Now that we have a short list of anxiety producers, we'll apply a scaling system called the SUDs scale, or the Subjective Units of Discomfort scale. Subjective, because the amount of anxiety you feel is totally up to you; no one can tell you how much anxiety you are feeling. Units, because we have to have some way of measuring this. Discomfort because that's what we're really measuring, how bad you really feel. Now the most important part of this is the word subjective, because what makes me anxious may not make you anxious, and it certainly won't make us anxious to the same degree. The way you do this is that you find some item on your hierarchy that you absolutely could not do under any circumstances because it would make you too anxious. That would be your 100. For me, that would be jumping out of an airplane with a non-guaranteed parachute. Physically, practically, I could do this, but I wouldn't because it would make me far too anxious (in addition to far too dead). This is my 100. Most people know what their 100s are; those are the things you'll have an easy time identifying, though maybe not an easy time writing them down. Now there are things on your hierarchy that you could probably do, that would cause you a lot of anxiety but you could grit your teeth and last an hour with the anxiety. You wouldn't like it, but you could do it. These would be your 50s. And at the bottom end of the spectrum would be the things that might give you almost no anxiety at all, like coming to group. For some of you, coming to this group might be a little anxiety producing, and it might really be a 20 or 30 for you. But for those of you that see it only as an information gathering process and therefore not too threatening, it might be a 10. Or suppose you have a contamination fear, and thinking about the trash can doesn't cause you too much anxiety. The idea of a 10 is that this creates almost no anxiety at all. Everything else fits in between as 20s, 30s, 40s etc. Some people find that certain items require a 95 or even a 99, but most items can be scored in levels of tens since for most things that's about the limit of resolution of anxiety. But please feel free to score them any way you need to. And you may have several 100s; that's OK, you might have several things at any level.

So let's see where each of these group items would fall in terms of the SUDs scale. For me, not looking for my keys would be about a 30 because it creates some anxiety but I can do it. Well, maybe I should make it a 40, since I tried it the other day, and it was really harder to not check than I thought it would be. Let's put 40 on the board next to this example. My old friend the stamp checker used to say that this assignment was about a 30 for him, so we'll put a 30 next to this example. Let's see, starting out on a trip without looking at a map - I will have to guess, since he never told me how much it bothers him, but I think about a 50 is right. This is something he could do, but it would really bother him. In fact, if I suggested that he do it without explaining why, he would probably say, "I don't want to do that; forget it!" And finally, jumping out of a plane with my "no-return-policy" parachute would be my 100. Now, what would everyone who contributed write down as their SUDs scale ratings for each of their items? [Here, we get each person to rate items they contributed] This is effectively a group hierarchy, and we could begin treating this group here with this tool. But individual hierarchies have a few other traits that we need to mention.

Personal Hierarchies. Now once you get 10-15 items on your personal list, like we did here for the group list, you'll need to do something else before you rate them. You already have something to work with; it isn't a hierarchy yet, it's still just a list. But there are things that we don't even know we do or that we avoid, so this is where the support people earn their keep. At this point we will be asking the support people to make up a list for the OCD sufferer just like this. Then they should give the lists to the OCD sufferer, and that person should put them together into one list. Now once all these items are written out and condensed onto one piece of paper from your support people, apply the SUDs scale to your personal hierarchies as we did for the group example (since anxiety is subjective, only the OCD sufferer can rate them on their SUDs scale). You may have a difficult time picking out the 10s; since they don't cause much anxiety, we often have a hard time recognizing them. They may be things like getting up when you'd rather be resting. Or going to the store when you'd rather be watching the ball game. They probably don't make you very anxious; you might have a preference, but feel very little anxiety. Now, once you have your hierarchy, hopefully you'll find that you have a continuum of numbers, from 10 through 100. If you look at the 100s, you'll probably find that you have some that are really 90s, some that are really 95s, and some that are true 100s. But hopefully you'll have a continuum of numbers, some low, some in the middle and some high.

Now we described the individual assignment before in terms of E & RP, and you will need to repeat the assignment one, two or several times per day each day for the week - the more exposures, the better. Then, at the end of the week, you would recount how your assignment went either in the behavior therapy group, with yor individual therapist, or in your journal if you're doing this on your own . Based on your report, we either help arrange a new assignment, or restructure the old one if it was either too hard or too easy for you. As we do each assignment, you might imagine that you'll be climbing up a ladder from the ground to the roof of a house (see Figure 13). Think of it this way: when you started, the top rung may have seemed way out of reach, but as you get higher up, the top rung won't seem so far away anymore. For the hierarchy, that gets translated into this: the more experience with this that you have, the less anxiety you will be feeling for each assignment, so the 100s will actually come down in value as you go up the ladder, and those 100s that you thought were just impossibly high won't seem as high anymore. As we go through this exercise, we will use this ladder analogy a couple of times.

One other analogy that may be useful here is that of getting allergy shots. An allergy is basically a problem with your immune system, where it thinks that some tiny chemical insult is really an invading army that requires a massive response. Allergy shots are ways to train the immune system that it doesn't need to react this way. The idea is that if you are allergic to cats, for instance, one good way to build up tolerance to them is to receive a graded series of shots of "cat juice," or tiny amounts of the thing that you're allergic to. Each time you get a tiny red spot on your arm where the shot is, but not the full-blown allergic reaction. As you increase the amount of the allergen, your immune system "learns" that it does not need to respond with its usual over-reaction. Similarly, with the hierarchy you will be receiving tiny doses of anxiety, and training the brain that it doesn't need to over-react. In this analogy, you can see that if you don't feel the anxiety, you won't get any benefit. It would be like getting a shot of pure water instead of the "Eau-du-Cat."

The Status of Your Hierarchy. This hierarchy is just the first tool you have to work with, and it won't be cast in stone. In fact, it will be a living thing, changing over time as some things get added and others drop off the list. I'm sure you've all experienced that some things that used to bother you don't anymore, and other things that never bothered you before are the most anxiety-producing ones now. Those things come and go. Other things will be added to your hierarchy as you have new exposures and find out "oh, I didn't know that would bother me." So don't worry about getting the numbers just right. But once you have the numbers, then re-write the hierarchy so that you have them listed in order from the 100s down to the 10s. If you want to think of the ladder analogy, we're going to climb from the bottom up. The next thing to do is to cross out the 10s, because they don't create enough anxiety to be useful. We need to have them on there so that we know what out bottom level of anxiety is, but we'll put a line through them and start with the 20s.

We also need to point out that many items on your list will have different levels of anxiety associated with them depending on the circumstances, so you might have to be very specific about the items. For instance, public speaking in front of the OCD group might be one level of anxiety. Speaking in front of the OCD group without notes might be another level. Speaking in front of a large audience of my peers might be another level; this one could be lower or higher. Speaking in a situation that will determine my employment, like a public job lecture, might be even higher. If you have ever gone on an interview that requires a one-hour lecture, as in an academic interview, you'll know this one. So there are lots of ways that your anxiety will be determined by the conditions of the exposure, and lots of ways to make each item break down into sub-items that are a little higher or a little lower. This immediately takes the 10-15 different items on your hierarchy and makes 30-45 items out of them, because each one should be a separate item on your hierarchy. This is important because we're going to use this hierarchy as a ladder, and we're going to climb this ladder one rung at a time. Anyone that's ever climbed a ladder knows that it's easier to climb it if the rungs are closer together than farther apart. Imagine trying to climb a ladder if the rungs are three feet apart - what a frustrating experience! It's much easier if they are only one foot apart. What we would like to do is to make it so that each incremental amount of anxiety won't be a lot more than the last one you just conquered.

Finally, because we need to make each item on the hierarchy as specific as possible, and because the items tend to change over time, most people find that they need to update their hierarchies often. At the very least, it needs to be current when you start behavior therapy, and it needs to be rewritten in between cycles if you do more than one. The most useful thing will be for you to rewrite it just after completing the behavior therapy cycle, because you will be right on top of everything then, you will know how much anxiety each thing currently causes you, and you will be ready to either repeat the cycle or go off and work the therapy on your own with a tool that's most up to date. You'll also know what new items come in. This is important because if your hierarchy gets cluttered by having a lot of things scratched out on it, you might lose items. Now if you go back some day and find,"Oh, I never did that 40 on my list," that's OK, but it would have been more useful to do it at the time you were working on your 40s, just for reinforcement purposes. So try to rewrite it every two months, especially if you're working on your own.

Homework Assignments. You now have an assignment that really needs to be done before going on in the program, and that is to do a first draft of your hierarchy. In the group we would discuss this, and you will need to have it with you when you do work in a group, or with a therapist. I would suggest doing this in a notebook of some kind so that you can keep track of your progress, and so that you will always have the ability to rewrite when it becomes appropriate. However you choose to keep it, bring it with you for each visit, or for each exposure. That's your first assignment. For many of you this will be enough, and it may even be anxiety producing to make your hierarchy, since you will be sitting down and listing all of your anxiety-producing stimuli. I guess making your hierarchy could be an item on your hierarchy, but don't put it down, because you'll only be doing this exposure once (and then adding to it over time). There is an example hierarchy (Figure 14) for someone with mixed symptoms, including several types of compulsions and obsessions.

For those of you who are ambitious, or who find that this process isn't too overwhelming, you can choose to do an optional assignment. After you line out your 10s, choose a 20. Expose yourself to your stimulus that is represented as a 20, inhibit your normal response, and stay with the anxiety for an hour. At the end of the hour, note how you feel. If you feel that you still need to do your ritual, go ahead and do it. If not, great! If you choose to do this assignment, you can do it once, twice, or every day if it seems appropriate. When you do this for real, you will be doing this every day for a week.