Creating the hierarchy

It is unrealistic that the hierarchy will be fully completed within a first session and easier exercises for a change method to be completed in week 1 is planned sufficiently. Completion of the hierarchy should never be prioritised over enabling the patient to start the active dose of the exposure and habituation change method from the first sessions homework. Therefore, in session one, aim to complete some of the hierarchy in the most difficult, easier and more difficult sections, ensuring that there is an exercise that gives sufficient predicted anxiety (50-60%) . This ensures enough time is left to ensure the patient is clear on the 4 essential conditions and how they operationalise, when to stop the exercise and how to record each exercise on the diary. The hierarchy gaps between these items put in can then be finished for homework or at the next session.

When creating the hierarchy, it should always be remembered that the aim of the hierarchy is increasing levels of fear, not decreasing levels of avoidance. The aim of the hierarchy is to enable sufficient physiological arousal to take place, using the exercises as a way of bringing autonomic arousal symptoms on. The hierarchy may include both interoceptive situations that bring on these physical symptoms, as well as confrontation of places they currently avoid or find trigger them. For example, a patient who thinks they are having a heart attack when their heart races, may avoid places they find triggers their panic, such as busy, crowded places. Similarly, they may also avoid exercise, as this increases the heart rate and brings the response on. They can do things that bring on an increase in heart rate, such as going up and down stairs, or jogging on the spot as well as going into situations. Often these options can be less daunting for initial steps if the patient is struggling to identify easier steps, as they can be done in the home and still bring on symptoms to a sufficient level. The patient is being exposed to physiological arousal, bringing on symptoms for them to habituate to them. The hierarchy should never be graded in the amount of time or amount of an activity that will be done, e.g. if going to the supermarket is an exercise, they would need to remain there until arousal drops by 50% to end the exercise. We don’t know how long that will take for each individual. The other important factor is the patient needs to be made aware this is treatment for the sake of treatment, they work to the plan at the planned times, not go out only when they need some shopping and combine this with an exercise. They need to complete the homework for the purpose of the exposure and habituation treatment and pay full focused attention on their arousal level, not be distracted by getting shopping or speaking to others.