How to construct a hierarchy for mastering-your-anxiety

The following instructions are intended for Dr. Ostoja’s current clients ONLY. This technique is not applicable to every situation or every patient. Please do not attempt any of the exposures by yourself or with your child unless specifically instructed to do so by Dr. Ostoja. Any hierarchy must first be reviewed by Dr. Ostoja, who will give you detailed instructions on how to implement it

Please remember that you can construct a SUDs hierarchy for any fear or a situation you want to get better at handling.

1. For example, you may wish to get better at talking to people you do not know.
2. Or you may wish to help your child overcome his or her fear of dogs.
3. You may want to become more relaxed when delivering speeches or when dealing with conflict.
4. You may wish to overcome your fear of germs.
5. You may wish to be less anxious in crowded settings.
6. You may desire to become more easy-going and flexible. Your fear would be situations that make you feel less in control, such as messy rooms or plans that are not firmly finalized.
7. Finally, the most over-arching fear is of feelings we experience and do not like. We have learned to equate them with something dangerous or catastrophic. For your hierarchy, please write down feelings that you dislike and attempt to avoid in yourself.

For the sake of simplicity, we will use a scale of 0 to 10 (some people prefer 0 to 100 and that is fine as well).

1. The rating of zero indicates “no anxiety at all”, like you are sitting in your pajamas on your couch on a completely relaxed day or sipping lemonade on a beach.
2. The rating of “10” is sheer terror. This rating signifies something so upsetting and terrifying that you will do anything to avoid it. It is somehow linked, in your amygdala and fear circuits to fight-or-flight response. Although your rational brain knows that your fear may be unreasonable, your fear circuits have labeled this situation as signifying terrible danger that must be avoided.
3. Once you have written down examples of situations that fall under the “0” category, and under the “10” category, try to scale other in-between experiences. You may wish to write them on index cards so you could rearrange them. You can expand your scale to go to 100, so you can rate more subtle differences between levels.

You may wish to ask a friend or a family member for help. This person can ask you questions such as:

1. What if you saw a tiny cute dog with a bow on its head? Imagine that this dog is on a leash, standing at least 50 feet away from you. How anxiety provoking would that be for you, from 0 to 10 (or from 0 to 100). 20? 45? Would it be higher if the dog was barking? How high? (assign a number)
2. If the anxiety is high, above 2/10 (or 20 out of 100), have your helper ask you: what would lower the anxiety? Would your anxiety be lower if the dog was in a dog carrier? How high/low? (assign a number)

3. Write down as many situations as you can. Note small variations in the anxiety provoking situations or triggers and write this down in detail next to the appropriate number along the scale.
4. Focus on the section between 1 and 4. You will need the greatest number of situations in those categories.
5. Bring your Hierarchy to your next appointment. DO NOT ATTEMPT THE EXPOSURES unless directed so specifically by Dr. Ostoja. Dr. Ostoja will have to give you important instructions to ensure your exposures are gentle enough and effective!
6. Create another hierarchy for other anxiety provoking situations or triggers.
7. See the table below for an example of a hierarchy that could be constructed by someone with social anxiety.

Please keep in mind that the hierarchies are very unique for each person. For example, for many socially anxious persons, having a friend with them may actually make the situation more anxiety provoking because there is an increased sense of being evaluated. Usually Dr. Ostoja will try to identify those small nuances, but some patients are very good at creating their own hierarchies, which can accelerate therapeutic progress.

To access a blank template of a hierarchy scale, please click below:
A template of anxiety scale

To access printable instructions for constructing the hierarchy, please click below:

Instructions for constructing a hierarchy for mastering your anxiety