Experiential Avoidance and Its Relevance to PTSD

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.

PTSD Without Trauma? A Scientific American article examines some controversies about diagnostic criteria for PTSD

PTSD Without Trauma? A Scientific American article examines some controversies about diagnostic criteria for PTSD

When I was delving into the trauma literature for my dissertation several years ago, I noticed a study that—while not particularly relevant to my needs at the time – offered an intriguing finding. Bodkin, Pope, Detke, and Hudson (2007) found equivalent rates of PTSD symptoms between individuals who did (78%) and did not (78%) report a history of trauma. That is, a significant portion of their sample (who had major depression) similarly exhibited symptoms for PTSD, regardless of whether they had had been exposed to a trauma or not.

This was the first time I became aware of an ongoing controversy relating to how PTSD is diagnosed. In our current nosology (as defined in the DSM-IV), a PTSD diagnosis requires a person to have experienced a traumatic event–Criterion A, defined as threat of injury or death to self or others. However, some data seem to indicate that people can can experience PTSD-like symptoms even in the absence of an identifiable Criterion A trauma (as defined by the DSM-IV).  There is a large group of proponents who think this reveals a deep flaw in our diagnostic critera for PTSD.

For a brief summary of this controversy, check out, Rosen, Spitzer, & McHugh (2008; click on this link for the full pdf). As I’ve written about in a previous post, the current task force is considering tightening up the criterion A definition of what is considered a traumatic event.

I bring all this up now because the controversy has reached the popular press. In an April issue of Scientific American (reprinted online in May), Scott Lilienfeld and Hal Arkowitz provide a brief, readable summary of these concerns in their article, “Does Post-Traumatic Stress Disorder Require Trauma?

This is an issue that can be easily misinterpreted by the public. Critics of diagnostic criteria of DSM are not suggesting that PTSD does not exist; rather, the concern is that our understanding of PTSD and the criteria we use to diagnose it are seriously flawed.

I look forward to watching how this debate plays out in the revision process for the DSM-V.

In the meantime, check out the Scientific American article, and follow it up with Rosen et al. (2008).

Does War Zone Impact Treatment Response for Veterans with PTSD?

Does War Zone Impact Treatment Response for Veterans with PTSD?

Back when I was a psychology intern at the Portland VA Medical Center, the majority of the veterans I worked with were Vietnam era. Veterans from the wars in Afghanistan and Iraq were trickling in, but were not a large presence yet. I’ve heard that’s changed in the last few years, and the Veteran’s hospitals are serving increasing numbers of younger vets.

A new study by Yoder and colleagues looks at whether there’s a difference among veterans in response to treatment for PTSD. The treatment is Prolonged Exposure (PE) therapy, an empirically-supported exposure-based therapy for PTSD. The study compares veterans of Vietnam, the Gulf War, and what are known as OEF (i.e., “Operation Enduring Freedom” aka the war in Afghanistan), OIF (i.e., “Operation Iraqi Freedom”), and OND (i.e., “Operation New Dawn” coined to indicate the shift from combat to stabilization in Iraq).

What Did They Look At?

Conducted at the VA Hospital in Charleston, SC, the researchers used archival data to test their hypotheses. What this means is that the study was not originally designed to answer the questions posed. This in itself is not a problem, but it means that the results should be taken with a bit more caution until replicated.

The study looked at veterans who completed PE for PTSD. There were 112 participants total: 61 OEF/OIF/OND; 34 Vietnam; and 17 Gulf War. Veterans were treated by one of three therapists using PE.

Gulf War Veterans May Respond More Slowly to Treatment

Overall, veterans improved with treatment regardless of war background. Interestingly, Gulf War veterans responded less well to PE than Vietnam and OEF/OIF/OND veterans even though all showed comparable scores of PTSD and depressive symptoms prior to treatment. Gulf War veterans were slower to respond to therapy.

Why did Gulf War veterans respond different? The researchers aren’t sure. What they suggest is that:

“It may be due to population differences related to variable stress-diathesis selection processes for chronic fear experiences versus acute types of trauma or to variable self-selection pressures and concurrent treatment seeking behaviors that may vary in some important, though unmeasured, ways among war-zone cohorts.” (p. 8)

This is just a long-winded, gobbledygook way of saying: We don’t know. Maybe Gulf War veterans are different.

My Thoughts

The good news is that veterans seem to respond well to PE for PTSD regardless of war. Why Gulf War veterans responded more slowly to treatment may be a fluke. I also wasn’t clear whether the researchers statistically accounted for this or not, but given that there were fewer of Gulf War veterans (n = 17) compared to Vietnam (n = 34), and OEF/OIF/OND (n = 61), it’s possible that the results may be skewed by a few Gulf War veterans who were poor responders to treatment (aka outliers).

For these reasons, I’d wait until the results are replicated with another sample before we can say with any confidence that Gulf War veterans may respond differently to treatment.

An Overview of the Emotional Processing Theory

An Overview of the Emotional Processing Theory

NOTE: This post is part of a larger series of on the theory, practice, and research on exposure therapy. If you are interested in other posts in this series, you can find them here.

Twenty-five years ago, in an attempt to create a unifying theory that would explain the processes of and guide the use of exposure in the treatment of anxiety disorders, Foa and Kozak (1986) developed the emotional processing theory (aka, information processing theory). The emotional processing theory has since guided an enormous amount of research, particularly for posttraumatic stress disorder (PTSD). Dr. Foa drew from the theory in developing prolonged exposure, a landmark PTSD treatment and the gold standard approach to PTSD treatment.

Much of my experience with the emotional processing theory comes from my training in prolonged exposure. When I was originally trained in prolonged exposure, I had the impression that it was more on the behavioral side of cognitive behavioral therapy. However, in reading about the emotional processing theory in greater depth, I realized that, although prolonged exposure looks procedurally like behavior therapy, the theory behind it is more of a product of the cognitive revolution with its emphasis on the computer as a metaphor for the human mind.

According to the emotional processing theory, fear is activated through associative networks that include information about the feared stimulus, escape or avoidance responses to the feared stimulus, and the meaning of the fear (e.g., threat or danger). Fear becomes problematic when it is intense to a degree that it gets in the way of functioning, or when it persists even when there are no clear indications of danger. In these instances, there may be maladaptive or pathological fear structures. The theory holds that chronic avoidance (e.g., escape behavior, avoidance, dissociation) often leaves these maladaptive schemas in place, as people do not remain in a situation long enough for new learning to occur.

Emotional processing theory proposes that exposure can alter the relationships between the fear stimulus and these networks. For this to happen, the network must first be activated, and then new information must be encoded that is incompatible with what is in the fear network. This is accomplished through habituation. Staying in contact with a fear stimulus until there’s a reduction in anxiety allows for the encoding of new information that is incompatible with the fear stimulus (e.g., it’s not dangerous). For example, in someone with OCD, repeated exposure to an obsession while refraining from engaging in a particular ritual serves to disconfirm maladaptive beliefs about the importance of the ritual in keeping harm away.

I break this process down with greater detail below.

Fear Structures

We’ll start with fear structures. Originally proposed by Lang (1977), fear structures are cognitive networks of maladaptive thinking that become activated through fear or anxiety. For people with anxiety-related problems, there are two common maladaptive beliefs about the fear stimulus: 1. That anxiety or distress will escalate to the degree it becomes unmanageable (e.g., “I can’t handle this”); 2. The feared stimulus or their experience of anxiety will cause harm (e.g., “I’ll lose control” or “I’ll go crazy”). For example, someone with panic disorder might think, “I’m going to die” when they start to notice panic cues like shortness of breath.

The major problem, according to emotional processing theory, is that people with anxiety disorders usually engage in some form of escape or avoidance behaviors when they feel anxious. As a result, they don’t remain in contact with their anxiety long enough to disconfirm the fear structure. Over time, people continue to engage in disruptive behaviors (e.g., escape) whenever they experience fear. An unfortunate side effect of continued avoidance behavior is that people’s lives begin to constrict in order to avoid things that trigger the fear structures. Their lives become narrower and more confined (e.g., they stop leaving the house).

Disconfirming Fear Structures Through Habituation

The solution then, according to the emotional processing theory, is for people to stay with their anxiety long enough for it to reduce on its own. Research suggests that so long as we don’t actively feed anxiety through worry, it tends to go down on its own after about 45 minutes –what is called habituation to the feared stimulus. Through repeated habituation, they begin to learn that what they’re afraid will happen (e.g., “I’ll go crazy”) doesn’t occur, and/or that the feared consequences are less likely to occur or are milder than expected (e.g., “If people notice I’m anxious, they’ll laugh at me”).

Foa and Kozak (1986) suggested that exposure weakens associations and replaces maladaptive fear associations with more adaptive ones. However, this view was revised in Foa and McNally (1996), where the authors incorporated animal behavior models of exposure from the lab of Bouton. Bouton’s work suggests that exposure does not actually alter associations so much as creates new, competing associations. What this means is that following exposure, there may now be two associations: a pathological one and a non-pathological one. Ideally, the person begins engaging in behaviors that are more in accordance with the non-pathological association, strengthening it over time.

Here’s an example: A motor vehicle accident survivor develops a fear structure involving thoughts that all automobiles are extremely dangerous. As a consequence, he stops driving. The therapist might arrange a series of exposure exercises involving automobiles. The person might start by sitting in a parked car each day until his anxiety decreases. He may then drive very slowly on low traffic streets, working his way up to driving again. The man may retain the association that all automobiles are dangerous, but through exposure a competing association that harm is unlikely accompanies it. The man may then make choices in accordance with this second association (e.g., the choice to drive a car).

A Glimpse Into the Future of the Emotional Processing Theory

This is a brief sketch of the emotional processing theory. It has been hugely influential in guiding research on anxiety treatment, particular for posttraumatic stress disorder and obsessive-compulsive disorder. The application of the emotional processing theory to PTSD has led to a very successful treatment—prolonged exposure. However, treatments may be effective even if the theories guiding them are not entirely accurate.

As I’ve written in a previous post, the main area in which newer research has brought the emotional processing theory into question is its emphasis on habituation. There’s no reason to offer a complete retread of the post, but newer research suggests that it’s not necessary for someone’s anxiety to go down during exposure in order for him or her to benefit. Additionally, McNally (2007) argued that the concept of “fear structures” is vague, circular, and not supported by research. Dr. Craske at UCLA, in particular, has criticized the principles underlying the emotional processing theory (See Craske et al, 2008 for a summary of exposure research; Baker et al, 2010, for study from Craske’s lab questioning the usefulness of habituation in predicting treatment outcome).

In upcoming posts, I’ll be discussing newer research that challenges the emotional processing theory, and that offers glimpses into where our understanding of exposure may go.

For more information about Emotional Processing Theory

If you want to read more about emotional processing theory, here’s a good book:

 Pathological Anxiety, Emotional Processing in Etiology and Treatment (2005), by Barbara Rothbaum.

Or for the most widely used guide for Prolonged Exposure, the main therapy approach guided by emotional processing theory, see:

Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences Therapist Guide (2007) by Edna Foa, et al.

For more about exposure therapy, check out my other posts on the topic.

Rape Survivors Who Rely on Avoidant Coping May Respond Better to Exposure-Based Treatment

Rape Survivors Who Rely on Avoidant Coping May Respond Better to Exposure-Based Treatment

One of the hardest things to predict in psychotherapy is how well someone will respond to a particular treatment. A brief report in an upcoming issue of Journal of Consulting and Clinical Psychology by Leiner and colleagues offers some insight into this question. The researchers look at the impact of avoidant coping on PTSD treatment.

What’s Avoidant Coping?

As defined in this article, avoidant coping involves attempts to reduce or block out distress and discomfort. Although not directly referenced in this article, there’s an interesting research literature that suggests avoidance behaviors may maintain PTSD symptoms over time, and that reliance on these strategies is related to greater PTSD symptom severity above and beyond the severity of the original trauma (see Batten, Follette, & Aban, 2001; Polusny & Follette, 1995; Rosenthal, Hall, Palm, Batten, & Follette, 2005). Not wanting to engage painful memories and triggers is very natural, but it may exacerbate and prolong posttraumatic stress symptoms in the long run.

What the Researchers Found

The researchers used data from a previous study comparing Prolonged Exposure (PE) therapy and Eye Movement Desensitization and Reprocessing (EMDR) for adult women rape survivors with PTSD. Both PE and EMDR are exposure-based treatments. (Some EMDR proponents would object to being classified as exposure-based treatments, but that’s another debate entirely.)

The researchers found that greater use of avoidant coping strategies at pretreatment was related to lower PTSD severity after treatment. The researchers then divided up the sample according to greater and lesser scores on a measure of avoidant coping (i.e., Coping Strategies Inventory – Disengagement subscale). They found that women who scored higher in avoidant coping were much more likely to respond to treatment. Conversely, women with lower scores in avoidant coping were less likely to respond to treatment.

What Does This Mean?

The results make sense conceptually. Exposure-based therapists structure treatment so that clients safely and collaboratively confront memories and triggers they typically avoid. Although it makes sense that people with greater avoidance benefit from a treatment that focuses on confronting the avoided experiences, I find it comforting that there doesn’t appear to be a ceiling effect. That is, the researchers didn’t find that too much avoidance negatively impacted treatment.

The study leaves me with the following questions: What about women with PTSD who are low in avoidant coping? Is there another treatment that works better for them? This remains unanswered.

It also makes me wonder what other variables might be important in predicting response to treatment in PTSD. After all, avoidant coping is only one variable. There may be others that are also important. Nevertheless, this is important work that could have real-world implications for therapists who are trying to figure out who may benefit most from exposure-based treatment for PTSD. Although it’s too early to say definitively, these findings suggest that clients who are relatively more avoidant may be the best candidates for exposure therapy.

UPCOMING TRAINING EVENTS


De-Mystifying Self-As-Context in ACT: Practical Strategies for Clients

Brian Pilecki, PhD and Kati Lear, PhD
December 3rd, 2021 from 12pm-1:30pm

This workshop will outline how self-as-context can be used to conceptualize commonly discussed topics in therapy such as self-esteem, confidence, identity, and inner conflict. Participants will learn how to flexibly practice practical self-as-context interventions that can be used with clients, as well as have a chance to practice newly learned skills through structured role-play exercises in breakout groups. Read More.


Values in Therapy: An Intro to Working with Values from an ACT Perspective

Jenna LeJeune, PhD
January 21, 2022 from 12pm-2:00pm

This workshop will provide a theoretical and conceptual overview of values from a contextual behavioral science perspective. We will cover the “what”, “why”, “when”, and “how” of values within ACT. While we will also provide an overview of various values exercises and measures that can be used with clients, the emphasis in this workshop will be on providing a foundational framework that will help clinicians approach values work from a functional perspective rather than a primarily technique-focused approach. Read More.



Culturally Responsive Therapy: How to Apply Anti-Racist Values in Session

Christy Tadros, LPCC and RaQuel Neal, LCSW
February 4th, 2022 from 1:30pm-4:45pm
and February 5th from 9:00am-12:00pm

This 2 day 6-hour training will help therapists develop their ability to support clients from a different racial background than them, with a particular focus on Black, Indigenous and People of Color. Through a multicultural social justice framework, it will integrate research and clinical experience to teach a therapeutic model for rapport building, assessment, and treatment. This model is not a rigid therapeutic modality, but provides a contextual lens to build a strong, culturally grounded therapeutic relationship. It is a flexible model and can align with many therapeutic modalities, including a contextual behavioral approach to therapy. Read More.


Truffle Hunting: Bringing Values to Life in the Therapy Room

Jenna LeJeune, PhD
February 25, 2022 from 12pm-2:00pm

This brief workshop is designed to help clinicians deepen their values work with clients by shifting the focus from the content of values conversations to the quality of those conversation. By listening for and deepening the qualities of effective values conversations participants will get a taste for how more experiential and relationally-based values work can supercharge therapy. Participants will have opportunities to both observe demonstrations and practice in small groups with the benefit of feedback. Read More.


Values Prototyping: Using Action to Help Clients Explore Their Values

Jenna LeJeune, PhD
March 11, 2022 from 12pm-2:00pm

This workshop will focus on one specific experiential tool called “values prototyping” that helps clients learn more about their values through engaging in intentional valuing. As participants will hopefully already have a solid foundation of some of the core concepts of the values process in ACT, this workshop will dive right in on how to use values prototyping to help clients learn more about what they would choose to value in their life. You will have the chance to practice developing a values prototype in small groups with the benefit of feedback, so that by the end of the workshop you will be able to use this tool in your work with clients. Read More.


The Invitation to Change Approach: Helping Families Affected by Addiction

Jeff Foote, PhD and Cordelia Kraus, LPC, CADC 1, certified CRAFT clinician
May 13th and 14th, 2022 from 9:00am-5:00pm
at University of Portland, Terrace Room
This two-day in-person workshop will provide skills training for professionals focused on the process of working with clients who have a loved one struggling with substance use issues. The Invitation to Change Approach draws on CRAFT (Community Reinforcement and Family Training), MI (Motivational Interviewing), and ACT (Acceptance and Commitment Therapy) to provide a compassionate and collaborative way of working with the families and concerned significant others of people who struggle with substance use. Read More.


Therapy and Research in Psychedelic Science (TRIPS) Seminar Series

Second Friday of each month from 12:00 PM – 1:00 PM (PT)

TRIPS is an online seminar series that hosts speakers discussing science-informed presentations and discussions about psychedelics to educate healthcare professionals. This series was created to guide healthcare providers and students preparing to be professionals towards the most relevant, pragmatic, and essential information about psychedelic-assisted therapy, changing legal statuses, and harm reduction approaches in order to better serve clients and communities. This seminar series is a fundraiser for our clinical trial of MDMA-assisted psychotherapy for social anxiety disorder that Portland Psychotherapy investigators are preparing for and starting in the Fall of 2021. All proceeds after presenter remuneration will go to fund this clinical trial. Read more.

January 14th, 2022Psilocybin-Assisted Therapy of Major Depressive Disorder using Acceptance and Commitment Therapy as a Therapeutic Frame with Jordan Sloshower, MD, MSc

February 11th, 2022 – Drug-Drug Interactions Between Psychiatric Medications and MDMA or Psilocybin with Aryan Sarparast, MD

May 13th, 2022Implementing Culturally-Attuned & Anti-Racist Psychedelic Therapy: Impact over Intention with Jamilah R. George, M.Div, M.S.