Exposure Therapy for PTSD: The Path Through Avoidance

Twin perils of avoidance—refusal and misdirection—lead to danger zones.

Posted Oct 20, 2019

Wikimedia Commons
Source: Wikimedia Commons

As elusive as facts without exceptions can be in the profession of researching psychotherapy, it is nearly a fact without exception that in order for patients with posttraumatic stress disorder (PTSD) to get better, they must talk about their traumatic experiences. Meta-analyses of psychotherapies for posttraumatic stress disorder (PTSD) concluded that the most effective techniques include talking about traumatic experiences by patients in a structured fashion (Bisson et al., 2007; Watts et al., 2013). Patients can’t not talk about their experiences and expect to get better. In other words, no pain, no gain.

I acknowledge that there is always a subgroup of patients who improve in approximately four sessions before much talking about traumatic experiences has occurred, and that may account for the positive results seen in a handful of studies that did not require much talking (i.e., acupuncture and transcranial magnetic stimulation) or not talking about trauma in a directive and structured fashion (i.e., psychodynamic therapy). But the distinction here is in the word much; some folks improve with a little talking, most need a lot of talking, but all are talking, or at least thinking about their traumas in some controlled fashion. For those patients who need much talking, we know that to finally find relief, they cannot avoid the painful memories, and therapists must conduct therapy that structures patients to talk about their experiences.

But the devilish aspect of the task is that at the moment of truth when patients come to the precipice of whether to talk or not to talk, they face a powerful force which prevents them from talking: Avoidance. Most patients do not want to talk about their traumatic experiences because the memories are emotionally painful, often gruesome, and involve shame, embarrassment, and fear. Indeed, avoidance is a requirement of the diagnostic criteria as it wholly constitutes one of the four clusters of symptoms. Hence, the job of dutiful therapists is to be directive and provide structure for patients to gently edge past that precipice. Helping patients re-engage with the memories of their traumatic experiences is the main way therapists can help patients find relief.

Structure and Direction Overcome Refusal and Misdirection

Whenever I contemplate this situation, I have had a recurring imagery for many years of the scene of Scylla and Charybdis in Homer’s Odyssey. Odysseus and his crew must navigate their ship between these two dangers. If they steer too close to Scylla to avoid Charybdis, the monster may pluck men off the ship or smash the ship entirely. If they steer too close to Charybdis to avoid Scylla, the whirlpool may suck the ship down to the depths of the sea. Scylla represents avoidance by refusal; some patients claim that they simply are not ready to talk because they cannot bear it at this time. Charybdis represents avoidance by misdirection; some patients misdirect therapists from the topic of trauma by bringing up all sorts of other distracting relationship dramas, childhood backstories, and crisis-of-the-week that they deploy like flares and aluminum chaff to draw attention.

It is possible for most patients to pass safely between these dangers and find relief from much of the pain of traumatic memories, but direction and structure are needed from therapists to meet the avoidance head-on, ignore the chaff, and stay the middle course. A central tenet of the effective psychotherapies for PTSD is to guide patients to get past their avoidance and re-engage with their memories in a more adaptive fashion. This is no easy task for therapists. Therapists must hold a solid commitment to do this repeatedly, and risk the ire of their patients.

In the parlance of psychotherapists, the successful deployment of technique to overcome avoidance is called exposure therapy, exposure exercises, or simply, exposures. For individuals with persistent symptoms of PTSD, this appears to be the only path that consistently works. Without these exposures in a therapeutic setting, studies have shown that their symptoms are chronic and last for years, perhaps entire lifetimes. Exposures are the daily grind of therapists who work with many clients with PTSD. Yet, there is no universally agreed upon way that exposures have to be conducted.


In cognitive behavioral therapy (CBT) with adults, adolescents, and children, these exposures are conducted over half a dozen sessions, with multiple exposures within each session. The typical sequence begins with patients talking about their traumatic events. Some models create a list of different scenes that are ranked from least anxiety-provoking to most anxiety-provoking, called a stimulus hierarchy. Patients work their way up the hierarchy during successive sessions. Other models allow patients to talk about their traumatic events in whatever order they like. With young children, whose verbal and autobiographical memory skills are still emerging, exposures are often facilitated with drawings. Relaxation techniques are often used during exposures to help patients manage their negative feelings. Associated automatic negative thoughts are explored to different degrees in different models. Often, exposures are also conducted outside the office as homework assignments.

In prolonged exposure therapy, the exposures are relatively more intense and compressed. In cognitive processing therapy, exposures are more incidental to the process, as the focus is on addressing automatic negative thoughts related to the traumas.

As technology changes and our experience grows, it makes sense that new methods will be created to try to facilitate exposures. Virtual reality has already been extensively tested. Violent video games have been informally tested; we have had clients use violent video games to simulate their traumatic experiences when exposing themselves in real life is not possible (e.g., motor vehicle accidents).

But a constant, guiding principle underlying all forms of exposure is structure, consisting of directiveness, repetition, and salience to be anxiety-provoking. It is not only no pain, no gain for patients, it is also no pain, no gain for therapists. Therapists have to persistently but gently push and prod patients to do something they know is painful. Therapists, with their relatively high levels of moral sensitivity, must endure their moral distress of purposefully upsetting their patients.

Unfortunately, many therapists lose the middle passage by either straying into the Scylla of stonewalling avoidance, or follow towards Charybdis, absorbed in the distracting chaff, or both. However, many of these therapists do not view the Scylla and Charybdis metaphors as dangers. Rather they view them as a therapeutic strategy of following the patients’ leads, which is their preferred model. Some neither know how nor want to conduct exposures. Others claim they are conducting trauma therapy, or CBT-Lite, but do not truly conduct exposures. They go through the formalities and come up close to it and ask patients if they want to talk more about their memories, and when patients say no, too many therapists back away. They fear upsetting their patients. Some patients truly are too unstable to process their memories, but I’m not talking about those patients. There is a place for being empathic and patient-centered, but backing away at the wrong time tells patients that exposures are optional. Without exposures, the distress related to memories remains, crouched, waiting to spring again and again. For those who are stable enough, and this is most patients, exposures are not optional. Being directive takes an expertise and commitment from therapists toward such a model.


Bisson JI, Ehlers E, Matthews R, Pilling S, Richards D, Turner S (2007). Psychological treatments for chronic posttraumatic stress disorder. British Journal of Psychiatry 190:97-194, doi: 10.1192/bjp.bp.106.021402

Watts BV, Schnurr PP, Mayo L, Young-Xu Y, Weeks WB, Friedman MJ (2013). Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. Journal of Clinical Psychiatry 74(6):e541-e550, doi: 10.4088/JCP.12r08225