Fear Ladder

[The fear ladder] has long been a standard tool in cognitive behavior therapy (CBT) and considered to be an integral component of any exposure-based treatment.

(Katerelos et al., 2008)

Exposure treatments are designed to reduce fear and anxiety by asking individuals to repeatedly face their fears, by either imagining or directly confronting them while remaining psychologically engaged (Magee, Erwin & Heimberg, 2009). Exposure aims to reduce the client’s fearful responses and reverse the patterns of avoidance that perpetuate the fear (Springer & Tolin, 2020). It is one the most effective interventions for overcoming fear (Kaczkurkin & Foa, 2022; Hofmann & Smits, 2008), and is the first-line treatment for some anxiety disorders (e.g., obsessive compulsive disorder: NICE, 2005). 

Exposure-based interventions have been incorporated into several therapies, most notably cognitive behavioral therapy (CBT), and can take several forms.

• In-vivo exposure: The client confronts their fear in real life. These fears may include objects, situations, bodily sensations (‘interoceptive exposure’), and thoughts.
• Imaginal exposure: The client confronts their fear using their imagination or a narrative form (e.g., re-reading a written description of their fear). Imaginal exposure is often used when exposure is impractical or impossible (e.g., the client’s fear relates to a traumatic event that has already occurred, or potential disaster that is improbable but nonetheless feared).
• Virtual reality exposure: This client faces their fear using virtual reality (e.g., giving a presentation to a computer-generated crowd of strangers). Like imaginal exposure, virtual reality is often useful when in-vivo exposure is difficult to facilitate.

Theoretical accounts of exposure-based treatments have developed over the past century. The influential emotional processing theory (Foa & Kozak, 1986) proposes that fear is represented by associative networks that maintain information about the feared stimulus, behavioral fear responses, physiological fear responses, and the meaning of the stimuli and responses. When an individual encounters a stimulus that resembles the feared stimulus, the fear representation is activated. Kaczkirkin & Foa (2022) propose that a fear structure is pathological when “the relationship among stimuli, responses, and their meaning do not match reality, such as when it is activated for safe stimuli” and that the fear structure is maintained by avoidance behaviors, which prevent new learning from occurring. According to the emotional processing theory account, exposure modifies the pathological fear structure by first activating it, and then providing new information that disconfirms inaccurate or pathological associations in the fear structure. Emotional processing theory suggests that within-session habituation leads to between-session habituation, and subsequently longer-term change, although more recent research suggests that habituation is not a strong predictor of treatment effectiveness.

An alternative account of exposure therapy is provided by inhibitory learning theory (ILT: Craske et al, 2008; Tolin, 2019). ILT proposes that the threat association learned during fear acquisition is not erased, replaced, or modified by new learning during exposure. Instead, the fear-inducing stimulus becomes ambiguous, with two meanings that both live in memory and compete for retrieval. Craske describes how a client might “enter therapy with a threat expectancy, such as ‘If I panic, I might die’ or ‘If I am socially rejected, it would be unbearable’. As a result of exposure therapy, a competing non-threat expectancy develops, such as ‘If I panic, I am unlikely to die’ or ‘If I am socially rejected, I will survive’. After completion of exposure therapy, the level of fear that is experienced when the stimulus is re-encountered is dependent upon which expectancy is activated. Activation of the original threat expectancy will enhance the expression of fear, whereas activation of the exposure-based non-threat expectancy will lessen fear expression.” Inhibitory learning theory helps to explain why fear can return easily, even in people who have successfully completed treatment, and why habituation does not seem to be important for exposure therapy to be effective. While the mechanisms of action underlying exposure are debatable (e.g., emotional processing versus inhibitory accounts of exposure), the stages of exposure as it is currently practiced are relatively consistent:

• Stage 1: The client identifies a fear stimulus they are willing to confront.
• Stage 2: The client describes what they expect will happen when they face the stimulus.
• Stage 3: The client exposes themselves to the stimulus for a prolonged period, without distraction. 
• Stage 4: Changes in the client’s fear levels are monitored throughout.
• Stage 5: After exposure, the client and therapist reflect on what has been learnt (e.g., whether the stimulus is as dangerous as the client initially thought).
• Stage 6: Exposure is repeated.

Exposure is usually preceded by the development of a fear ladder (sometimes referred to as an “exposure hierarchy”: Beck et al., 1985). Fear ladders are an idiographic list of stimuli (e.g.,activities, situations, or sensations) that generate fear for the client and are avoided. Once the list is generated, items are ranked and ordered according to the level of fear they generate. Fear ladders have many applications in therapy, including:

• Setting goals for treatment (e.g., situations where the client wants to feel comfortable).
• Assessing when and where the client struggles with fear.
• Identifying the areas of difficulty which are most relevant to the client.
• Deciding which exposure exercises will be implemented.
• Pacing exposure so that the client is not overwhelmed.
• Tracking progress.

How clients ‘climb’ their fear ladder during exposure varies according to the theoretical framework informing its use. Traditionally, clients have been encouraged to face their fears in a graded manner, starting with lower items on their ladder (i.e., graded exposure therapy). Once anxiety has diminished (i.e., the client habituates to the stimulus), they move ‘up’ their ladder and face a more threatening item. Each step is repeated until habituation occurs (Knowles & Olatunji, 2019). Beck and colleagues (1985) suggest that these “successive approximations to a goal” (p.265) are helpful because they break difficulties down into manageable steps and prevent clients from moving ahead too quickly (which may backfire). Other rationales for graded exposure include increasing client buy-in, the motivating effects of successfully confronting less threatening stimuli, and maximizing habituation and emotional processing during exposure (Foa & Kozak, 1986; Watts, 1971). 

More recently, inhibitory learning models have emphasized the importance of variability during exposure (Craske, 2015). For example, clients might be encouraged to face different types of feared stimuli in various contexts (e.g., in the therapist’s office, at home, etc.). Regarding the fear ladder, variability would entail exposing the client to items in a random order rather than working up the list in a graded, predictable manner. Inhibitory learning suggests that variability helps maximize learning during exposure, increases clients’ fear tolerance, and strengthens new associations between the feared object and the non-occurrence of negative outcomes (i.e., safety learning) (Knowles & Olatunji, 2019). Research indicates that variable exposure may have an advantage over non-variable (i.e., graded) approaches to exposure (e.g., Kircanski et al., 2012). However, Craske (2015) recommends that exposure should still begin with clients’ least feared items, to minimize the risk of treatment refusal.

1. Identify the fear the client wants to overcome. Ensure that the fear is clearly specified. For example, “My fear of dogs” will help generate a more relevant and informative list than “My fear of pets”.
   • What are you afraid of?
   • Tell me about the fear that is getting in the way of your life
   • What fear do you want to overcome?
2. Generate a pool of feared stimuli. Depending on the client’s fears, items for the ladder may include situations, activities, thoughts, or sensations. The ladder prompts clients to think of stimuli that are mildly, moderately, and highly threatening. If the client finds it difficult to generate items, consider using the following prompts:
   • Are there things you don’t currently do because of your fear?
   • What would you like to feel comfortable doing?
   • What scary things can you only do if absolutely necessary?
   • What is the scariest situation you can possibly imagine?
   • What specific situations are you avoiding because of your fear?
   • What situations related to your fear do you find challenging to confront?
3. Exploring factors that would make each item easier or harder to confront (e.g., being near or far from the thing, facing it alone or with a loved one, etc.) can also help to elaborate the list. Safety behaviors are things that people do to cope with their fear when they can’t avoid. Clients will often report that safety behaviors make them feel better, or reduce their anxiety. However, the unintended consequence of using safety behaviors is that theyprolong fear by preventing clients from learning that they can face their fear without negative consequences. It is therefore worth exploring the client’s safety behaviors when creating a fear ladder.
   • What do you do to cope or feel safe when you can’t avoid?
   • When you’re worried about <client’s fear> but you can’t avoid it, what do you do to prevent the worst from happening?
   • How much fear would you feel if you were asked to do with that safety behavior? What if you didn’t use it?
4. Give each item a predicted fear rating. We suggest asking clients to rate their predicted fear level, but some therapists may prefer to use subjective units of distress (SUDS) (Wolpe, 1990). Using anchors can give the scale some context. For example, a rating of 100 might represent “the most intense fear I can imagine”, while 0 would mean “no fear whatsoever”.
   • How much fear do you think you would feel if you were in that situation right now?
5. Put the list in rank order. As a final step, put the activities in order. The scariest stimulus should go at the top of the ladder, and the least scary should go at the bottom.

• Beck, A. T., Emery, G., & Greenberg, R. L. (1985). Anxiety disorders and phobias: A cognitive perspective. Basic Books.
• Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46(1), 5-27.
• Craske, M. (2015). Optimizing exposure therapy for anxiety disorders: an inhibitory learning and inhibitory regulation approach. Verhaltenstherapie, 25, 134-143. DOI: 10.1159/000381574.
• Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20–35, https://doi.org/10.1037/0033-2909.99.1.20
• Hofmann, S. G., & Smits, J. A. (2008). Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. Journal of Clinical Psychiatry, 69(4), 621.
• Kaczkurkin, A. N., & Foa, E. B. (2022). Cognitive-behavioral therapy for anxiety disorders: an update on the empirical evidence. Dialogues in clinical neuroscience.
• Katerelos, M., Hawley, L. L., Antony, M. M., & McCabe, R. E. (2008). The exposure hierarchy as a measure of progress and efficacy in the treatment of social anxiety disorder. Behavior Modification, 32, 504-518. DOI: 10.1177/0145445507309302.
• Kircanski, K., Mortazavi, A., Castriotta, N., Baker, A. S., Mystkowski, J. L., Yi, R., & Craske, M. G. (2012). Challenges to the traditional exposure paradigm: Variability in exposure therapy for contamination fears. Journal of Behavior Therapy and Experimental Psychiatry, 43, 745-751. DOI: 10.1016/j.jbtep.2011.10.010.
• Knowles, K. A., & Olatunji, B. O. (2019). Enhancing inhibitory learning: The utility of variability in exposure. Cognitive and Behavioral Practice, 26, 186-200. DOI: 10.1016/j.cbpra.2017.12.001.
• Magee, L., Erwin, B. A., & Heimberg, R. G. (2009). Psychological treatment of social anxiety disorder and specific phobia. Oxford handbook of anxiety and related disorders, 334-349.
• National Institute for Health and Clinical Excellence. Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. London: NICE, 2005. (Clinical guideline 31.)
• Springer, K. S., & Tolin, D. F. (2020). The Big Book of Exposures: Innovative, Creative, and Effective CBT-Based Exposures for Treating Anxiety-Related Disorders. New Harbinger Publications.
• Tolin, D. F. (2012). AARP Face Your Fears: A Proven Plan to Beat Anxiety, Panic, Phobias, and Obsessions. John Wiley & Sons.
• Tolin, D. F. (2019). Inhibitory learning for anxiety-related disorders. Cognitive and Behavioral Practice, 26(1), 225-236.
• Watts, F. (1971). Desensitization as an habituation phenomenon: I. Stimulus intensity as determinant of the effects of stimulus lengths. Behaviour Research and Therapy, 9, 209–217, https://doi.org/10.1016/0005-7967(71)90006-4
• Wolpe, J. (1990). The practice of behavior therapy (4th ed.). Plenum.