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Health anxiety~15 min

Facing a fear of illness: step ideas

Step ideas to choose from with your therapist for facing a fear of illness, from news stories to places and less checking. Based on Warwick and Salkovskis (1990), Schwind et al. (2016) and Craske et al. (2014): a list of graded practice ideas for fear of illness, with safety behaviours to drop and steps to carry to the exposure hierarchy.

Written by Tarun Vermani, Trainee Clinical Psychologist Updated

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This sheet gives you ideas for facing a fear of illness, one small step at a time. Read through the ideas and tick any you could try, including ones that feel hard right now. Ticking an idea does not mean you have to do it. You will not do any of these steps on your own or before you have agreed them with your therapist. Together you will choose the steps that fit what you fear and add them to your graded exposure hierarchy. That is where you rank them and plan when and how to practise. Write the ones you choose in the last section. Therapist note: Use after the health anxiety formulation, once current symptoms have had an appropriate medical assessment and you have agreed with the client which checks a doctor wants kept. This sheet is the menu; the health checking and reassurance-seeking diaries track day-to-day reduction, and the graded exposure hierarchy ranks the chosen steps.

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How facing the fear helps

When you fear having or getting a serious illness, it makes sense to avoid reminders of it, or to check and seek reassurance until the worry eases. But avoiding, checking and asking stop you finding out what really happens, and that you can cope with not knowing for sure.

Each step on this sheet is a chance to test what you fear, for example that thinking about an illness makes it more likely, or that the worry will grow until you cannot bear it. Before a step, you and your therapist write down what you expect to happen. Afterwards, you write down what did happen. Your anxiety does not have to go down before you start or before you stop: what matters is finding out.

Practise each step more than once, and vary it: a different time, place or length.

Only practise steps you have agreed with your therapist, and leave out anything that would put your health or safety at real risk.

Words, stories and news about illness

These ideas bring you into contact with illness in words and pictures. They run roughly from easier to harder, but what is hard differs from person to person. The aim is to face the reminder, not to look for answers about your own health.

Ideas I could try with words and news

Writing and imagining

Imagining can be a way to face the fear before, or alongside, real-life steps. Pick what fits; what is hard differs from person to person.

Writing and imagining ideas I could try

Places and people

These ideas take you to places and people you may have kept away from because they remind you of illness.

Places and people I could face

Doing it differently: checking and reassurance

These ideas are about letting the worry be there without acting on it, or, if you avoid doctors, going to a routine check you have put off. Your therapist will help you agree which checks to keep.

Ways I could do it differently

Safety behaviours to drop

Safety behaviours are things you do to feel safer, like checking your body or asking others if you are all right. They can stop you finding out what really happens, so dropping them is part of each test. Tick the ones you use.

Choose which safety behaviours to drop with your therapist. Keep precautions that protect your real health or safety. Do not stop or change any prescribed medication on your own; talk to your prescriber first.

Still see a doctor about new or different symptoms, and keep any checks or appointments your doctor has asked for.

Safety behaviours I use

Steps to add to my ladder

With your therapist, write down the steps you would like to try and what you fear will happen in each. Then rate how anxious you expect to feel, from 0 (no anxiety) to 100 (the most anxious you can imagine).

You and your therapist will add these steps to your graded exposure hierarchy, where you rank them and plan your practice.

#Step I could tryWhat I fear will happenExpected anxiety (0 to 100)Actions
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When to use ‘Facing a fear of illness: step ideas’

‘Facing a fear of illness: step ideas’ is an interactive cognitive behavioural therapy (CBT) worksheet, most often used in CBT for health anxiety.

It is designed to be used within therapy rather than as a standalone self-help tool: a therapist introduces it, works through it collaboratively, and helps make sense of what it surfaces. You can preview the full worksheet above, then assign it digitally for clients to complete between sessions on any device or download it as a print-ready PDF.

How it works

Most people work through it in around 15 minutes. It moves through six short steps:

  1. How facing the fear helps: When you fear having or getting a serious illness, it makes sense to avoid reminders of it, or to check and seek reassurance until the…
  2. Words, stories and news about illness: These ideas bring you into contact with illness in words and pictures. They run roughly from easier to harder, but what is hard differs…
  3. Writing and imagining: Imagining can be a way to face the fear before, or alongside, real-life steps. Pick what fits; what is hard differs from person to person.
  4. Places and people: These ideas take you to places and people you may have kept away from because they remind you of illness.
  5. Doing it differently: checking and reassurance: These ideas are about letting the worry be there without acting on it, or, if you avoid doctors, going to a routine check you have put off.…
  6. Safety behaviours to drop: Safety behaviours are things you do to feel safer, like checking your body or asking others if you are all right. They can stop you finding…

Completed on the Formulate platform, your client's answers are saved automatically and shared straight back to you, so you can review them before the next session rather than waiting for a paper copy to come back.

The CBT approach behind it

In common with other CBT methods, ‘Facing a fear of illness: step ideas’ works by gradually and safely facing avoided situations so anxiety can subside (exposure). The aim is not positive thinking but a clearer, shared understanding of what keeps a difficulty going and practical, testable ways to change it.

Because it is a CBT tool it stays focused on the here-and-now links between thoughts, feelings, the body and behaviour, and it works best as one part of a wider course of therapy rather than as advice or a diagnosis.

Evidence & sources

This worksheet is grounded in established cognitive behavioural therapy theory and practice. Key sources include:

  • 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. doi:10.1016/j.brat.2014.04.006
  • Warwick, H.M.C., & Salkovskis, P.M. (1990). Hypochondriasis. Behaviour Research and Therapy, 28(2), 105-117. doi:10.1016/0005-7967(90)90023-C
  • Schwind, J., Neng, J.M.B., & Weck, F. (2016). Changes in free symptom attributions in hypochondriasis after cognitive therapy and exposure therapy. Behavioural and Cognitive Psychotherapy, 44(5), 601-614. doi:10.1017/S1352465816000163
  • Tyrer, P., Cooper, S., Salkovskis, P., Tyrer, H., Crawford, M., Byford, S., et al. (2014). Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients: A multicentre randomised controlled trial. The Lancet, 383(9913), 219-225. doi:10.1016/S0140-6736(13)61905-4

For use alongside professional support

Formulate provides educational CBT resources for use with a qualified therapist. They are not a substitute for professional assessment, diagnosis, or crisis care.

If you need urgent help now:

  • Emergency services: 999 — if you or someone else is in immediate danger
  • NHS 111 (NHS 24 in Scotland): 111 — choose the mental health option for urgent help, in England, Scotland and Wales (in Wales, press 2)
  • Lifeline: 0808 808 8000 — for urgent help in Northern Ireland, free, day or night
  • Samaritans: 116 123 — free, day or night, 365 days a year
  • Shout: 85258 — text SHOUT, free, day or night
  • SANEline: 0300 304 7000 — 4pm–10pm, every day

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