How Having an Exposure Hierarchy Can Help Control OCD

An Essential Piece of Exposure Therapy

Woman wearing washing up gloves to clean toilet with brush and flushing water
Howard Shooter/Getty Images

Exposure therapy can be extremely helpful for people who suffer from obsessive-compulsive disorder (OCD). This type of therapy involves repeatedly exposing the patient to those things that trigger fear the most until their anxiety lessens. Exposure therapy takes plenty of courage and may take a good chunk of time.

What Is an Exposure Hierarchy?

An exposure hierarchy is a list that is used to guide your progression through exposure therapy. It details the main situations or sources of anxiety that trigger your fear, arranged in order of how severe each fear is.

The SUDS Scale in an Exposure Hierarchy

Your therapist might use a scale called the Subjective Units of Distress Scale, or SUDS scale, to rate your anxiety, ranging from 0 (completely relaxed) to 100 (the worst anxiety you can imagine feeling) when you encounter the thing you fear.

For example, if you have a fear of contamination, your exposure hierarchy might look like this:

  1. Putting hand in toilet bowl water (SUDS rating: 100)
  2. Touching toilet seat (SUDS rating: 95)
  3. Touching floor beside toilet (SUDS rating: 90)
  4. Handling raw poultry or hamburger meat (SUDS rating 85)
  5. Touching wall in toilet (SUDS rating: 80)
  6. Touching bathroom door handle (SUDS rating: 75)
  7. Shaking hands with a stranger (SUDS rating: 65)
  8. Touching the bottom of your shoe (SUDS rating: 60)
  9. Pressing a button on a vending machine (SUDS rating: 55)
  10. Handling money (SUDS rating: 50)

An exposure hierarchy is usually developed with the help of your therapist as it can sometimes be difficult to decide in what order to place the items. 

Making Your Way Through the Exposure Hierarchy

You usually start exposure exercises with items that have at least a SUDS rating of 60, but it can sometimes be helpful to start with items that are ranked lower. The point is to start with something that makes you anxious, but not so anxious that you can't get past it and gain some confidence to tackle the next fear.

Once you have mastered an item on your hierarchy, you move on to a more difficult item. You continue this process until you have met your goals. This usually, but not always, means feeling comfortable with the highest item on your hierarchy.

What Happens During Exposure

You and your therapist will identify a fear to address with your exposure hierarchy. Let's use the exposure hierarchy example from above and start with number eight since it has a SUDS rating of 60. Your therapist will have you touch the bottom of your shoe and then not engage in any cleaning behaviors for a specified amount of time, perhaps several hours.

You will feel anxiety as you resist the urge to engage in your compulsive behavior, but repeatedly doing this will eventually decrease your anxiety until touching the bottom of your shoe without cleaning your hands won't bother you at all. When this happens, you will move to the next item on your exposure hierarchy. In this example, the next item would be number seven, shaking hands with a stranger.

Making Progress in Exposure Therapy

When you are going through exposure therapy, your therapist will most likely have you do the same exposure exercise at home every day in between sessions. This is extremely important for your progress.

It's also absolutely essential to get through everything your therapist recommends on your exposure hierarchy since the triggers that are not addressed could actually get worse and cause the triggers you worked to overcome to come back.

2 Sources
Verywell Mind uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Hezel D, Simpson H. Exposure and response prevention for obsessive-compulsive disorder: A review and new directions. Indian J Psychiatry. 2019;61(Suppl 1):S85-S92. doi:10.4103%2Fpsychiatry.IndianJPsychiatry_516_18

  2. Jones M, Wootton B, Vaccaro L. The efficacy of exposure and response prevention for geriatric obsessive compulsive disorder: a clinical case illustration. Case Rep Psychiatry. 2012;2012:394603. doi:10.1155%2F2012%2F394603

By Owen Kelly, PhD
Owen Kelly, PhD, is a clinical psychologist, professor, and author in Ontario, ON, who specializes in anxiety and mood disorders.