Shy No Longer

Module 10

Graded Exposure:
Building Situation Stepladders
Introduction

2

How Does Situation Exposure Work?

2The Situation Stepladder2

Situations That You Fear and Avoid

3

SUDS: Subjective Unit of Distress

4

Planning Goals

5

Building Stepladders

6

Module Summary

8

About the Modules

9

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Introduction
In Module 1, we mentioned that avoidance is one way that social anxiety is maintained. While it might feelnatural to avoid some situations, you will need to face your fears in a real situation and begin to turn social
activity into a positive experience. Let’s call this “situational exposure”.
Some people might encourage you to tackle your biggest fear first – to “jump in the deep end” and get itover and done with. However, many people prefer to take it “step-by-step”. We call this “gradedexposure”, Sometimes, if you try to tackle your biggest fear straight away, it can end up being too
overwhelming, or it may even leave you more anxious than when you started. Graded situational exposure
consists of structured and repeated exposure to anxiety-provoking social situations. These are presented
in levels of difficulties, starting with the situation that provokes the least amount of anxiety and moving
towards more challenging situations.

HOW DOES SITUATIONAL EXPOSURE WORK?
Exposure gives you the chance to disconfirm your fears. People with anxiety in social situations
often think that the likelihood of a social disaster happening is very high, and continue to avoid thesesituations. Taking the first step might feel the hardest. At first, the anxiety might feel uncomfortable, but bystaying in the situation you can learn that what actually happens is not so bad after all.
Exposure gives you the chance to use your skills. Feeling comfortable in these situations is notinstantaneous. First of all you need to stay in the situation long enough so that your body adjusts youranxiety downward. Then you can use the strategies you have learnt so far to help you cope with anxious
thoughts and feelings.
Exposure gives you the chance to get used to social situations. By continuingwith more and more exposure tasks, repeatedly confronting situations in which you had
previously felt embarrassed or anxious, you will become used to them. It might not feellike it at first, but it does happen. By entering into these situations, in a planned andproper way, your body will respond more calmly. After a while these situations will lose
their power to bring on as much anxiety as they had before.
Exposure gives you the chance to improve your confidence in social situations. If you plan thesesteps carefully, you will build up on your confidence and this will allow you to take further steps forward.
With increased confidence, you are more likely to face what you call your 'fears'.

The Situation Stepladder
We can now start building a stepladder of exposure situations that you can begin to climb. Remember thatby taking a step-by-step approach you can get through the smaller challenges, which will in turn help you
feel more confident.
In this module, we’ll focus mainly on planning your stepladder. If you are finding the tasks particularly difficult
or are concerned that you will find this task particulalry difficult, enlist the help of a friend.
1. SITUATIONS THAT YOU FEAR AND AVOIDFirst of all, let’s look at the social situations you tend to avoid. You can list these on the next page. You
may not have thought much about the kinds of situations that you avoid, so this exercise will increase yourawareness about them. If you have been working through your thought diaries, you’ve probably mentioned
a few situations that you’ve felt anxious about and avoided, so it might be worthwhile looking at those.
We’ll be using these situations when we look at building the stepladder, so try list a few different ones.
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To give you an idea, below are some examples of situations that often cause distress for people with social
anxiety. If you see any that seem familiar to you, you can rephrase them on your “Social Situations that I
Avoid” list, so that they are more relevant to you.
• Parties and social gatherings.
- Small groups or large groups?
- Friends or people you don’t know?
• Being assertive, such as making acomplaint, inquiring about a problem, or
refusing a request• Being complimented• “Bumping into someone” you know
unexpectedly• Receiving feedback• Being the center of attention• Meeting new people• Talking to people.
- People in authority, strangers, friends,or acquaintances?
• Presentations or talking in front of people• Being watched while doing somethingsuch as signing your name, eating, ordrinking- People you know or strangers?

Write down the situations in the left column. Ignore the right column (“SUDS”) for now.

Social Situations That I Avoid
Situation

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SUDS

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2. SUDS: SUBJECTIVE UNITS OF DISTRESS
You may have noticed the word SUDS in the second column. This stands for Subjective Units of Distress
Scale. This rating is a little like the way you rated the intensity of emotions in the thought diaries. TheSUDS scale is a numerical rating from 0-100 that indicates your level of distress and anxiety in a socialsituation. These ratings will help you to track changes over time. To practise using the scale, read throughthe following guide, then try to think of an example of when you’ve felt that level of distress and anxiety.
SUDSRating
025-49

50-64

65-84

85-100Description

Can you think of a situation
when you’ve felt this way?

You feel absolutely no distress, you are calm and relaxed. Eg
laying in the bath, having a massage, watching a funny movie.
You feel a mild level of anxiety but you can still cope withthe situation. You might feel like you’re more alert or a little
nervous. Eg. Athletes before a competition, and evenconfident speakers before a public presentation.
You feel a moderate level of distress that is becoming difficult
to cope with. You might be distracted by the anxiety, or
behaving in ways to avoid anxiety eg avoiding eye contact,
sitting quietly, but still attending to what’s happening.
You feel a high level of distress that is really difficult to copewith. You’re more concerned with your anxiety and how toescape, and less able to concentrate on what’s happeningaround you.
You feel a severe to extreme level of distress and you think
you cannot cope. Your body response is so overwhelmingthat you think you can’t possible stay in the situation anylonger.

Use this guide to rate your level of distress in the situations that you have listed on theprevious page.
••

Use any number between 0 and 100 to represent how much distress you would feel in the situation.
Use the numbers to represent how much distress you feel in the particular situation, rather than how
distressed you think you look to everyone else.

Now that you have identified a number of situations that you fear and avoid, how do you build a stepladder
to where you want to get to? First of all, let’s take a look at where it is that you do want to get to byplanning your goals. After that you can start thinking about the steps you'll need to take to reach thosegoals by building your stepladder.
It's important to be specific when it comes to building stepladders and working towards your goals. Manypeople who have used this type of exposure have found that small, specific steps helps them feel
comfortable with the situation by knowing what's coming up. It also means that you'll be able to make surethe steps are small enough to take, but big enough that you believe you're heading in the right direction.
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3. PLANNING GOALS
Let’s think about how you can turn those situations that you fear and avoid into specific goals that youwould like to achieve. When you’re planning goals for exposure you can follow the acronym PRAMS:
Personal, Realistic, Achievable, Measurable, Specific.
Personal: Choose the situations you listed that are most relevant to you at the moment. For example, if
you feel anxious about eating in public and your avoidance of that situation is interfering in your ability toenjoy the company of your family or friends, then you might set a goal in that area.
Realistic: For example, expecting not to feel any anxiety is not realistic, as we all feel some anxiety attimes, and sometimes it can even help our performance! Generate goals that are possible.
Achievable: Similarly, write goals that are achievable for you at the moment. Perhaps singing a ballad at afriend’s wedding is an unreachable expectation for most people, let alone for you right now. Generate goals
that are probable.
Measurable: Make sure your goals can be easily measured. “Speaking to people with confidence at a party”
might be difficult because “confidence” is hard to measure. Action based goals are easier to measure:“Speaking to someone at a party for at least 2 minutes” allows you to accurately assess whether you’vereached that goal.
Specific: As the above example shows, goals also need to be specific. So, if the situation that you avoid is“Eating out in public” then your specific goal could be “To eat a meal in a restaurant”. If the situation is“Talking at meetings” then your goal might be “To comment on an agenda item at a monthly teammeeting”.
To start with, you might want to just choose just a few situations to turn into goals, rather than trying to
do it all at once.
•Choose situations that you want to change, rather than planning goals that are not very important toyou.

•Choose situations over a range of different SUDS levels so that you can set some easier, less distressing
goals, but at the same time you don’t exclude the more difficult, distressing goals.

Based on the situations that you listed under “Situations That I Avoid”, write down the specific goals you
would like to achieve below. It is also useful to rate your SUDS level for each goal as it may have changed
from when you were thinking of it as a general situation.

Specific Goals

SUDS (0-100)

1.
2.
3.
4.
5.

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4. BUILDING STEPLADDERS
In situational exposure it is important to determine how you can reach your goals.
You need to break down each goal into smaller steps so it is a little like climbing aladder towards your main goal. Try to think of a set of exposure tasks that startwith less anxiety provoking situations, then build up in intensity until you reachyour main goal. The number of steps depends on how much distress is associatedwith the particular goal. A high-challenge exposure situation (SUDS: 80+) willneed more steps than a medium-challenge exposure situation (SUDS: 40-60).

80
75
65
5035Perhaps you avoid going out with your friends because you are worried thateveryone is watching you, that they’ll draw attention to you and embarrass you. Your specific goal might beto go out to a pub or a party on a weekend evening and stay there for at least 2 hours. This might be quite
a difficult goal, with a SUDS rating of 80. You can break this goal into smaller steps by changing WHO isthere, WHAT you do, WHEN you do it, WHERE you do it, and HOW long you do it for. Sometimes yourgoals will be opportunity-specific, that is, there might not always be a steady stream of parties where you
can practise your steps. So you need to think of situations that can act as steps that will still help you toclimb the ladder to your goal. Below is an example of building a stepladder. On the next page is some spacefor you to complete the steps for your own goal.
EXAMPLE:GOAL: To go out to a pub on a weekend night and stay there for at least 2 hours

SUDS (0-100)
80

STEP

SUDS

1

Go to the local pub on a week day afternoon, (with a friend who knows
about the problem), buy a soft drink and stay for 10 minutes

30

2

Go to the local pub on a week day afternoon (with a friend who knows
about the problem), buy a soft drink and stay for 30 minutes

45

3

Go to the local pub on a weeknight, staying from 7pm to 8pm (with afriend who knows about the problem)

55

4

Go to the local pub on a weekend night, stay at least 30 minutes (with afriend who knows about the problem)

65

5

Go to the local pub on a weekend night staying from 8 pm to 10pm
(with friends who know about the problem)70

6

Go to the local pub on a weekend night staying from 8 pm to 10pm
(some of the friends don’t know about the problem)

80

Remember, your stepladder might have more or fewer steps depending on how difficult the challenge is(how high the SUDS rating is). You can also include more ‘in-between’ steps if you think the jump between
one step and the next is too big.
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Situation Stepladder
GOAL:SUDS

STEP

SUDS

Break the goal into smaller steps by changing•••••

WHO is there
WHAT you do
WHEN you do it
WHERE you do it
HOW long you do it forfor
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Shy No LongerModule Summary•

One of the ways to start turning your thoughts into actions is through “graded exposure”, or“situational exposure”. This means that you begin to confront your fears in a step-by-step
approach•

Situational exposure is helpful because when you enter the social situations that you usually
avoid, in a planned and proper way, your body will react more calmly. After a while thesesituations will lose their power to bring on as much anxiety as they did .

•Building situation stepladders is part of a process Identify the social situations that you feel anxious in and tend to avoid
 Use SUDS (Subjective Units of Distress Scale) ratings as a gauge of how much distress you
feel in particular situations, from 0 - 100. This rating scale will help you to plan yoursituation stepladders, and it will help you to track changes in level of anxiety over time.
 Plan specific goals that give you something to aim for. When you’re planning goals for
exposure you can follow the acronym PRAMS: Personal, Realistic, Achievable,Measurable, Specific.
 Build stepladders by breaking down each goal into smaller steps. Use the SUDS scale toplot the order of steps so it is a little like climbing a ladder towards your main goal. You
can make each step easier or harder by adjusting the WHO, WHAT, WHEN, WHERE, andHOW component in each step.

In the next module we will
look at how to actually workthrough your stepladders.

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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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