Behavioral Therapies for Anxiety

Learning Objectives

  • Understand the principles of behavioral therapy for anxiety disorders.
  • Learn about different exposure methods including in vivo and imaginal exposure.
  • Learn how to create and apply desensitization hierarchies in therapy.

Behavior refers to what you actually do. Behavioral therapy can be conceptualized as no-nonsense, as a trial-by-fire, as what happens when the rubber hits the road. Behavioral therapy is about what you do in the real world and it’s consequences. As such, behavior is the whole point of therapy. Whatever your anxiety is preventing, that’s what needs to happen (or not happen) for the therapy to be considered successful. That’s what you need to work on. Behavior therapy treats phobias and panic, but can be used with any anxiety disorder.

Since behavioral therapy relies on what happens in the real world, it requires exposure. Almost all therapies for the anxiety disorders involve exposure in one form or another. This means facing whatever is causing your anxiety. Exposure creates discomfort, and the person endures the discomfort. Eventually, your nervous system learns that the feared situation is actually safe.

The real question is how to do exposure and at what pace. If exposed too quickly, your anxiety could become so intense that you feel overwhelmed and discouraged. For example, if you drive twenty miles to avoid bridges, then actually driving over a bridge means the therapy is working. But you have to crawl before you can walk. So you don’t take on the bridge in your first attempt. That would lead to intense anxiety, possible panic, and maybe dropping out of therapy. Instead, you get some success under your belt and grow your courage to take on bigger challenges. You and your therapist design an exposure plan together, using the techniques below.

Desensitization Hierarchies

For exposure therapy, you and your therapist create what is known as a “desensitization hierarchy.” First, you brainstorm a list of behaviors that provoke anxiety or fear. Just list them out, taking care to include items that cause just a little anxiety, items that cause moderate anxiety, and items that cause extreme anxiety. Next, rate each item from zero to one hundred in terms of “subjective units of distress,” called SUDs. Zero means no anxiety at all. One hundred means the most anxiety that you could ever imagine. This transforms your distress into a number. The items can now be ordered from least distressing to most distressing. This is the hierarchy.

A good desensitization hierarchy consists of items that span low, moderate, and high levels of anxiety or challenge. You start at the bottom and practice putting yourself in each anxiety-provoking situation. You experience anxiety, which gradually subsides. This way, you experience some success, and increase your self-efficacy, that is, your confidence about the treatment and about your ability to handle the anxiety. When the anxiety has subsided enough, you move on to the next item up the hierarchy, in the list. The fundamental idea is to allow yourself to experience a moderate level of anxiety at each step.

Imaginal Exposure

Imaginal exposure is exposure in imagination. Since imagination is not reality, imaginal exposure is less anxiety-provoking than in vivo exposure. Imaginal exposure is a good choice where fear is especially intense, or where in vivo exposure is impossible, impractical, or inconvenient.

Case Example: Exposure With Phobia

Here’s a real example from my caseload:

A client came in with a fear of flying and a fear of airports. She was a world traveler who had many trips to Europe, and in two months she was supposed to fly to Europe again. So why the sudden fear of airports? Terrorism had been in the news, and for some reason, she had become very concerned. Terrorists could bomb an airport or hijack a plane. Yes, she knew that was improbable, but it still worried her. The more she thought about it, the more her worries generalized. There were many scenarios, but she especially feared that she would not be allowed to re-enter the United States trying to come through immigration. Something would go wrong with her passport and she would be detained.

She recognized that the fear was irrational. There were no potentially traumatic events, like excessive flight turbulence, in her past. She had never been detained previously. She had experienced flight delays, but nothing too serious. She agreed that even if she was detained upon reentering the United States, it wouldn’t last forever. In the worst case, she would miss her connecting flight back home and would be delayed a day.

And yet, the client was certain she would not be able to board her flight, coming up in just two months. The fear would be too strong. The nearest large airport, suitable for in vivo exposure was over an hour away. Possible, but impractical. So what to do? We decided on imaginal exposure.

I also warned the client that sooner or later, these sessions would become boring. Anxiety and boredom are incompatible: Anxiety is a state of being excessively alert to threat. As such, one cannot be both bored and anxious at the same time. Boredom means the treatment is working. Just as a practical matter, it’s much better to instruct clients that they will become bored rather than have them drop out of therapy.

Over the next month, at two sessions per week, the client and I went through every conceivable catastrophic scenario. She sat on the couch and listened. I described these scenarios in great detail, while she turned them into videos in her mind. In one scenario, the pilot announced that the landing gear had a problem. The runway was being foamed, the plane would land on its belly, and passengers would deplane by sliding down an inflated chute. In another scenario, the plane had to land on a highway. In another scenario, there was as fight between an irate passenger and a stewardess. In another scenario, the client was detained by homeland security and interrogated. She was forced to sleep in a small room overnight while her credentials could be validated. Describing each scenario, I could see her body stiffen as the anxiety became more and more intense. We adopted a signal: As she approached the panic point, she’d lift her hand. That let me know when to stop talking.

Two months later the client boarded her departing flight to Europe with no anxiety. Upon her return, she called from the airport. Everything had gone smoothly. More importantly, she had experienced no anxiety at all. She had already lived through the worst possible scenarios in her mind. In comparison, reality was boring.

In Vivo Exposure

In Vivo is a Latin phrase that means “in real life.” So in vivo exposure means facing your fears in real life. Imaginal exposure is often combined with in vivo exposure when in vivo exposure alone would be too threatening, too big a step.

Case Example with Panic Disorder

An example comes from a young lady who showed up in my office experiencing, on average, two panic attacks per day. She went to work and went home. At work, she would lock herself in a closet, silently ride out the attacks, and eventually recover enough to show her face again. Her boss understood her situation and was sympathetic. Outside work, she couldn’t go anywhere without her boyfriend. She usually experienced a panic attack when going to any local store. Her anxiety hierarchy involved driving to CVS and Walgreens, then working up to going inside, then working up to standing in line and buying something, then doing the same at Target and Wal-Mart. That’s in vivo exposure.

One day she came in and said that her friends were planning a trip to Washington, DC. She wanted to go, but she knew that would involve riding the subway, and for her, the subway was a crowded, closed-in place of dread, a worst-case scenario. Even after extensive imaginal exposure, she was still having panic attacks to her subway fantasies. She was on the fence about canceling the trip. In the end, however, she decided that she was tired of letting panic control her life. She would do her own in vivo exposure. Once in Washington, she rode the subway over and over and over again, until the panic subsided to nothing. This gritty attitude was a turning point. She was so tired of panic attacks.

Upon her return, we made a new hierarchy consisting of local stores that still evoked anxiety. I expected that it would take weeks to months for her to work her way through. The next week she came in, explaining that she’d finished the whole hierarchy. She had just toughed out the anxiety for every item on the list. We constructed another anxiety hierarchy, which she also finished in a week. She was now literally fearless. No more panic attacks. Her therapy was done.

Combining Imaginal and In Vivo Exposure

No hard and fast rule in psychotherapy says, for example, that “Every item in the desensitization hierarchy must be subjected to imaginal exposure, followed by in vivo exposure.” Instead, the purpose of therapy is to construct a situation the provokes a moderate amount of anxiety that the client can tolerate, that the client will allow themselves to experience. A client might start with imaginal exposure and quickly progress to in vivo exposure. Or not. The level of challenge can be calibrated to the client’s individual fears and circumstances.

Reading Comprehension Questions

1. What is the main objective of behavioral therapy for anxiety disorders?

  • A. To avoid situations that provoke anxiety.
  • B. To change thought patterns around anxiety.
  • C. To face and endure the situations that provoke anxiety.
  • D. To eliminate all sources of anxiety.

2. What is a desensitization hierarchy?

  • A. A list of behaviors that provoke anxiety, ordered from least to most distressing.
  • B. A list of behaviors that are to be completely avoided.
  • C. A ranking of different types of anxiety disorders.
  • D. A measure of a patient’s progress in therapy.

3. What is the purpose of imaginal exposure?

  • A. To avoid facing real-life situations that provoke anxiety.
  • B. To gradually introduce the patient to anxiety-provoking situations in a less intense manner.
  • C. To strengthen the patient’s imagination and creativity.
  • D. To test the patient’s ability to differentiate reality from imagination.

4. What does in vivo exposure involve?

  • A. Avoiding real-life situations that provoke anxiety.
  • B. Imagining anxiety-provoking situations.
  • C. Facing anxiety-provoking situations in real life.
  • D. Reducing exposure to anxiety-provoking situations over time.

5. How should a patient progress through a desensitization hierarchy?

  • A. They should tackle the most distressing item first.
  • B. They should progress from the least to the most distressing item.
  • C. They should choose the item they want to tackle at any given time.
  • D. They should avoid all items in the hierarchy.


1. C – To face and endure the situations that provoke anxiety.

2. A – A list of behaviors that provoke anxiety, ordered from least to most distressing.

3. B – To gradually introduce the patient to anxiety-provoking situations in a less intense manner.

4. C – Facing anxiety-provoking situations in real life.

5. B – They should progress from the least to the most distressing item.