Exposure Therapy

Although exposure is predicated upon the purposeful non-avoidance of anxiety-related stimuli, non-avoidance of anxiety triggers is not equivalent to exposure.

Anxiety Principle of the Day: Non-Avoidance is not equivalent to exposure.

Although exposure is predicated upon the purposeful non-avoidance of anxiety-related stimuli, non-avoidance of anxiety triggers is not equivalent to exposure.

What is non-avoidance?

I liken non-avoidance to being in a particular place at a particular time. Essentially, it involves being in a situation in which your anxiety is triggered by proximity to anxiety-related cues. Non-avoidance requires no action on your part aside from being physically present in the situation. As such, like a hole, it’s possible for a person to accidentally stumble into a non-avoidance exercise.

Isn’t that the same thing as exposure?

No. Exposure is not merely a situation, and as such, it can’t be entered into by accident.

Although exposure therapy has situational elements, it is a dynamic experience that has best practices, as well as Do’s and Don’ts. It is also based on a specific “philosophy of doing” that has essential cognitive components.

When done properly, exposure is a personal, deliberate, and reasoned assault against your anxiety. In contrast to simplistic non-avoidance, exposure is premeditated and thoughtful, it has cognitive and emotional goals, it is prolonged, and it is grounded in pragmatic application of sound theoretical principles.

That can be a tall order for individuals new to exposure. That is why I often suggest that people begin exposure therapy under the supervision of a therapist who specializes in anxiety disorders.

When I see a patient for the first time in my Palm Beach, Florida office who has struggled with chronic anxiety, they often tell me that they’ve completed “exposures” in the past and that “exposures” didn’t help them get better. In fact, these patients are most often misconstruing non-avoidance exercises for exposure exercises. They might have been in the right place at the right time, but they weren’t doing the right types of things while they were there.

Let me illustrate the difference between non-avoidance and exposure. Suppose I have arachnophobia, and I have decided to overcome my fear of spiders. To accomplish this end, I will no longer actively avoid spiders. I will operate according to a new set of principles that involve not letting spiders dictate my behavior. I’ll go outside when I want to, and I’ll even tolerate being in the same room with a spider when I see one.

These are sound non-avoidance guidelines.

The difference between non-avoidance and exposure is exemplified by the fact that I can implement my non-avoidance guidelines while clothed in a spider-proof Hazmat suit. Although close proximity to spiders is an act of non-avoidance, I am not actually doing an exposure while wearing my protective suit. This is because the necessary cognitive components of exposure are absent from such a situation.


Because my approach to the situation gives truth to the following:

1. This situation is “too dangerous.”
2. I am not capable of handling this situation on my own.
3. That spider is something from which I need to protect myself.

These ideas are not consistent with the philosophical foundations and goals of exposure therapy. To truly overcome my spider fear, I must be both smarter and braver than Miss Muffet.

Admittedly, the Hazmat suit example is quite extreme. Not many people walk around my neighborhood wearing Hazmat suits.

However, real-life examples of behaviors that interfere with exposure include subtle things like hoping in my head that the spider won’t touch me, keeping my body rigid, tracking and labeling where in the room the spider has gone, and scanning the room for other spiders. These things undermine exposure and prevent the type of habituation that results in sustainable change.

Many people in my neighborhood do these types of things every day without attributing much significance to them.

However, turning a blind eye to these habituation-interfering behaviors is to passively accept limited treatment gains. This is because these behaviors demote exposure exercises to non-avoidance exercises. Even consistent non-avoidance exercises (when practiced in lieu of “true exposure”) are likely to provide only marginal relief (if any) from a strong anxiety disorder.

The semblance of an exposure is not an exposure.

Exposure, on the other hand, involves testing the limits of my fear…sitting with the fear in an unadorned way…inviting closer proximity gradually and deliberately…in conscious efforts to rewire the fear circuitry in my brain.

Exposure is used to learn experientially (not just logically) that this situation is not as scary as I think it is…or that even if it’s scarier than I think it will be, that I can handle it….or that even the worst panic in the world diminishes if I stick it out…or that I can control my own actions even when I’m under great strain and pressure.

The form the anxiety takes is irrelevant. Whether the issue is panic, phobias, OCD, PTSD, agoraphobia, test anxiety, hoarding, health anxiety, social anxiety, or something else… The basic premise and theoretical rationale underlying recovery from an anxiety disorder is essentially the same:

1. Embrace non-avoidance as a guiding principle in your life.
2. Complete a variety of deliberate exposures every day (even if you think you don’t need them).
3. During exposure, refrain from all rituals and avoidance behaviors (including mental avoidances). Lean into the fear rather than away from it.
4. Select exposures that will allow you to recalibrate your cognitions to reflect healthy, sustainable beliefs about the world and yourself.
5. Repeat all of the above each and every day.

Questions? Comments? What “true exposures” have you done today?