This worksheet allows the individual to recognize the figures that make him anxious, causes of obsessions and compulsions. OCD Exposure Hierarchy Packet Research supports exposure and response prevention therapy as the leading form of psychotherapy for OCD. treatments for OCD CBT that relies primarily on behavioral techniques such as exposure and response prevention (ERP) is recommended because it has the best evidentiary support *American Psychiatric Association. An exposure hierarchy is basically a list of all the situations surrounding your obsessions and compulsions that cause you varying degrees of anxiety (see the example below). Behavioral (Functional) Assessment form 3. An exposure is when you do something on purpose to provoke an anxiety spike. Avoiding your fears never helps and in fact may even make them worse. For this reason, be sure to list a variety of triggers, including some that that only cause a low level of distress, with a steady progressi… First, I have added a cognitive therapy (CT) component to treating OCD, making my philosophy a cognitive-behavioral therapy (CBT) approach.  The premise behind adding cognitive therapy to ERP is the belief that there are “errors” in thinking that generate the anxiety in the first place.  It is believed that everyone makes these errors in thought from time to time, but that someone with OCD tends to make them more often and have a harder time self-correcting them.  An example of a type of thinking error that an OCD sufferer would make is an overestimation error.  Here an individual is overestimating the likelihood of a bad event occurring (e.g., believing that you will contract HIV from touching a doorknob and not washing your hands).  Cognitive therapy helps one identify and better self-correct these errors in thought.  I believe that cognitive therapy or what others and I call “thought challenging” is a good addition for most of my OCD patients.  I have developed worksheets that provide individuals the structure and framework for learning how to better identify and ultimately better self-correct the errors in thought that they make.  Clearly, I believe the main emphasis should still be on ERP, but the CT plays an important role.  I would say that my protocol is 80-85% ERP and 15-20% CT. Second, in talking with colleagues from other OCD treatment facilities, it appears that my exposure hierarchies tend to have more specific exercises on them.  An exposure hierarchy is a master list of all the exposure exercises that an individual will perform to reduce their OCD symptoms.  These exercises are then ordered in some fashion from least to most difficult to do (i.e., in a hierarchical fashion).  I have patients rate potential exercises on a zero (i.e., “no anxiety whatsoever”) to seven-point scale (i.e., “the most anxiety you could possibly imagine experiencing”) in terms of how anxious they think the exercise would make them feel if I actually had them perform the exercise.  My average hierarchy probably has 100 exercises on it.  Many other clinicians I have talked to have far fewer exercises (e.g., 20-25) on their hierarchies.  The reasons for these differences are varied and not entirely clear.  Some clinicians feel they can successfully “bunch” or combine exercises (i.e., combining two or more exercises into one entry on the hierarchy) in an attempt to make exposure therapy more time efficient.  Others have stated that they believe the process of generalization (i.e., anxiety will habituate or go down in certain OCD areas without directly exposing one’s self to those areas) will occur (e.g., by touching light switches an individual’s fear of touching doorknobs will also substantially reduce). Compulsions are behaviors or rituals that are performed repeatedly in order to reduce the anxiety. The disorder may appear in childhood or later; it is often chronic, exacerbated by stress, and co-morbid with other anxiety and mood difficulties. These rituals of cleaning, checking, ordering, or counting are a means of anxiety avoidance. You press the elevator button several times in a row. By Bradley C. Riemann, Ph.D. – Director, OCD Center at Rogers Memorial Hospital. The easiest way to start is to keep a diary of your rituals / compulsions for one week using the OC Rituals Diary. Obsessions are intrusive unwanted thoughts, images, or impulses that cause much distress and anxiety. The OCD Hierarchy worksheet helps you to plan a hierarchy of situations which trigger obsessions. Response prevention is the key component here. OCD Triggers in Daily Life? ERP and Moral Scrupulosity OCD. Finally, change during exposure happens through what is known in the literature as expectancy violations, as predicted disastrous consequences fail to materialize. Facts about OCD information sheet 2. Practice guideline for the treatment of patients with obsessive-compulsive disorder. International OCD Foundation PO Box 961029, Boston, MA 02196 617.973.5801 CBT refers to a group of similar types of therapies used by mental health therapists for treating psychological disorders, with the most important type of CBT for OCD being Exposure and Response Prevention (ERP). This approach involves constructing an exposure hierarchy in which feared stimuli are ranked according to their anticipated fear reaction . Although some generalization does take place in exposure therapy, in my experience it is rarely enough to completely eliminate the need to work on an entire OCD area (e.g., light switches completely generalizing to doorknobs and thus eliminating the need to address).  Thankfully, generalization is present to an extent but I see it usually within an OCD area (i.e., there is no need to touch every light switch to overcome a fear of them) not as much between them.  I have individuals demonstrate their mastery over every OCD area.  Despite the observed generalization effect in my patients, I also tend to develop separate exposure exercises within each area (e.g., light switches) to address the differences most patients perceive between certain circumstances (e.g., differences between light switches in bedrooms and ones in bathrooms).  In summary, I believe these are the reasons my hierarchies are larger in terms of number of items than most behavioral therapists.  I believe that the more specific the exposure exercises are the more functional (i.e., anxiety reducing) they will be in the long run.  Obviously, this is a bit of a balancing act and too big of a hierarchy can really slow someone’s progress.  It also does not help an individual’s confidence to give them a hierarchy the size of a phone book! As in any workout, you tend to get out of it what you’ve put in. As a part of this treatment, your clients will be gradually exposed to their triggers, which results in their anxieties, obsessions, and compulsions diminishing. This is the OCD Exposure Hierarchy Worksheet. For example, they may believe they are responsible for some harm that may come to themselves or others, and assume that any influence they have over an outcome equals total responsibility for it (“I will fail to do something and it will lead to myself/others being hurt”). In Vivo Exposure for OCD OCD & Contamination: Washing & Cleaning Compulsions/Rituals OCD & Contamination: Reasons Why People Do Rituals/Compulsions OCD Treatment: Back to Basics Pure-O OCD Rituals: Starting Over, Resetting, & Undoing Scrupulosity Exposure … Third is psychological empowerment, whereby the client learns from experience that they can manage distress, thus developing greater self-efficacy regarding coping. This worksheet serves as a guide to organize feared and uncomfortable situations that your client faces each day. Each item in the hierarchy will receive a SUDS rating (0-100), ranking items in order from least distressing to most distressing. Please consult a medical professional before changing or commencing any course of treatment. Exposure doesn’t work for all types of anxiety, and there are things we want to know before starting to use it. Biology is certainly involved, as obsessions and compulsions run in families, and appear in various medical conditions, including Huntington’s chorea, Parkinson’s disease, Tourette disorder, schizophrenia, and certain epilepsies, brain injuries, and tumors. You wear your lucky tie to the job interview. Identify the feared consequences (“if you had thought X and couldn't perform ritual Y what are you worried would happen?”) 4. Obsessive-compulsive disorder (OCD) is a difficult, yet treatable, psychological disorder. Sessions are often longer than usual (90-120 minutes), and twice or thrice weekly sessions are common. For each title, we have listed direct links to appendices containing free, downloadable forms. For instance, when people first move to a new neighborhood, they may be aggravated by the noise of a busy highway that runs near t… Identify avoidances, situations that the client avoids so as not to feel anxious or have intrusive thoughts, images, or urges. Identify the client’s obsessions, their intrusive thoughts, images, or urges. ERP is a sort of psychological workout. With regard to obsessions, the goal of ERP is to have the client learn that they can have intrusive thoughts and experience distress without losing control of their behavior and without having to suppress their feelings or escape (or avoid) fearful situations. 2. Exposure Response Prevention, commonly referred to as ERP, is a therapy that encourages you to face your fears and let obsessive thoughts occur without ‘putting them right’ or ‘neutralising’ them with compulsions.. Habituation occurs when a person stops responding or paying attention to a stimulus, such as a thought, object, place, person or action, with repeated exposure. Exposure Hierarchy form 5. First is physiological habituation, a process whereby nervous system arousal (which is necessary for the experience of anxiety) is reduced upon prolonged exposure to the same stimulus. Get the help you need from a therapist near you–a FREE service from Psychology Today. Ten Things You Need To Know To Overcome OCD, Examining The Link Between OCD And Social Anxiety Disorder, Archived Articles on OCD Treatment & Research. Many of us have occasional repetitive, intrusive, or strange thoughts. The client then stays in those situations long enough for the anxiety to decrease. Fourth is skill acquisition whereby practice makes competence and competence reduces the need for fear. The first part of the therapy – exposure – happens when the individual allows themselves (with the help of their therapist) to encounter the triggering object, image, or environment that begins their cycle of intrusive thoughts. Exposure therapy starts with confronting items and situations that cause anxiety, but anxiety that you feel able to tolerate. Exposure is a procedure in which the client purposely confronts objects, images, thoughts, or situations that elicit distress and anxiety (but pose no real danger). As with classic OCD, Exposure and Ritual Prevention (ERP) is the treatment for any OCD subset, like Harm OCD. Second is inhibitory learning, a process whereby new associations inhibit (rather than extinguish) old ones. Exposure with response prevention: Exposure and response prevention (ERP) is a treatment for obsessive compulsive disorder (OCD) in a patient is exposed to their feared situation and encouraged not to engage in their typical neutralizing response. Such a decrease in anxiety is achieved via several concurrent processes. Washing your hands 100 times until they are red and raw is. ERP is also aversive by design. They often seek perfection and are distressed by its unattainability (“my hands are not perfectly clean; not clean enough”). But you may be concerned that exposure to moral concerns means doing immoral things or may have consequences that are not immediately revealed. Treatment will usually begin with a thorough assessment of symptoms. When complete, the worksheet can serve as a guide for your therapeutic work with your client. As stated before, there are far more similarities than differences in the way I treat OCD and the ways others choose to.  The bottom line is that ERP works.  Most of the “spins” that others and I have made are really only slight modifications.  These modifications come from personal philosophies and professional experience in attempt to make an already powerful treatment approach a little bit better. Specifically, clients with pedophilia-themed OCD (P-OCD) experience excessive worries and distressing intrusive thoughts about being sexually attracted to, and … Then, the therapist and client will usually develop an ‘exposure hierarchy,’ (AKA ‘anxiety ladder’) consisting of feared and avoided things, places, and situations. The client needs to summon their courage and perseverance, and accept the fact that short-term pain is the price of acquiring long-term health and wellbeing. An exposure hierarchy is a master list of all the exposure exercises that an individual will perform to reduce their OCD symptoms. How OCD Treatment Will Change Due to the COVID-19 Pandemic, Harm Obsession OCD: Beyond Hand Washing and Orderliness, Psychology Today © 2021 Sussex Publishers, LLC, 5 Recent Findings About Dark Personalities, How Mindfulness Can Improve Relationships, What Dogs Can Teach You About Your Own Personality, Why Change Is Hard Even When We Know It’s Needed, The One Diagnosis All Therapists Should Understand, Mental Rituals in Obsessive-Compulsive Disorder, Scrupulosity OCD Treatment Shouldn't Be a Hard Sell, Obsessive-Compulsive Disorder: Research Update. His health anxiety symptoms were expressed in the “Three B’s” of Body, Belief, and Behavior. It involves, as the name indicates, preventing the client from performing the ritual behaviors they engage in to reduce anxiety. Many of us perform stereotyped or superstitious behaviors. While reassurance is often useful in therapy, it undermines the effectiveness of ERP, interfering with full exposure. Identify the client’s rituals, what they do to decrease their anxiety, get rid of the thoughts, images, or urges, or minimize the likelihood of a feared consequence. To create a fear hierarchy, a person will identify an obsession that they're struggling with. The main symptoms of OCD are, as the name suggests, obsessions and compulsions. The second step is a process known as psycho-education in which, as the name implies, the client will receive accurate information about OCD, including prevalence statistics, common symptoms, available treatments and their effectiveness. We hope that by the end of this part of the group you’ll have an idea of when exposure can be helpful and how to use it. In this chapter, we discuss strategies for developing a symptom hierarchy and for using it effectively in treatment. COVID-19’s Ripple Effect on Mental Health and Addiction, Netflix’s "Big Mouth" Animates Sexual Intrusive Thoughts. With regard to compulsions, the goal of ERP is for the client to learn, through experience, that they don’t need rituals to manage anxiety well. And with two children, his anxiety grew along with his responsibilities. It works through pain, not away from or around it. Once the hierarchy is set, ERP sessions will tackle each item on it, working gradually up the levels of distress. The third main way I have tweaked the treatment for OCD is emphasizing the graduated nature of exposure more than some clinicians.  I believe the three keys to successful exposure therapy are making sure the exposure is prolonged, repetitive, and done in a graduated or hierarchical fashion.  As mentioned before, I use a zero to seven–point scale when developing an exposure hierarchy.  Generally, I suggest individuals start doing their exercises in their two’s and three’s.  I consider anything less than four on this scale to be in the manageable range of anxiety.  Fours and fives cause pretty significant anxiety, and sixes and sevens is unmanageable anxiety.  I believe starting people off in their two’s and three’s allows them to learn how to do exposure work, and increases compliance with doing their exposure exercises and with the ritual prevention portion of the treatment.  The latter issue is an important one.  Overall, refusal and dropout rates for ERP are very high (i.e., 25%).  There certainly are many reasons for this, but the major one appears to be their lack of willingness or ability to do ERP.  By making it more “user friendly” my refusal / dropout rates are considerably lower (i.e., anecdotal estimate of roughly 8-10%). The therapist and patient develop a hierarchy of avoided activities that the patient practices through in vivo exposure between sessions. Can This 6-Second Trick Prevent a Panic Attack? We aim to connect people dealing with OCD and anxiety with the resources and information they need to thrive. Response prevention, in contrast, facilitates the client’s heightened anxious arousal during exposure, and therefore helps the exposure exert its therapeutic effects. A symptom hierarchy is a central tool in exposure therapy, and it provides a birds’ eye view of what needs to be accomplished in treatment. People with OCD often spend much energy and time ‘looking for trouble’ so to speak, acutely attuned to the cloud in the silver lining. People with OCD often experience what is known as, ‘thought-action fusion,’ equating a thought with an action. The causes of OCD are not known. Fears of sexually harming children are fairly common among clients suffering from obsessive–compulsive disorder (OCD), yet these symptoms are largely unrecognized and frequently misdiagnosed by mental health professionals. Noam Shpancer, Ph.D., is a professor of psychology at Otterbein College and a practicing clinical psychologist in Columbus, Ohio. Exposure is the key therapeutic component to that end. People with OCD end up working for their rituals long after the rituals have ceased working for them. Washing your hands routinely after you go to the bathroom is not OCD. It is possible that you may have heard of Cognitive Behavior Therapy (CBT) before. The therapist must remain accepting and non-punitive yet firm in emphasizing the importance of full exposure head on, sans distractions or detours. Exposure-based treatments take advantage of a natural process called habituation. These behaviors may resemble OCD, but what sets them apart from the disorder is that they do not overwhelm you or cause significant distress and disruption in your life. How to Face Uncertainty at the End of the Pandemic, The Mental Health Costs of Caring for COVID-19 Patients, Coping with Stress Caused by Watching the U.S. Capitol Riot, How Ideas About Autism Were Shaped in the Early USSR. To find a therapist, please visit the Psychology Today Therapy Directory. Alas in the long term they become a problem themselves. ERP is done by: o Exposing yourself to situations that bring on obsessions (triggers) o Not engaging in the unhelpful coping strategies (compulsions or avoidance). Some have questioned the speed and efficiency of this approach, believing that it will take individuals much longer to complete their hierarchies if they start “so low” in them.  On the contrary, it appears to be a “tortoise and the hare” kind of phenomenon.  Despite starting lower in the hierarchy, I believe individuals complete treatment in roughly the same amount of time that others do in treatment facilities that don’t emphasize the need for graduated exposure as much.  What I lack in terms of starting place in the hierarchy I make up in needing fewer repetitions to achieve anxiety habituation with a particular exercise and thus being able to move on to new exercises faster.  It should also be noted that the individual whom I am working with has a strong say in where we start in their hierarchy.  Some opt to start higher, but most see the “method” behind what some of my colleagues teasingly call the “madness” behind this approach and start in that manageable anxiety range.  In summary, I believe emphasizing the graduated nature of exposure ultimately allows more individuals to seek and complete treatment in roughly the same amount of time. One therapeutic approach that helps with this process is exposure and response prevention (ERP) for OCD. ERP is designed to break the two maladaptive associations that reside at the core of OCD: The association between sensations of distress and the objects, situations, or thoughts that produce the distress, and the association between performing ritualistic behaviors and decreasing the distress. For Adam, these eventual catastrophes were legion. As mentioned above, compulsive rituals are a form of anxiety avoidance. Clients will face their triggers beginning with the least distressing items, and moving to more difficult levels as they improve. Exposure Therapy Practice form 6. For OCD, the technique for facing fears is called exposure and response prevention (ERP). It can also be carried out as homework without a therapist, and the therapist may also use ‘imaginal exposure’—having clients use their imagination to picture an exposure situation. Question: I recently watched the harm OCD webinar (really enjoyed it-thank you) and I was wondering whether or not I could get some ideas or suggestions for hierarchy items-exposure for fear of molesting their child-pedophile OCD. You ruminate over lost love. In this case, to paraphrase Marks, quantity often creates quality. To access forms, worksheets, and handouts, look for the relevant Treatments That Work or Programs That Work title below. Dreams have been described as dress rehearsals for real life, opportunities to gratify wishes, and a form of nocturnal therapy. A new theory aims to make sense of it all. To deal with the distress caused by fearful thoughts and images, people with OCD turn to increasingly elaborate rituals and safety behaviors. One form of treatment that focuses on the disruption of this cycle is called exposure and response prevention therapy. 3. Compulsions, too, tend to fall into fairly clear categories: Cleaning/washing, checking, arranging/ordering, and counting/mental rituals. These can then be tackled in order of increasing difficulty. If you are curious about your own OCD symptoms, here is a link to a solid screening instrument. As the client faces distressful items, they are concurrently prevented from engaging in corresponding rituals or distracting ‘safety behaviors.’ ERP can be conducted in session—in the therapy room, with a therapist; or In Vivo—in real-life situations with a therapist. By the available empirical evidence, the best behavioral treatment for OCD is Exposure and Response Prevention (ERP). 3 Tips for Fighting OCD. Not surprisingly, ERP consists of two parts: 1) exposure, and 2) response prevention. Conquering Your Fear The best way to overcome fears is to face them in small steps. Thus, many people with OCD ask for constant reassurance during therapy. Self-Monitoring form 7. The exposure hierarchy lays out a roadmap for the rest of treatment. Both client and therapist need to be aware of this. The ERP approach is usually introduced during the process of psycho-education, and the client learns about the treatment rationale, goals, structure, and components. Over the course of 10 years, his fears accumulated as he built his career and got married. Exposure and Response Prevention (ERP) What is Exposure and Response Prevention? During the treatment of OCD, this cycle will be identified and broken. Most exposure therapists use a graded approach in which mildly feared stimuli are targeted first, followed by more strongly feared stimuli. Part of traditional CBT treatment for OCD is exposure to situations which trigger obsessions (classically accompanied by the prevention of the associated compulsion). The content of this field is kept private and will not be shown publicly. Obsessive-compulsive disorder (OCD) is an oft-debilitating disorder that affects 1-3% of the U.S. population. Am J Psychiatry 2007; 164(suppl):1–56. You imagine punching your boss in the face. See below for a recent question Light on anxiety received after our Harm OCD webinar. Beyond OCD's mission is to reach as many people affected by OCD as possible. Reassurance seeking is in essence an OCD symptom (a ritual). ... of a SAMPLE fear hierarchy of exposures for a particular patient seeking treatment at an anxiety specialty center. Guidelines for Exposure sheet 4. OCD exposure hierarchy packet is a two-page worksheet presented by the therapistaid.com website. These exercises are then ordered in some fashion from least to most difficult to do (i.e., in a hierarchical fashion). Be Strategic! Exposure is a way to get out of OCD and ... of Obsessive–Compulsive Disorder: Fundamentals and Beyond. This hierarchy is a checklist of activities that increase in intensity as a person makes progress. How to Do It 1. However, over time most behavioral therapists have added their own “personalized spin” to ERP and in some cases added other types of therapy to the mix.  In this article I will discuss the ways that I have “tweaked” the basic approach to treating OCD.  As you will see, there are far more similarities to the basic protocol than differences but there are some divergences that are worth noting. The short-term pain of ERP is a better deal than living with the long-term punishment of untreated OCD. When distressing thoughts come to occupy and overwhelm them, they will often attempt to suppress the thoughts directly, a futile effort sometimes known as the ‘white bear problem’ (if we try not to think of a white bear, we end up thinking about it). ERP works best when the exercises are specific and well designed, when the client’s anxious arousal is intense, and when the ‘dose’ of exposure is substantial and systematic. As such they prevent the clients from ever experiencing the benefits of true exposure. Exposure and response prevention (ERP) is the most effective way to treat any kind of OCD. Overall, the psychosocial treatment protocol for obsessive-compulsive disorder (OCD) has been well established and empirically supported.  Exposure and ritual prevention (ERP) has been found to produce successful management of symptoms in roughly 85% of OCD cases.  This strategy was first described by Meyer in 1966 and has since been studied and refined by many outstanding researchers and clinicians (e.g., Edna Foa). To gauge the client’s distress, the therapist will often use a Subjective Units of Distress Scale (SUDS). BeyondOCD.org does not provide medical advice, diagnosis, or treatment. Once those are established, they'll work together to create something called a "fear" or "exposure" hierarchy. Don’t Ritualize. Graded exposure vs flooding. Preoccupations with dangers, flaws, or mistakes are common. People with OCD characteristically find themselves preoccupied with distressing unwelcome thoughts. I have not had much luck with combining exercises or a generalization effect.  I have found it difficult to combine exercises due to what I will call a “stock piling” of anxiety that I have seen occur when I have attempted to do this.  Meaning that sometimes two plus two equals five (i.e., combining an exercise that was rated a two on their hierarchy with another two yields a higher anxiety rating, say a five, than what you had wanted, which was a two).  This stock piling effect I have found makes exposure less efficient due to it taking many more repetitions to see the necessary anxiety reductions within and between exposure trials.  Therefore, I have individuals conduct one exercise at a time. Everyday life is full of examples of habituation. To do this, you can create an Exposure Hierarchy which will gradually “expose” you to the situations that you fear until you can face your fears with a minimum of concern. Generally, ERP treatment will proceed in an orderly sequence of stages. 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