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

How to be Experiential in Acceptance and Commitment Therapy

Jason Luoma, Ph.D.
April 23, 2021 from 12-1pm

Acceptance and commitment therapy (ACT) is, at its core, an experiential treatment, but is frequently delivered in a non-experiential way. Experiential learning involves going beyond verbal discussion, insight, and explanations of experience. But how do we do this in ACT and how do we know when we are spending too much time engaged in non-experiential modes of learning? This workshop will outline a simple model you can use to identify when you are in less or more experiential modes during therapy and easy methods to switch to more experiential modes. You will then have a chance to practice it in breakout groups and get feedback. Read More.


Ethical & Legal Considerations in Psychedelic Integration Therapy

Jason Luoma, Ph.D. and Brian Pilecki, Ph.D.
May 7, 2021 from 12-2pm

This workshop is based on extensive research and writing we have conducted into the legal and ethical issues of working with psychedelics in the current regulatory climate, as well as clinical practice doing harm reduction and integration therapy with psychedelics. It is informed by consultation with multiple experts on harm reduction, as well as attorneys knowledgeable about criminal and civil matters relating to drug use and professional practice. We will share with you all we know so that you can be more informed in the decisions you are making in your practice and be better able to decide whether to jump into this kind of work if you are considering it. Read More.


Case Conceptualization in Acceptance and Commitment Therapy

Jason Luoma, Ph.D. and Brian Pilecki, Ph.D.
May 21, 2021 from 12-2pm

This workshop provides a chance to learn concrete methods for conceptualizing cases from the perspective of Acceptance and Commitment Therapy. Formulating a useful case conceptualization is a foundational clinical skill that is essential in delivering effective treatment, and one that can be often overlooked in the process of working with clients. Participants will learn several formats for doing formal case conceptualization outside of session as a means to further develop knowledge and skill with ACT theory, as well as to learn a means to enhance treatment planning. The importance of ongoing case conceptualization throughout a course of treatment will be emphasized, as well as common pitfalls in conceptualizing client problems. Participants will also have a chance to practice newly learned skills with a case in breakout groups. Read More.


ACT Precision Training: In-Session Case Conceptualization in Acceptance and Commitment Therapy to Help You be Focused and Strategic in Your Interventions

Jason Luoma, Ph.D. and Jenna LeJeune, Ph.D
June 18, 2021 from 12-2pm

This workshop provides a chance to learn and practice in-session, in-the-moment case conceptualization of cases from the perspective of Acceptance and Commitment Therapy. This workshop focuses on helping you use ACT theory & in-session clinical markers to make more precise and strategic interventions. The main goal of this workshop is to help you become more adept at identifying in-session client behaviors that are indicators for particular ACT processes that are likely to be most relevant. The workshop uses a process we call ACT Circuit Training, which involves intensive analysis of a video of an ACT session and intentional practice in conceptualizing client behavior and generating possible ACT responses, followed by discussion and feedback. Read More.


ACT Agility Training: In-Session Case Conceptualization in Acceptance and Commitment Therapy to Increase Flexible Responding

Jason Luoma, Ph.D. and Jenna LeJeune, Ph.D
July 16, 2021 from 12-2pm

This workshop provides a chance to learn and practice in-session, in-the-moment case conceptualization of cases from the perspective of Acceptance and Commitment Therapy. This workshop is intended to help therapists be more flexible and nimble in their use of ACT processes, strengthening their ability to fluidly shift as needed between processes within sessions. Therapist learning ACT often develop tunnel vision, focusing too much on particular processes or responding rigidly when more flexibility is needed. 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.

April 9th, 2021 – Ketamine 101: An Introduction to Ketamine-Assisted Psychotherapy with Gregory Wells, Ph.D.
May 14th, 2021  Research on MDMA and Psychedelic-Assisted Therapy: An Overview of the Evidence for Clinicians with Jason Luoma, Ph.D.
June 11th, 2021 Becoming a Psychedelic-Informed Therapist: Toward Developing Your Own Practice with Nathan Gates, M.A., LCPC