Graduated Exposure is an Oxymoron

Graduated exposure is a therapeutic method which has proven to be widely effective in all types of psychological disorders relating to fear. This approach, however, contains a significant paradox: it proposes to place someone in contact with that which they fear, with the ultimate goal of making said fear disappear. Strangely, it is simultaneously training approach and avoidance. A type of therapeutic oxymoron.

Avoidance is at the heart of these psychological disorders, the main presentation of which is fear (phobias, obsessive compulsive, PTSD, etc.) It is even considered by some to be the source of these difficulties, or at least as a source of maintenance. It is a well known fact, the more we avoid something that we fear, the stronger the fear will grow. Graduated exposure’s approach aims to counter these avoidance behaviors and to shape up one’s voluntary approach to fear-provoking stimuli.

A priori, these objectives make sense. After all, since everyone is aware that the danger isn’t real, even the person who feels the sensations of fear, it would be reasonable to silence our emotional alarm by disobeying and noting that nothing serious is happening. This is what the therapist is proposing to their patient, and this is how they explain it to them as well. In a sense, graduated exposure consists of experimenting with our gut sensations what we know intellectually, that nothing serious will happen, even if the situation is likely to be painful. In the background, the messages are “there is no risk of feeling fear, even if it is unpleasant; you can do what you want in the presence of fear, even get closer to what triggers it, it does not dictate your actions.”

Patients who are engaging in this type of intervention have well understood that the danger in front of them isn’t real. They accept to voluntarily move towards that which they fear. In fact, they give permission to the fear to assail them. They carry out the movement of approaching fear, encouraged by the therapist. What is the goal of this approach behavior? To avoid fear! Ultimately, the end-goal of this approach behavior is to no longer feel fear when faced with the stimuli in question ! We ask patients to do the opposite of what they generally do- rather to expose themselves than to avoid that which they fear- with the promise that they will end up no longer feeling fear in those situations. Moving closer to get further away, strange… The internal contradiction is evident: if the fear isn’t dangerous, if it doesn’t force nor restrict any actions, why would my therapist then try to make it go away? Furthermore: if fear isn’t dangerous, why would my therapist ask me to move gradually closer to it?

Graduated exposure therapy is effective, without a doubt. The question of its mechanisms of action remains however posed. Perhaps its effectiveness comes from acting in opposition to fear, that is to say, to get closer when everything tells us to flee. Perhaps its efficacy could stem from an independence gained from the feelings of fear. However, in contradicting an emotion, while you free yourself from it a little, you will always be in touch with it, always have something to do in regards to that emotion. To act completely independently of fear is neither to try to avoid it, nor to seek to approach it, neither to obey it, nor to disobey it, nor to contradict it. To truly be independent of fear would be to let the fear do what it wants, so we too can do what we want.

Translated by Chelsea Davis-Laurin

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