Making an Exposure Hierarchy for OCD with examples
In OCD, individuals experience distressing intrusive thoughts (obsessions) and feel compelled to perform certain behaviors (compulsions) to reduce anxiety or prevent a feared outcome.
The goal of an exposure hierarchy is to gradually expose yourself to situations that trigger obsessive thoughts without performing the associated compulsions. Over time, this helps desensitize the anxiety and breaks the cycle of obsession-compulsion.
Here's how you can build an exposure hierarchy for OCD step by step:
1. Identify Your Obsessions and Compulsions
Start by identifying the specific obsessions (unwanted, distressing thoughts) and compulsions (repetitive behaviors or mental acts) that you experience. OCD varies greatly from person to person, so it’s important to focus on your unique triggers and responses.
Examples of Obsessions and Compulsions:
Contamination Obsession: Fear of germs or dirt.
Compulsion: Washing hands repeatedly.
Harm Obsession: Fear of harming others (even accidentally).
Compulsion: Checking locks or appliances multiple times.
Symmetry Obsession: Fear of things being "out of place."
Compulsion: Arranging or organizing objects to ensure symmetry.
Forbidden Thoughts Obsession: Fear of having inappropriate or blasphemous thoughts.
Compulsion: Mentally repeating specific prayers or neutralizing thoughts.
2. Rate the Anxiety for Each Trigger (0-100)
Once you’ve identified your specific obsessions and compulsions, rate the anxiety that each situation causes you on a scale from 0 to 100. The goal is to assess how intense the anxiety is for each obsession/compulsion combination, with 0 being no anxiety and 100 being the highest level of anxiety.
For example:
Fear of germs when touching a doorknob: 70
Fear of leaving the house without checking the stove: 80
Fear of having an intrusive thought about harming someone: 90
Fear of leaving a chair out of place in the living room: 60
3. Create a List of OCD Triggers (from Least to Most Anxiety-Provoking)
Now, take your list of obsessive triggers and rank them from least to most anxiety-provoking based on the anxiety ratings you assigned. This helps you create a hierarchy of exposures, starting with the least distressing and working up to the most difficult.
Example of a Possible OCD Exposure Hierarchy:
Touching a doorknob without washing hands afterward – 70
Leaving a chair slightly out of place in the living room – 60
Not checking the stove before leaving the house – 80
Allowing a minor imperfection (e.g., a picture frame slightly crooked) in the house – 75
Going to a public place without using hand sanitizer – 85
Having a forbidden thought about harming someone without neutralizing it – 90
Not mentally repeating prayers or phrases to "undo" intrusive thoughts – 95
4. Set a Clear Goal for Each Exposure
For each situation in the hierarchy, set a specific goal. This helps you focus on what you’re trying to achieve, which is resisting the urge to perform the compulsive behavior (or neutralizing thought) in response to the obsession.
For example:
For touching a doorknob: The goal might be, "I will touch the doorknob without washing my hands afterward."
For leaving the house without checking the stove: The goal might be, "I will leave the house without checking the stove, and I will accept the discomfort without performing any compulsions."
5. Start with the Least Anxiety-Provoking Exposure
Begin with the situation that causes you the least anxiety. This allows you to build tolerance and gradually prepare for more challenging exposures. Take your time with this first step, and focus on practicing tolerating the anxiety without resorting to compulsions.
Example Exposure Step:
Exposure Goal: Touch a doorknob without washing your hands immediately afterward.
Action Plan: Touch a doorknob (e.g., at home, a public space), and then resist the urge to wash your hands. Stay with the discomfort and allow the anxiety to decrease naturally.
Coping Strategies During Exposure:
Mindfulness: Focus on your breathing or use grounding techniques to stay in the moment.
Acceptance: Remind yourself that the discomfort and anxiety are temporary and will decrease with time.
Thought Restructuring: Challenge the belief that something bad will happen if you don’t perform the compulsion. Ask yourself, “What is the worst that could happen, and how likely is it?”
6. Repeat Each Exposure Until Anxiety Decreases
Repetition is key in exposure therapy. Do the exposure repeatedly until your anxiety begins to decrease or until you are able to tolerate it without performing the compulsion. This may take a few tries, so be patient.
Example:
If touching a doorknob and not washing your hands gives you anxiety at a level of 70, keep doing this exposure regularly until your anxiety rating decreases to, say, 40-50. This could take several days or weeks depending on how intense your anxiety is.
7. Move on to More Anxiety-Provoking Situations
Once you feel that the anxiety around a less distressing situation has decreased significantly (for example, you’re able to touch the doorknob and not wash your hands with less discomfort), move on to the next situation on your hierarchy.
Example:
The next step could involve leaving a chair out of place. The goal here is to sit in the living room with the chair left askew, and resist the urge to adjust it.
8. Use the "Behavioral Reversal" Strategy
Sometimes in OCD, people engage in compulsions to "neutralize" bad thoughts. This is an important part of exposure therapy: to resist the neutralizing behavior. If your compulsions involve mental rituals (e.g., repeating prayers or phrases), the goal is to experience the distress of the obsessive thought without engaging in the ritual.
Example:
If you have an intrusive thought about harming someone, don’t engage in mental rituals to "undo" or neutralize the thought. Allow yourself to experience the discomfort of the thought without performing the compulsion. This can be difficult, but with practice, the anxiety will lessen over time.
9. Evaluate Your Progress and Adjust the Hierarchy
After you complete an exposure, evaluate how you felt. Did your anxiety decrease from before the exposure? How manageable was the situation? It’s important to recognize your progress and adjust the hierarchy if needed.
If you find a step too difficult, break it down into smaller, more gradual exposures.
If a step feels easier than expected, move ahead to the next item in your hierarchy.
10. Keep Practicing and Be Patient
OCD can be a long-term challenge, and progress may be slow at times. However, repeated exposure to feared situations will help to break the cycle of obsession-compulsion. It’s crucial to be consistent, and don’t let setbacks discourage you. Over time, the compulsions will lose their power.
Final Thoughts
Building an exposure hierarchy for OCD is about confronting the things that trigger your obsessions, but in a controlled and gradual way that allows you to resist the compulsions that usually follow. The key is gradual exposure, patience, and consistency. With time, you’ll learn that your anxiety decreases naturally and that you can tolerate the discomfort without needing to engage in the compulsive behavior.
If possible, working with a therapist, especially someone trained in Cognitive Behavioral Therapy (CBT) or Exposure and Response Prevention (ERP) such as those at Still Minds Psychology can help guide you through the process and ensure that you're following the most effective steps. Reach out to schedule your free 15 minute consultation.
