Building a hierarchy for exposure therapy for social anxiety with examples
Building an exposure hierarchy is a critical part exposure therapy, which is a gradual and systematic approach to confronting fear. The goal is to help individuals face situations they avoid, starting with less intimidating scenarios and working up to more anxiety-provoking situations. Research shows exposure therapy is extremely effective for anxiety, social anxiety, OCD, phobias, and more.
While it can be intimidating to get started, I’ll guide you through the basic steps to help get you started. Exposure therapy is often done with the assistance of a therapist, but self-guided exposure if still very effective.
Here’s how to create your own exposure hierarchy step by step:
1. Identify Your Fears and Triggers
The first step in creating an exposure hierarchy is identifying the social situations that cause you anxiety. Start by brainstorming a list of situations that make you anxious, ranging from minor discomfort to severe fear.
Examples of Social Anxiety Triggering Situations:
Ordering food at a restaurant
Talking to a cashier
Attending a party
Giving a presentation at work
Asking a question in a meeting
Going to a social event alone
Attending a large gathering or wedding
2. Rate the Anxiety for Each Situation (0-100)
Once you’ve made your list, rate the level of anxiety each situation causes on a scale from 0 to 100. The number represents how intense the anxiety is for you, with 0 being no anxiety at all and 100 being the highest level of anxiety possible.
For example:
Ordering food at a restaurant: 30
Talking to a cashier: 40
Attending a party: 70
Giving a presentation at work: 90
This step helps to prioritize which situations to tackle first, starting with the less anxiety-provoking situations and gradually moving up to the more challenging ones.
3. Rank the List from Least to Most Anxiety-Provoking
Now, organize your list from the least anxiety-provoking situation to the most anxiety-provoking. This will form the foundation of your exposure hierarchy, which you’ll gradually work through.
Example of a Possible Exposure Hierarchy:
Ordering food at a restaurant – 30
Talking to a cashier – 40
Asking someone for directions – 50
Making small talk with a colleague – 60
Attending a small social gathering (with people you don’t know well) – 70
Attending a larger party or gathering – 80
Giving a presentation at work – 90
4. Set a Goal for Each Exposure
For each situation, set a clear goal. This helps you focus on your specific objective, whether it's simply facing the situation or doing something more specific, like initiating a conversation or staying in the situation for a set amount of time.
Example Goals:
For ordering food at a restaurant, the goal might be: "I will order food without rushing or avoiding eye contact."
For attending a small social gathering, the goal might be: "I will talk to at least two people at the event, even if it’s just small talk."
5. Plan the First Exposure
Start with the least anxiety-provoking situation from your hierarchy. Choose a manageable exposure that feels challenging, but still doable. For your first exposure, it’s important not to overwhelm yourself.
For example, if you rated “ordering food at a restaurant” a 30, your first step could be something like going to a restaurant and ordering food. You don’t need to go beyond that at first. The goal is to gradually desensitize yourself to the experience, so you don’t have to do too much at once.
Example:
Exposure Goal: Go to a restaurant, order food, and stay calm.
Action Plan: Go to a fast-casual restaurant where there isn’t too much pressure. Try to maintain eye contact with the cashier and speak clearly when placing your order.
6. Practice the Exposure
The key to exposure therapy is repetition. The more you expose yourself to a feared situation, the less anxiety it will provoke over time. After completing the first exposure, rate your anxiety again on the 0-100 scale. You may notice that the anxiety goes down after the exposure, and this is normal.
It’s helpful to practice the same exposure several times before moving on to the next level in your hierarchy. Consistency is crucial in breaking the avoidance cycle.
Example:
Repeat Exposure: Go back to the same restaurant and order food again, this time trying to remain more relaxed or adding a small new step (e.g., making casual small talk with the cashier). Continue this until your anxiety decreases.
7. Gradually Move Up the Hierarchy
Once the first situation feels more manageable, move to the next item on your list. Each step should be progressively harder, but it’s important to pace yourself. You don’t need to rush through the hierarchy, and some steps may require more time or repeated exposures before you feel comfortable moving forward.
Example:
After you've become comfortable ordering food, you might tackle talking to a cashier, which might feel slightly more anxiety-provoking. Gradually add in small, manageable steps to keep pushing your boundaries.
8. Evaluate Progress
After completing each exposure, evaluate how well you handled it. Did your anxiety decrease from before the exposure? Did you manage to stay in the situation long enough? If so, you’ve made progress! If not, that’s okay too—consider whether the exposure was too difficult and make adjustments for next time.
9. Keep Track and Adjust the Hierarchy as Needed
As you progress, it may be necessary to adjust your hierarchy. Sometimes, a situation that initially feels too difficult can become manageable with practice. Or, you may need to break down a step into smaller, more gradual exposures. Flexibility is key.
For example, if you find that "making small talk with a colleague" feels overwhelming, you might break it down into smaller steps like “greeting a colleague in the hallway” or “asking a colleague about their weekend.”
Final Thoughts
The goal of building an exposure hierarchy is to reduce avoidance and gradually build confidence in facing anxiety-provoking situations. The process requires patience, practice, and persistence, but by taking small, manageable steps, you’ll gradually diminish the power of your social anxiety. As you progress, you’ll learn that many of your fears are not as threatening as they seem, and that you are capable of handling situations that once felt overwhelming.
Remember to be kind to yourself and celebrate the small victories along the way!
Reach out to Meghan Cromie LPC, an ERP specialist who can guide you through the process.
