A practical worksheet that helps therapists and clients construct a graded exposure hierarchy for obsessive compulsive disorder (OCD), supporting structured exposure and response prevention (ERP).
Includes client-friendly guidance. Downloads are in Fillable PDF format where appropriate.
Offers theory, guidance, and prompts for mental health professionals. Downloads are in Fillable PDF format where appropriate.
The Obsessive Compulsive Disorder (OCD) Ladder is designed to help clients develop a hierarchy of feared situations that can be used to guide exposure and response prevention (ERP). By organizing situations from least to most anxiety-provoking, the worksheet provides a structured roadmap for treatment.
The resource includes therapist guidance, a reusable worksheet and completed examples, making it suitable for use throughout ERP.
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Clients preparing for ERP.
Choose one OCD fear to target.
List triggering situations.
Establish compulsions and avoidance behaviors.
Estimate predicted anxiety for each situation.
Arrange situations into a graded hierarchy.
Revise the ladder as treatment progresses.
The worksheet is based on the principles of exposure and response prevention (ERP). Clients identify a specific OCD fear, generate triggering situations, identify the compulsions they normally perform, predict anxiety ratings, and arrange exposures from least to most anxiety-provoking. The completed ladder then serves as the basis for repeated ERP practice, beginning with lower-level items and progressing gradually as confidence and learning increase.
OCD ladder worksheet
Therapist guidance
Worked examples
Reference list
The worksheet supports consistent delivery of ERP by helping clients approach feared situations systematically rather than avoiding them. It promotes collaborative planning, reinforces response prevention, and provides a practical framework for graded exposure throughout treatment.
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Jacoby, R. J., & Abramowitz, J. S. (2016). Inhibitory learning approaches to exposure therapy: A critical review and translation to obsessive-compulsive disorder. Clinical Psychology Review, 49, 28-40.
Koran, L. M., Hanna, G. L., Hollander, E., Nestadt, G., & Simpson, H. B. (2007). Practice guideline for the treatment of patients with obsessive-compulsive disorder. American Journal of Psychiatry, 164(7 Suppl.), 5-53.
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Rachman, S., & de Silva, P. (1978). Abnormal and normal obsessions. Behaviour research and therapy, 16(4), 233-248.
Rachman, S., & Hodgson, R. (1980). Obsessions and Compulsions. Englewood Cliffs, NJ: Prentice-Hall.
Salkovskis, P. M. (1985). Obsessional-compulsive problems: A cognitive-behavioural analysis. Behaviour research and therapy, 23(5), 571-583.
Stein, D. J., Ruscio, A. M., Altwaijri, Y., Chiu, W. T., Sampson, N. A., Aguilar-Gaxiola, S., ... & Kessler, R. C. (2025). Obsessive-compulsive disorder in the World Mental Health surveys. BMC medicine, 23(1), 416.
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