization, especially when experiencing unpleasant emotions. While they can frequently be used in therapy, relaxation techniques are commonly taught as self-care methods. A few common approaches are discussed below.

Progressive muscle relaxation

Progressive muscle relaxation may be one of the best-evidenced ways to relax quickly. You practice this skill in a setting designed to evoke a sense of calm, such as a dimly lit room with soft background music. To complete a course in PMR, you can begin by clenching your toes for a few seconds and releasing them. Take a deep breath as you do so. Then, work upward through your body, gradually clenching each muscle group. As a result, you may find you’re able to manage stress over the duration of the exercise.

Diaphragmatic breathing

Diaphragmatic breathing or belly breathing may be one of the simplest ways to relax quickly. Begin by taking a long, slow, deep breath in. It should take about four to six seconds. Hold your breath for a second or two, then release your breath as slowly as you inhale. 

Positive imagery

If fear is crowding your mind, try to think consciously of positive scenes that do not provoke fear. Going to your "happy place" can be an effective technique for preventing fear from escalating. It can also be combined with muscle relaxation or diaphragmatic breathing for added effect.

Seeking help online

If you've found that your fear is overwhelming or negatively impacts your day-to-day activities, even a single word of encouragement from a therapist may be empowering. Online therapy through platforms like BetterHelp can help you find the services of a licensed professional qualified to assess your phobias and initiate the appropriate treatment for you. Attending therapy online typically removes common barriers, like traveling to an office or being restricted to only nearby therapists. Depending on how your fears have impacted you, seeing a therapist from the comfort of your home may be helpful.

Evidence indicates that exposure therapy can be effectively administered online. Two large randomized controlled trials generally demonstrated similar outcomes for those who underwent eight to 12 weeks of online exposure therapy compared to those who attended therapy in person. At the end of treatment, both groups typically demonstrated a significant reduction in their symptoms. Follow-up research indicated that long-term treatment gains were normally equally maintained for both online and in-person therapies.