July 14, 2025
by Federico Ferrarese
in NEWS, OCD
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7 Effective Exposure Hierarchies for Mental Wellness

Introduction: A Moment That Changed Everything

A few years ago, I was working with a client who came to my office feeling completely stuck. She had tried therapy before, had read all the right books, and even printed off some ERP worksheets from the internet. But still, her OCD was running the show. It told her she was unsafe, that her thoughts were dangerous, and that one wrong move could hurt someone she loved. Her compulsions were exhausting. She avoided everything from cooking to cuddling her dog. We needed a new way in.

That’s when I first saw the power of a flexible, well-designed exposure menu. Not a rigid checklist, but something living and breathing. Something that met her exactly where she was, and helped her take small, brave steps forward. It was one of those moments that reminded me why I do this work.

Hi, I’m Federico Ferrarese, a CBT therapist based in Edinburgh specialising in OCD treatment. I recently had the privilege of attending the 30th Annual OCD Conference hosted by the International OCD Foundation (IOCDF) in Chicago. One of the most powerful sessions I attended was called “Building Effective Exposure Hierarchies Menus for Mental Wellness” led by Michelle Massi, LMFT and Beth Brawley, LPC. It wasn’t just a clinical deep dive—it was a total mindset shift.

In this article, I want to share what I learned, how it can change the way we approach OCD treatment, and how this method can help you, or someone you love, break free from OCD’s grip.

What Is an Exposure Hierarchy or Menu?

Let’s start simple. Imagine you’re terrified of getting sick, so you avoid door handles, public toilets, and even shaking hands. For someone with OCD, this is daily life. An exposure hierarchy is a structured list of the situations or triggers that cause this anxiety, ranked from the least to the most distressing. Think of it like a staircase, with each step being a challenge that’s just a bit scarier than the last. As you climb each step—starting with easier ones—you gradually become more confident and less afraid. That’s the heart of ERP: gradually facing fears to show your brain it’s safe.

Now, an exposure menu is a little different. It’s less of a staircase and more like a buffet. It lists all the possible fear-inducing situations without worrying about the order or intensity. This gives clients the flexibility to choose based on what feels doable that day. Maybe today they want to take on a medium challenge, or mix two smaller ones together. It’s more adaptable and better suited for certain subtypes of OCD or when motivation levels vary.

Both hierarchies and menus are incredibly useful. They help us organise exposures in a meaningful, individualised way. And more importantly, they give the client control and clarity over their healing journey.

These tools are central to Exposure and Response Prevention therapy (ERP)—the gold standard for OCD treatment. They’re not just about doing scary things; they’re about learning new truths. According to NICE guidelines, ERP has a recovery rate of approximately 60–70% when delivered appropriately (National Institute for Health and Care Excellence, 2005). That means for most people, these methods actually work—and that’s hopeful, isn’t it?

Why ERP Is a Game Changer for OCD

OCD is sneaky. It tells people that their thoughts are dangerous. ERP flips that on its head. Instead of avoiding fear, we move towards it—gradually, compassionately, and with purpose.

ERP teaches us something radical: fear doesn’t need fixing. We just need to learn how to live with it. That means building confidence in our ability to tolerate discomfort, rather than trying to erase it.

From Hierarchies to Menus: What’s the Difference?

At the IOCDF conference, Michelle and Beth made a crucial point: Hierarchies tend to follow a linear approach, focusing on gradually reducing anxiety. These are typically built using SUDS ratings (Subjective Units of Distress), which help track how anxious someone feels when they imagine or confront a feared situation. The goal? Work your way up the list—from less scary to more scary—and ideally, feel less anxious over time.

Menus, on the other hand, change the game. They’re not about getting rid of anxiety, but about expanding tolerance and insight. With a menu, there’s no pressure to follow a set path. Clients can pick exposures based on what feels most meaningful or manageable on that day. It’s less about ticking boxes and more about building a flexible toolkit.

Think of it like this: hierarchies are like walking up a staircase with a set number of steps. Menus are more like a training gym—you pick the exercise that matches your strength and stamina that day. Both help you grow, but one allows more freedom to explore and adapt.

What really matters—whether you’re using a hierarchy or a menu—is that the exposure teaches something new. That the client comes out of it thinking, “I faced it and survived,” or even better, “That wasn’t as dangerous as OCD made it seem.” We shift from “I need to stop feeling anxious” to “I can handle feeling anxious and still live my life.” And that’s a powerful transformation.

The Shift: Inhibitory Learning Model (ILM) vs. Habituation

Traditional ERP focused on a concept called habituation. The idea was pretty straightforward: keep doing the exposure until your anxiety naturally drops. If you were afraid of touching a door handle, you’d touch it repeatedly until your fear faded. It’s a valuable approach, and it helped a lot of people—but it also had limitations. What if your anxiety doesn’t go away quickly? What if it stays high no matter how often you do the exposure? That’s where many clients felt defeated and gave up.

Enter the Inhibitory Learning Model (ILM), a more modern take that shifts the focus from reducing anxiety to building new learning. Instead of measuring success by how calm you feel, we look at what you’ve learned. Did you face the fear and survive? Did the worst-case scenario actually happen? Can you tolerate uncertainty and keep going? These are the kinds of questions ILM prioritises.

The beauty of ILM is that it gives clients permission to feel anxious without seeing it as failure. You can be anxious—and still make progress. You can feel fear—and still function. Anxiety becomes something you carry, not something you run from. That’s a big deal.

And here’s a twist: sometimes anxiety doesn’t go away because your brain is still testing whether the threat is real. ILM says, “Let’s help the brain see the truth.” So, rather than aiming for comfort, we aim for clarity. We collect evidence. We update the brain’s assumptions.

This approach builds resilience. It teaches people that anxiety is just a feeling, not a signal of danger. And that lesson? It sticks.

Creating a Hierarchy: The First Steps

So, how do we actually build this thing?

Step One: Psychoeducation

You can’t tackle a fear if you don’t understand it. That’s why we start with psychoeducation. We help clients understand OCD, intrusive thoughts, compulsions, and why ERP works. When clients understand why they’re doing something challenging, they’re more likely to persist with it.

Step Two: Functional Analysis

This part is crucial and often overlooked. It’s where we slow down and get curious. Before we can create a useful exposure list, we need to understand the mechanics of the OCD cycle in that person’s life.

We start by identifying three key things:

What’s the obsession? That intrusive thought or image that causes distress.
What’s the compulsion? The behaviour or mental act used to neutralise the obsession.
What’s the core fear underneath it all? The deeper belief or catastrophic outcome that the person is desperate to avoid.

Sometimes the surface compulsion seems odd or disconnected. But when we ask, “What would happen if you didn’t do that?” or “What are you afraid it would mean about you?” we often uncover fears such as causing harm, being immoral, or going crazy. These are the real drivers.

We use tools like the Downward Arrow Technique to dig deeper. This involves asking layered questions: “If that happened, why would it be bad?” and “What would that say about you?” It’s like peeling an onion. With each answer, we get closer to the emotional core.

This isn’t just about labelling symptoms. It’s about forming a shared understanding between therapist and client. When we uncover the ‘why’ behind the rituals, we can design exposures that target the true fear—not just the surface behaviour. And that’s when the real shifts begin.

Real Talk: A Sample Menu From The Conference

Here’s a slice from a real-life menu shared at the conference (names changed):

Put a steak knife on the desk
Read the article about serial killers
Dress up a fake knife with a post-it note
Ask mum to hide a knife in a drawer
Look at blood-stained objects in photos

Notice how creative this is? It’s not just “stand near a knife.” It’s layered, multi-dimensional. That’s what makes it powerful.

Addressing Different OCD Subtypes

One of the session’s biggest takeaways: customisation is key. You can’t copy and paste a menu for every OCD sufferer. Subtypes matter.

Contamination OCD? Touch “dirty” surfaces. Harm OCD? Sit near knives or drive past schools. Relationship OCD? View triggering photos or write fear narratives.

We must tailor exposures to match the person’s symptoms and values.

When Clients Say: “Everything Feels Too Hard”

It happens more often than you might think. A client sits down, looks at their list of exposures, and says, “I can’t do any of this. It’s all a 10 out of 10.” In that moment, it’s easy to feel stuck. But actually, this is a starting point. It tells us something important: we need to slow down and adjust the pace.

First, we look at the intensity. Can we scale it back? Instead of touching a knife, maybe we start by looking at a picture of one. Instead of walking into a crowded train, maybe we just stand near the station. Tiny steps count. In fact, they’re essential.

Then, we look at support. Who’s alongside the client in this work? Sometimes it helps to do the first exposure together in a session. Or to plan it out with a family member or friend who understands the process. Even the simple act of sending a message after completing an exposure can create accountability and reassurance.

We also use willingness scales to track motivation. A 10/10 anxiety rating doesn’t mean we can’t move forward. But if willingness is 2/10, we know we need to meet the client where they are. We explore what might help increase their sense of readiness. Maybe it’s adjusting the language, reframing the fear, or adding more context.

Most importantly, we normalise it. Progress in ERP is rarely a straight line. It’s messy, frustrating, and sometimes emotional. But even when it feels hard—especially when it feels hard—those small moments of bravery matter. We remind clients that courage doesn’t mean feeling ready; it means taking the first step. It means showing up anyway.

Facing Challenges Head-On

Some clients struggle when anxiety doesn’t drop. They say, “ERP isn’t working.” But remember the ILM approach? It’s not about feeling less anxious—it’s about learning that anxiety is safe, tolerable, and temporary.

Others fear relapse. They think, “What if it comes back?” That’s why we build flexible, living exposure menus. Ones you can revisit and revise.

Tracking the Right Stuff

Forget just counting SUDS scores. While it can be useful to know how anxious someone feels before and after an exposure, it doesn’t give us the full picture. We want to track what actually matters—the learning.

So instead, we shift our focus to three essential pieces:

What the client expected: This helps identify the fear or prediction that OCD is pushing. Did they think they’d get sick, lose control, or be judged?
What actually happened: This is the evidence-gathering part. Did the feared outcome come true? Was it as bad as predicted? Most of the time, it wasn’t.
What they learned: This is where the magic is. Clients start to realise, “I can do hard things,” or “My anxiety didn’t break me.” Sometimes they even discover they were stronger or braver than they thought.

It turns the exposure into an experiment, not just an exercise. We’re not chasing relief—we’re chasing insight. The goal is to teach the brain that discomfort can be survived, that uncertainty can be handled, and that thoughts are not threats.

That’s the gold. That’s the change that lasts long after the anxiety fades.

Practising Self-Compassion

OCD sufferers often beat themselves up. “Why can’t I get over this?” But progress in ERP isn’t about perfection. It’s about showing up, again and again.

We encourage clients to validate every win—even if it’s just thinking about the exposure. That’s courage.

Making It Practical: Exposure in the Real World

We don’t keep exposure inside the clinic. We:

Take field trips to supermarkets
Send tasks via WhatsApp
Encourage family involvement (when safe and helpful)

ERP is about life. We need to make it part of real living.

Let’s Talk Numbers: ERP Works

According to the IAPT NHS data from 2023, ERP delivered through CBT has a recovery rate of up to 65% for OCD. In a study by Foa et al. (2005), over 80% of participants reported a significant reduction in symptoms following ERP treatment.

These aren’t just stats. They’re stories of people who got their lives back.

How I Can Help

If you’re in the UK and struggling with OCD, you don’t have to go it alone. At my clinic in Edinburgh, I develop custom ERP programs that incorporate thoughtful exposure hierarchies or menus.

I make space for your fears, your values, and your pace. Whether you’ve never tried therapy or feel stuck in it, there’s always room to grow.

Final Thoughts: You’re Not Broken

So here’s the thing. OCD lies. It tells you that you can’t trust yourself. That you’ll lose control. That you’re dangerous, unclean, or immoral. ERP helps you see the truth: you are capable. You are brave. And yes, you can learn to live a full life again.

I am Federico Ferrarese, a CBT therapist based in Edinburgh specialising in OCD treatment, and I am here to walk alongside you. Not above you, not ahead of you—with you.

So, what would your first step on the menu look like?

References
Foa, E. B., Huppert, J. D., Leiberg, S., Langner, R., Kichic, R., Hajcak, G., & Salkovskis, P. M. (2002). The Obsessive-Compulsive Inventory: Development and validation of a short version. Psychological Assessment, 14(4), 485–496.

National Institute for Health and Care Excellence (NICE). (2005). Obsessive-compulsive disorder and body dysmorphic disorder: treatment. Clinical guideline [CG31]. Retrieved from https://www.nice.org.uk/guidance/cg31

Massi, M., & Brawley, B. (2025). Building Effective Exposure Hierarchies/Menus for Mental Wellness [Conference presentation]. 30th Annual IOCDF Conference, Chicago, IL. Retrieved from https://events.iocdf.org/event/OCD30/about

IOCDF. (2025). 2025 Annual OCD Conference Prospectus. Retrieved from https://iocdf.org/wp-content/uploads/2025/02/2025-Annual-OCD-Conference-Prospectus.pdf

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