Sunday, August 21, 2011

Avoiding Avoidance

Clinicians and scholars across the spectrum of theoretical perspectives seem to agree on quite a bit. Indeed, both cognitive behavioral therapists and psychoanalysts will tell you that their clients' problems have often been caused by some form of avoidance.

To be sure, they use different language. Cognitive behavioral therapists may actually say "avoidance." More specifically, they might say "experiential avoidance," referring to efforts to avoid any distressing internal stimuli (thoughts, feelings, memories, sensations) For example, a behaviorist may suggest that a phobia develops through habitual avoidance of a feared object, or a dialectical behavioral therapists may argue that self-injurious behavior has developed as a way to avoid distressing emotions. In the short term, avoidance is negatively reinforcing (i.e., it results in short-term relief from discomfort, which strengthens the avoidance behavior), so it can be a hard pattern to break, even when it begins to cause harm in the long-run. 

In contrast, psychoanalysts and psychodynamic therapists speak of conscious and unconscious intrapsychic conflicts, and defense mechanisms that allow the individual to avoid whatever is unacceptable or threatening to them. Problems arise when defense mechanisms cause harm, or don't work (i.e., allow inner conflicts to cause distress). Common defense mechanisms include:
  • denial - ignoring or disavowing the reality and implications of a painful event
  • projection - attributing an unacceptable impulse or painful thought to another person
  • acting out - avoiding conscious recognition of distress by immediately acting on wishes, impulses, and fantasies
  • dissociation - separating a thought or memory from associated feelings, thereby altering its emotional meaning and impact
  • regression - retreating to an earlier level of psychosexual functioning in the face of anxiety or a challenge that cannot be mastered
  • repression - removing upsetting thoughts, feelings, or memories from the conscious mind
  • reaction formation - transforming an unacceptable wish or impulse into its opposite
  • displacement - directing wishes and impulses away from the person with whom they originate, who is perceived as inappropriate or dangerous, to someone else, who is perceived as appropriate or safe
  • undoing - acting in ways that symbolically or actually make amends for unacceptable thoughts, feelings, or behaviors
  • sublimation - transforming unacceptable wishes and impulses into socially acceptable behaviors 
  • humor - using humor to minimize discomfort when expression painful or unacceptable wishes or feelings
While therapists practicing from each of these theoretical perspectives conceptualize treatment differently, they agree that ending the pattern of avoidance is an important part of the process. For psychoanalytical and psychodynamic practitioners, the goal is to integrate parts of the client's inner experience that have been conflicted or disowned. Practitioners using CBT or DBT work to stop the avoidance behavior and replace it with more adaptive alternatives.

The common thread is a process of learning to accept the full range of internal experiences and respond in ways that are consistent with one's values and long-term goals, including mental and emotional health. Would you say that this is a goal of your clinical work? If so, how do you go about it?

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