Exposure versus avoidance: Striking a balance

For various issues in therapy, a go-to treatment is exposure. This entails repeatedly entering and remaining in challenging situations rather than avoiding them. Exposure works because, over time, the person learns that they can cope with the situation’s challenges. This is typically accompanied by experiencing a significant and lasting reduction in the intensity of emotions they experience in the situation. In contrast, avoidance spares the person from experiencing short-term discomfort but deprives them of the more substantial and lasting long-term benefits which come from exposure.

So, it seems that choosing exposure over avoidance is a ‘slam dunk’. However, this is not necessarily the case. In fact, although exposure is ultimately preferred over avoidance, there are many instances in which it is wise to strike a balance between exposure and avoidance. In the following sections, I will use examples from several issues to illustrate this point.

Post-traumatic stress disorder

Exposure is fundamental to healing from traumatic events which lead to post-traumatic stress disorder (PTSD). This includes exposure to memories of the events along with situations and stimuli which remind the person of the events. Over time, repeated exposure leads to a reduction in the intensity of anxiety and other emotions the person experiences when they recall the events or encounter reminders of the events.

However, this exposure must be done gradually and in tandem with planned avoidance of memories and stimuli associated with the traumatic events. For example, avoiding exposure to the most emotionally charged memories and reminders of the traumatic events early in therapy is standard practice because exposure in these instances is likely to overwhelm the person. As a result, they are unlikely to be able to sit with their emotions long enough for the benefits of exposure to kick in.

It is also wise to avoid exposure to memories and reminders of traumatic events at times when the person needs to focus on other activities like work and social relationships. Avoiding exposure in trauma therapy is also recommended until the person has developed ‘grounding’ strategies to calm oneself when needed during exposure. In addition, if the person has an exceptional level of stress in their life at a given time it is often recommended that exposure work be delayed until the stress in their life has reduced to a more manageable level.

Phobias

As with PTSD, exposure is the key to overcoming phobias—fears of specific situations or stimuli such as driving, heights and animals. Over time, repeated exposure leads to a reduction in intensity of anxiety and the person experiences when they encounter the phobic situations or stimuli.

However, this exposure must be done gradually and in tandem with planned avoidance of certain stimuli or situations. For example, avoiding exposure to the most emotionally charged stimuli or situations early in therapy is standard practice because exposure in these instances is likely to overwhelm the person. As a result, they are unlikely to be able to sit with their anxiety long enough for the benefits of exposure to kick in.

It is also wise to avoid exposure to stimuli and situations at times when the person needs to focus on other activities like work and social relationships. Avoiding exposure is also recommended until the person has developed ‘grounding’ strategies to calm oneself when needed during exposure.

Social anxiety

As with PTSD and phobias, exposure is the key to overcoming social anxiety issues—fears of social situations such as parties and public speaking. Over time, repeated exposure leads to a reduction in the intensity of anxiety which the person experiences when they are in social situations.

However, this exposure must be done gradually and in tandem with planned avoidance of certain social situations. For example, avoiding exposure to the most anxiety-provoking social situations is standard practice because exposure in these instances is likely to overwhelm the person. As a result, they are unlikely to be able to sit with their anxiety long enough for the benefits of exposure to kick in.

It is also wise to avoid exposure to anxiety-provoking social situations at times when the person needs to focus on other activities like work and social relationships. Avoiding exposure is also recommended until the person has developed ‘grounding’ strategies to calm oneself when needed during exposure.

Anger management

Greater exposure to anger triggers (such as critical comments) is beneficial because this will, over time, decrease the intensity of one’s anger through the process of habituation/desensitization. However, given that it takes time for this process to occur, it is advisable to begin the exposure away from actual triggers with imaginal exposure and through role-play exposure with a therapist or other trusted person. Exposure to actual triggers too soon risks the person’s anger in these situations being so intense that they are prone to acting on their anger in an aggressive manner.

Once the person’s anger has reduced to a manageable level and they have acquired a repertoire of coping skills, the planned avoidance can shift toward gradual exposure to actual triggers. However, by this point the person has a greater chance of success in managing their anger in these situations.

Couples counselling

Striking a balance between exposure and avoidance is a prominent strategy in couples counselling in helping couples to communicate constructively about their issues. Although the goal is to have couples expose themselves to discussions so that they can work through issues while expressing their thoughts and feelings, choosing a time when both partners are in an emotional state conducive to constructive communication is a key to success.

Planned avoidance of discussions of issues when one or both partners are not in an emotional state conducive to constructive communication is an effective strategy to prevent discussions from going sideways with nonconstructive communication. In that regard, I recommend that both partners announce whether they are on ‘green light’ (an emotional state conducive to constructive communication) or ‘red light’ (an emotional state not conducive to constructive communication) before they start discussions of issues and postpone the discussion if one or both partners is on red light. We also practice having each partner respectfully shut down discussions in progress when either partner notices that they have moved from green light to red light.

It is important to note that although planned avoidance plays a central role in helping couples to communicate more constructively, exposure to discussions of issues is the goal. The key is to choose a time when exposure to discussions is most likely to lead to productive dialogue and less likely to lead to nonconstructive communication. As a result, couples who avoid discussions of issues at the outset or pull out of them once they have begun are instructed to set a specific later time to start or resume the discussion.

A final word on exposure versus avoidance: Avoid the extremes

A good principle to follow when integrating exposure with avoidance is to avoid the extremes of either practice. For example, using extreme avoidance with little or no exposure typically leads to little or no progress in addressing your issues. On the other hand, not using avoidance at all usually results in exposure being ineffective and even counterproductive because it is not occurring at the right time or in the right manner. As the old saying goes, everything in moderation.

May you strike the right balance between exposure and avoidance when addressing your issues,

-Dr. Pat