EXPOSURE hierarchy

“Whether you think you can, 

or you think you can’t

-you’re right.”

― Henry Ford



How do you know that things truly are as you think they are?


Can we truly predict the future with 100% Certainty?


What could the the result of changing your thinking?


An example

  • Suppose you have been having more headaches recently, and they are worse around brighter lighting and neck stiffness
  • Next time you see bright lights, how would you know you were ‘right-sizing’ (i.e., accurately estimating) the effect the lights will have?
  • What could be the consequence of overestimating the effect of the lighting?
  • How would your relationship to bright lights vary from other patients’ who have headaches?
    • Why the difference?
  • Would you notice it if your sensitivity had reduced by say 10%?
  • Would you be able to recognize if the lighting was not “destined” to create a headache this time?
  • Do you know what it would look like if the lighting was not as gripping as you thought it was?
  • What could be the consequences of changing your thinking? or what you pay attention to like the the task that waits for you on the other side of this well lit room?


Reality exists in our perception, not in the perception of the trigger

  • If we perceive a signal/stimulus as threatening, it becomes more threatening
  • If we focus on the part of our experience that is compatible with the experience we want right now, our chances are higher of experiencing that
  • There is neurophysiological backing for these statements, for example in headaches (Bingel and Tracey, 2008; Lorenz et al., 2003)


Look at the model below

  • Can you see the vicious cycle below?
    • we feel a sensation
    • we estimate the meaning of that sensation in the context of our lives to be worse than it otherwise needs to be
    • we get worked up about it and our fight-or-flight system gets revved up
    • we pay more attention to the sensation and what it means and recognize it’s getting worse
    • and the cycle continues
  • How do we break this cycle?
  • Would you be able to see the sensation as a sensation without adding “fuel to the fire” in the form of “catastrophically misinterpreting” the meaning of the sensation?
  • Where would you start in ‘not looking’ past the sensation step in the diagram below?
  • What if the approach is not in thinking about what you don’t want to see happen?

Rightsizing our fear response


If we wish to conquer undesirable emotional tendencies in ourselves,

we must assiduously, and in the first instance cold-bloodedly,

go through the outward motions of those contrary dispositions we prefer to cultivate.

—William James, MD, Father of Psychology



Look before you leap


  • A first step in restructuring how we relate to symptoms that we may be misinterpreting catastrophically is in checking it out.


  • How many neurologists do you need to see? And how many scans do you really need? In order to get on in a way that honours the way you would like to live your life.


  • Once it has been deemed that there is no medication, injection or surgery to fix your symptoms, it’s time to start retraining  the brain to function the way you would like for it to function.


  • If you could experience life the way you would like to experience it (perhaps again), would that not be a cure?


  • We have spoken about the functional model of medical illness(e.g., headache) in our article Headache Behavioural Therapy.

Think of a kid who scrapes her knee falling off her bike.

Is not one of the first things we do is to hug and kiss her?



In the short-term, there are thing you can do to make your situation better.

However, there is a sense of freedom to interrupting the vicious cycle at the sensation level (rather than at the catastrophic misinterpretation stage of the cycle).



The problem with avoiding the situation or using safety behaviours to protect yourself is the following:


1.  You do not give yourself the opportunity for corrective information about yourself and the situation.

e.g., Maybe there is a way you can get on with things by changing your reaction to your neck pain.


2. You don’t give yourself the opportunity to hone the skill of tolerating and coping with anxiety

Cognitive Approach (Top-Down)


1. Identify the symptom/situation to which you have an aversion

  • This is not the problem for most patients.
  • Most patients are hypervigilant for these symptoms; they have physiological hypersensitivity.


2. Create enough distance between

  • how you experience of the symptom; and
  • what you’re telling yourself about what that symptom means


3. Evaluate what we are telling yourself


4. Common Cognitive Themes

  • All-or-none thinking
    • Health perfectionism; Many of these patients are intolerant of uncertainty surrounding their health
    • e.g., “But what if …”+ any disastrous consequence


  • Emotional Reasoning is very common
    • If I’m afraid, that means there is something that to fear


  • Negative Filtering is very common
    • e.g., “Those sensations are dangerous until proven otherwise


Behavioural Approach (Bottom Up)


However, there is another way of making cognitive changes that does not involve cognitive strategies like Socratic Dialogue: Behavioural Approaches like an Exposure Hierarchy.


The best place to succeed is where you are with what you have.

-Charles Schwab


Some people call this “fake it till you make it”.



Understanding the physiology behind what you are experiencing helps improve your experience of the condition.

  • A theory as to why this is is because it reduces fear, and affective networks make the experience of pain and other symptoms worse
  • e.g., Women’s Health and Migraine Trial (Bond et al., 2018)


However, knowing the physiology behind your experience is not often necessary to function in a way that would please you again.


This is the premise of a functional model.

  • The South African Psychiatrist, Dr. Joseph Wolpe, who first brought forward systemic desensitization purported that if you break fear into steps, you can get used to it.


  • If we can weaken fears grips over us, we can “right-size” the experience of our situations.


Desensitization metaphor

  • Desensitization can be seen kind of like allergy shots
    • Although your head gets it that pollen is not really dangerous, your body seems to have a mind of its own
    • By slowly increasing our exposure to pollen, little-by-little, we can train our bodies to also see the pollen as benign


  • Desensitization can also be seen like a video game
    • Although you may know how to beat the level, it can be hard to do unless you break it down into baby steps
    • As you defeat smaller challenges, you finally make it to the end boss.

The premise of an exposure hierarchy is actually quite simple.

  1. You start off with a scale like the one seen in our Exposure Hierarchy Worksheet.
  2. You define what is the most distressing thing on the SUDS (Subjective Units of Distress Scale) scale (100/100)
  3. You define what 0/100 is.
  4. You define every rung of the scale (i.e., 10/100, 20/100, etc.)


In practice

Creating your exposure hierarchy can take a bit of time as you will have to rank different things in your life relative to one another in order to place them at the appropriate level on the Exposure Hierarchy Worksheet.




All of these methods take several sessions with a licensed professional to perform.

This information is very educational purposes.


Imaginal Exposure Therapy

1. Exposure

  • You have to imagine yourself exposed to something you actually fear or have an aversion to
    • something on your Subjective Units of Distress Scale Worksheet, starting at the bottom
  • This can be tricky because people may find it difficult to effectively visualize an aversive situation.


2. Fear

  • The body can’t maintain peak anxiety/fear for a prolonged period of time, it will eventually calm down
  • Sometimes that takes 90 minutes (i.e., for anxiety run it’s course and come all the way back down) to occur.


3. Corrective information

  • i.e., getting through the situation, the catastrophe you were expecting didn’t happen
  • This needs to happen while you are actually going through the thing to which you have an aversion


Prolonged Exposure Therapy

1. Exposure

  • You have to expose yourself to something you actually fear or have an aversion to
    • something on your Subjective Units of Distress Scale Worksheet, starting at the bottom


2. Fear

  • as for Imaginal Exposure


3. Corrective information

  • for Imaginal Exposure


Gradual Exposure Therapy

1. Relaxation

  • You start off in a state of relaxation (i.e., 0/100 on the Subjective Units of Distress Scale); this level of relaxation will be maintained for the whole exposure session


2. Exposure

  • You have to imagine yourself exposed to something you actually fear or have an aversion to
    • something on your Subjective Units of Distress Scale Worksheet, starting at the bottom
  • You need to have a good handle on relaxation skills
  • Once you can do that for a minute while maintaining your state of relaxation at 0/100 on the Subjective Units of Distress Scale, then we progress up the Exposure Hierarchy.
  • Once you have habituated to thinking about these things while in a state of relaxation, this exercise is progressed to actual exposure (rather than imaginal exposure), again, while you maintain a low level of relaxation through the entire exposure process


More details Explanation

  • The premise of this is to stay relaxed for the whole exposure session. That is, you will start out by performing a relaxation practice that keeps you at SUDS = 0. Ideally, you want to start at SUDS=0 and stay there for the whole experience.
  • Next, imagine something that you are in a situation that is the lowest on your Exposure Hierarchy Scale (i.e., SUDS=10) for 1 minute. If you get through that one minute without any distress, stop imagining it and focus on relaxing for the next 30 seconds.
  • We repeat this process up to 3 times (3 iterations).
  • If at any point during these iterations you feel distress, stop and go back to focusing on relaxing instead of imagining being in the distressing situation. Once SUDS=0, go back to where you left off in the imaginal exposure experience (i.e., if you stopped at iteration 2, go back to iteration 2).
  • You will not progress to the next level (i.e., SUDS=20) until you can perform 3 iterations of this practice without distress (i.e., while maintaining SUDS=0).
  • Before going on to the next level (i.e., SUDS=20), stop and relax for as long as you like.
  • When you progress to real-world exposures (i.e., rather than imaginal exposures), it’s important to have enough items on your Exposure Hierarchy Scale at the lower SUDS levels (i.e., 10, 20, 30). That is, it’s good to have a pyramid structure to your Exposure Hierarchy Worksheet (i.e., more items at the lower levels relative to the higher levels).


3. Corrective information

  • i.e., getting through the situation, the catastrophe you were expecting didn’t happen

1. Normalize the phobia

    • e.g., light sensitivity is a “real thing” in many headaches, there is no point criticizing yourself over it or taking all the blame upon yourself, you are not the cause of your situation.


2. Have a written rationale

    • It’s good to write out why you would like to overcome any response to a situation that is not helping you to live the way you would like to live
    • What is waiting for you on the other side of this hurdle?
    • e.g., To be able to go outdoors (where there is light) would allow me to do more things I enjoy again


3. Ensure there are at least 20 items


4. Include some exposure beyond what is normal

  • This is called overtraining
  • e.g., orthodontists leave braces on teeth for quite a while after the teeth have been straightened.


5. Schedule daily exposure, but not on holidays


6. Continue exposure until anxiety ↓ 50%

  • If you stop before this happens, it’s called sensitization
  • It would be kind of like stopping your antibiotics before you were instructed to (which could make the infection actually worse)


7. Assess success of exposure with respect to behaviour, not the emotion felt at the time

  • e.g., “I know it was hard, but you did it!”


8. Model 1st

  • Visualize first in detail the way you would like to see you behave in that situation


9. Be flexible

  • Setbacks are par for the course, i.e., Rome wasn’t built in a day
  • What’s important is the process; this is what sets the trend
  • Get back on the horse quickly


10. Have booster sessions often

  • Cultivate a self-exposure attitude, e.g., someone who has a fear of heights should make a point of taking the high road

Beck, J. S. (2011). Cognitive behavior therapyBasics and beyond (2nd ed.). Guilford Press

Bond, D. S., Thomas, J. G., Lipton, R. B., Roth, J., Pavlovic, J. M., Rathier, L., O’Leary, K. C., Evans, E. W., & Wing, R. R. (2018). Behavioral Weight Loss Intervention for Migraine: A Randomized Controlled Trial. Obesity (Silver Spring, Md.)26(1), 81–87. https://doi.org/10.1002/oby.22069

Bingel, Ulrike & Tracey, Irene. (2009). Imaging CNS Modulation of Pain in Humans. Physiology (Bethesda, Md.). 23. 371-80. 10.1152/physiol.00024.2008.

Dubord, Greg. (2011). Part 12. Systematic desensitization. Canadian family physician Médecin de famille canadien. 57. 1299.

Lorenz, Juergen & Minoshima, Satoshi & Casey, Kenneth. (2003). Keeping pain out of mind: The role of the dorsolateral prefrontal cortex in pain modulation. Brain : a journal of neurology. 126. 1079-91. 10.1093/brain/awg102.

Wolpe J. Psychotherapy by reciprocal inhibition. Palo Alto, CA: Stanford University; 1958.

Writing: Dr. Taher Chugh

Last update: March 2021