CBT Exposure Hierarchy: How to Build One Step-by-Step

CBT Exposure Hierarchy: How to Build One Step-by-Step

Avoidance is jet fuel for anxiety.

The more clients avoid feared situations, the scarier those situations feel — and the smaller their world becomes.

A CBT exposure hierarchy is a structured way to help clients gradually face fears, at a pace that feels challenging but safe. Instead of “throwing them in the deep end,” you walk up a ladder together, one step at a time.

This guide shows you exactly how to build an exposure hierarchy step-by-step, with examples you can use in session.

What Is an Exposure Hierarchy?

An exposure hierarchy is:

  • a ranked list of feared situations
  • ordered from least distressing to most distressing
  • used to guide gradual exposure work

Clients use it to:

  • face fears systematically
  • learn that anxiety peaks and falls
  • discover that feared outcomes often don’t happen
  • build confidence and reduce avoidance

It’s used for:

  • social anxiety
  • phobias (e.g., driving, flying, animals)
  • panic disorder
  • OCD (paired with ERP)
  • health anxiety
  • trauma-related avoidance (carefully, and usually as part of a larger trauma plan)

Principles of a Good Exposure Hierarchy

A good hierarchy is:

  • specific (not vague like “talk to people”)
  • graded (small steps, not giant leaps)
  • collaborative (client has buy-in)
  • numbers-based (using SUDS ratings, e.g., 0–10 or 0–100)
  • flexible (can be updated as you go)

Step 1: Choose the Target Fear

First, clarify what you’re building the hierarchy around.

Examples:

  • public speaking
  • eating in public
  • driving on highways
  • leaving the house alone
  • touching “contaminated” surfaces (OCD)
  • initiating conversations
  • being far away from “safe” people or places

You might say:

“Let’s pick one area where anxiety is really limiting you right now, and we’ll break it into small steps.”

Step 2: Brainstorm a List of Situations

Ask the client to list as many related situations as possible, from easier to harder — or just in any order for now.

For example, with social anxiety around talking to people:

  • making eye contact with a stranger
  • saying “hi” to a neighbor
  • asking a shop worker a question
  • making small talk with co-workers
  • sharing an opinion in a group
  • giving a brief update in a meeting
  • going to a social event alone
  • giving a short presentation

Don’t worry about the order yet — just get everything out.

Step 3: Assign SUDS Ratings (Fear Levels)

SUDS = Subjective Units of Distress Scale
You can use 0–10 or 0–100; 0–10 is easier.

Ask:

“If you imagine doing this, how anxious would you feel, from 0 to 10?”

Example for social anxiety (0–10 scale):

  • Make eye contact with a stranger → 3
  • Say “hi” to a neighbor → 4
  • Ask a shop worker a question → 5
  • Make small talk with a co-worker → 6
  • Share an opinion in a small group → 7
  • Go to a party for 30 minutes → 8
  • Give a short presentation at work → 9

You now have a rough exposure ladder.

Step 4: Order the Hierarchy from Easiest to Hardest

Reorder the list based on SUDS ratings.

Continuing the example:

  1. Make eye contact with a stranger (3)
  2. Say “hi” to a neighbor (4)
  3. Ask a shop worker a question (5)
  4. Make small talk with a co-worker (6)
  5. Share an opinion in a small group (7)
  6. Go to a party for 30 minutes (8)
  7. Give a short presentation at work (9)

This becomes your roadmap for exposure work.

Step 5: Choose a Starting Point (Not Too Easy, Not Too Hard)

Don’t start at 0–1 (too easy) or 9–10 (too overwhelming).

A good starting point is often 3–5/10 on the SUDS scale.

You might say:

“Which of these feels challenging but doable — something around a 3, 4, or 5 out of 10?”

Step 6: Plan the First Exposure in Detail

Get very concrete:

  • What exactly will you do?
  • Where?
  • For how long?
  • How many times this week?
  • What will you not do (safety behaviors to drop)?

Example:
Target: Ask a shop worker a question.

  • Location: local supermarket
  • Frequency: 3 times this week
  • Script: “Excuse me, do you know where the [item] is?”
  • Safety behaviors to reduce: rehearsing in head 20 times, apologizing excessively

Step 7: Do the Exposure and Track Anxiety

Ask clients to rate:

  • anxiety at the start
  • peak anxiety
  • anxiety after a few minutes
  • anxiety at the end

Clients usually discover that:

  • anxiety rises
  • plateaus
  • then drops — even if they don’t escape or avoid

This is habituation and new learning in action.

Step 8: Repeat Until Anxiety Drops, Then Move Up

Exposure is repetition-based.

Rough guide:

  • Repeat the same step until SUDS drops by at least 50% on average across attempts
  • Then move to the next step in the hierarchy

Example:

  • First time asking a shop worker: 7/10 → 5/10
  • Third time: 5/10 → 2/10

Now they’re ready to move up one rung.

Get our done-for you exposure worksheets

Example Hierarchies

1. Public Speaking Anxiety

0–10 SUDS scale:

  1. Read a paragraph out loud alone (2)
  2. Read a paragraph out loud to a friend (3)
  3. Ask a question in a small meeting (5)
  4. Share a short opinion in a meeting (6)
  5. Practice a 2-minute talk in front of a friend (7)
  6. Give a 2-minute update in a meeting (8)
  7. Give a 5-minute presentation to a small group (9)

2. Driving Anxiety (Highways)

  1. Sit in the parked car in the driveway (2)
  2. Drive around the block (3)
  3. Drive on quiet local streets (4)
  4. Drive on busier local roads (5)
  5. Drive on a short, quiet highway stretch (6)
  6. Drive one highway exit during non-peak times (7)
  7. Drive multiple exits at busier times (8–9)

3. OCD Contamination (with ERP Integration)

(This would usually be done as part of structured ERP with proper training.)

  1. Touch “mildly dirty” surface, wash immediately (4)
  2. Touch same surface, delay washing for 2 minutes (5)
  3. Touch bin lid, delay washing 5 minutes (6)
  4. Touch public door handle, wait 10 minutes (7)
  5. Touch public surface, wait 20+ minutes (8–9)

Here the hierarchy includes both contamination triggers and reducing compulsions (delaying or skipping washing).

Tips for Making Exposure Hierarchies Client-Friendly

  • Collaborate: never impose steps. Ask, “Does this feel realistic?”
  • Normalize discomfort: “Anxiety going up means the exercise is working.”
  • Remove safety behaviors gradually: like reassurance-seeking, distraction, or “escape plans.”
  • Celebrate effort, not outcome: showing up is success.
  • Adjust as you go: move steps up/down based on real experiences.
  • When an Exposure Hierarchy Isn’t Appropriate

Be cautious or use a modified approach when:

  • the client is in acute crisis
  • there’s active self-harm risk
  • trauma exposure is being considered without proper stabilization
  • the feared outcome is actually realistic and harmful (e.g., ongoing abuse, unsafe environments)

Exposure is not about forcing people into danger — it’s about teaching their nervous system that many “danger” signals are false alarms.

Read more CBT posts:

Simple Exposure Hierarchy Worksheet Layout

You can keep it to one page:

# Situation SUDS (0–10) Date Practiced SUDS Start / Peak / End Notes

 

FAQ Section (Exposure Hierarchy)

1. What is an exposure hierarchy in CBT?

An exposure hierarchy is a ranked list of feared situations, ordered from least distressing to most distressing. Clients use it to gradually face anxiety triggers and reduce avoidance in a structured, step-by-step way.

2. How do you build an exposure hierarchy with a client?

You identify the target fear, brainstorm related situations, assign fear ratings (SUDS), and then organize these into a graded ladder. The client starts with easier steps and works upward as their anxiety decreases.

3. Does exposure make anxiety worse?

Anxiety may temporarily increase during exposure, but this is normal and expected. Over time, repeated exposure helps the brain learn that the feared situation is safe, causing anxiety to decrease.

4. How long does exposure therapy take?

It varies. Some clients notice improvement within a few sessions, while others progress gradually over weeks. Consistency and repetition are key to reducing fear responses.

5. Can exposure hierarchies be used for OCD?

Yes—but typically as part of ERP (Exposure and Response Prevention). Clients face feared situations while reducing or delaying compulsions, allowing anxiety to naturally rise and fall without ritualizing.

6. Is exposure appropriate for trauma?

Exposure can be helpful in trauma therapy, but only when clients are stable, resourced, and working with a trained therapist. Trauma exposure should never be rushed or used before adequate grounding and safety planning.

Back to blog