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BUILDING AN IN-VIVO HIERARCHY

1. An in-vivo hierarchy is a list of exposures that the patient will work through as homework.
   1. It should contain items with a wide range of SUDS ratings, so the intensity of in vivo exposures can increase gradually over the course of treatment.
   2. Ideally, a hierarchy will contain 10-15 items. However, 5-10 is usually enough to get the patient started on in vivo homework.
2. You should work with the patient to brainstorm items for the hierarchy.
3. A good way to start is to ask the patient to list things he's been avoiding, and ask him to give each one a SUDS rating.
4. From there, you can suggest items as necessary.
5. The same trauma reminder can often evoke different levels of anxiety in different situations. For example, the survivor of a dog mauling might assign different SUDS ratings to looking at a picture of a chew toy, seeing a chew toy in a pet store, and holding a chew toy. Those could all be different items on the hierarchy.