A strong principle for the practice of CBT is the facing of our fears. There is good reason for this, and avoidances can certainly cause us more trouble in the long run, but is there a place for avoidance too?
I recently went to an Acceptance and Commitment Therapy Workshop (ACT) as part of the ACT annual conference in London. I like the flexibility of the ACT approach, a large aspect of which is that we are encouraged to do the right thing in keeping with our personal values, regardless of the feelings this may evoke. This is something I have found personally helpful with being assertive. In my teens and early twenties I used to find it highly anxiety provoking to speak my mind in a way which was true to myself, partly due to lack of confidence but also because I did not really know my own mind. However, over time and with a little help I became aware of my values and what is important to me and started to express myself in an authentic way. This was not easy, I can tell you, but I did it because I truly believed it was the right thing to do.
Examples of this can be found in CBT for problems such as agoraphobia. Many people begin to confront their fears of being out because they know it will be better for their children if they are able to bring them to school and pick them up, for example. This would involve the heroic act of risking having a panic attack, or having a panic attack and remaining in the situation – no small deal. Or if you want to travel the world but have a needle phobia to may decide that your desire to see the world is strong enough to face the anxiety of having an injection for your vaccinations.
So there are many times when it is helpful to us or those around us when we face our fears. Going back to the ACT workshop – the trainer there was adamant that all avoidance of emotions, however that is achieved, is a bad thing, and that all avoidances must be faced. In fact Mindfulness is usually considered to be an important aspect of ACT, but this trainer considered that Mindfulness is a way of avoiding emotion. I would strongly disagree with this but that’s for another blog. But is she right? I thought it was a bit harsh. Must we always face our difficult feelings or can we live well without doing this?
One of the great things about working as a freelance therapist is being able to help people make changes at their own pace. Take the example of someone with Obsessive Compulsive Disorder (OCD) who has intrusive thoughts that they will harm someone unless they do every activity with the number 3 in their head. This person has no intention to hurt anyone, by the way, they are just unlucky enough to have these intrusive thoughts which cause anxiety, and although they don’t really believe the thoughts, they daren’t take the risk of not keeping the number 3 in their head just in case. Can you imagine how complicated this person’s life can become? And can you imagine how scared you would be if you thought your freedom and someone else’s safety rested on being able to hold the number 3 in your head every time you did an activity. And this problem doesn’t lend itself well to logic either, so this person must understand that their thought is as obsession which is part of OCD, and their way of keeping everyone safe with the number 3 is a compulsion. If we understand this then the next bit is what? Yes, that’s right! The next bit is to face the fearful feelings, the anxiety. So now we are going to encourage our friend to do an activity regardless of whether the number 3 is present or not, and face the anxiety which will emerge. I won’t go into more detail here, but this person will be experiencing a huge amount of anxiety which will be present for a good while as well, but they must stick to their intention not to get rid of this feeling with a compulsion. Now in order to reduce the impact of OCD as much as possible this person must increase the facing of fears over several months, regardless of the levels of anxiety they will experience. Sometimes this goes relatively easily, but not so for everyone. Being anxious a lot of the time is really tiring, so we must have some understanding of this. Maybe this person has done enough for time being and just needs to stay at this level until they feel a bit calmer at this level. The work they have done will already have helped them to function must better and that will bring benefits and relief. So maybe now we can allow our friend to continue with some of their avoidances, having faced some of them too. Sure, they are still managing their anxiety with compulsions, effectively avoiding them, but they have decided that for them this is enough, at least for the time being. Now they have a choice that they did not have before – they know they are capable of facing their fears but are choosing not to do so at the present time, and my job as a therapist is to agree that there is avoidance which could leave them vulnerable to relapse, but at the same time respect the huge undertaking that has already taken place and the wish to continue with avoidances. Often this person will come back in a few months and continue, or they may come back at any point in the future. The choice element is crucial.
We all avoid some things that we find anxiety provoking, and if nothing causes a person anxiety then lucky them. Many people get by with varying levels of a social anxiety; people avoid places where something difficult or traumatic happened; people avoid thinking about certain things; I will not go on a fairground ride; people drink alcohol to avoid. The list is long and we would do well to give ourselves a break, I think. We are programmed to avoid anxiety, but because we humans are scared of things which we think about as well as actual danger, this can become problematic if we let it get out of control when it is our only coping strategy.