Misophonia is a recently recognized condition characterized by extreme intolerance of idiosyncratic and repetitive sounds (often human-generated gustatory or breathing-based noises), coupled with intense affective-based reactions, that results in significant impairment and distress. Cognitive-behavioral therapy approaches, including exposure principles and stress management/distress tolerance skills, have demonstrated promise for the treatment of misophonia. However, efforts to develop interventions remain ongoing and further empirical examination of candidate treatment models is needed. In the pilot study described in this article, we preliminarily examined the efficacy of exposure and stress management therapy (ESMT) individually delivered via synchronous telehealth modality for adults with misophonia. Data from 26 participants (mean age=34.4 y) enrolled between April 2016 and September 2020 provided initial support for ESMT on the basis of pretreatment to post-treatment reductions in misophonia symptomology and increases in distress tolerance. Gains were generally maintained at 3- and 6-month follow-ups. The results did not appear to differ based on the order in which the exposure and stress management modules were delivered, which was randomized across participants. Participant perceptions of ESMT homework regarding adherence, comprehension, and usefulness were generally acceptable. This study provides preliminary support for ESMT as a potentially viable psychosocial intervention for misophonia and highlights the promising roles of exposure (with appropriate adaptations) and stress management for alleviating misophonia-related distress and impairment. Findings are discussed in the context of continuing to develop, refine, and test ESMT using more rigorous methodologies and diverse samples.