Psychotherapy 101: Help clients overcome experiential avoidance
It’s fun to be outspoken, controversial and counter-intuitive if you enjoy attention and value provoking discussion. However, for all the negative connotations that being “conservative” has come to attract in politics, the origin of the word “conservative” is from the latin conservare meaning “to keep, preserve, keep intact and guard”. As a psychotherapist, being conservative of the most important technical training and foundational knowledge - much of which you would have received at the beginning of your training - is a great strength and source of dependability for the people you serve. I say this as a prelude to this week’s study because the findings are not really…new. So, before your brain does what brains often do, which is “switch off” when there’s nothing surprising to attend to, I wanted to put in a plug to keep reading and spend a moment reflecting. Just because you learnt about this before doesn’t mean it’s not worth taking a moment to consider whether you have appreciated the importance of these findings by fully integrating them into your practice. Some of the most important concepts in psychotherapy are both intuitive, easy to understand and so fundamental that you learn them early, that they quickly fade into the bank of things we take for granted, leaving us preoccupied with minutiae with a low yield per unit time invested. This article is a prompt to review how central to your practice is assessing and intervening to reduce experiential avoidance – a fundamental maintenance factor of virtually every psychological disorder.
As I’m sure you all know, Experiential Avoidance is “the unwillingness to experience uncomfortable or distressing physical sensations, thoughts or emotions, with subsequent attempts to escape or avoid such experiences despite unfavourable long-term consequences” (Eustis et al., 2020, p.275). Eustis and colleagues looked at the data of clients who had been through either the Unified Protocol for Emotional Disorders or a disorder-specific CBT protocol in a larger randomised controlled trial. All clients had either social anxiety disorder, generalized anxiety disorder, obsessive compulsive disorder or panic disorder. All received 16 sessions of individual CBT, apart from those with panic disorder who received 12 (and were therefore not included in some analyses). Experiential avoidance was measured by self-report and anxiety by independent assessors using the Hamilton Anxiety Scale, at 5 points: pre-treatment, at session 4, session 8, session 12 and post-treatment (after session 16). Surprising to no one, they found that reductions in experiential avoidance preceded and were associated with reductions in anxiety.
Why did we need this study when a number of studies have already shown that CBT and not just mindfulness and acceptance-based therapies reduce experiential avoidance and that these changes are associated with improvements in anxiety symptoms? 1. This study had a larger sample than usual (179 clinical clients, 132 excluding those with panic disorder). 2. This study used the Multidimensional Experiential Avoidance Questionnaire (MEAQ), a 62-item questionnaire with 6 factors that has better psychometric properties than the more commonly used Acceptance and Action Questionnaire (AAQ II). The AAQ-II appears to more strongly measure distress than people’s response to their distress. 3. Establishing that experiential avoidance changes occurred before changes in anxiety is new. Usually there are coincident changes in experiential avoidance and symptoms. Temporal precedence gives us more confidence that there is a causal relationship. 4. There is a slight nuance to the findings in that the MEAQ Total was not associated with subsequent anxiety. It was one specific subscale that predicted anxiety: Distress Aversion, which measures negative evaluations or attitudes toward distress. 5. Most (79%) of the reduction in Distress Aversion that occurred during therapy happened during the first 8 sessions, whereas by that stage, only 55% of the anxiety reduction that occurred in therapy had happened.
Clinical Implications
The following recommendations for addressing experiential avoidance are based on my experience of practising and receiving supervision across theoretical perspectives, observing what works in my clients and those of my supervisees, and is common to most approaches. I have at times received all kinds of other “rules” which I am not including because they either interfere with effective practice or, at least, do not contribute to it.
The client needs to be motivated to overcome experiential avoidance. The client needs to understand and agree that either experiential avoidance makes the problems they have sought treatment for worse, or interferes with them achieving an important goal, or that overcoming experiential avoidance would help solve the problem they’ve sought help for or help them achieve their goal. Obvious, right? Except that I’ve lost count of how many supervisee sessions I’ve watched where it wasn’t clear that the client knew why they were being asked to attend to an unwanted experience.
Your case formulation here is critical. You should be crystal clear about what the client thinks are their problems and goals. The client should be crystal clear and agree with how they avoid, and how that avoidance affects their problems and goals.
Examining the pros and cons of both avoidance and overcoming avoidance is the simplest structure to explore the client’s motivation to reduce experiential avoidance. Contrasting the short-term and long-term consequences is often needed.
You can’t accept an experience on a client’s behalf. No matter how hard you try. So, don’t focus on selling the rationale or trying to coerce clients into exposure tasks. Focus on eliciting change talk from the client: statements of desire, ability, reasons to and need to overcome avoidance.
Remember that attending to anxiety-provoking thoughts is more difficult than attending to neutral thoughts. Anxiety narrows attention down to threat-monitoring and escape-scanning, depleting working memory resources that are needed to adopt a detached perspective on thoughts, emotions and sensations we would encourage them to accept. Therefore:
Brainstorm a range of possible exposure tasks and allow the client to choose their first steps.
Practice experiential acceptance with neutral stimuli first if necessary, to coach good openness and attentional focus and drop coping strategies that interfere with attention to the experience or what clients might learn from practising acceptance
If you have concerns about the client’s ability to cope with exposure, first explore with them ways to effectively reduce arousal and ground any dissociative tendencies.
Don’t collude with the client’s experiential avoidance. If you have problems with your own urges to avoid unwanted experience, do some guided self-help, or consider enlisting a therapist for a while to help you not be the factor that prolongs a client’s anxiety disorder. Watch for ways you inadvertently contribute by engaging in excessive “explaining” or “unfocused rapport building” conversations. If you help your client overcome crippling anxiety, you’ll get all the rapport you want.
Monitor process as well as outcome because Eustis and colleagues’ (2020) study highlights that changes in experiential avoidance may precede improvements in anxiety. The MEAQ is somewhat cumbersome for weekly clinical use but even home-made rating scales help you track a client’s progress: e.g., “How much do believe that you need to face your fears to reach your goals for therapy? (0-100)
For the original article, go to:
https://link.springer.com/article/10.1007/s10608-019-10063-6
REFERENCES
Eustis, E.H., Cardona, N., Nauphal, M., Sauer-Zavala, S., Rosellini, A.J., Farchione, T.J., & Barlow, D.H. (2020). Experiential avoidance as a mechanism of change across cognitive-behavioral therapy in sample of participants with heterogeneous anxiety disorders. Cognitive Therapy and Research, 44: 275-286.