Experiential Avoidance and Its Relevance to PTSD
This post is the first part of a series on using exposure in Acceptance and Commitment Therapy
Within the Acceptance and Commitment Therapy (ACT) literature, there’s a core concept called experiential avoidance. Experiential avoidance was arguably the lynchpin in ACT theory in the early days of ACT. The theory has been broadened since then.
Experiential avoidance is a basic umbrella terms for all sorts of avoidance behavior that people use to deal with all sorts of private experiences (e.g., thoughts, emotions, bodily sensations). Attempts to block out, reduce, or change these experiences are all forms of experiential avoidance. Behaviors associated with experiential avoidance include disputing thoughts, using substances (e.g., alcohol), and escaping or avoiding uncomfortable situations.
Everyone engages in some experiential avoidance on a daily basis. Less problematic examples include putting on sweater when it’s cold, turning on a light switch when we enter a dark room, or mindlessly perusing the internet when we feel listless. Experiential avoidance becomes a problem when it is applied rigidly and inflexibly, and when it gets in the way of what’s important to us.
One of the clearest examples of experiential avoidance is how it functions in people with posttraumatic stress disorder (PTSD).
Experiential Avoidance and PTSD
As you might imagine, people with PTSD engage in a lot of experiential avoidance. In fact, avoidance behaviors are one of the core cluster (C) of symptoms for a PTSD diagnosis. There’s a large body of research suggesting that experiential avoidance plays a big role in maintaining PTSD symptoms over time. For example, experiential avoidance predicts PTSD in adult survivors of childhood sexual abuse more than the severity of the abuse itself (Batten, Follette, & Aban, 2002; Rosenthal, Hall, Palm, Batten, & Follette, 2005).
Here are some possible reasons experiential avoidance may result in PTSD symptoms.
Reason 1: Avoidance leads to more of what the person wants avoid
Dostoevsky famously challenged his brother to not think of a white bear.
Can you do that? Can you not think of a white bear?
As you can imagine, trying not to think of something is really hard. Decades of research on thought suppression (e.g., Wenzlaff & Wegner, 2000) have shown that the very strategy of suppressing a thought tends to lead to more of the very thought the person is trying to avoid.
For people with PTSD, the result is that avoiding trauma-related internal experiences results in more of those very experiences over time. For example, in survivors of motor vehicle accidents, those who attempted to avoid thinking about the accident showed greater PTSD symptom severity (Mayou, Ehlers, & Bryant, 2002; Steil & Ehlers, 2000).
Part of what maintains this tendency to avoid PTSD-related thoughts and feelings is probably a momentary sense of relief that comes from suppressing those thoughts and feelings. Unfortunately, this moment of relief becomes increasingly insignificant when compared against the long-term consequences of avoiding trauma reminders. As trauma reminders recur, avoiding them becomes a major focus on the person’s life. Other life goals and values get neglected and avoidance gains more and more influence of the person’s life.
Additionally, as people begin to avoid more and more experiences, even neutral stimuli can become reminders of the trauma. For example, a person may avoid a particular alley in which he was attacked. Over time, the person may avoid all alleys. Features of the alley, such as red brick, similar to what lined the alley, or even the experience of closed spaces, may become linked to the trauma if they are continually avoided. Only through maintaining contact with these stimuli can one learn or re-learn that these stimuli (e.g., bricks, enclosed spaces) do not need to be avoided.
Reason 2: Some avoidance behaviors increase the risk of further painful experiences
The potential for danger increases significantly when a person spends time abusing drugs and alcohol, having unprotected sex with people they hardly know, or engaging in daredevil activities. People with PTSD often do things like this to block out the trauma, putting them at risk for further harm (Chapman, Gratz, & Brown, 2006; Polusny & Follette, 1995). Actions such as substance use, overeating, and staying home from work can lead to painful consequences in the short-term and across time.
Please be clear: I don’t mean that people should be blamed for this pattern. The horrifying images involved in PTSD and painful feelings can easily overwhelm people’s ability to cope and people understandably turn to behaviors that bring relief. Unfortunately, strategies that decrease pain in the short term (such as those above) may actually lead to more suffering in the longer term.
Reason 3: People may lose out on helpful experiences
In addition to avoidance leading to harmful experiences, someone who chronically avoids may lose contact with experiences that are potentially helpful. The more time people spend avoiding events, memories, feelings, and thoughts, the smaller and narrower their lives become. This reduces contact with positive experiences over time, and it stymies valued and meaningful living. As behavioral activation research for depression has suggested (e.g., Kanter, Busch, & Rusch, 2009), it’s very important for people to be engaged in a variety of enjoyable and personally meaningful activities.
When avoidance becomes the norm, people lose contact with sources of positive reinforcement and reward. This might include relationships, exercise, hobbies, and other interests. Over time, someone’s life may become increasingly narrow (e.g., staying inside much of them time). In the absence of other enjoyable and meaningful experiences, someone’s range of activity may become so small, that all she has left is what is being avoided (e.g., trauma).
ACT and Experiential Avoidance
Nowadays, it’s more common to hear ACT therapists talk about “increasing psychological flexibility,” but in the not-so-distant past, the focus was on decreasing or undermining experiential avoidance. ACT theory and technology were specifically developed to target experiential avoidance.
ACT has a number of interventions and techniques that focus on helping people contact stimuli that are typically avoided: thoughts, emotions, bodily sensations, meaningful goals, and activities. ACT has been called an exposure-based treatment (e.g., Luoma, Hayes, & Walser, 2007); however, you could also consider exposure as one technique among many used by ACT therapist to reduce experiential avoidance and expand behavioral repertoires.
ACT is less procedural than other treatments, and, therefore, harder to manualize. Because ACT has so many methods for targeting experiential avoidance, though, ACT offers therapists an array of tools to use for conditions (e.g., PTSD) where exposure-based approaches remain the gold standard.
At this writing, there is little written guidance about how to use exposure in an ACT. People are talking about it, and giving workshops about using exposure in ACT, but it remains new territory.
This series of posts focuses on how therapists can use exposure in an ACT context to undermine experiential avoidance in people with PTSD.
I will mainly organize the posts according to ACT-specific processes. My hope is that the series will offer clinicians some practical guidance on using exposure-based interventions in an ACT-influenced way. Additionally, it is my aspiration that even non-ACT clinicians will find these posts helpful in expanding their understanding of clinically significant processes of change and range of potential clinical interventions.