Experiential avoidance

Experiential avoidance (EA) has been broadly defined as attempts to avoid thoughts, feelings, memories, physical sensations, and other internal experiences—even when doing so creates harm in the long-run.[1] The process of EA is thought to be maintained through negative reinforcement—that is, short-term relief of discomfort is achieved through avoidance, thereby increasing the likelihood that the behavior will persist. Importantly, the current conceptualization of EA suggests that it is not negative thoughts, emotions, and sensations that are problematic, but how one responds to them that can cause difficulties. In particular, a habitual and persistent unwillingness to experience uncomfortable thoughts and feelings (and the associated avoidance and inhibition of these experiences) is thought to be linked to a wide range of problems.[2]

Background

EA has been popularized by recent third-wave cognitive-behavioral theories such as acceptance and commitment therapy (ACT). However, the general concept has roots in many other theories of psychopathology and intervention.

Psychodynamic

Defense mechanisms were originally conceptualized as ways to avoid unpleasant affect and discomfort that resulted from conflicting motivations.[3] These processes were thought to contribute to the expression of various types of psychopathology. Gradual removal of these defensive processes are thought to be a key aspect of treatment and eventually return to psychological health.[4]

Process-experiential

Process-experiential therapy merges client-centered, existential, and Gestalt approaches.[5] Gestalt theory outlines the benefits of being fully aware of and open to one's entire experience. One job of the psychotherapist is to "explore and become fully aware of [the patient's] grounds for avoidance" and to "[lead] the patient back to that which he wishes to avoid" (p. 142).[6] Similar ideas are expressed by early humanistic theory: "Whether the stimulus was the impact of a configuration of form, color, or sound in the environment on the sensory nerves, or a memory trace from the past, or a visceral sensation of fear or pleasure or disgust, the person would be 'living' it, would have it completely available to awareness…he is more open to his feelings of fear and discouragement and pain...he is more able fully to live the experiences of his organism rather than shutting them out of awareness."[7]

Behavioral

Traditional behavior therapy utilizes exposure to habituate the patient to various types of fears and anxieties,[8][9] eventually resulting in a marked reduction in psychopathology. In this way, exposure can be thought of as "counter-acting" avoidance, in that it involves individuals repeatedly encountering and remaining in contact with that which causes distress and discomfort.[10]

Cognitive

In cognitive theory, avoidance interferes with reappraisals of negative thought patterns and schema, thereby perpetuating distorted beliefs.[11] These distorted beliefs are thought to contribute and maintain many types of psychopathology.[12]

Third-wave cognitive-behavioral

The concept of EA is explicitly described and targeted in more recent CBT modalities including acceptance and commitment therapy (ACT), dialectical behavior therapy (DBT), functional analytic psychotherapy (FAP), and behavioral activation (BA).

Associated problems
  • Distress is an inextricable part of life; therefore, avoidance is often only a temporary solution.
  • Avoidance reinforces the notion that discomfort, distress and anxiety are bad, or dangerous.
  • Sustaining avoidance often requires effort and energy.
  • Avoidance limits one's focus at the expense of fully experiencing what is going on in the present.
  • Avoidance may get in the way of other important, valued aspects of life.

Empirical evidence
  • Laboratory-based thought suppression studies suggest avoidance is paradoxical, in that concerted attempts at suppression of a particular thought often leads to an increase of that thought.[13]
  • Studies examining emotional suppression and pain suppression suggest that avoidance is ineffective in the long-run.[14][15] Conversely, expressing unpleasant emotion results in short-term increases in arousal, but long-term decreases in arousal.[16]
  • Exposure-based therapy techniques have been shown to be effective in treating a wide range of psychiatric disorders.[8]
  • Numerous self-report studies have linked EA and related constructs (avoidance coping, thought suppression) to psychopathology and other forms of dysfunction.[17][18][19][20]

Relevance to psychopathology

Seemingly disparate forms of pathological behavior can be understood by their common function (i.e., attempts to avoid distress). Some examples include:

DiagnosisExample BehaviorsTarget of Avoidance
Major depressive disorderIsolation/suicideFeelings of sadness, guilt, low self-worth
Posttraumatic stress disorderAvoiding trauma reminders, hypervigilanceMemories, anxiety, concerns of safety
Social phobiaAvoiding social situationsAnxiety, concerns of judgment from others
Panic disorderAvoiding situations that might induce panicFear, physiological sensations
AgoraphobiaRestricting travel outside of home or other "safe areas"Anxiety, fear of having symptoms of panic
Obsessive-compulsive disorderChecking/ritualsWorry of consequences (e.g., "contamination")
Substance use disordersAbusing alcohol/drugsEmotions, memories, withdrawal symptoms
Eating disordersRestricting food intake, purgingWorry about becoming "overweight", fear of losing control
Borderline personality disorderSelf-harm (e.g., cutting)High emotional arousal

Relevance to quality of life

Perhaps the most significant impact of EA is its potential to disrupt and interfere with important, valued aspects of an individual's life.[1] That is, EA is seen as particularly problematic when it occurs at the expense of a person's deeply held values. Some examples include:

  • Putting off an important task because of the discomfort it evokes.
  • Not taking advantage of an important opportunity due to attempts to avoid worries of failure or disappointment.
  • Not engaging in physical activity/exercise, meaningful hobbies, or other recreational activities due to the effort they demand.
  • Avoiding social gatherings or interactions with others because of the anxiety and negative thoughts they evoke.
  • Not being a full participant in social gatherings due to attempts to regulate anxiety relating to how others are perceiving you.
  • Being unable to fully engage in meaningful conversations with others because one is scanning for signs of danger in the environment (attempting to avoid feeling "unsafe").
  • Inability to "connect" and sustain a close relationship because of attempts to avoid feelings of vulnerability.
  • Staying in a "bad" relationship to try to avoid discomfort, guilt, and potential feelings of loneliness a break-up might entail.
  • Losing a marriage or contact with children due to an unwillingness to experience uncomfortable feelings (e.g., achieved through drug or alcohol abuse) or symptoms of withdrawal.
  • Not attending an important graduation, wedding, funeral, or other family event to try to avoid anxiety or symptoms of panic.
  • Engaging in self-destructive behaviors in an attempt to avoid feelings of boredom, emptiness, worthlessness.
  • Not functioning or taking care of basic responsibilities (e.g., personal hygiene, waking up, showing up to work, shopping for food) because of the effort they demand and/or distress they evoke.
  • Spending so much time attempting to avoid discomfort that one has little time for anyone or anything else in life.

Measurement

Self-report

The Acceptance and Action Questionnaire (AAQ)[21] was the first self-report measure explicitly designed to measure EA, but has since been re-conceptualized as a measure of "psychological flexibility".[22] The Multidimensional Experiential Avoidance Questionnaire (MEAQ)[23] was developed to measure different aspects of EA.

See also

Opposite concepts

Notes
  1. Hayes, S. C.; Strosahl, K. D.; Wilson, K. G. (1999). Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change. New York: Guilford Press.
  2. Hayes, Steven C.; Wilson, Kelly G.; Gifford, Elizabeth V.; Follette, Victoria M.; Strosahl, Kirk (1996). "Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment". Journal of Consulting and Clinical Psychology. 64 (6): 1152–68. CiteSeerX 10.1.1.597.5521. doi:10.1037/0022-006X.64.6.1152. PMID 8991302.
  3. Freud, A. (1966). The Ego and the Mechanisms of Defense. New York: International Universities Press.
  4. Karon, B. P.; Widener, A. J. (1995). Bongar, B.; Beutler, L. E. (eds.). Comprehensive Textbook of Psychotherapy. New York: Oxford University Press. pp. 24–47.
  5. Greenberg, Leslie S.; Watson, Jeanne C.; Lietaer, Germain (1998). Handbook of Experiential Psychotherapy. Guilford Press. pp. 6–. ISBN 978-1-57230-374-4. Retrieved 15 September 2013.
  6. Perls, F. S.; Hefferline, R. F.; Goodman, P. (1951). Gestalt Therapy: Excitement and Growth in the Human Personality. New York: Julian Press.
  7. Rogers, C. R. (1961). On Becoming a Person: A Therapist's View of Psychotherapy. Houghton Boston: Mifflin Company. p. 188.
  8. Barlow, D. H. (1988). Anxiety and its Disorders. New York: Guilford Press.
  9. Craighead, W. E.; Craighead, L. W.; Ilardi, S. S. (1995). "Behavior therapies in historical perspective". In Bongar, B.; Beutler, L. E. (eds.). Comprehensive Textbook of Psychotherapy. New York: Oxford University Press. pp. 64–83.
  10. Baum, Morrie (1970). "Extinction of avoidance responding through response prevention (flooding)". Psychological Bulletin. 74 (4): 276–84. doi:10.1037/h0029789. PMID 5479591.
  11. Clark, D. M. (1988). "A cognitive model of panic". In Rachman, S.; Maser, J. (eds.). Panic: Psychological Perspectives. Hillsdale: Erlbaum.
  12. Beck, A. T. (1976). Cognitive Therapy and the Emotional Disorders. Madison, CT: International Universities Press.
  13. Wegner, Daniel M.; Schneider, David J.; Carter, Samuel R.; White, Teri L. (1987). "Paradoxical effects of thought suppression". Journal of Personality and Social Psychology. 53 (1): 5–13. doi:10.1037/0022-3514.53.1.5. PMID 3612492.
  14. Gross, James J.; Levenson, Robert W. (1997). "Hiding feelings: The acute effects of inhibiting negative and positive emotion". Journal of Abnormal Psychology. 106 (1): 95–103. doi:10.1037/0021-843X.106.1.95. PMID 9103721.
  15. Cioffi, Delia; Holloway, James (1993). "Delayed costs of suppressed pain". Journal of Personality and Social Psychology. 64 (2): 274–82. doi:10.1037/0022-3514.64.2.274. PMID 8433273.
  16. Hughes, Cheryl F.; Uhlmann, Carmen; Pennebaker, James W. (1994). "The Body's Response to Processing Emotional Trauma: Linking Verbal Text with Autonomic Activity". Journal of Personality. 62 (4): 565–85. doi:10.1111/j.1467-6494.1994.tb00309.x. PMID 7861305.
  17. Abramowitz, Jonathan S.; Lackey, Gerald R.; Wheaton, Michael G. (2009). "Obsessive–compulsive symptoms: The contribution of obsessional beliefs and experiential avoidance". Journal of Anxiety Disorders. 23 (2): 160–6. doi:10.1016/j.janxdis.2008.06.003. PMID 18657382.
  18. Forsyth, John P.; Parker, Jefferson D.; Finlay, Carlos G. (2003). "Anxiety sensitivity, controllability, and experiential avoidance and their relation to drug of choice and addiction severity in a residential sample of substance-abusing veterans". Addictive Behaviors. 28 (5): 851–70. doi:10.1016/S0306-4603(02)00216-2. PMID 12788261.
  19. MMarx, Brian P.; Sloan, Denise M. (2005). "Peritraumatic dissociation and experiential avoidance as predictors of posttraumatic stress symptomatology". Behaviour Research and Therapy. 43 (5): 569–83. doi:10.1016/j.brat.2004.04.004. PMID 15865913.
  20. Gratz, Kim L.; Rosenthal, M. Zachary; Tull, Matthew T.; Lejuez, C. W.; Gunderson, John G. (2006). "An experimental investigation of emotion dysregulation in borderline personality disorder". Journal of Abnormal Psychology. 115 (4): 850–5. doi:10.1037/0021-843X.115.4.850. PMID 17100543.
  21. Hayes, Steven C.; Strosahl, Kirk; Wilson, Kelly G.; Bissett, Richard T.; Pistorello, Jacqueline; Toarmino, Dosheen; Polusny, Melissa A.; Dykstra, Thane A.; Batten, Sonja V. (2004). "Measuring Experiential Avoidance: A Preliminary Test of a Working Model". The Psychological Record. 54 (4): 553–78. doi:10.1007/BF03395492.
  22. Hayes, Steven (December 27, 2009). "Acceptance and Action Questionnaire (AAQ) and Variations". Association for Contextual Behavioral Science. Retrieved November 12, 2012.
  23. Gámez, Wakiza; Chmielewski, Michael; Kotov, Roman; Ruggero, Camilo; Watson, David (2011). "Development of a measure of experiential avoidance: The Multidimensional Experiential Avoidance Questionnaire". Psychological Assessment. 23 (3): 692–713. doi:10.1037/a0023242. PMID 21534697.

References
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