Avoidance versus confrontation of fear

Thirteen phobic and four obsessive ritualizing patients completed a balanced crossover trial of two types of treatment instruction, each lasting a week and given three times during that week, with 40 minutes of therapist contact a week. During exposure patients were instructed to confront stimuli which evoked fear and rituals for as long as possible, hours if need be, without the therapist, until discomfort diminished. During avoidance patients were asked to consistently avoid all contact with stimuli which evoked fear or rituals. Patients were asked to keep daily diaries of exposure and of avoidance; diary entries were consonant with adherence to treatment instructions. Changes after each treatment were small but consistent. Phobics improved with exposure instructions, significantly more so than with avoidance instructions. Avoidance led to slight worsening of phobias which was reversible after subsequent exposure instructions for one week. Compulsive ritualizers showed similar trends to phobics. The superiority of exposure to avoidance is unlikely to be attributable to patients' expectancies, as these were similar for both approaches before the treatment began and failed to correlate significantly with outcome.