The Hidden Risks of Using Standard Therapies with Fearful Avoidants: CBT, ERP, and ACT
Many therapists working with clients who struggle with obsessive thoughts, emotional dysregulation, or trauma-related patterns turn to evidence-based standards such as Cognitive Behavioral Therapy (CBT), Exposure and Response Prevention (ERP), and Acceptance and Commitment Therapy (ACT). These modalities are well-researched, effective for many, and often integrated into a therapist’s core training. However, when applied to individuals with a fearful avoidant attachment style, especially those with a history of complex trauma, these very tools can not only fall short but, in some cases, actively retraumatize.
This article outlines the often-unseen risks of applying standard therapies to this population, not to discredit these modalities, but to advocate for a more nuanced, trauma-informed, attachment-sensitive approach that prioritizes the internal safety of the client.
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1. CBT: Rational Thought in the Midst of Emotional Collapse doesn’t work for Fearful Avoidants
CBT operates from the assumption that distorted thoughts cause maladaptive feelings and behaviors, and that rational examination and restructuring of those thoughts can lead to relief. While this is true in many cases, fearful avoidants often exist in a nervous system state where their body doesn’t feel safe, and where the intensity of survival fear overrides the prefrontal cortex.
When a fearful avoidant is in a crash or survival state, rational thought cannot reach the roots of their experience. Not even close. Attempting to restructure their thinking in these moments may result in:
Dissociation rather than integration
Shame for “not getting better”
Internal compliance masking a lack of emotional engagement
Clients may “do the homework” and appear to be improving while emotionally checking out. They may not tell the therapist it’s not helping, out of a deep fear of being blamed, abandoned, or seen as hopeless. The result is often deeper internal fragmentation.
Furthermore, the language of CBT can unintentionally reinforce a sense of brokenness. Terms like “cognitive distortions” or “maladaptive behaviors” may make perfect clinical sense, but for a fearful avoidant who has survived by adapting to unsafe environments, this framing can feel pathologizing rather than validating.
2. ERP: When the Therapist Is the Trigger for the Fearful Avoidant
ERP is a gold standard for OCD, particularly when compulsions are tied to concrete actions or objects. It involves exposing the client to a feared thought or situation while preventing the usual response (e.g., checking, reassurance-seeking), in the safety of the therapeutic container.
But what happens when connection itself is the core fear? When the person in the room (the therapist) is the threat?
Fearful avoidants often carry complex PTSD. Their nervous systems are hypervigilant to power dynamics, emotional closeness, or even perceived emotional availability. Asking them to do exposure work in the presence of someone they cannot yet trust enough to co-regulate with (and most fearful avoidants never will, because they have negative associations with co-regulation to begin with) is asking them to override a deep, survival-based threat response.
The result? Many leave sessions more triggered than they entered them. Their bodies may interpret the therapeutic environment as unsafe, and exposure becomes an act of retraumatization rather than healing. Paulien Timmer has heared countless stories of those struggling with the Fearful Avoidant Attachment Style, going through Healed & Happy, about Fearful Avoidants complying, but being triggered and taking days or even weeks to recover.
Worse, because fearful avoidants tend to perform and mask their discomfort, a therapist might not even notice it is happening. Most therapists assume that they can create trust with a client. But even the most empathic, kind and patient therapist can still be perceived as a threat, because the threat came unexpectedly when they were growing up, and therefore Fearful Avoidants will always stay hypervigilant. That is, until the root causes are addressed.
3. ACT: Telling a Fearful Avoidant to Float in a Storm
ACT encourages clients to accept difficult emotions without judgment, identify values, and take committed action. This, too, is a valuable modality with wide-reaching benefits, but for the fearful avoidant, especially one in a hyperactivated or shutdown state, this process can feel like emotional abandonment.
Telling someone to “accept” emotions that are genuinely overwhelming (terror, abandonment grief, existential shame) is like telling a drowning person to “just float.”
This metaphor is key: ACT may work beautifully when the sea is choppy. But fearful avoidants often live in internal hurricanes. Asking them to stop swimming and accept the storm can feel like asking them to die in a storm that produces waves several feet high.
The consequence is often premature shutdown. The client disengages. Or worse, they try to follow the protocol, fail, and internalize it as personal failure rather than misapplied treatment.
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A Call for Informed Compassion
This article is not a criticism of CBT, ERP, or ACT. Each has value. But they were not designed with the fearful avoidant attachment system in mind. Therapists using these tools with this population must:
Assess for complex trauma and insecure attachment first
Recognize signs of nervous system dysregulation and masking
Move slower than the protocol suggests
Prioritize co-regulation and relational safety above all else
Therapists who are not trained in working with fearful avoidants should not feel ashamed—but they must be humble enough to recognize when their tools may not fit. Healing is not one-size-fits-all. And what is evidence-based in one context can be harmful in another.
For fearful avoidants, the wrong approach, even if research-backed, can reinforce the very beliefs they are trying to escape: that they are broken, unreachable, or doomed to repeat their patterns forever.
They are not. But they need a different path.
🕰️ This page was written by Paulien Timmer, published on July 23, 2025.