Exposure Exercises for Fear of Heights (Acrophobia)

Systematic reviews show that graded exposure—whether in real life or virtual reality—reduces acrophobic distress with large effect sizes, and gains last six months or longer.
Below is a practical roadmap for designing, running, and troubleshooting exposure sessions.

1. Preparation

Quick Psycho-Education

Anxiety = false alarm; avoidance keeps the alarm sensitive.
Repeated, prolonged exposure lets the brain learn “safe but high” cues.

Identify Safety Behaviors

Examples: clinging to railings, looking only at the horizon, holding someone’s hand. These must be dropped gradually or the learning is diluted.

2. Build a Hierarchy (Fear Ladder)

| Step | Height Situation (modify for local context) | Predicted SUDS (0-100) | |------|---------------------------------------------|------------------------| | 1 | Look at a photo of a tall building | 20 | | 2 | Watch a first-person YouTube video of rooftop view | 30 | | 3 | Stand on 1-step stool at home, hands by sides | 35 | | 4 | Lean over a second-floor balcony for 2 min | 45 | | 5 | Ride a glass elevator to 3rd floor, face outward | 55 | | 6 | Walk pedestrian bridge mid-span, pause 3 min | 65 | | 7 | Climb open stairwell to 5th floor, look down | 75 | | 8 | Observation deck (≥10 floors), circle perimeter | 85 | | 9 | Rooftop sky-deck with transparent floor | 95 |

Tips

Aim for moderate anxiety (40-70); stay until SUDS drops ≥50 % or plateaus.
Randomize order later (inhibitory learning).

3. Session Structure

Baseline SUDS & brief relaxation breath (not avoidance).
Enter exposure—no distractions, no safety props.
Stay & Monitor every 1-2 min; note worst and ending SUDS.
Debrief: What did you predict? What actually happened?
Homework: Repeat same step daily or move up when peak SUDS ≤40.

A single exposure can last 10-30 min; shorter but frequent trials beat occasional marathons.

4. Virtual-Reality (VR) Options

RCTs show 3-session VR exposure cuts fear as effectively as real-life bridges and balconies, with 70–80 % remission at follow-up.

Commercial apps (e.g., Acrophobia VR, Limbix) offer graded environments.
Combine VR with tDCS or iTBS for potential booster effects—early trials report extra symptom reduction.

5. Troubleshooting

| Issue | Fix | |-------|-----| | Anxiety spikes & client flees | Return to previous step; shorten duration; drop hidden safety behavior. | | Plateau, no anxiety | Increase height or remove aid (e.g., handrail grip). | | Dissociation / dizziness | Use “anchored feet” + describe surroundings aloud to stay present. | | Motion sickness in VR | Reduce headset movement speed; use in-vivo photos first. |

6. Measuring Progress

Acrophobia Questionnaire (AQ) pre/post every 2–3 weeks.
Behavioral Approach Task: time in seconds client can stand at a balcony edge.
Improvement ≥20 % on AQ or doubled BAT duration signals meaningful change.

Key Takeaways

Graded, repetitive exposure—not avoidance—is the gold standard for fear of heights.
Safety-behavior fade-out is crucial for learning safety.
VR and in-vivo exposure are similarly effective; combine them when real heights are hard to access.
Track SUDS and questionnaires to keep therapy data-driven.