In this post I thought I would return to expanding on the suggestions in the recent PDF I shared on Guidelines for Doing Exposure Therapy. Item 6 is:
“6. An exposure hierarchy may be a good place to start.”
How to Construct an Exposure Hierarchy to Treat Anxiety
Cognitive Behavior Therapy (CBT) is the usual treatment of choice for anxiety and with CBT we often create an exposure hierarchy. By “hierarchy” we mean that you identify situations that make you uncomfortable or scare you, give them a ranking between 0 and 100 (this is usually called a SUDS rating, which stands for Subjective Units of Disturbance Scale) and then to list the items from the most difficult at the top to least difficult at the bottom. This list usually consists of between 10 and 15 different potential exposures and can form the framework for the exposure therapy work to come.
What is A SUDS Rating?
It’s important that this hierarchy have at the top of the scale, at a SUDS rating of 100, the most difficult exposure. Exposures that are rated at 20 or below might be useful to have on the list, but are usually not the best place to start because they simply are too easy. A better starting point usually is around a SUDS rating of 30 or 40 and then week by week to gradually progress up the scale towards the most difficult exposure at the top. It isn’t always necessary to progress up the hierarchy one item at a time, and, in fact, there is some evidence that bouncing around a bit, though making the exposures potentially a bit more difficult, can produce a better long term outcome. I usually allow my clients to do whatever method works best for them. A hierarchy is by necessity a very fluid document and can change from week to week. In fact, as you progress through the hierarchy it’s almost inevitable that your rankings of various items will change as you progress.
An Example of an Exposure Hierarchy for Hit and Run OCD
I have listed below a sample hierarchy of a client I’m currently working with. Of course, I’ve disguised many of the details to keep my clients identity confidential, but the basics are there. This client suffers from what’s called Hit and Run OCD where he fears that going over a bump in the road means he actually ran over somebody and hurt them, or that he will, by being negligent in some way, end up hitting and hurting someone. Fearing that he hit someone with his car is the obsession and the compulsion in this case is to do various kinds of excessive checking such as looking in the rear view mirror checking for a body laying in the street, repeatedly driving back around the block to make sure there isn’t a body in the street, upon arriving home carefully repeatedly reviewing his memory checking for some evidence that somebody had been hit and then repeatedly checking the newspapers or news broadcast on television for reports of a hit and run accident that happened in the area where he was driving.
Exposure SUDS Rating
Drive after a teaspoon of alcohol 100
Drive after shop class 85/90
Drive car with my phone GPS 80/85
Drive at night while raining 80
Drive at night 75
Drive on a bumpy road 70
Drive while tired 60
Drive when I feel normal 60
Drive after sports practice with ?
fear of concussion or other injury
Driving with sunglasses ?
Drive just for fun ?
Drive after drinking a cranberry ?
I can bounce up and down the list, doesn’t all have to be in order
NO CHECKING- REALLY IMPORTANT, No news, no mirrors, no checking memory, no turning around
Some Things to Notice About This Hierarchy
There are a few things worth noting within this hierarchy. Notice item 1, which is his highest SUDS rating, is driving after consuming a teaspoon of some kind of alcohol. The concern here, and the reason it is at the SUDS level of 100, is he fears that he would be driving impaired and thus even more responsible for whatever harm and damage may happen. This is a reflection of the hyper-responsibility theme that is so common within OCD. Items 2, 3 and 12 follow that same theme with item 2 being rated so high because he fears that he is somehow impaired by the various chemicals, smells and substances he will be exposed to in shop class. Item 3 is scored high because he fears that by looking at his phone he is somehow being less responsible and careful he would be if he used the car’s GPS. Item 12 is included because the word “cocktail” makes him think there may be alcohol in the juice. So the reason these exposures are on the hierarchy is because they reflect the concern about being irresponsible and because of that irresponsibility causing harm to somebody else.
Items 4 through 8 are still disturbing for him, but he would feel a bit less responsible and thus the SUDS rating is a bit lower. Items 9, 10, 11 and 12 don’t yet have a SUDS rating assigned to them because he wasn’t sure where they’d fall on the hierarchy. As I mentioned above, hierarchy is a fluid document and so this is a reflection of the fluidity I mentioned. Part of his assignment for the coming week is to engage in one or more of these exposures to get a sense of their actual SUDS rating.
You will also notice that part of my instructions allow him to “bounce around” the hierarchy and that it is not necessary to progress up the scale item by item. This is one of the suggestions put forth by Michelle Craske, PhD in the article I mentioned in last week’s post. Though bouncing around a bit can make engaging in the exposures initially a bit harder, it apparently produces a better long-term outcome.
You will also notice that at the very bottom of the hierarchy he has put in bold my instructions to engage in no compulsions. This is a crucial part of any exposure…no compulsions! As part of the hierarchy construction we discussed what compulsions he is likely to want to use and to then commit to not doing them.
As always, let me know if I can be of any help and I’m happy to answer any questions you might have. This post isn’t meant as a substitute for therapy and so if you’re struggling with anxiety/OCD please consult a qualified therapist.
If you know someone who might benefit from this post, please forward it to them and if someone was kind enough to forward this post to you and you’re interested in subscribing you can go here.
If you’re struggling with OCD then you might want to consider attending the annual International Obsessive Compulsive Disorders annual conference this summer in Denver, CO. I’ve attended many conferences and this one is hard to beat.
By: Robert McLellarn
Title: How to Use Cognitive Behavior Therapy to Treat Anxiety
Sourced From: www.anxiety-treatments.com/blog/2022/4/19/example-of-an-exposure-hierarchy
Published Date: Fri, 22 Apr 2022 14:00:00 +0000
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