Fear Hierarchy defined
A fear hierarchy, also called an exposure hierarchy, is a list of feared situations that activate OCD-related thoughts. It is an important tool that you and your therapist create at the beginning of Exposure and Response Prevention to guide the therapy process. Here’s more details on how it is created and how it is used.
Identifying the core fear
Before you and your therapist even start the process of creating an exposure hierarchy, you and your therapist will identify the core fear or fears that are associated with intrusive thoughts. This is because fear hierarchies are actually created to expose you to the underlying theme that OCD is using to scare you. This means that people who have on the surface similar presentations of OCD may have very different exposure practices listed in their hierarchies. For example, one person with contamination OCD may fear the possibility of making others sick. Another person who also has contamination OCD may be afraid that they could make themselves sick with a rare illness. This might mean that one person focuses Exposure to situations that they fear could cause other people to be sick, while the second person may work with their therapist to create exposure practices to the fear that they could catch a rare disease. Identifying the core fear is a crucial part of practicing exposure and response prevention and will make exposure and response prevention more effective.
Creating an intensity scale
Different therapists use different methods of creating exposure hierarchies. More recently I have been asking people to rank their intensity level as low, medium, and high. Low level exposures might include exposure practices that stretch their comfort zone but feel doable at the start of therapy. A lot of times, this includes imaginal exposures, or exposure practices where you imagine that a feared outcome has come true. Medium intensity includes exposure practices that are in line in intensity with practices that clients are moving toward wanting to do in their everyday life. For instance, a client with harm OCD who avoids using knives in their kitchen, may have a therapy goal of being able to use knives to cook, so exposure practices in the medium range for this client might be associated with practicing using knives for cooking. High exposures are exposures that are beyond the comfort zone of what they would like to be able to do in their everyday life. For someone with Contamination OCD, this might look like eating food that has fallen on the ground.
When creating exposure practices, we identify exposure practices that are relevant to the client’s goals in therapy, as well as experiences that often activate a client’s intrusive thoughts. As we’re building this, I may talk with a client about examples of intrusive thoughts and compulsive behaviors that they’ve shared with me during their intake process, and we talk more about other situations that may increase or decrease intensity of the exposure practice so that we have a good number of possible exposure practices in the low, medium, and high ranges. As a therapist, I am spending time looking over the exposure practices listed in the fear hierarchy to make sure that we are covering a broad range of activities. I also talk with the client to identify ways to increase intensity of exposure practices to create Variety in their exposure practice and to challenge themselves once the initial exposure practice is no longer anxiety provoking in the same way. This way clients can continue to move forward in their progress toward completion of their exposure hierarchy and to become more proficient in understanding how to manage OCD on their own. This last part is very important to me because I like to be very collaborative in the creation of exposure practices so that clients understand the process and can apply the exposure practices on their own in the future should OCD symptoms return after their course of treatment with me ends.
Other notes on exposure hierarchies and practices
It’s important to note that exposure hierarchies can and often do change as treatment progresses. For instance, clients sometimes want to add more practices because in the course of treatment they have identified other ways that OCD shows up in their lives. Exposure therapy can sometimes be dynamic, and it can be helpful sometimes to be flexible.
The way that people move through their exposure hierarchies depends on the client and therapist. Sometimes therapists and clients choose to work on exposure hierarchies in order of intensity, while other therapists and clients decide to work in a random order, since life can be random and unexpected. In my work, I talk with clients at the beginning of treatment about what will be more workable for them in their therapy process.
Creating exposure hierarchies is a collaborative process that can feel intimidating, but is a crucial step that sets the foundation for exposure and response prevention work.
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