Exposure ladder worksheet (for use with a therapist)

How to use it

1. Read Before you start. It sums up what trusted sources say about exposure and response prevention (ERP), and what this worksheet does and does not do.
2. Choose Add an item. Write what you would do, where, and for how long. Give it a 0 to 100 distress rating if you want to: 0 is not at all distressing and 100 is the most distress you can imagine. Say where the item is now. You write every item yourself. The worksheet never suggests any.
3. Open My ladder to see your items in the order of your ratings. Start the list with the highest or the lowest rating. Move up and Move down change the order of items that have the same rating.
4. After you practice something you and your therapist agreed on, open Practice records. Write the date, and if you want to, your distress before, at its highest and after, and what you did and did not do. You can turn on a line chart of your own numbers.
5. Under Print and share, print the worksheet, copy it as text, or download two files for a spreadsheet. Switch on Hide what I wrote on screen at any time to show the word Hidden in place of your words.

Good to know

• This worksheet is not therapy and it is not medical advice. It works best alongside a qualified therapist. It never suggests, chooses or checks what you should practice, and it has no list of examples. You write every item yourself. If you feel unsafe, or you might hurt yourself or someone else, go to Crisis help now.
• The International OCD Foundation says ERP is done under the guidance of a therapist at the beginning, with a trained clinician working with you on a plan. Our own advice, not the foundation's: if this feels hard, talk with a therapist before you try anything on your ladder.
• The 0 to 100 rating is a distress rating, and this worksheet only uses it to put your items in order. A University of Texas page describes subjective units of distress scales (SUDS) and suggests building your own anchors for 0, 25, 50, 75 and 100 from past experiences of distress. This worksheet does not decide what your numbers mean, and it does not treat a lower number as a goal. The same page notes that some have argued against putting the focus on lowering anxiety as the goal of an exposure exercise.
• Order: the ladder is always sorted by your ratings, and you choose whether the highest or the lowest comes first. The NHS describes starting with the situations that cause the least anxiety and moving on to harder ones, so you can show the lowest rating first if that is the order you and your therapist use. Move up and Move down only work between items with the same rating. Items with no rating come last.
• Hide what I wrote on screen shows the word Hidden in place of your words, so you can open the worksheet near other people. The form for adding or editing an item shows your words while you type. Print, Copy and the files always include what you wrote. Hiding is not a lock. Anyone who can use this browser on this device can switch it off.
• Practice records show only the numbers you write. The worksheet does not add them up, score them, compare them or say whether they are good or bad. The chart, if you turn it on, draws your own numbers for before, highest and after. Each has its own shape and line style, so you never need to tell colors apart. It does not draw a trend line.
• Limits: 40 items, 200 practice records for each item, 300 characters for each item, 1,000 characters for item notes, and 500 characters for each text box in a record. Ratings are whole numbers from 0 to 100. Everything is saved in this browser only. Clearing your browser data erases it, so print or copy anything you need to keep.
• Your therapist may prefer a different scale or layout. You can bring the printout as a starting point, or use it to remember what you want to say.
• If keeping a worksheet starts to feel like something you must do, or it makes things harder, take a break from it and tell your therapist or someone you trust.

Where this comes from

• The International OCD Foundation says the most important type of cognitive behavioral therapy for OCD is exposure and response prevention (ERP), that it is done under the guidance of a therapist at the beginning, and that you will feel an initial increase in anxiety, uncertainty and obsessional thoughts: International OCD Foundation: Exposure and Response Prevention (ERP)
• The same foundation offers worksheets for people and for clinicians to list situations, thoughts or triggers linked to OCD and organize them by anticipated difficulty or distress: International OCD Foundation: Building an Exposure Hierarchy Worksheet
• The NHS says therapy for OCD is usually cognitive behavioral therapy with ERP, and that you start with the situations that cause the least anxiety first, before moving on to more difficult thoughts: NHS: Obsessive compulsive disorder (OCD), treatment
• A University of Texas exposure therapy page describes subjective units of distress scales (SUDS), suggests building your own anchors for the scale, and notes that some have argued to move away from using SUDS during exposure therapy: University of Texas at Austin: SUDS worksheet
• The OCD guide
• Crisis help

More tools

General support only. These tools are not medical, legal or diagnostic advice, and they do not replace professional help. If you are in crisis, go to Crisis help.