Initial Step in Hierarchy-Based Exposure Therapy
When exposing a patient to fear according to a hierarchy in exposure therapy, the initial step is to start with the least anxiety-provoking task from the hierarchy, though this does not need to be followed rigidly—tasks that are most likely to result in functional gains should be prioritized. 1
Constructing the Hierarchy First
Before any exposure begins, the patient must generate a comprehensive list of all feared situations and avoided behaviors, then rate how anxious they would feel confronting each one using an individualized anxiety scale (typically 0-10 with specific anchors). 1
Psychoeducation as Foundation
Prior to hierarchy-based exposure, patients require psychoeducation about anxiety habituation—specifically that when confronting a feared situation, anxiety initially increases but subsides naturally over time, and with repeated practice it extinguishes altogether. 1 This foundational understanding is critical because it prepares patients for the temporary discomfort they will experience during exposure. 2, 3
Starting Point on the Hierarchy
The standard approach is to begin with less anxiety-provoking tasks and gradually build up to more challenging tasks over the course of therapy. 1 This graduated exposure approach, also called systematic desensitization, trains patients to cope with stressors incrementally before actual exposure to the most feared situations. 1, 3
Important Caveat About Rigid Adherence
The hierarchy does not need to be followed rigidly—tasks that are most likely to result in functional gains should be prioritized over strict adherence to anxiety ratings. 1 This flexibility allows clinicians to target exposures that will most meaningfully improve the patient's quality of life and daily functioning.
Alternative Approach: Variable Exposure
While traditional graduated exposure is the standard, research suggests that random and variable exposure (not following a strict hierarchy) can be equally effective, with some evidence that greater variability in fear levels during exposure may predict better outcomes. 4 However, the graduated approach remains the guideline-recommended standard for clinical practice. 1, 2
Therapist-Assisted Implementation
Exposure tasks should be completed in-session with therapist assistance initially, then assigned as homework for practice between sessions to reinforce skills and generalize to the natural environment. 1, 2 This dual approach of in-session practice with between-session homework is essential for achieving the 40-87% remission rates demonstrated in controlled studies. 2, 3
Common Pitfall to Avoid
Do not assume relaxation training is necessary before beginning exposure—current mechanisms of change focus on extinction learning rather than relaxation as the central mechanism. 5 The goal is for the feared stimulus to no longer activate the fear circuit in the brain through repeated confrontation, not through achieving a relaxed state. 5