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,

“We’ve talked about how exposure can help people overcome their fears and what it involves. I’m glad you’re willing to try it for yourself. Before we use it, I’d like to show you a Fear Ladder. A Fear Ladder is a list of things that scare you, and which you’d normally prefer to avoid. We can use this list to guide what you’ll need to expose yourself to at which time, so that you can overcome your fear. Can we look at it together?”

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?

• 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