Estimated reading time: 12 minutes

By: Dr. Dennis London

Back during my doctoral training at the VA, I was in a therapy session with a patient, and the unexpected happened: My patient chose to end the session 30 minutes early. They became too overwhelmed by their emotions and were unable to tolerate the uncomfortable feelings coming up in session. 

At the time, I (as a novice therapist) felt ineffective and defeated. No matter all of the therapist tricks I had up my sleeve that I tried, my patient was unable to tolerate the session any longer and had to end it. 

I remember consulting with my supervisor later and feeling insecure. Out of the many thoughts swirling around in my head, here were a few that kept coming up: 

Was I to blame? 
Did this reflect poorly on me as a therapist? 
Could I have done something differently? 
Should I have done something differently? 

I told my supervisor about every clinical attempt I made to try and get my patient to stay in the session. Admittedly, I was fearful of being scolded by my supervisor and my therapy skills being criticized. 

I anxiously explained to my supervisor how I tried my best to help my patient tolerate the discomfort, anxiety, and distressing feelings that were coming up for him in the session (we were discussing a previous trauma), and my supervisor stopped me. She told me a story and taught me an important lesson I will never forget: 

“Dennis, I have had patients straight up jump up out of their seat, bolt out of my office, and run out of the building before.” 

Oh….I thought, admittedly feeling slightly better about my therapy skills now knowing this has happened before. My supervisor explained to me an important phenomenon in trauma therapy – avoidance. 

I learned how, because of the trauma people have experienced, they become stuck in a cycle of avoidance. This is actually protective by design; the brain seeks to avoid what is painful to protect us. As a result of trauma, the brain learns to avoid potential situations, people, and places that resemble some aspect or memory of the original trauma. Unfortunately, this avoidance can start to interfere with daily life if it becomes over generalized and we don’t break these connections.

The function and purpose of avoidance

I’ve written about avoidance briefly before (check out my Difficult Conversations post), but in this piece I want to take a deeper look at this phenomenon and specifically how it relates to trauma. By the time you’re done reading, I want you to be able to understand what avoidance is, know the difference between unhelpful avoidance and healthy coping, and think about if you might be engaging in any type of avoidance in your life. And here is the good news – I have included tips to help you overcome that avoidance. 

Depending on your therapist and their theoretical orientation (the lens they use to view and understand human behavior), they’re going to call avoidance something slightly different. A CBT therapist might call avoidance negative reinforcement. An ACT therapist would call it experiential avoidance. A DBT therapist would call it a distraction skill. 

Avoidance is one of the greatest barriers to change. All of us (yes, even us therapists), engage in avoidance behaviors every day.  Have you ever procrastinated? Avoidance. Ever put off a difficult conversation? Avoidance. Ever postponed a dental appointment because you don’t like teeth cleanings? Avoidance. Ever put off that New Year’s resolution? Avoidance.

Okay, so you get my point. But, what do all of these situations have in common other than the theme of avoidance, and why is it harmful? Avoidance prevents you from confronting your anxiety, or the thing you fear that’s holding you back, and growing past it. 

It’s important to understand in these situations the brain does not seek to avoid the actual places, people, or things associated with the discomfort; it seeks to avoid the anxiety or emotional discomfort associated with the painful or traumatic memory that is connected to these things. In other words, the brain wants to avoid these thoughts or feelings that create discomfort. 

Perhaps ironically, it’s the ongoing attempt to get rid of uncomfortable inner experiences that actually creates more painful experiences in the long run. Knowing this, and in trauma therapy, we can directly confront the thoughts and feelings to change the relationship to these triggers. Essentially, with this problematic connection broken, triggers are no longer tied to past traumatic memories. This disconnection allows one to move forward. Unfortunately, when the feeling of anxiety or pain is avoided, the connections to these triggers become strengthened through a process called negative reinforcement. 

Types of avoidance I commonly see in therapy: 

1. Avoidance behaviors
   • Not making eye contact while discussing difficult experiences (if not due to a cultural norm)
   • Frequently changing the subject during session 
   • Missing sessions, arriving late to session or ending early 
   • Self-medicating with alcohol or drugs
2. Emotional avoidance
   • Describing emotions with vague descriptions like “bad”
   • Not finding the words to describe an emotional experience 
   • Over identifying with a singular emotion (e.g., anger instead of sadness)
3. Cognitive avoidance
   • Describing thoughts when asked to identify a feeling
   • Engaging in “rationalization” or overly focusing on thoughts related to a situation (e.g., overanalyzing)
   • Toxic Positivity

The consequences of avoidance 

Avoidance creates problems and interferes with our quality of life. Imagine the brain as an overprotective helicopter mother. If it never allows us to leave the home and wants us to avoid every potential source of danger, then our world becomes smaller and smaller. Soon, our life will become very limited in interactions. 

Or when we do leave the house, our brain is so hypervigilant and on high alert we miss what’s happening around us. When we’re constantly scanning our environment for any potential sign of danger, this limits our opportunities for social interaction. We will never learn, more often than not, we will not get hurt. Or even if we do, we in fact have the ability to cope and are resilient. 

Signs you might be engaging in avoidance in your life: 

• Your emotions tend to build up and you experience a lot of them at once 
• You tend to react to others out of emotion instead of responding thoughtfully 
• You experience a lot of irritation and annoyance, especially over the small things (e.g., crying over spilt milk) 
• You experience alexithymia: You might have difficulty identifying your feelings
• You tend to panic or become overwhelmed when trying mindfulness, yoga, or other meditation practices that require you to sit in silence with your thoughts
• You feel uncomfortable when others express their emotions 
• You find yourself reaching for the same behavior to cope with stress and don’t feel any better after 
• You engage in strategies to numb your feelings (e.g., spending money, drinking alcohol, using other substances, mindlessly scrolling through social media)
• Always staying busy: You have difficulty sitting still and are always on the go to the point of exhaustion where you are too tired to experience your emotions

What is the difference between temporary distraction and avoidance?

Distraction is “temporary” avoidance. It is a useful tool when our emotions or distress are so high, and we feel too dysregulated at the moment, to be able to confront the cause. In these moments, we might feel flooded and unable to respond in an effective way. In these situations, we need some time or distance to self-soothe and regulate our emotions. 

Taking some time to engage in distraction, grounding, or some other form of self soothing to regulate our emotions will allow us to effectively respond. What is important and necessary though is later returning to the situation (or thought) that was causing the distress. It is not problematic as a “sometimes” coping skill, but if we always rely on distraction and never return to confront the difficult emotions, then we never achieve resolution. 

And how do you know if a regular coping mechanism or behavior is avoidance or truly something that’s helpful? To distinguish, it’s helpful to look at the function of the behavior. Any behavior could actually be used as avoidance. Not sure you agree? Let’s look at a behavior that most would assume is healthy – something you learn in therapy. We’ll use reframing your thoughts as an example. 

Your therapist might teach you to challenge and reframe unhelpful thoughts that are causing self-doubt or anxiety. Essentially, this is just coming up with new thoughts that may be more realistic. Could something like this behavior ever be used as avoidance? Yes! But it depends on how that behavior is being used; that is, what is the function of that behavior, and what are you trying to accomplish by using it? 

Let’s imagine any time a thought pops into your head and it prompts anxiety, you immediately jump to reframing it. This could be problematic and signal avoidance of the discomfort associated with that thought. The process of reframing usually looks something like this: 

First, you take a second to clearly identify the thought.

Second, you identify if any unhelpful thinking patterns are present.

Then, you determine if it’s a thought that would be helpful to challenge and reframe. Finally, you identify the emotional experience in your body. 

If reframing is being used immediately, as a way to prevent the feeling of a painful emotional experience related to that thought, then this is an example of a “healthy” behavior being used in a not-so-healthy way as avoidance. 

I’m going to teach you a shortcut rule to determine whether you might be using behaviors or other coping strategies as avoidance: If the purpose of your act or behavior is to avoid feeling an emotion that might be painful or difficult to feel, then the behavior is likely avoidance.  

How to Overcome Avoidance: 

1. Become aware of how you respond to stressors
   • It’s helpful to start noticing your patterns and what you turn towards immediately when you face a stressor. Do you notice you tend to come home after a long and stressful day at work and reach for that glass of wine? Or maybe you come home and zone out by scrolling through social media for an hour. 
   • Regardless, identify what your habits and patterns are when you experience stress, anxiety, or any kind of emotional pain.
2. Identify if you might engage in problematic avoidance during these moments
   • Next, ask yourself if this habit or thing you are turning to is to avoid or escape some pain. Remember the difference between temporary distraction and avoidance described above. 
3. Increase your motivation for a different outcome
   • Identify how this current behavior is holding you back. Maybe it’s interfering with a long term goal or affecting your relationships. 
   • What are its pros and cons? Sure it might be temporarily helpful in some way, but do you also notice if it tends to make the problem bigger? Do the painful feelings always somehow return, and when they do are they more intense?
4. Understand what is coming up for you in these situations
   • Whatever you turn to, ask yourself what feelings or thoughts are coming up during this moment. Do they cause discomfort? Identify and name them.
   • The ABC model, or cognitive triangle, is a helpful starting point. Some might scoff at this model for being basic, but it really is a fundamental starting point to begin to understand the connection between situations and associated thoughts/feelings. Many patients tend to name thoughts when I ask them to identify a feeling or vice versa. Using this model, you can begin to untangle your experience in different trigger situations to have greater clarity. 
   • Ask yourself why might the situation provoke feelings of anxiety or other discomfort? Is it associated with a painful memory or traumatic experience? 
   • Be specific about the emotions. Use an aid like this one to name what you’re feeling.
   • Drop out of your head and into your body. Pay attention to what you feel and where. Try and describe that feeling. Does it feel heavy and large or small and sharp? Where in your body do you feel it?
5. Fight the urge to avoid.
   • Remind yourself you are safe and these feelings are just emotions that will pass in time. Think of emotions like ocean waves. They rise and fall with the tide of your emotional experience, experience crescendos and peaks, but they also always fall and recede. 
   • Engage in grounding if you start to feel unstable. Use a technique like the 5-4-3-2-1 method to ground yourself in the here-and-now, or carry a piece of sour candy with you to pop in your mouth if you start to panic.
6. Pay attention to the range of emotional intensity. Once it starts to subside, engage in a value-oriented behavior or healthy self-care like exercise, journaling, or talking to a supportive friend or family member. 
7. Seek out the help of a professional/licensed therapist. Cognitive processing therapy is an evidence based intervention to help process and become unstuck from these trauma-related thoughts. It has shown to be an effective treatment for PTSD with lasting benefits.   

Avoidance is natural. Let me write it again: Avoidance is natural, and you are not at fault or to blame. Blame the brain (and everyone else’s)! Our brain is just trying to keep us safe, which is why emotions exist. Emotions are neither bad nor good; they are information and data about our environment and whether or not something might be safe for us.

Think back to thousands of years ago, when our ancestors saw a saber-toothed tiger. They likely (hopefully) experienced fear. This was information about a threat in the environment, and then their stress response system activated to motivate them to action to respond to the threat or flee to safety. If they didn’t experience fear, if emotions were “bad” or served no purpose, then they would not have acted on that information of a threat and would have been a very tasty dinner for a hungry predator. 

Human beings by design are resilient. We are an adaptive species who have lived through plagues, wars, and famine, and yet we have persevered. You are resilient too, and you have the inner strength to face these painful feelings. 

If you find you keep coming back to the same strategies to deal with your stress that feel ineffective, if you want to process and become unstuck from trauma, or if you simply want to explore whether your current patterns are in your future self’s best interest, call me today. 

Together, we’ll explore, discuss, and overcome the avoidance that is holding you back from being your best self.

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