An exposure hierarchy is a list that is used to guide your progression through exposure therapy. It is a list of the main things you are afraid of, arranged in order of how severe each fear is.
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:
- Putting hand in toilet bowl water (SUDS rating: 100)
- Touching toilet seat (SUDS rating: 95)
- Touching floor beside toilet (SUDS rating: 90)
- Handling raw poultry or hamburger meat (SUDS rating 85)
- Touching wall in toilet (SUDS rating: 80)
- Touching washroom door handle (SUDS rating: 75)
- Shaking hands with a stranger (SUDS rating: 65)
- Touching the bottom of your shoe (SUDS rating: 60)
- Pressing a button on a vending machine (SUDS rating: 55)
- 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.
You usually start exposure exercises with items with at least a SUDS rating of 60; however, it can sometimes be helpful to start with lower ranked items. 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 often (but does not always) means feeling comfortable with the highest item on your hierarchy.