Using the Fear Hierarchy List in PTSD Therapy

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A fear hierarchy is a list you make of the triggers that make you feel afraid or anxious. After you write them down, you rank them--from the one that makes you feel least fearful or anxious to the one that scares you the most.

If you have posttraumatic stress disorder (PTSD), your list will likely be a catalog of situations, images, thoughts, memories, and other things related to your traumatic event.

When Is a Fear Hierarchy Used?

Typically used in exposure therapy for PTSD, a fear hierarchy is your guide to gradually exposing yourself to your PTSD triggers, starting with the least upsetting one and moving down the list.

The goal: reducing your avoidance of triggers over time--and experiencing more of life as a result.

For example, a woman who was raped may start off, at the beginning of her fear hierarchy, by watching television programs that include sexual assault. As she becomes more comfortable with seeing that experience, she moves down her list, gaining confidence, until she can successfully cope with her last item: actually visiting the place where her assault occurred.

What Is Exposure Therapy?

Exposure therapy is a behavioral treatment for PTSD that focuses on helping you “unlearn” learned behaviors (most commonly avoidance) that do little or nothing to help you cope with your frightening or anxiety-provoking PTSD triggers.

Of course, it’s understandable that, after a traumatic event, you might take action to avoid situations that appear threatening, even though they may not be. You naturally want to prevent your original trauma from happening again; it’s just that avoiding your fear and anxiety triggers isn’t an effective way to do it.

However, if you’ve been avoiding your PTSD triggers, don’t be down on yourself. Avoidance is a common safety-seeking, protective response. But it’s important to know that in PTSD, as avoidance behavior becomes more extreme, your quality of life may lessen.

  • For example, you could lose touch with family and friends or have problems at work or in relationships.
  • In addition, avoiding your PTSD symptoms can make them stick around longer or even get worse.

Fortunately, exposure therapy and the use of a fear hierarchy can be effective in helping you face your fears and anxieties and approach new experiences with more confidence.

In addition to the fear hierarchy, exposure-treatment therapists often use the following techniques.

In Vivo Exposure

In vivo exposure is directly facing your feared objects, activities, or situations under the guidance of a therapist. For example, a woman with PTSD who fears the location where she was sexually assaulted (perhaps the most frightening item in her fear hierarchy) may be assisted by her therapist in going to that location and directly confronting those fears--assuming it’s safe to do so.

Imaginal Exposure

Imaginal exposure may help you “directly” face your fear and anxiety triggers by calling them up in your imagination. Why use this technique instead of real-life approaches? One reason may be that the real-life situation is no longer available or too dangerous--for example, a traumatic combat experience.

Interoceptive Exposure

Interoceptive exposure was originally developed to treat panic disorder. However, it’s been successful in the treatment of PTSD as well.

This technique can help you face body symptoms you fear, such as shortness of breath or rapid heartbeat. For example, if you’ve listed shortness of breath on your fear hierarchy, your therapist may set up a safe and controlled situation in which you hyperventilate (take short, quick breaths), exercise until you're breathing rapidly, hold your breath, or breathe through a straw.

Should You Try Exposure Therapy?

Maybe you’re thinking that exposure therapy sounds scary in itself. (After all, you’ve probably worked hard to avoid your PTSD triggers.) But it’s really just like other treatments for PTSD that help you connect with and overcome situations, memories, thoughts, and feelings that frighten you and keep you from living a full life.

With your fear hierarchy to guide you, you’ll hopefully move through exposure therapy with confidence that you’re treating your PTSD effectively.

3 Sources
Verywell Mind uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Hendriks L, de Kleine RA, Broekman TG, Hendriks GJ, van Minnen A. Intensive prolonged exposure therapy for chronic PTSD patients following multiple trauma and multiple treatment attemptsEur J Psychotraumatol. 2018;9(1):1425574. doi:10.1080/20008198.2018.1425574

  2. NIMH. Post-traumatic stress disorder.

  3. Hofmann SG, Asnaani A, Vonk IJ, Sawyer AT, Fang A. The efficacy of cognitive behavioral therapy: A review of meta-analysesCognit Ther Res. 2012;36(5):427–440. doi:10.1007/s10608-012-9476-1

By Matthew Tull, PhD
Matthew Tull, PhD is a professor of psychology at the University of Toledo, specializing in post-traumatic stress disorder.