Exposure Record: Practitioner Guide

The exposure hierarchy worksheet forms the basis of a structured tool for implementing exposure-based interventions in CBT. The process requires clients to gradually confront anxiety-provoking situations in a graded, planned way. By experiencing gradual reduction in anxiety over time, the client is helped to build confidence and willingness to manage anxiety-provoking situations effectively.

CLINICAL EVIDENCE BASE

The effectiveness of exposure therapy is supported by multiple lines of evidence:

  • Exposure therapy is an effective treatment for many anxiety disorders, with large effect sizes (Abramowitz et al., 2019).
  • Several systematic reviews show efficacy with specific phobias, social anxiety, and panic disorder (Choy et al., 2007; Mayo-Wilson et al., 2010; Sanchez-Meca et al., 2010).
  • Prolonged exposure therapy appears to be efficacious in the treatment of PTSD (Powers et al,. 2010).

WORKSHEET USES

When to Use

  • For treatment goals focused on reducing avoidance of anxiety triggers
  • Where the client wishes to enter situations that are currently avoided, or endured with great distress.
  • Treatment of specific phobias.
  • To reduce anxiety in social situations
  • Treatment of panic disorder and agoraphobia
  • Treatment of other disorders and problems where exposure is indicated as an important intervention component.

EMOTIPAL WORKSHEET STRUCTURE

Task - 8 columns

Once you have identified a key fear (e.g., fear of being evaluated by others in public) you should work with the client to list a full list of specific anxiety-provoking scenarios related to the key fear. You should then rank these scenarios in ascending order using the SUDS rating (as per below). You can then use this activity worksheet to plan and conduct exposure exercises.

Situation

SUDS Rating

Plan

Anxiety Before

Anxiety During

Anxiety After

Notes

List situation that triggers anxiety in relation to a key fear

Use the Subjective Units of Distress Scale (SUDS) to rate the intensity of distress for the situation listed (0= no distress, 100 = extreme distress)

Record exposure plan related to this situation. Specify date, time, duration, coping strategies, required SUDS score change, etc.

Record SUDS rating immediately before entering the planned exposure activity

Record peak SUDS score while conducting the exposure exercise

Record SUDS score immediately after the exposure exercise. Note that a client should normally persist with the exposure exercise until SUDS score has reduced by at least 50%

Record key additional pieces of information, such as important observations, learning points. etc.

TROUBLESHOOTING

Common Challenges and Solutions

Large gaps in SUDS when listing feared scenarios

  • Add intermediate steps or challenges
  • Break challenging situations into component steps, behaviours, or components

Avoidance and other safety behaviours during exposure exercises

  • Provide additional management strategies to substitute for safety behaviours
  • Perform intermediate exposure exercises with lower SUDS

Insufficient exposure duration

  • Provide intermediate exposure exercises with lower SUDS, then return to more challenging tasks
  • Use positive coping statements and other strategies to facilitate anxiety tolerance
  • Use prior success to demonstrate anxiety reduction through prolonged exposure

Limited between session practice

  • Identify and problem-solve barriers
  • Incorporate motivation enhancement strategies and social support

References

Note: While this guide references various studies, practitioners should verify current research as the field continues to evolve. The core principles remain well-established in the literature and clinical practice.

Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2019). Exposure therapy for anxiety: Principles and practice (2nd ed.). Guilford Press.

Choy, Y., Fyer, A. J., & Lipsitz, J. D. (2007). Treatment of specific phobia in adults. Clinical Psychology Review, 27(3), 266-286.

Mayo-Wilson, E., Dias, S., Mavranezouli, I., Kew, K., Clark, D. M., Ades, A. E., & Pilling, S. (2014). Psychological and pharmacological interventions for social anxiety disorder in adults: A systematic review and network meta-analysis. The Lancet Psychiatry, 1(5), 368-376.

Powers, M. B., Halpern, J. M., Ferenschak, M. P., Gillihan, S. J., & Foa, E. B. (2010). A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clinical Psychology Review, 30(6), 635-641.

Sánchez-Meca, J., Rosa-Alcázar, A. I., Marín-Martínez, F., & Gómez-Conesa, A. (2010). Psychological treatment of panic disorder with or without agoraphobia: A meta-analysis. Clinical Psychology Review, 30(1), 37-50.

Template Information Block

The exposure record helps you systematically confront anxiety-provoking situations in a gradual, manageable way. This worksheet guides you through planning and tracking exposure exercises—situations that trigger your anxiety that you'll intentionally face to reduce fear over time. For each situation, you'll rate your distress level (SUDS), create a specific exposure plan, and track your anxiety before, during, and after each exercise.

By repeatedly facing feared situations and staying in them until your anxiety naturally decreases, you'll learn that these situations aren't as dangerous as anticipated and that your anxiety will subside without avoidance. This process builds confidence and reduces avoidance behaviors that maintain anxiety. Your practitioner will help you develop an appropriate hierarchy of situations and support you through each step of the exposure process.

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