Driven to Distraction

In my last post, on urge surfing, I mentioned distraction as a coping strategy for intense urges, with the goal of getting your mind off the urge while waiting for it to pass. On the other hand, I've also mentioned in several posts that avoidance tends to increase rather than decrease distress. Isn't distraction just a fancy name for avoidance?

Yes and no. The purpose of both is to limit your exposure to distressing thoughts and feelings. However, true avoidance seeks to limit exposure indefinitely, while distraction (when used appropriately) is intended to be a time-limited break from distress, with the assumption that you will ultimately deal with the problem at hand, when it is less overwhelming to do so.

Since this line between distraction and avoidance is so fine, I think it is important for clinicians who introduce distraction to clients as a coping skill (e.g., as part of DBT skills training) to also educate clients about when and how distraction can become problematic, and be observant for signs that they may be over-using distraction as an avoidance strategy.

So, why introduce distraction at all? Well, clients often come to treatment with limited ability to tolerate and manage their own thoughts and feelings, and many have developed unhealthy coping strategies to avoid distress/discomfort (e.g., addictive behaviors, numbing/dissociation). It would be overwhelming to ask them to face and fully experience all of their internal experiences at once - particularly since those internal experiences tend to be heightened in intensity early in treatment. Overwhelming someone that way can lead to decompensation and relapse rather than stabilization and recovery. While tolerating, processing, and modulating thoughts and feelings without needing to distract is the ultimate goal, I'd much rather that someone distract than relapse!

Here are my general guidelines for healthy distraction:

1) It should be time-limited, and the client should return to the problem/distressing thought/feeling as soon as they are able to safely do so.

2) Distraction is better for distress/triggers that are by nature time-limited, rather than an ongoing problem or emotional state. For example, distress works well for urges, or physical discomfort that will pass (e.g., fullness for clients with eating disorders), but less well for a problem that requires action (e.g., school difficulty, relationship conflict), or an emotion.

3) It should not be the first coping strategy the client tries. They should first try strategies that allow them to process their internal experiences (mindfulness, self-soothing, journaling, seeking support, etc.), and only turn to distraction if these other methods aren't working, and they don't think they can safely continue trying other things.

What do you think about distraction as a coping strategy? When is it helpful, and when might it be harmful?

Not-So-Happy Holidays

There are plenty of reasons to dread the Holidays: family conflict, loneliness, and perhaps most of all, loss. Indeed, while the first holidays following a loss may be the hardest, each holiday season brings the sense of loss back, with old traditions and rituals serving to highlight the absence of those who have passed away.

Sometimes people try to lessen their grief by avoiding or changing their traditions. For example, my family has always taken a big group picture on Christmas, the one day each year when we're all together. The first Christmas after my grandmother died,  my aunt decided that gathering for a picture without Grandma at the center would be too sad, and so we didn't take a picture. The following year, we intended to take a picture, but everyone "forgot" until some of the group had already left. Will we take a picture this year? I hope so, but I don't know - it may be that the tradition has died, too.

Since we know that avoidance tends to increase rather than decrease distress, the logical assumption is that avoiding the traditions and rituals associated with the loved one whom we've lost will not prevent, and may ultimately compound, grief. The most likely result, in fact, is that we will also lose the traditions and rituals that have defined us as a family or group.

It may be wiser, and more satisfying in the long-run, to instead give up the notion that holidays have to be "happy." Actually, the word "holiday" implies nothing of the sort - the word references "holy" days, days that have been set apart from ordinary days, and can run the full spectrum from celebrations, to solemn observances, to days of mourning. We can observe our familiar traditions and rituals of holidays with joy, or with sadness, and have them be no less valid and meaningful. The meaning may shift in the absence of loved ones lost, but some meaning, value, and our link to the past will be preserved.

I invite those who are facing a holiday season with grief following loss to observe the holidays without avoidance, to allow yourselves to mingle joy and grief, tears and laughter, but not to relinquish the traditions that make up your connection to each other, to the past, and to the future.

Avoiding Avoidance, Revisited

A few months ago, I wrote about the potential for forms of avoidance to contribute to emotional and psychological problems. Most basically, avoiding aspects of human experience that may be uncomfortable or distressing alleviates discomfort/distress in the short-term, but exacerbates difficulties in the long-term by intensifying anxiety about that aspect of experience, and inhibiting the ability to cope with and modulate distress.

The most empirically-supported treatment for the various anxiety disorders (panic, phobias, OCD, PTSD), is called "exposure and response prevention" - in other words, a guided process of exposure to triggers for anxiety while preventing "safety behaviors" (ways of stopping/avoiding the anxiety without dealing with the trigger). The person experiences anxiety in response to the trigger, but waits for the anxiety to dissipate (like other emotions, when allowed to happen, anxiety peaks and then lessens on its own). Each time the person is exposed to the trigger the "peak" of anxiety is less intense, as a result of the previous exposures, until eventually the trigger is no longer triggering.

DBT expands the use of exposure, to apply to any emotion that causes a client problems in functioning (e.g., anger, guilt, shame, fear). It also expands our understanding of exposure to include anything that evokes the immediate or remembered experience of the emotion. Finally, it clarifies that the exposure has to include a "corrective" experience - in other words, the exposure should not reinforce the problematic emotional response, but should "correct" in with incongruent information or an incompatible emotional response. The same principle applies with classic exposure and response prevention - the idea is that when nothing bad happens as a result of exposure to a feared trigger, the fear begins to be disproven.

Based on all of this, it seems obvious that, for therapy to be effective, it is necessary for it to expose clients to the distressing emotions (and triggers thereof) that are causing problems for them. However, while doing so, it's also important to keep the overall level of emotional arousal within the "therapeutic window" - neither so little arousal that there is no real exposure to the emotions, nor so much arousal that the client's internal processing system is overwhelmed and the exposure itself becomes traumatic.

In group therapy, a significant challenge is to keep exposure to emotions within each individual group member's therapeutic window, so that nobody is traumatized, but everyone has the opportunity for growth. I've been filling in at a day program location (while waiting for my own location to open) that has dealt with concern about group process becoming traumatizing for someone by making it their policy to avoid triggering anyone (i.e., to avoid exposure altogether). As a result, everyone tip-toes around the issues, and nobody work through the issues that brought them to the program. Yesterday, one of my clients expressed frustration with this dynamic, and i have to say I'm frustrated too.

So, what is the answer? How do we bring emotional exposure into the therapeutic window, when clients are at very different levels of emotional tolerance/arousal? I'm interested in hearing your suggestions!

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?