Mindfulness and Exposure: At Odds?
Patients often ask about the relationship of mindfulness and acceptance exercises and exposure therapy. I am an advocate of both, even though they can feel so opposite: acceptance exercises are about not striving in the face of anxiety, while exposure exercises are clearly a form of effortful striving in order to face anxiety. So how can they be reconciled?
In short, the answer is that the exercises are on a spectrum.
At one end of the spectrum you have neutral mindfulness exercises; for instance, practicing mindfulness of the breath. This does not involve any direct exposure, internal or external, to anxiety. And yet, it can help people get over anxiety disorders.
In the middle of the spectrum you have mindfulness-of-anxiety exercises. These do not involve any external steps taken to exposure one to one’s fears; but instead one faces internally the sensation of the fear, using mindfulness skills to do so (for instance, centering the mindful breath in the middle of the anxiety). This has all the benefits of the previous approach, and has the added benefit of being more direct, and therefore faster.
At the other end of the spectrum you have exposure therapy, in which you do something external (or imaginal) to provoke the sense of anxiety, while using mindfulness to focus your attention on the sensation of the anxiety. Since it incorporates the skills used in the previous two approaches, it has all their benefits, with the added benefit of being even faster.
There are also two different levels of intensity inside exposure therapy: you can either start with small amounts of provoked anxiety (aka “systematic desensitization,” provoking it to 4/10 and then mindfully “metabolizing” it), or with large amounts (aka “flooding,” provoking it to 9 or 10/10 and then practicing mindfulness of it). The only difference is that provoking larger amounts to “metabolize” gets people better even faster.
I often present these same three approaches as three consecutive steps: first learn to practice mindfulness, then learn to practice mindfulness of anxiety, and finally learn to provoke anxiety while mindfully “metabolizing” it.