Behavioral Interventions 241
Graduated versus Intense Exposure
Most clinicians conduct exposure in a graduated fashion guided by an exposure hierar-
chy. The hierarchy lists 10–20 situations relevant to the individual’s anxious concerns
that are associated with fear and avoidance ranging from mild to severe intensity. An
expected anxiety level rated on a 0–100 scale is estimated for each situation in the hier-
archy. Therapists begin exposure with one of the moderately distressing situations and
proceed as quickly as possible to increasingly more difficult situations (Antony & Swin-
son, 2000a; Kozak & Foa, 1997). Table 7.3 presents an illustrative exposure hierarchy
that could have been used with Maria in treating her social anxiety.
In this case example the cognitive therapist would begin with a moderately dis-
tressing situation such as “walking downtown alone on a busy street” or “meet with
friend at a café” and repeatedly assigns these exposure tasks until there was a significant
reduction in anxiety. Treatment would then progress to the next most distressing situ-
ation (e.g., “go shopping with a friend”). Appendix 7.1 presents an Exposure Hierar-
chy form for use in developing graduated exposure programs for anxious individuals.
Clients rank their experiences from least to most difficult in terms of associated anxi-
ety and avoidance. In addition, individuals are asked to note the core anxious thought
associated with each situation, although this might not be accessible until the individual
initially confronts the situation. Appendix 7.2 is then used to record both within- and
between- session exposure practice sessions. The information from the Exposure Prac-
tice Record can be summarized on the Empirical Hypothesis- Testing Form (see Appen-
dix 6.5) and used as a behavioral experiment for evaluating exaggerated threat- related
appraisals and beliefs and their alternative perspective.
table 7.3. maria’s illustrative exposure hierarchy of social situationsItems in fear hierarchyLevel of anxiety
(0= no anxiety to 100 =
maximum anxiety/panic)
Sitting at home talking to family 10
Going for a drive 15
Going for a walk around unfamiliar neighborhood
(minimal risk of meeting a familiar person)25Going for a walk around my neighborhood
(greater risk of meeting a familiar person)35Walk downtown by myself on busy street 40
Go to movies with a friend 55
Meet with friend in a café 55
Go shopping with a friend 60
Go shopping alone 75
Go grocery shopping alone 80
Go to a party with familiar people 90
Participate in a class or group 95
Make a speech 100