ACT for Trauma: PTSD and Beyond

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Last Updated Dec 8, 2022|

ACT for Trauma: Experiential Avoidance and PTSD

By Sonja V. Batten, Ph.D.

This presentation is an excerpt from the online course “ACT for Trauma: PTSD and Beyond”.

Highlights

  • Experiential avoidance is a process, key to the development and maintenance of PTSD and other posttraumatic problems.
  • Fusion with problematic thoughts about self and others can lead to rigid behaviors.
  • Avoidance and fusion can lead the individual to engage in behaviors not consistent with their values.

 

Transcript

Now, I’d like to go into a little more detail about the ACT conceptualization of posttraumatic problems in living.

First, I want to talk about experiential avoidance which is a core concept in ACT. First, I’ll give the technical definition and then I’ll break it down into some more bite-sized pieces. Experiential avoidance has been defined as a process by which individuals engage in strategies designed to alter the frequency or experience of private events such as thoughts, feelings, memories, or bodily sensations…

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

…and the resulting model holds that avoidance is key in the development and maintenance of a variety of psychological disorders. We all have thoughts, feelings, memories, bodily sensations, urges to act that at some point we evaluate as negative. We don’t want to have them and we take some sort of action—either an internal action or an external action—to make them go away or to reduce them in some way.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

And the idea in this model is that if avoidance is your primary way of responding to those private events, those thoughts, feelings, memories that you evaluate as negative, that over time that will lead to problems in living. So, even though those processes may be reinforced in the short term because they reduce immediate distress right away, we believe that using avoidance over and over is likely to cause increased symptoms and behavioral problems over time.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

So, if experiential avoidance is so pervasive and so problematic, then does that mean that all avoidance is bad. The ACT approach is all about flexibility. It’s all about looking for adaptive patterns of behavior. So, it would be a real overstatement to say that all forms of avoidance are bad or they’re going to lead to psychopathology. So, for example, the obvious example that I like to use is that if you really don’t like going to the dentist and you have your headphones and you listen to music while you’re at the dentist or you distract yourself with positive imagery while the dentist is drilling on your tooth, that sort of avoidance is not going to cause somebody to develop a psychological health problem.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

The trouble with experiential avoidance is when it’s the most frequent way that a person chooses to deal with difficult experiences or it’s the most characteristic way that they respond to private events, like thoughts or feelings or memories or when the person just doesn’t have other more adaptive coping skills to rely on during times of stress or distress. So again, we want people to have a variety of responses in their repertoire. And if avoidance is really all they have, then that’s what we think is going to be a problem.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

So, I’d like to talk a little bit about the evidence for an avoidance-based conceptualization of PTSD. As I mentioned before, active efforts to avoid are part of the diagnostic criteria for PTSD. And some people argue that numbing is the most distinguishing symptom cluster for PTSD. And that’s hypothesized to serve as an emotional control or escape function when a person can’t effortfully avoid trauma triggers.

References

Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in the treatment of posttraumatic stress disorder. Behavior Modification, 29(1), 95–129.

We also know from the thought and emotion suppression literature that the more you try not to think about something or try not to feel a certain way that you may be able to suppress it in the short term, but over time, it’s likely to rebound to probably a higher level than it was in the beginning.

References

Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in the treatment of posttraumatic stress disorder. Behavior Modification, 29(1), 95–129.

We also think that that cycle between avoidance, suppression, and then rebound may provide an explanation for the relationship between the avoidance and reexperiencing symptom clusters in PTSD.

References

Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in the treatment of posttraumatic stress disorder. Behavior Modification, 29(1), 95–129.

We also know from the coping styles literature that avoidant coping styles are associated with more symptoms in trauma survivors. We can think about dissociative behavior as avoidance. And there are several studies demonstrating that there’s a mediational role of avoidance between the experience of being exposed to a trauma and longer-term symptomatology.

References

Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in the treatment of posttraumatic stress disorder. Behavior Modification, 29(1), 95–129.

Another part of the case conceptualization from an ACT model with trauma is what we call excessive fusion with cognitive content. And we’ll call that cognitive fusion. We’ll talk about it in a few different ways.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

But ACT is really based on a comprehensive theory of human language and cognition, which we wouldn’t go into too much detail about, but that theoretical model is called relational frame theory, or RFT. And RFT suggests that one of the ways in which humans are different from any other animal is that we have the ability to arbitrarily relate things and events to each other and in combination and to change the way we perceive the characteristics of specific events and experiences just by relating them verbally to others. So, words take on the properties of the things to which they refer.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

Like if I’m thinking of the word hammer or I have the image of a hammer in my mind, that can help me to solve a problem if I need to tap something back into place. Even when there’s not a hammer immediately present in my environment, just being able to call up the image of a hammer can help me think, “Oh, this is how I’m going to manage this thing that needs to be fixed in my room.” But it also means, for example, that when a rape survivor has thoughts about her trauma experience, it can bring up in the present all of the thoughts and feelings and memories associated with the original experience—even if it was many years ago.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

This process is what we call fusion, where verbal processes come to influence behavior in an excessive way that becomes problematic.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

And it can lead people to behave in ways that are guided by inflexible cognitive and verbal networks rather than by the direct consequences that you would encounter in the environment. So, for example, the rape survivor who’s fused with the thought, “I can’t trust anyone.”

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

We would encourage her to instead of simply paying attention to that thought, “I can’t trust anyone,” that can be 1 source of information. But at the same time, we would work with her to actually test out, in her environment, a number of different interpersonal connections and behaviors to see what happens, rather than having her choices guided by just that rule suggesting that people can’t be trusted.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

So, ACT treatment places emphasis on helping individuals not be governed rigidly by the thoughts and rules in their head like the thought, “I can’t stand this feeling anymore.” So, instead of having your life be dependent on that thought, “I can’t stand this feeling anymore,” but instead working to find ways to interact more effectively with the directly experienced world rather than the one that’s verbally constructed in one’s mind.

References

Batten, S. V. (2011). Essentials of acceptance and commitment therapy. SAGE Publications Ltd.

And then the third area that we look at in the ACT conceptualization is life behaviors that are not consistent with the individual’s values. So, when individuals have been dealing with the aftereffects of trauma for a long time, they may find that they’ve been living their life more about getting away from the things that are painful and they want to avoid instead of having a life that’s moving them toward the things that they value. So, oftentimes what happens is their lives become smaller and smaller, more constricted, as more things have to be avoided in order to escape from those trauma triggers.

References

Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in the treatment of posttraumatic stress disorder. Behavior Modification, 29(1), 95–129.

And the avoidant strategies themselves can create their own difficulties. Like if somebody is drinking to be able to go to sleep or overworking so they don’t have to think about other things in their life or engaging in self-injury, not only do those avoidance strategies make the person’s life smaller and smaller, but they can have their own negative effects.

References

Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in the treatment of posttraumatic stress disorder. Behavior Modification, 29(1), 95–129.

So, some key points. Experiential avoidance is a process that is believed to be key to the development and maintenance of PTSD and other posttraumatic problems in living in the ACT model. And the way that trauma survivors may come to have their behavior guided by fusion with problematic thoughts about themselves and others in the world can lead to rigid behaviors that aren’t functional for the individual. Avoidance and fusion can both lead a trauma survivor to engage in behaviors that are not consistent with the individual’s values.

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