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How to build an exposure ladder
A ladder is a list of things your child is avoiding, ordered from easiest to hardest, with a number on each one.
The format has been in use since the 1950s and it has not changed much, because the hard part was never the format. The hard part is writing steps that are small enough and specific enough to attempt.
Write steps you could watch happen
A step should describe an action, at a place, for a length of time. "Be braver about school" is not a step. "Sit in the car outside school for ten minutes on Tuesday morning" is a step, because you can tell afterwards whether it happened.
- Name the place. The parking lot, the front door, the second-floor bathroom, room 14.
- Name the length. Ten minutes, one period, one day, five days.
- Name what is dropped. No phone, no check-in text, no washing after.
- Keep one variable moving at a time, so a step that fails tells you which variable was the problem.
Rate every step 0 to 10
0 means your child could do it today without much thought. 10 means it is out of reach right now. Rate from your child's point of view, not your own: a step that looks trivial to an adult can sit at a 9. Your first guesses will be wrong in places, and the first real attempt will correct them.
If your child is old enough to rate the steps themselves, let them pick the number and do not argue it down. A 10 is information. It tells you the step is too big and needs splitting, which is a useful thing to find out on paper rather than at 7:40 in the morning.
Start low and repeat
Start at the bottom, not in the middle. Repeat a step until it stops being the hardest thing on the list; a common rule of thumb is to move on once the rating has dropped by roughly half. Repetition across different days, different rooms, and different people matters more than any single attempt going well.
Three things that stall a ladder
- Steps that are too big. If nothing on the list is under a 4, the list is missing its bottom half.
- Safety behaviours left in place. A step done while holding a phone, sitting by the door, or texting home has not really been done yet. Drop those one at a time as their own steps.
- Doing each step once. One good attempt is not the finish line. Repeat until it is boring.
Sources for this page
- Wolpe, J. (1958). Psychotherapy by Reciprocal Inhibition. Stanford University Press. The origin of the 0 to 10 subjective units of distress rating and of ordering exposure steps by that rating. The ladder in this tool is that idea, unchanged.
- Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10-23. Why fear dropping within a single attempt is not the thing that predicts lasting change. Variety, repetition in different contexts, and dropping safety behaviours matter more than waiting for the number to fall.