Exposure Hierarchy: Building Your Fear Ladder

What Is a SUDS Rating?

How to Build Your Hierarchy

1. Define the broad fear or avoidance pattern Start by describing, in general terms, the theme that drives your anxiety, such as social evaluation, contamination, or public speaking.Example: Your broad theme might be 'fear of being judged negatively by others in social situations.'
2. Brainstorm specific situations List as many concrete, specific scenarios related to the fear as you can. Include situations you already avoid as well as situations you manage with high distress.Example: For social anxiety, your list might include: making small talk with a cashier, attending a party alone, asking a question in a meeting, and calling a stranger on the phone.
3. Assign a SUDS rating to each situation Rate each scenario from 0 to 100 based on the anxiety you would expect to feel if you confronted it right now.Example: Making small talk with a cashier: 20. Attending a party alone: 60. Giving a presentation at work: 85.
4. Arrange from lowest to highest Order the scenarios from the lowest SUDS rating to the highest. Aim for a spread of ratings that covers the full 0 to 100 range with items at roughly 5 to 10-point intervals.Example: A completed ladder might read: smile at a neighbor (15), chat with a coworker (30), eat lunch in the break room (45), attend a group outing (65), give a toast at a dinner (80).
5. Fill in gaps If there are large jumps between items (more than 15 points), brainstorm intermediate steps. Gradual progression is key to successful exposure.Example: If there is a jump from 'order coffee at a cafe' (35) to 'attend a party alone' (60), you might add 'sit and eat lunch alone at a busy restaurant' (45) to bridge the gap.

Tips for an Effective Hierarchy

• Be specific Instead of writing 'talk to people,' specify 'ask a coworker about their weekend in the break room.' Specificity makes exposure exercises easier to act on.Example: Rather than 'go to a store,' write 'walk into the grocery store at 5 p.m. on a weekday, ask an employee where the bread aisle is, and make a purchase.'
• Include both imaginal and in-vivo items Lower-rated steps might be imaginal (imagining a scenario or watching a video), while higher-rated steps are in vivo (facing the real-life situation directly).Example: For a dog phobia, a lower step might be looking at photos of dogs (SUDS 20), a middle step could be watching dogs in a park from your car (SUDS 50), and a higher step could be petting a calm dog (SUDS 75).
• Expect ratings to change As you complete lower items, your ratings for higher items often decrease. Revisit and update your hierarchy throughout treatment.Example: After successfully making small talk several times, you might find that 'attending a party alone' drops from a 60 to a 45.
• Collaborate with your therapist Your therapist can help you identify safety behaviors to drop, set appropriate durations, and troubleshoot items that feel overwhelming.Example: Your therapist might notice that you always bring a friend as a 'safety person' to social events and help you plan exposures where you attend briefly on your own.