Shy No Longer

Module 11

Graded Exposure:
Climbing Situation Stepladders
Introduction

2(Before) The First Step

2

Completing a Step on the Stepladder3

Climbing the Stepladder4

Stepladder Diary

6

Module Summary

7

About the Modules

8

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Introduction
Now that you have built your situation stepladders, it’s time to take the first step towards putting yourplans into action. Remember, situational exposure is helpful for a number of reasons:• It gives you the chance to get used to the situation. You might feel very anxious at first, but you’ll
find that your body will start to relax after a while your.
• The process of graded situational exposure gives you the opportunity to use the skills you havelearned so far, such as the calming technique and challenging your negative thoughts.
• By being in the situations, you can do the detective work in those situations that you might beanxious about. This way, you can collect real evidence to test your unhelpful thoughts and beliefs.
In this module we’ll talk about how you can take the steps to climb up your stepladder, and how you canapply the skills you’ve learned so far in these situations.
As we mentioned in the last module, though, working through exposure tasks usually occurs with the support of amental health professional who can more clearly guide you through the process. If you are finding the tasks
particularly difficult, or are concerned about your progress, please see your doctor or a mental health practioner tohelp you to continue to achieve your goals.

(Before) The First Step
In the last Module you used SUDS ratings to construct a series of steps on your stepladder that lead toyour final goals. If you have a few different goals, you may be asking yourself, “Which one do I start with?”Once again, your SUDS rating for each goal will help give you an idea of which goal to work on first.
Usually, for example, you would choose the goal that had the lowest SUDS rating. If the goal only has a few
steps and a lower SUDS rating, perhaps 30, it is still useful to work up to these goals, even though you
might think that it’s a “waste of time”. These goals give you extra situations for your body to get used tosituations that are uncomfortable for you, if not very distressing. They also give you extra opportunities topractise your skills and gather evidence about your negative automatic thoughts. Finally, if they are goals
that are important to you, then they are worth working on.
So, you’ve selected a goal that you want to work on first. Where do you go from here? Let’s have a look at
the skills that you’ve learned so far and how you can use them to help you prepare for the process of
situational exposure – even before you take the first step.
1. THE CALMING TECHNIQUE AND RELAXATION
Hopefully you have continued to practise the calming technique during relaxation sessions – you may haveeven used it a few times in stressful situations to reduce your level of anxiety. If the calming technique has
worked to relax your body during stressful situations, or if your breathing rate consistently slows down toa normal rate after using the calming technique, then you are probably ready to use it during exposure.
If you have not consistently practised the calming technique or if you’re breathing rate is still high after
practising the calming technique, then you might need to practise more often. If you choose to do thesituational exposure exercises anyway, just be aware that the calming technique might not work as well as
you hope it might when you are in those situations. In the few days before you take the first step it may beespecially helpful to practise the calming technique and relaxation exercises to get your body to a morerelaxed level.
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2. THOUGHT DIARIESWhen you’re thinking about your goal or the first step on your stepladder, what goes through your mind?
Do you feel anxious thinking about the situation? If you have any negative unhelpful thoughts about thesituation, now is an excellent time to do some detective work and disputation. Use a thought diary to workthrough how you’re thinking and what you’re feeling about the situation.
•Think about the situation that you’ve outlined in the step – imagine what it might be like - what do you
think might happen? How do you think it will go? Be sure to note your feelings about the situation andhow strong the feelings are – which emotion best sums up how you’re feeling about the situation?

•What thoughts are running through your head when you think about the step? Which of those is thehot thought – the thought that best relates to the primary emotion? How much do you believe thatstatement? Note any unhelpful thinking styles related to your thoughts.

•Work through the detective work and disputation questions about your hot thought.

•Use this information to construct the “end result” balanced thought about the situation that is part ofyour stepladder. You can write this balanced thought onto a thought card and take it with you when
you go into the situation. You might even want to read it over and over before you go into thesituation, making particular note of any part of the statement that you can really relate to.

When preparing for a step on the stepladder, be sure to use the skills that you’ve developed. The more
you practise your skills, the better you’ll get at reducing your anxiety about particular situations.

Completing a Step on the Stepladder
Now that you have prepared yourself for climbing your situation stepladder, you can make an appointment
with yourself to take the first step. By setting a date, time, and place you are making a firm commitment toyourself to begin the process of change. When you are in the situation that you have planned, there are afew points that will help you to complete each step on the stepladder successfully.
1. EXPECT SOME ANXIETYWhen you enter the situation – at any step - remember that you’ll probably experience some anxiety or
discomfort. That’s why it’s important to start small, and work your way up. This gives you the chance toadapt to that level of anxiety, so that you aren’t overwhelmed by higher levels of distress. After all, the only
way to get used to those feelings is by experiencing them.
2. USE YOUR SKILLSUse the calming technique to slow down your breathing and to respond to the situation in a more relaxedway. Repeat your balanced thought to yourself if you notice any of the unhelpful thoughts coming up. Just
focus on these two things to begin with. When you take the first step, it may seem that there is a lot toremember, so just focus on slowing your breathing, and use your balanced thought, to star with.
3. STAY IN THE SITUATION
Some anxiety is expected, and it might be tempting to leave if you feel uncomfortable, but try to stay in thesituation until the anxiety goes down. In this way you can see that, as frightening as the feelings are, they
are not dangerous, and they do subside. If you leave just as the level of anxiety experiences reaches its
highest point, it may be more difficult to accomplish the same step the next time. On each attempt, youshould try to face as much fear as you can stand and ‘keep on keeping on’.

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4. STAY INVOLVED
For some steps on your stepladder, it might be important to stay involved in the situation. Regardless ofthe situation, try to stay involved in what is happening around you. ‘Staying away' can happen in manydifferent ways. Some people might sit far away from others, or avoid eye contact with people. Being anexpert at avoiding social situations often means being an expert at avoiding anxiety in social situations, andpart of this is making the situation around you feel less real. So stay involved in the situation, notice what ishappening around you to make it as real as possible for you. Really taking part in these situations is the only
way to make sure you get used to the anxiety that you might feel at the upper steps.
5. STAY SOBER
Staying involved means being fully aware of what is happening around you. This means not taking alcoholor drugs to try and “mentally escape” the situation, even though you are physically in the situation.

Climbing the StepladderOK, so now that you have some tips on how to get through one step, how do you keep moving onwards
and upwards? Here are some guidelines for how you can continue to climb each step to reach your goal.
1. ONE STEP AT A TIME
Climbing a stepladder is not about taking one giant leap, it’s about taking one small step at a time. You
begin with the least difficult step and gradually work your way up the step ladder. As you climb higher up
the ladder, your SUDS rating becomes higher, but you also get used to the anxiety at each of those steps.
Your primary aim at each step is to complete that step and that step alone.
2. OVER AND OVER AGAIN
Do a step frequently and repeatedly, and try to do them in close succession to make sure you are
comfortable with the situation before you move onto the next step. This might take 3 or 4 times. If you
only enter a situation once, you might convince yourself that it was luck or that it was a different day thanmost. If you can, it is best to repeat them in a short period of time so that you can get used to the situation
more quickly and become comfortable. This helps to build up the evidence for when you are disputing any
unhelpful thoughts.
3. USE YOUR SKILLS
That’s right – use your skills again! Work through any unhelpful thoughts about the situation after you havecompleted each step, or repeated a step. Allow yourself to unwind with a relaxation session.
4. ACKNOWLEDGE THE STEPS YOU’VE MADE
When you are comfortable with a particular step, admit to your successes and acknowledge the steps thatyou’ve made so far.
5. STEPBACKSWe all have our up and down days, and sometimes you might think might you’ve taken a ‘step-back’
because the situational exposure exercise didn’t go as well as you hoped. It’s unlikely that each time an
exposure exercise is attempted, it will definitely become easier. That’s why it’s important to do a step over
and over until you are comfortable with that step. There are different reasons that play a part in how muchanxiety you experience in any given situation – and sometimes we don’t recognise what those reasons arein the same way that sometimes people say they have ‘bad hair’ days!
6. TROUBLESHOOTING STEPBACKS
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Shy No LongerIf you do think that a situation hasn’t gone as well as you hoped, or you’ve taken a step backwards there
are a number of things you can do.
•Use your thought diary as a way of challenging what unhelpful thoughts might arise about the situation.

•Set a time and date to try the step again (remember – over and over).

•If you have tried it a few times and you still find it distressing, you may find it useful to create an ‘inbetween’ step, by planning another step that is slightly less distressing and has a slightly lower SUDS
rating. You might think of this as a ‘bridging step’ in the same way that some people might take a‘bridging course’ to get them ready for the next step. Use your stepladder-planning skills from Module
10 to make sure that it fits between the step that you have completed and the step that you are having
difficulty with.

•You may find it helpful to go back and repeat the previous step. Sometimes, if it has been a while since
you’ve completed a situational exposure exercise, or if you weren’t completely comfortable with theprevious step, you may need extra situational exposures to make sure you are fully ready for the next
step above. You might think of these as ‘refreshers’ in the same way that people take ‘refresher
courses’ before they go on to the next step.

7. USE THE STEPLADDER DIARYOn the next page is a Stepladder diary for you to record details about the steps that you make. This isuseful because it helps you to acknowledge the steps that you’ve made, it reminds you of the skills thatwere useful, and it helps you identify what you can do if the situation didn’t go as well as you hoped.

Turtle Tip
Try talking to atrusted friend or
family member
about what you aredoing. They can offer
support andencouragement
while you areworking throughyour steps.

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Stepladder Diary

You can use this sheet to record your progress on your stepladders. You can describe: what you did, when you did it(including how long it took), and what your SUDS ratings were - how nervous you both expected to be and how nervous
you actually were. The last column asks you to jot down any comments about the experience – if you were able to stayin the situation for the time you specified for that step, what tools did you used. If you experienced a great deal of
difficulty, you can note down why you think this might have been the case, and how you might prepare yourself to go
into the situation the next time.
Situation

Expected
SUDS

ActualSUDS

0-100

0-100forCentrelinical
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Did you
completethesituation/step?

Describe what you did/what skills you used that helped
you complete the situation/stepOR
Describe what made it difficult to complete thesituation/step and how you can prepare for next time

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Module Summary• Situational exposure is an important part of reducing your anxiety in social situations andfeeling more comfortable in them
• Before you take the first step, you can prepare yourself to climb the stepladder. Thisincludes Using the calming technique and relaxation to reduce your level of anxiety.
 Using thought diaries to examine and challenge unhelpful thoughts about thesituation. The balanced thought that you create can be used during the situational
exposure exercise.
• When you complete a step on the stepladder, there are several points that are useful toremember.
 Some anxiety is expected as it is the anxiety that situational exposure are designed tohelp you get used to Use your skills, such as the calming technique and your balanced thought.
 Stay in the situation so that you can get used to it.
 Stay involved with the situation to make it as real as possible for you Stay sober so that you can fully engage with what’s happening around you• When you are climbing the stepladder, there are some points to remember.
 Climbing a stepladder is about focusing on just the next step, and taking it one step ata time.
 Do a step frequently and repeatedly, and try to do them in close succession to makesure you are comfortable with the situation before you move onto the next step.
 Use your skills such as thought diaries and relaxation after each situation
 Acknowledge the steps you’ve made
 Recognise that everyone has their up and down days and that sometimes stepbacks
occur. If a situation doesn’t go as you hoped, there are still things you can do to keep
yourself on track, such as completing the previous step again, or building a bridging
step.

In the next module, we willdiscuss how you can maintainthe gains you have made, andhow to enhance your wellbeing.

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About The Modules
BACKGROUNDThis module was created in 2003 by Patrick Kingsep at the Centre for Clinical Interventions, under thesupervision of the Centre’s Founding Director, Paula Nathan.
The concepts and strategies in these modules have been developed from evidence-based psychologicalpractice, primarily Cognitive-Behaviour Therapy (CBT). CBT for social anxiety is based on the approachthat anxiety is a result of problematic cognitions (thoughts) and behaviours.

REFERENCES

These are some of the professional references used to create the modules in this information package.
Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, M. R. Liebowitz, D.
A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment and treatment (pp. 69–93). New
York: Guilford Press.
Heimberg, R. G. & Becker, R. E. (2002). Cognitive-behavioral group therapy for social phobia. New York: Guilford
Press.
Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-behavioral model of anxiety in social phobia. Behaviour Researchand Therapy, 35, 741–756.

“SHY NO LONGER”
This module forms part of:Kingsep, P., & Nathan, P. (2003). Shy No Longer. Perth, Western Australia: Centre for ClinicalInterventions.

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