The previous chapters looked at a number of challenges in developing strong CBGT programs—such as how to prepare people for group treatment, ensure their expectations are positive and realistic, combine different mental health problems in the same group, and augment CBT by integrating it with elements of another therapy approach. This chapter offers suggestions for how to fine-tune common CBGT interventions. CBT therapists, especially if they were primarily trained to do individual therapy, can feel a bit thrown off their otherwise confident CBT stance when having to transfer their skills from individual to group settings. The following topics reflect some of the more technical struggles. I have often been asked about by therapists who lead CBT groups. We will review how to develop exposure hierarchies, support homework completion, and prepare clients for becoming their own therapists after the group is over.

Why Exposure Hierarchies are Important

Supporting clients in systematically facing their fears is one of the fundamental principles of CBT. It is the feature that most distinguishes CBT from other forms of psychotherapy. CBGT therapists can introduce the concept by describing how exposure therapy is based on the principle of extinguishing fears by preventing an escape from experiencing them. When human beings engage fully with unpleasant emotions and associated uncomfortable body sensations, these will, over time, diminish. This process is referred to as habituation or desensitization, but really means to become used to a feeling, to become bored with it! The therapist can go on to explain that, when humans are too quick to avoid unpleasant feelings, we deprive ourselves of the opportunity to learn that those feelings and body sensations are time limited and not harmful. New parents, for example, often remark how unpleasant and even disgusting it at first is to change a baby’s diaper. But because escape is not an option, it surprisingly quickly becomes routine and boring. However, as grandparents will say, after several years of having “escaped” changing diapers, it may take a little while to get used to it again.

Despite research consistently confirming the robustness of this evidence-based therapeutic procedure, many CBT and other clinicians seem to struggle with the implementation of exposure and are at times hesitant to engage in its practice (Schare & Wyatt, 2013). And exposure interventions for different kinds of disorders can without doubt be challenging to implement in a group setting. Hence, the majority of CBGT therapists will need to spend some time preparing their clients—and themselves—for the exposure part of group treatment.

In the first couple of CBGT sessions, where group therapists cover education about a particular illness and its treatment approach, they repeatedly tell group members their exposure will be gradual and systematic and that they will always be in charge. Therapists may add: “You will not be doing anything you do not agree to. Our job as therapists is to work with you to find the place where you push just a bit beyond your comfort zone. We will never push you to do anything that is not safe.”

There are some exposure approaches that rely on flooding instead of graded exposure. As the word implies, in flooding the client is basically thrown into their worst fears right away. An example could be going to a dog obedience training class if one has a fear of dogs or being forced to use a public bathroom 24 hours a day every day for a 2-week summer camp. With sufficient time in flooding, anxiety will gradually come down. It can be a faster way to get to the ultimate goal of tolerating what one is avoiding, but since it can require hours of exposure in a given day, it is often not practical to implement in community settings. Flooding is usually limited to more intense treatment programs, where people stay all day or overnight.

Graded exposure is by far the most common approach in CBGT. The key technique involves building an exposure hierarchy that lists a range of situations the client fears or may be entirely avoiding. Each situation is given a subjective anxiety rating from a range of 0 to 100, where 100 is the most intense anxiety one can imagine and 0 is completely relaxed. Clients can also rate the intensity of their avoidance, where 100 would be complete avoidance, 50 would be avoiding half the time, and 25 about a quarter of the time. These anxiety ratings are called SUDS, an acronym for Subjective Units of Distress Scale. Since this term sounds technical, some therapists prefer to avoid it and instead just talk about degrees of anxiety or fear. Other therapists and clients have fun with the acronym and turn it into a verb: “I was sudsing at 60 during the public toilet exposure.”

The exposure hierarchy becomes the master plan from which individual exposure exercises are derived. Not everything on the hierarchy is necessarily turned into an exposure challenge, and it is important to remind clients of that. Some clients will be reluctant to put their worst fears down on paper, assuming the therapists are going “to make me do it.” Therapists can assuage group members’ anxiety by again reminding them that they are in control and may not get to their top items during their group treatment, but that it is helpful to get a sense of the full range. Hierarchies are most commonly used in groups for panic disorder, social anxiety disorder (SAD), obsessive–compulsive disorder (OCD), and compulsive hoarding and of course any groups for specific phobias such as fear of heights, dogs, or injections. It is important to dedicate at least one group session in the early part of treatment, usually session 3 or 4, to developing exposure hierarchies.