Avoidance and Exposure

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by Malek Mneimne, M.A.

Many psychologists agree that avoidance, which can be cognitive (mental) or behavioural, is a risk factor for a range of anxiety and depressive disorders when the avoidance is irrational, distressing, and interferes significantly with activities of daily living.

Targets of avoidance vary from one disorder to the next. For instance, in generalized anxiety disorder (GAD), individuals often avoid their own worry process, whereas in social anxiety disorders (SAD), individuals often avoid social situations in which they might be evaluated. In post-traumatic stress disorder (PTSD), individuals often avoid cues that remind them of their trauma.

Avoidance strategies vary from telling oneself to stop thinking a thought to snapping a rubber band on one’s wrist to remaining at home for periods of time. Attempts at avoidance, including distraction, are often successful in the short-term in that they provide temporary relief from anxiety, but in the long-term, such strategies may prevent individuals from achieving their goals, which can contribute to sadness and depression. Research has shown that attempting to avoid thoughts, or thought suppression, actually results in a higher frequency of the thought. Similarly, studies have found that depriving oneself of food, as in the case of restrictive dieting, results in a preoccupation with food and, in some cases, food binges.

It is important to note that not all avoidance is distressing or interferes significantly with activities of daily living. For example, phobialist.com lists hundreds of phobias (extreme, irrational fears and avoidance of specific objects or situations), from consecotaleophobia, or fear of chopsticks, to triskaidekaphobia, or fear of the number 13, which can be avoided with minimal distress and impairment, unless the phobic individuals wish to pursue careers or relationships in which they are around chopsticks or the number 13. While these fears are clearly irrational, individuals with them can still pursue long-term goals and organize their lives such that exposure to their feared object or situation never occurs and its avoidance is not problematic.

Avoidance Strategies

Similarly, not all avoidance strategies are irrational. It is not uncommon for people to avoid objects or situations associated with risk of psychological distress or pain. For example, like many others, I will often choose to bring my laundry to the Laundromat on a day when it is not raining or snowing heavily.

Choosing to avoid somebody who contributes to abuse of some sort is also common. In these cases, progress toward long-term goals is likely unaffected or even improved.

When avoidance strategies are irrational, impair functioning across various domains, and hinder progress toward long-term goals, clinicians often encourage their patients to expose themselves to the feared object or situation. Studies have found that exposure strategies are superior to other forms of treatment for anxiety symptoms and disorders; however, less is known about the efficacy of exposure for depression. Individuals with GAD are encouraged to expose themselves to their own worry process. Individuals with SAD are encouraged to expose themselves to social situations in which evaluation is probable. Individuals with PTSD may be asked to write about their trauma or partake in a virtual reality scenario similar to the one associated with their trauma (e.g., combat).

The mechanism behind exposure that aids in the long-term alleviation of distress and impairment is learning. Because avoidance strategies reinforce or strengthen the perception that “something truly terrible will happen if I come into contact with my feared object or situation,” exposure teaches (shows) individuals the opposite: That nothing truly terrible will happen upon contact with the feared object or situation. Contact with the feared object or situation will probably be difficult and uncomfortable at first, but nobody has died from it.

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