The antidote to avoidance is acceptance
If it’s alright with y’all, I’m going to take some time to talk about some clinical stuff I’ve been excited about recently. This is geeky psych stuff, so if you’re here for the TTRPG discussion, feel free to skip over this.
The longer I’m a psychotherapist, the more I realize that my primary interest is, broadly speaking, anxiety. That’s not to say that I have no interest in depression, or emotion regulation, or attachment, or whatever else, but I’ve come to see how important the psychological processes that underlie anxiety disorders are to psychological suffering, and that some of these same processes contribute to that other stuff. One thing that we see, for instance, is that in spending a lot of time and energy trying to avoid the feeling of anxiety, people start avoiding other feelings as well, and not just painful ones. In the extreme, this presents as alexithymia, a persistent difficulty identifying, describing, and even experiencing emotion. Now, alexithymia isn’t actually an inability to feel emotions, but rather lacking the skillset and vocabulary to recognize and describe them. This deficit is most likely caused by a sort of turning away from emotions, even positive ones, in an attempt to avoid psychological pain.
The role of avoidance is central in anxiety disorders. From phobias to PTSD to obsessive compulsive disorder and generalized anxiety, it is avoidance that drives the suffering. The attempt to rid yourself of anxiety is what, ultimately, makes your anxiety worse.
As described in the video, the self-reinforcing nature of anxiety makes a lot of sense: of course we want to avoid painful feelings, and of course we want to do the things that relieves those feelings. The problem is that avoidance doesn’t address the source of our anxiety, so while we do “get rid of” the anxiety in the short-term, we actually increase it in the long-term. And for whatever reason, our minds are much better at recognizing that short-term relief than the long-term suffering.
The primary treatment for anxiety disorders of all types is called exposure. I’m a big fan of exposure when it’s done correctly and in a compassionate manner. It is worth mentioning that there are very harmful, widely discredited “therapies” that are based on or may have similarities to exposure therapy, and even “gold standard” exposure therapies can be harmful if not done thoughtfully. At the same time, novel treatments that are presented as an alternative to exposure probably work because of exposure. All of this, in my opinion, is evidence that we must be very intentional in how we approach treatment, focusing on known psychological processes that mediate change, delivered in a format tailored to the individual rather than as part of a technological “package” that is designed to be “one size fits all.”
So why does exposure work?
There are three models that explain this. The first, “traditional” model is what’s known as emotional processing and focuses on habituation: the reduction of anxiety when repetitively exposed to a feared stimuli, leading to the eventual extinction of anxiety. The second is the inhibitory learning model, which uses ideas from learning theory to focus on learning to tolerate anxiety in the short-term to reduce it in the long-term. Rather than extinguishing the anxiety, the goal is to inhibit it by building better, stronger learning. Finally, the newest model is the psychological flexibility model, which is most similar to inhibitory learning, but there’s no focus on the eventual reduction of symptoms, but rather the acceptance of anxiety so that a person is less impacted by it. The ultimate goal of this model would be to continue to live your life according to your values without the anxiety getting in the way.
The emotional processing model has been the dominant model for a long time, despite the fact that the underlying processes of habituation and extinction are not well supported. Particularly, many people experience habituation of anxiety during and between therapy sessions but do not improve, or later relapse. This doesn’t disprove habituation per se, but it does suggest that it is more complicated than the traditional behavioral model. The other aspect that research shows is that anxiety isn’t actually extinguished in the traditional sense: you can’t “unlearn” a fear, just like you can't unlearn, say, your childhood phone number. The inhibitory learning model, then, involves teaching new information (safety) that is stronger than the original information (fear). When facing a feared stimulus, there is a “retrieval competition,” and the newer, stronger information “wins out” (or inhibits) the previous learning. This would help explain lack of improvement or relapse in the traditional model.
The psychological flexibility model is highly compatible with the process of change proposed by the inhibitory learning model, but makes a very important change. Building “tolerance” of anxiety isn’t done in hopes of one day being rid of anxiety; rather, this model suggests that trying to “get rid of” anxiety is futile. Anxiety will always come back. Instead, our goal is to develop acceptance of anxiety in order to live a meaningful life. In this view, it’s not the anxiety itself that’s the problem; it’s how we respond to it. It’s that experiential avoidance, when reinforced, leads to a narrow behavioral repertoire: life gets smaller and the walls close in the more we focus on ridding ourselves of difficult internal stuff—thoughts, feelings, bodily sensations. Just like how avoiding anxiety might lead to avoiding all feelings, even “positive” ones, we start to avoid the things that bring meaning to our lives. The things that are most important to us are precious, and thus we become more and more afraid of doing something that could hurt them, to the point where we are no longer engaging with them at all, and we start to lose our vitality. And again, on a certain level this all makes sense, but we end up turning real and unavoidable pain into a sort of synthesized, unnecessary pain: psychological suffering.
Think of it this way. You live in a room, and over time, a pipe that runs above the room develops a leak. Knowing that calling a plumber takes time and effort that you’d rather not have to deal with, you grab some duct tape and wrap up the pipe where the water was leaking from. And this works! Well, for a while. Eventually a new leak springs, and so out comes the duct tape again and you wrap up the pipe there. And again, you manage to get rid of the problem for a little while. But then it happens again, and again, and again. And before you know it, you’re living in a room full of duct tape. There’s no room to move, let alone do those things that really matter to you. Hell, you can barely breathe in here, there’s so much fuckin’ duct tape.
This isn’t to make you feel foolish for using the duct tape in the first place. This is something we all do. But at a certain point, we need to face the fact that we have a leak, making room for the discomfort that comes with calling a plumber (eg it’s a pain in the ass, it’s going to be expensive, and so on). The processes of psychological flexibility are what allow us to do this: to “tolerate” the discomfort so that we can get on with our lives, to expand our behavioral repertoires so that we can make contact with what’s most important to us and regain a sense of vitality.
Do you enjoy reading pieces like this one? If so, please reply and let me know. They’re helpful for me personally, to nail down what I think and my own understanding of sometimes difficult concepts, but it’d be good to know whether others find them beneficial at all.