Avoidance Hierarchy (Archived)

The Avoidance Hierarchy helps clients identify and rank feared or avoided situations to support graded exposure in therapy.

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Full resource pack (PDF)

Everything you could need: a PDF of the resource, therapist instructions, and description with theoretical context and references. Where appropriate, case examples and annotations are also included.

Client version

Includes client-friendly guidance. Downloads are in Fillable PDF format where appropriate.

Exercise only (PDF)

A copy of the exercise in PDF format.

Fillable version (PDF)

A fillable version of the resource. This can be edited and saved in Adobe Acrobat, or other PDF editing software.

Editable version (PPT)

An editable Microsoft PowerPoint version of the resource.

Overview

Avoidance and safety-seeking behavior serves to maintain anxiety while exposure to feared stimuli/situations is an effective treatment for anxiety. This Avoidance Hierarchy CBT worksheet helps clients to plan exposure tasks.

Why Use This Resource?

The Avoidance Hierarchy helps therapists guide clients through exposure therapy effectively.

Structures exposure therapy by ranking feared stimuli.
Supports the process of gradual and repeated exposure.
Helps clients reduce avoidance and overcome their fears.

Key Benefits

Structure

Guides the assessment and ranking of feared stimuli.

Personalization

Tailors exposure exercises to individual client needs.

Progress

Helps monitor fear reduction over time.

Learning

Promotes understanding and revision of avoidance behaviors.

Who is this for?

Specific Phobias

Provides a roadmap for addressing fear-inducing stimuli like animals or heights.

Obsessive Compulsive Disorder (OCD)

Helps break down and prioritise obsessions for step-by-step exposure.

Social Anxiety Disorder (SAD)

Facilitates exposure to feared social situations.

Other Difficulties

The avoidance hierarchy can be used with other difficulties, including panic disorder and PTSD.

Integrating it into your practice

Identify

Determine the specific fear the client wishes to overcome.

Generate

Develop a comprehensive list of feared stimuli that the client avoids

Rate

Assign anticipated anxiety ratings to each item.

Rank

Order the list of stimuli.

Expose

Use the ladder to guide exposure exercises.

Theoretical Background & Therapist Guidance

The Avoidance Hierarchy is a worksheet used in cognitive behavioral therapy (CBT) that helps clients create a hierarchy of feared or avoided situations, ranging from the most anxiety-provoking at the top to the least feared at the bottom. In this process, clients are encouraged to rate their anticipated levels of fear, anxiety, or distress for each situation based on how distressing they think it would be to face that scenario.

The order of the items can be adjusted according to these anticipated fear ratings until a final hierarchy is established. Once completed, the avoidance hierarchy serves as a guide for a process known as graded exposure. Clients begin by facing the least feared items and gradually work their way up the hierarchy as they gain confidence.

Prior to implementation, it is important to discuss key principles of exposure with clients, such as staying in the situation without escaping and repeating each exposure multiple times to encourage desensitization.

What's inside

An introduction to avoidance and exposure.
A structured worksheet for creating a personalized avoidance hierarchy.
Therapist guidelines for using the resource with clients.
Key references and recommendations for further reading.

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FAQs

An avoidance hierarchy is a list of feared or avoided situations arranged from least to most distressing, based on anticipated anxiety ratings.

Exposure therapy involves methodically confronting fears, which helps desensitize the client to stimuli and diminish avoidance behaviors over time.

Begin with less feared stimuli to build confidence and gradually progress to more challenging exposures, adjusting the pace as needed.

Identify safety behaviors that clients use to cope with fears and encourage them to refrain from using them to maximize learning and anxiety reduction.

How This Resource Improves Clinical Outcomes

The Avoidance Hierarchy enhances the effectiveness of exposure therapy by:

Targeting individualized fears and avoidance patterns.
Tracking progress and fear reduction.
Helping clients to face their fears within a structured framework.

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References And Further Reading

Kircanski, K., Mortazavi, A., Castriotta, N. et al. (2012). Challenges to the traditional fear hierarchy in exposure therapy. Journal of Behavior Therapy and Experimental Psychiatry, 43, 745–751.

Unified Protocol For Transdiagnostic Treatment Of Emotional Disorders In Adolescents