From Avoidance to Action: Promoting Willingness in ACT for PTSD


Professor in the Department of Psychology at the University of Toledo

Key Points

  1. The paradoxical consequences of avoidance behavior show that, while providing short-term relief, it ultimately intensifies emotional distress and aggravates symptoms.
  2. The metaphor of a tug-of-war with unwanted internal experiences illustrates the futility of emotional avoidance and the value of focusing energy on effective living.
  3. Emotions serve as valuable communication channels between the environment and the brain, and recognizing this can help in managing emotional intensity and developing self-efficacy.

Mark needed to recognize the counterproductive effects of his avoidance behavior, especially how it exacerbated his symptoms and generalized his fear response to various stimuli. Dr. Tull enabled his understanding of these paradoxical consequences early in treatment, alongside psychoeducation on PTSD, while working to avoid any increase in Mark’s feelings of shame. The therapist drew an analogy to natural human responses – such as pulling away from a hot stove – to highlight the universality of the instinct to avoid pain, including emotional pain, thereby normalizing and validating Mark’s reactions.

Paradoxical Consequences

However, a paradox arose when avoidance strategies that gave Mark short-term relief ultimately intensified his distress and aggravated his PTSD symptoms. His emotional reactions became increasingly frequent and severe. His confidence in his ability to handle his emotions dwindled, leading to a low tolerance for any level of anxiety or guilt.

This emotional avoidance not only increased Mark’s distress but also negatively impacted his personal relationships, his confidence in his ability to return to work, and his sleep patterns. These effects demonstrate the high long-term cost of momentary relief brought about by avoidance.

Use of Metaphors

Dr. Tull used metaphors during treatment to convey such paradoxical consequences more effectively. One such metaphor involved a tug-of-war with a monstrous embodiment of Mark’s unwanted internal experiences. Despite his efforts to win the battle by pulling the ‘monster’ into a chasm, it always pulled back harder, representing the futility of trying to avoid internal experiences.

The solution Dr. Tull proposed was not about winning the impossible battle, but recognizing the futility of the struggle and ‘dropping the rope’. Though this approach means acknowledging the presence of emotional pain, it frees up time and effort to focus on meaningful and more effective living.

Willingness vs Unwillingness

As part of the process, Dr. Tull encouraged Mark to monitor instances when he chose unwillingness over willingness, and to evaluate the resulting costs. The concept of willingness and unwillingness was presented as behavior; one can feel very unwilling but still choose to act willingly.

The goal was to help Mark recognize the detrimental outcomes of being unwilling and the benefits associated with willingness. This process formed a critical part of his journey toward understanding and managing his emotions.

Addressing Negative Emotions

Working on Mark’s negative beliefs about emotions was another central aspect of therapy. Dr. Tull described emotions as a communication channel between the environment and the brain, providing valuable information about how to react in different situations.

When these emotions are suppressed or viewed as harmful, the body tends to intensify the emotional response to ensure the message gets through. However, if one is willing to examine these emotions, they usually dissipate after the message is received, reducing their intensity.

Control of Behavior

Even in the face of intense emotions or unpleasant thoughts, Dr. Tull reassured Mark of his control over his behavior. While he could not control his thoughts or emotions, he could control his actions. The focus was on guiding him to manage his emotional distress and other internal experiences effectively. As Mark learned to act contrary to intense emotions and urges to avoid, his self-efficacy increased.

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From Avoidance to Action: Promoting Willingness in ACT for PTSD

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