Exposure Hierarchy Plan (Exposure/ERP)

Patient: [name and identifiers per local policy]

Date Created: [date] / Last Updated: [date]

Author: [name, credentials, role]

Diagnoses: [DSM/ICD codes being targeted]

Plan Status: [Initial / Update] — [treatment phase or session descriptor]

Clinical Indication

[Brief indication statement describing what ERP is treating, why it is indicated at this time, and primary functional targets]

• Main obsession/intrusion themes: [brief thematic descriptors] (Use minimum necessary detail to guide ERP safely.)
• Main compulsions/rituals/avoidance patterns: [behavioral descriptions in neutral language]
• Functional targets: [functional goals such as role/social/ADL targets and time-cost of symptoms]

Baseline severity measure: [measure name and current score / Baseline measure planned]

ERP Preparation

Education provided: [ERP rationale, expected discomfort, and goals discussed]

Patient understanding and agreement: [patient demonstrates understanding and agrees to participate / education partial / consent deferred — specify what remains]

Readiness factors and barriers: [facilitators, barriers, accommodations needed] (If not assessed, state "Not assessed.")

Case Formulation

(Use concise behavioral language. A working hypothesis for core fear themes may be noted if labeled as clinician hypothesis requiring patient confirmation.)

Triggers

• External situations:
  • [trigger/cue] — [contextual modifiers] — [typical avoidance pattern]
• Internal sensations:
  • [trigger/cue] — [contextual modifiers] — [typical avoidance pattern]
• Intrusive thoughts/images/urges:
  • [trigger/cue] — [contextual modifiers] — [typical avoidance pattern] (Use minimal necessary content detail.)
• Uncertainty cues:
  • [trigger/cue] — [contextual modifiers] — [typical avoidance pattern]

(Omit trigger categories that do not apply.)

Feared Outcomes

• [Linked trigger/category]:
  • Predicted catastrophe: [what the patient predicts will happen] (Include brief patient quotes only if they clarify.)
  • Feared meaning/consequence: [what it would mean about them or lead to]

(Repeat for each main trigger. If the patient cannot articulate feared outcomes, state this explicitly and note the plan to clarify.)

Compulsions and Safety Behaviors

• [Linked trigger/category]:
  • Overt compulsions: [behavioral rituals]
  • Covert/mental rituals: [cognitive rituals]
  • Reassurance seeking: [from others / online / self]
  • Safety behaviors: [avoidance, checking, neutralizing, distraction]
  • Family/caregiver accommodation: [accommodation behaviors] (Omit if not applicable.)

(Use neutral, nonjudgmental language. Do not infer behaviors not reported.)

Exposure Hierarchy

SUDS anchors: [scale definition, e.g., 0 = no distress, 100 = worst imaginable distress]

Step	Exposure Task	Type	Feared Outcome Being Tested	Predicted SUDS	Response Prevention	Notes
[step number]	[setting, what patient does, duration/repetitions]	[in vivo / imaginal / interoceptive / uncertainty]	[linked feared outcome / to be clarified]	[number / pending]	[rituals/safety behaviors to block]	[variations, advancement criteria, allowed coping]

(Add one row per hierarchy step. If SUDS estimate is pending, write "pending" rather than guessing. If feared outcome is unclear, mark "to be clarified" and treat as provisional.)

Response Prevention Plan

Global rules:

• [patient-specific response prevention rule applying across exposures]
• [additional rule as needed]

Safety behavior plan: [Elimination / Limited aid permitted early] (If limited aid is allowed, specify which behavior, conditions of use, fading schedule, and rationale.)

Family/caregiver coaching: [accommodation behaviors to stop and replacement responses] (Omit if no caregivers involved.)

Lapse management: [definition of lapse and recovery plan] (Emphasize return to exposure, log event, review next session.)

Between-Session Practice Schedule

Date Range	Hierarchy Step(s)	Frequency	Duration/Trials	Response Prevention Rules	Data to Record	Troubleshooting
[dates]	[step numbers or descriptions]	[days/week]	[minutes or number of trials]	[specific rules to apply]	[SUDS pre/peak/post, ritual urges, completion]	[what to do if distress exceeds threshold or practice cannot be completed]

(If patient cannot commit to full schedule, document the limiting factor and provide minimum viable dose with plan to increase.)

Safety Screen

Suicide/self-harm screen: [positive / negative / Not assessed]

Risk considerations: [special considerations tied to compulsions, medical vulnerabilities, or severe self-neglect] (If intrusive harm or sexual thoughts are present, document that these are assessed as intrusive obsessional phenomena. Omit if none.)

Emergency plan: [steps patient will take if distress escalates beyond agreed bounds]

Plan

• Next planned in-session exposure target(s): [upcoming hierarchy step(s)]
• Data to review next session: [homework logs, SUDS data, accommodation changes]
• Follow-up: [next appointment date/time or interval]

Author signature: [name, credentials] — [date]