The OCD Hierarchy is a cognitive behavioural therapy (CBT) tool designed to help therapists and clients plan graded exposure tasks in the treatment of obsessive compulsive disorder (OCD), providing a structured pathway for confronting situations which trigger anxiety.
Offers theory, guidance, and prompts for mental health professionals. Downloads are in Fillable PDF format where appropriate.
Includes client-friendly guidance. Downloads are in Fillable PDF format where appropriate.
An editable Microsoft PowerPoint version of the resource.
The OCD Hierarchy exercise guides clinicians and clients through the process of identifying, organizing, and rating situations that trigger obsessions and compulsions. By listing situations from least to most distressing and assigning subjective distress ratings, therapists can develop a clear, structured plan for exposure and response prevention (ERP) work.
This gradual approach helps clients systematically confront fears, reducing avoidance and compulsive behaviours over time.
This resource enhances therapy by:
Assists in systematically exposing clients to obsessional triggers.
Support the client to list situations, thoughts, or objects that trigger distress.
Assign a subjective distress rating (0 - 100%) to each item.
Arrange situations from least to most anxiety-provoking.
Develop an exposure schedule based on the hierarchy.
Update the hierarchy regularly as exposures are completed and new triggers are identified.
The OCD Hierarchy is grounded in the cognitive-behavioural model of OCD, which highlights the role of avoidance and compulsions in maintaining distress. ERP, the gold-standard treatment for OCD, involves exposing clients to feared situations without engaging in compulsions, thereby allowing for habituation, disconfirmation of feared outcomes, and cognitive restructuring (Foa & Kozak, 1986).
Creating a hierarchy enables a gradual, manageable approach to ERP, helping clients to build tolerance and confidence progressively. Exposure tasks organised in a stepwise manner promote success experiences, reduce dropouts, and increase client motivation (Abramowitz, 2006).
Effective use of the hierarchy requires collaboration, flexibility, and attention to clients' emotional readiness. Therapists should work sensitively to ensure the pace matches the client's capacity while encouraging persistence in the face of discomfort.
