Does Non-Avoidance = Exposure? No! Anxiety Disorder Treatment Principles for OCD, Panic, Social Anxiety, & Phobias.

Posted by Steven J. Seay, Ph.D. on Nov 29, 2011 in CBT, ERP | 10 comments

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.

Why?

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?

10 Comments

Janet Singer / December 10, 2011

Excellent Post!! I think the sentence, “Lean into the fear rather than away from it,” pretty much summarizes what you are saying.

Now it is easy to see that Woody Allen’s quote, “Showing up is half the battle,” doesn’t apply to ERP Therapy. You need to do the work also. Thanks for the reminder and easy to understand explanation.

Amy IK / March 1, 2012

I just wanted to say thank you for all your posts. They help me very much.

- Steven J. Seay, Ph.D. / March 2, 2012
  
  I’m so glad, Amy! Best wishes on your recovery!
  
Lea / November 3, 2012

I have suffered from anxieties for a long time. I am a Christian and God’s Word has been valuable for me during this struggle. I have an appointment with a counselor and I am looking forward to the session with him. My anxieties have been Scrupulosity anxieties along with doubting my husband’s love for me. I have realized that the thoughts were coming from anxieties and not from reality.
After reading you articles, I understand a lot more and I thank you for that. But there is still struggles with the anxieties which cause the negative thinking. Am I on the right track? Sometime I just have a flood of anxiety without even aware of why. Should I each time name it, look at, and proceed or just let the anxiety subside?
Thank you so much for your info. I am encouraged. <

- Steven J. Seay, Ph.D. / November 19, 2012
  
  Hopefully, the meeting with your counselor went well and that you’re on the right track for managing your anxiety. There are many different strategies which can be helpful for dealing with anxiety, such as labeling your internal experiences. Some mindfulness exercises have you identify and label thoughts vs. feelings vs. sensations vs. judgments (FYI, a judgment is a specific type of thought). It can be easy to confuse thoughts with truths, so this type of exercise can be helpful for some people.
  
  When you’re not practicing this technique, though, it’s often best to practice redirecting back to the situation at hand. Worry thoughts should not be given more importance than they deserve.
  
Christina / January 7, 2014

Hi Dr. Seay,

I so appreciate your words of wisdom. One question, though – would you mind clarifying the statement, “4. Select exposures that will allow you to recalibrate your cognitions to reflect healthy, sustainable beliefs about the world and yourself?”

I am a nurse and have what I think is an unhealthy fear that I’ll accidentally hurt one of my patients. I understand that there is risk involved with my role and that I need to be conscientious, but my fears have become obsessive/excessive. I usually try to use positive thoughts and mantras to combat the fear, but I’m starting to think ERP would be a useful alternative to that approach. Could you provide an example of an exposure that would allow me to “recalibrate [my] cognitions?”

Thanks so much in advance!

Jezia Talavera / October 12, 2016

Hi Dr. Seay,

I would just like to clarify, Sir: when you said, “Lean into the fear rather than away from it,” it doesn’t actually mean that we do not recognize or acknowledge that fear towards something, may it be a thought or an object or an action, right? Also meaning to say, that we actually have to recognize and acknowledge that fear so that we may be able to effectively re-calibrate it into “leaning into it.” In simpler words, it’s more like acknowledging the presence of something to value its absence and vice versa. Like yin and yang also. Is this what I think you also mean, Sir?

For the record, I was not actually diagnosed with OCD, but with moderate to severe depression as well as visual psychosis in May 2014. However, recently, I begin to feel and observe physical and mental urges to stab my mother and father. And so the simple reason I stay away from home for the past few days, because I am still trying to analyse and maneuver this new and probably acquired behavior, and trying to learn the “exposure” technique or skill, in which you have discussed in great detail here as well, Sir.

Thank you and hoping for your kind response and thoughts on these.

Ang Sinapian (The Possessed),
Jezia

Angela / March 25, 2017

I’d like to know what you think would be a healthy way to approach triggers that happen in the middle of the night when a person is too weak to perform exposure. I often wake up in the middle of the night, having slept soundly for a few hours, and experience a triggering thought that sends me straight to an 80 out of 100. It’s related to chronic pain, sometimes the trigger is just the idea of possible future pain. My self control in the middle of the night is extremely low, so when I have tried exposure techniques at this time, they have gone very badly and I’ve ended up doing more compulsions than in the daytime. But I am unsuccessful at attempts to just lie in bed and allow the thought to continue. I feel like I need to do something. DO you have some ideas for appropriate responses? Even turning on the iight feels like a compulsion that propels the anxiety. Sometimes eating carbs seems to improve everything. Would deep breathing, without trying to expose myself to the thought but also without trying to make myself feel better, be appropriate?

- Steven J. Seay, Ph.D. / March 25, 2017
  
  I’m not sure that practicing exposure in the wee hours of the morning is the best idea anyway. My thought is that you need to load up on exposure during the day in order to work on making progress with some of these obsessions. This would allow you to target the OCD on your own terms rather than just waiting for it to show up. But I do think that daytime exposure will be critical for fixing the nighttime problem. At night, though, I would probably recommend some sort of mindfulness practice. The goal would be to acknowledge the thoughts if, and when, they come (i.e., it’s not about avoidance) — but to refocus on your breathing. Many people find that this kind of practice provides an alternative to mental compulsions, kind of like a cognitive anchor.
  
Aleksandar Petrović / May 30, 2018

This… certainly is interesting. Here I thought ERP doesn’t really invoke anxiety in my case, while the problem probably was that I committed my compulsions during the exercise itself (I have somatic OCD). Whilst becoming aware of my breathing and blinking at the same time (My worst fear is that I’ll be locked breathing and blinking forever), I was always hoping it would go away, maybe there are other compulsions too. Hah. So this ERP with compulsions did help me a lot, sometimes the obsessions were barely present at all, but yesterday I got locked in my breathing, causing massive anxiety, which means I probably did it wrong. I do go to CBT treatment, but my therapist didn’t really scratch this important detail with me.

What are your recommendations for this? Do I expose myself to the somatic obsession the entire day, since I’m afraid of it not stopping? How do I detect my other compulsions, since it took me quite a while to detect this one.

By the way, thank you a lot Steven, this might just be the key in beating my somatic OCD.