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Build a hierarchy of feared situations ranked by anxiety level, from least to most challenging, to guide graded exposure work.
List situations you avoid or find anxiety-provoking, and rate how anxious each one makes you (0–100 SUDS). The list will automatically sort from most to least anxiety-provoking, creating a visual ladder. Start exposure work from the bottom of the ladder and work your way up as confidence builds.
Use when avoidance is a maintaining factor, which is relevant in depression as well as anxiety disorders. In depression, the hierarchy might target avoidance of social situations, challenging tasks, or activities associated with low mood. Construct the hierarchy collaboratively, ensuring the steps are graduated from least to most anxiety-provoking.
Explain the graduated approach: 'Rather than tackling the hardest thing first, we're going to build a ladder of steps from the easiest to the most challenging. You'll work your way up gradually, building confidence as you go. We'll design it together so the steps feel manageable.'
For depression, frame the hierarchy around approach behaviours rather than solely anxiety reduction. Include mastery and achievement items alongside feared situations. For clients with low motivation, ensure the first few steps are highly achievable to build momentum and self-efficacy.
Not appropriate if avoidance is serving a genuine protective function, such as avoiding an abusive relationship. Ensure the client has adequate coping skills before beginning exposure. Avoid if the client is too depressed to engage with the hierarchy; address activation and basic functioning first.
Rate each item using SUDs (Subjective Units of Distress) from 0-100. Aim for 8-15 items spanning the full range. Ensure there are several items in the 20-40 range to build early success. Review and adjust the hierarchy as the client progresses, as ratings often shift. Combine with cognitive preparation for each exposure step.
Suitable for clients working with graded exposure, hierarchy, avoidance, fear ladder, suds, cbt, phobia, anxiety. This tool can be used as a standalone worksheet or as part of a structured homework plan.
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