Now that you have populated the anxiety hierarchy up to the compulsions column, it will soon be time to bite the bullet and face your fears. The premise in ERP for the treatment of ROCD is systematic desensitization and not flooding. In flooding, you face all your fears at once and get used to them, whether you feel ready or not. You are not explained why you have to do what you have to do. It is more like ‘I’m ordering you to do something’ rather than ‘Let us discuss what you can do’. It is a more difficult form of exposure. It can get overwhelming and may also derail the recovery process if not done well.
In systematic desensitization, the approach is more collaborative rather than dictatorial, where you are expected to face your fears systematically, one after the other and learn to manage your obsessions without doing your compulsions. When you face your fears, the anxiety that you experience should be high enough to make a difference but not so high that it overwhelms you into giving up. As you get better at handling the smaller fears, you progress to the larger ones. You decide which fears to pick first. You decide the pace. You decide the frequency. You decide when to start. You decide when to stop.
Think of it like resistance training. When you start off, the weights are small enough to lift without causing exertion or damage, but also large enough to exercise your muscles well. When you get adjusted to those weights, you begin to lift larger ones. Or think of it like learning a new language. You start with the basics, sometimes even the script, if it is different from English, like Mandarin or Arabic or Hindi. You proceed to the more difficult lessons only once you have mastered the easier ones.
In the case of ERP, you decide which exposures are easier and which ones difficult. You design your own course. So, you can sort the sheet on the SUDS scores from lowest to highest. We want to start with the smallest fears first and move our way to the larger ones as we progress. Reorganizing the hierarchy can help the recovery process to proceed in a structured manner.
In the next chapter we shall look at understanding the concept of mini-hierarchy.