ellmos-ai English — Official English version of
exposure-guidance.
Exposure Guidance (English)
Fear hierarchy, SUDs scale, graded exposure and habituation: Planning and guidance — actual exposure only with a therapist
See: ETHICS.md
Context
Exposure (confrontation therapy) is one of the most effective methods in behavioral therapy for anxiety disorders, phobias, OCD, and PTSD. It is based on the principles of habituation and extinction: When one repeatedly faces an anxiety-provoking situation, the anxiety response decreases over time.
Evidence: Exposure therapy is the gold-standard treatment for specific phobias, social anxiety, panic disorder, and agoraphobia (NICE Guidelines, Bandelow et al. 2014, S3 Guideline Anxiety Disorders). Effect sizes are among the highest in psychotherapy research.
IMPORTANT: This skill supports PLANNING of exposure exercises and conveys understanding of the mechanisms. The IMPLEMENTATION of exposure must be conducted under the guidance of a qualified therapist. Never implement: EMDR, Prolonged Exposure (PE), Narrative Exposure Therapy (NET)
1. Understanding the Mechanisms
Habituation
HABITUATION: Adaptation through repeated confrontation
Anxiety level
100 | *
| * *
80 |* *
| *
60 | *
| *
40 | *
| * *
20 | ** * *
| * * * * * *
0 |________________________________
Time (during exposure)
Anxiety initially rises, reaches a peak,
and then drops on its own WITHOUT flight or avoidance.
Key experience: "The anxiety passes, even when
I stay in the situation."
Extinction (New Learning)
EXTINCTION: New experiences overwrite old fear associations
Old experience: Dog -> Danger -> Fear -> Flight
New experience: Dog -> No danger -> Fear decreases -> I am safe
The old association is not erased but overlaid by new
experiences. Therefore, fear can return in certain
contexts (renewal, reinstatement) — which is NORMAL.
Why Avoidance Maintains the Problem
THE AVOIDANCE CYCLE:
Anxiety-provoking situation
|
v
Anxiety rises (unpleasant)
|
v
Avoidance/flight
|
v
Short-term relief (anxiety drops immediately)
|
v
Long-term reinforcement of anxiety
("The situation IS dangerous, good that I fled")
|
v
Next time: Even more anxiety, even more avoidance
2. The SUDs Scale
Subjective Units of Distress (0-100)
SUDs SCALE (Subjective Units of Distress)
0 Completely relaxed, no anxiety
10 Minimal tension, barely noticeable
20 Slight unease, easily tolerable
30 Noticeably unpleasant, but controllable
40 Noticeable anxiety, still able to function
50 Moderate anxiety, strenuous but manageable
60 Strong anxiety, clear urge to avoid
70 Very strong anxiety, hard to endure
80 Intense anxiety, at the edge of tolerance
90 Extreme anxiety, feeling of panic
100 Maximum anxiety, worst imaginable distress
Using the SUDs Scale
Before exposure:
- Estimated anxiety in the planned situation (expected value)
During exposure:
- Assess current SUDs value every 5 minutes
- Document the progression (rising, falling, fluctuating)
After exposure:
- Highest SUDs value? Final value? How quickly did anxiety decrease?
- Was it as bad as expected?
3. Creating a Fear Hierarchy
Principle
A fear hierarchy ranks anxiety-provoking situations from lowest to highest anxiety level. Exposure begins with easy situations and increases step by step.
Example: Fear of Dogs
FEAR HIERARCHY: Dog Phobia
SUDs | Situation
-----|--------------------------------------------------
10 | Look at a picture of a dog
15 | Watch a video of playing dogs
25 | Talk about own experiences with dogs
30 | Watch a small dog from 10 meters away
40 | Watch a small dog from 5 meters away
50 | Stand next to a leashed small dog (2 meters)
55 | Touch a small leashed dog (owner holding)
60 | Watch a medium dog from 5 meters
65 | Sit next to a leashed medium dog
70 | Pet a medium dog
75 | Walk past an unleashed dog (park)
80 | Be alone in a room with a calm dog
85 | Pet a large dog
90 | Be in a park with multiple unleashed dogs
95 | Feed a dog
100 | Let an unfamiliar dog run toward you
Template for Completion
MY FEAR HIERARCHY
Anxiety topic: [...]
SUDs | Situation
-----|--------------------------------------------------
| [...]
| [...]
| [...]
| [...]
| [...]
4. Types of Exposure
Graded Exposure (In Vivo)
Principle: Step-by-step confrontation with real situations, starting at low SUDs values.
Flooding
Principle: Direct confrontation with highly anxiety-provoking situations for extended periods. Only under therapeutic guidance. NOT to be guided by an AI assistant — only explained.
Exposure in Sensu (Imaginal)
Principle: Experiencing anxiety-provoking situations in imagination. Helpful as preparation for real exposure.
Interoceptive Exposure
Principle: Deliberately inducing physical anxiety symptoms (e.g., rapid heartbeat through exercise, dizziness through spinning). ONLY under therapeutic guidance.
5. Guided Exposure Planning
Preparation Protocol
EXPOSURE PLANNING PROTOCOL
Date: [...]
Therapist informed: [ ] Yes [ ] No (MANDATORY!)
Anxiety topic: [...]
Chosen situation: [...]
Expected SUDs value: [...]
Level in hierarchy: [...]
What exactly will I do: [...]
Where: [...]
When: [...]
How long: [...]
Alone or accompanied: [...]
My greatest fear: [...]
What will realistically happen: [...]
Emergency plan (if SUDs > 90 or dissociation):
1. Grounding (5-4-3-2-1)
2. Breathing exercise (box breathing)
3. [Call trusted person]: Tel. [...]
4. Leave situation in an orderly manner (no panicked fleeing)
Post-Session Protocol
EXPOSURE DEBRIEFING
Date: [...]
Situation: [...]
SUDs before (expectation): [...]
SUDs highest value during: [...]
SUDs at the end: [...]
How long stayed in situation: [...]
Habituation occurred: [ ] Yes [ ] Partial [ ] No
What I learned: [...]
Was it as bad as feared: [ ] Worse [ ] As expected [ ] Less bad
What I want to do differently next time: [...]
Next level: [...]
6. Safety Notes and Abort Criteria
Prerequisites for Exposure
CHECKLIST BEFORE STARTING EXPOSURE:
[ ] Qualified therapist is involved
[ ] Sufficient stabilization is present
[ ] Fear hierarchy is created and discussed
[ ] Emergency plan is prepared
[ ] Person understands the mechanism (habituation)
[ ] No acute suicidality
[ ] No uncontrolled psychotic symptoms
[ ] No severe dissociative disorder (without therapeutic support)
[ ] No acute substance intoxication
[ ] Person has voluntarily consented (no forced exposure!)
Abort Criteria
ABORT EXPOSURE IF:
- Dissociation occurs (person is "gone," unresponsive)
- Panic attack with loss of control
- Person explicitly wants to stop (respect autonomy!)
- Physical symptoms: chest pain, shortness of breath, fainting
- Suicidal thoughts during exposure
- The situation becomes objectively unsafe
ON ABORT:
1. Grounding and stabilization (5-4-3-2-1, breathing exercise)
2. Ensure person is oriented and stable
3. Discuss experience (what happened, what was learned)
4. No blame ("You should have stayed")
5. Plan next step with therapist
Ethics and Boundaries
An AI assistant may:
- Explain exposure principles (psychoeducation)
- Create fear hierarchies together
- Explain and use the SUDs scale
- Support exposure planning (fill out protocols)
- Document debriefing
- Provide safety information
- Motivate and normalize ("Anxiety during exposure is desired and normal")
An AI assistant must NOT:
- Independently conduct or guide exposure
- Guide flooding (ONLY therapist)
- Guide interoceptive exposure (ONLY therapist)
- Conduct prolonged exposure for PTSD
- Accompany exposure in severe dissociation
- Pressure toward exposure ("You must face this")
- Guarantee results
- Make diagnoses or create treatment plans
- Make medication-related recommendations
PARTICULARLY STRICT BOUNDARY: An AI assistant plans and explains. Actual exposure takes place under the guidance of a qualified therapist. For any request regarding implementation: refer to professional. Exposure without professional support can re-traumatize or intensify anxiety.
In case of acute crisis, ALWAYS refer to:
- 988 Suicide & Crisis Lifeline (US): 988
- Crisis Text Line (US): Text HOME to 741741
- Samaritans (UK): 116 123
- Telefonseelsorge (DE): 0800 111 0 111 / 0800 111 0 222
- Emergency services: 911 (US) / 112 (EU)
Ported from BACH v3.8.0 | Standalone Version Sources: Foa & Kozak (1986), Craske et al. (2014), Bandelow et al. (2014), S3 Guideline Anxiety Disorders (2014) — Not professional therapy