About this worksheet
An exposure and response prevention (ERP) hierarchy is the ranked list of exposures a client will work through, ordered by Subjective Units of Distress (SUDS). It's the spine of OCD treatment. The hierarchy serves two purposes: it gives the client a roadmap that makes treatment feel finite, and it ensures exposures are graded — challenging but doable. This worksheet provides a ten-rung ladder with SUDS columns (predicted and actual), the specific exposure, and the response to be prevented. A good hierarchy is concrete (no 'touch germs' — instead 'shake hands with a stranger and don't wash for an hour'), spans the SUDS range (a 30, a 50, a 70, a 90 — not all 80s), and is built collaboratively. ERP is a specialist intervention; therapists not trained in it should refer rather than improvise. The worksheet is for clinicians already practicing it.
When to use it
- All OCD subtypes — contamination, harm, taboo, symmetry, scrupulosity.
- Specific phobias and some health anxiety presentations.
- Always after psychoeducation on the OCD cycle and informed consent for ERP.
- Requires ERP training. If you're not trained, refer to an IOCDF-listed clinician.
How to use it
- 1
Brainstorm 15-20 exposures
Wide net first, including things the client thinks they could never do. You'll cut later.
- 2
Rate each one in SUDS
0–100 predicted distress. Aim for a spread across the range, not bunched at the top.
- 3
Pick 8-10 for the ladder
Order from lowest SUDS to highest. Skip steps that are duplicative; keep ones that test different obsessions.
- 4
Define the response prevention
For each exposure, name exactly which compulsions are off-limits (including mental ones). The exposure without RP is just exposure.
- 5
Start near the bottom, repeat until SUDS drops
Don't move up until predicted distress and actual post-exposure distress are both meaningfully lower. Habituation is the mechanism.
Frequently asked questions
What is an ERP hierarchy?+
A ranked list of exposures for OCD treatment, ordered by SUDS (Subjective Units of Distress, 0-100). Each rung specifies the exposure and the compulsions to be prevented. It's the structural backbone of exposure and response prevention.
How many steps should an ERP hierarchy have?+
Typically 8-10 rungs, spanning the SUDS range. Too few and there are big jumps that scare the client off; too many and progress feels stalled. Aim for steps about 10 SUDS apart.
Do I need ERP training to use this worksheet?+
Yes. ERP is a specialist intervention. Improvised exposure can worsen OCD by reinforcing avoidance or doing exposures without proper response prevention. Refer to an IOCDF-listed therapist if not trained.
What's the difference between ERP and inhibitory learning?+
Classical ERP uses habituation as the mechanism (anxiety drops within an exposure). Inhibitory learning (Craske) targets new learning ('this can happen and I can handle it') and de-emphasizes SUDS drops. Both work; most modern ERP blends them.
Worksheet — ERP Exposure Ladder — provided by TherapistAssist for clinical use. Not a substitute for assessment or treatment.
