Using Acceptance and Commitment Therapy (ACT) in the Treatment of Trauma
At the heart of the Acceptance and Commitment Therapy (ACT) model there is one concept that is found to be a common thread among many, if not most, mental health issues: experiential avoidance. There is a growing base of evidence that experiential avoidance is a factor in the development and maintenance of anxiety, depression, and substance abuse disorders, all of which have a high degree of comorbidity with trauma-based disorders. As regarding the trauma implicated in Post Traumatic Stress Disorder (PTSD) specifically, the DSM-V posits an entire symptom cluster (one of three) of PTSD as revolving around experiential avoidance.
Understanding what experiential avoidance is will help us to begin to see it clearly in our trauma clients. This increased awareness will provide us the opportunity to help them create a more flexible relationship with these avoidance strategies. The importance of creating more flexible relationships with avoidance strategies cannot be overstated, as from the ACT perspective the hallmark of psychological health is psychological flexibility. The more flexible we can be with our internal experience in general (thoughts, feelings, emotions, memories, etc.), the more psychological well-being we will experience. Simply stated, experiential avoidance is the unwillingness to experience one’s thoughts, feelings, or emotions. It’s the process whereby individuals attempt to change the frequency, duration, and intensity of private experiences in an effort to make them disappear or at least lessen their impact. While these attempts may work in the short term (e.g., getting high to escape intrusive thoughts of interpersonal violence), they aren’t very “workable” as long-term solutions to relating to these painful internal experiences.
Experiential avoidance is something that we all engage in to one extent or another depending on many variables, and many of our avoidance strategies fall within the realm of being quite innocuous. It’s completely natural to want to avoid things that are unpleasant or aversive. The trauma survivor will naturally want to avoid flashbacks and intrusive thoughts related to their trauma. However, the human experience has at its core things like pain, loss, anxiety, etc., with the trauma survivor having more of these difficult experiences than most. Regardless of the depth or the scope of these experiences, we can’t really avoid them to any lasting extent. If we care at all about anything, we will experience these things to some degree. From the ACT perceptive though, the struggle that we engage in to avoid these difficult internal experiences can become part of the problem. This is for two reasons. First, for example, an attempt to avoid a certain memory related to trauma, let’s say, puts us in contact with that which we are trying to avoid—the trauma memory. That is, you have to remember that which you are trying to forget in order to try to forget it! So it’s never really forgotten. In fact, the memory is made more salient. The second reason avoidance is not a workable long-term strategy is that avoidance behaviors are often antithetical to our long-term values. For example, I had a client who valued connection to peers but his avoidance of social situations due to anxiety (related to trauma from his mother’s death) served to assuage his anxiety in the short-term but left him fundamentally disconnected and alienated in the long-term. In short, avoidance strategies have the paradoxical effect of increasing long-term suffering.
Early on in treatment, it’s important to introduce to clients the idea that there may be another option to avoidance; that is, if we can focus on something other than trying to control or avoid our difficult internal experiences, we might find that we have more energy to be able to pursue those things that are important to us--energy that up to that point had been exerted in trying to avoid internal experiences. Many of our clients have an “if only” relationship with their difficult internal experiences. Their internal dialogue may go something like this: “If only I could get rid of my anxiety (insert any mental health issue here), then I could move on with my life.” As ACT practitioners, we don’t spend much time on symptom reduction. Instead, we help our clients get in touch with their values and take committed action in service of them. This can be tough for a trauma survivor to come terms with. I’ll often hear something to the effect of, “What? You’re not going to help me make my painful memories go away?” I’ll speak to clients who have experienced trauma about a very simplified conceptualization of trauma: “Trauma has a way of creating a mess in our lives, often a very big mess. Where there was once some order in our world, now there is disorder. The world is largely disorderly. It’s messy. The question for you is, ‘Can you live a powerful life in a messy world?’” One of my treatment goals with trauma clients is to help them create a more flexible relationship with their trauma experience so that they can move more freely in the world.
Living powerful lives for trauma survivors means helping them “defuse” from a conception of themselves (i.e., identity) that collapses their psychological and behavioral flexibility. Trauma survivors often identify themselves in ways that narrowly define who they are and, subsequently, how they can act in the world. In ACT vernacular, clients become “fused” with a conceptualized self that limits their behavioral repertoire in the face of difficult internal stimuli (i.e., thoughts, feelings, memories, urges). What this looks like on a day-to-day level with our clients is that they engage in unhealthy avoidance strategies—drugs, social isolation, sleep, etc. The list goes on ad infinitum. It’s important to remember that any behavior can be an avoidance behavior. The problem comes when the behavior becomes pervasive and begins to limit healthy options.
As ACT relies heavily on direct experience as the fulcrum for change, the clinician will employ a myriad of experiential exercises throughout treatment. One that I have found of great value to illustrate how avoidance behaviors can so thoroughly consume our energy (and, hence, our lives), is one in which a client will identify a difficult internal experience that is pervasive and persistent for them—anxiety, shame, guilt, etc. I will ask them to write it on a 3x5 card, and I begin by holding the card in front of them, with the issue written on the card facing them so they can see it. As I slowly move it closer to their face, I ask them what is happening to their experience of the world as their “issue” closes in on them (i.e., they are in the process of becoming “fused” with this difficult internal experience). As the issue is right in front of their faces, they recognize that their identified issue has limited their perspectives of the world. They will say things like, “All I can see is my anxiety.” At this point, I will ask them to take their hand and begin to gently push back against the card. Here, I will ask how available they would be to doing something they valued, taking action in the world. In the wilderness context I would ask them if they could make a bow-drill fire or write a letter to a loved one. The answer, of course, is “No, I can’t do anything really, because I’m pushing back against my anxiety (for example) right now.” This is exactly the experience that I’m trying to foster with this exercise. I would point out that this is what is happening when they push back against, or try to avoid, these tough internal experiences through drugs, isolation, sleep, etc. The harder they push against their issue, the less energy they have to engage the world. With some clients I might push hard enough so they have to stand up out of the therapy chair and have to brace themselves to avoid having their issue be in contact with them. They’re experiencing just how limited and powerless they are to engage in the world. I end this exercise by putting the card (i.e., the issue) in the client’s shirt pocket and pointing out that the issue is still with them. We haven’t made it go away. It’s still with them and more than likely always will be to some extent. In spite of their issue still being with them, now that they are not trying to avoid it, they have much more energy and ability to take value-driven action in the world. In the wilderness context, they can now bust a bow-drill fire, they can write an important letter, or have a meaningful conversation with a peer. We’ve created a much more flexible relationship with this difficult internal experience as we’ve illustrated the great cost avoidance strategies have in their lives and how “unworkable” these strategies are if they are to be able to take value-driven action in the world.
This is one of many exercises that can be used to help a trauma client experience the great cost of experiential avoidance. Play around with this one and others, remembering that the goal is to help our clients increase their psychological flexibility in relation to their experience of trauma. It’s not the content of the trauma experience (thoughts, memories, etc.) that is important. We’re not going to change the content of these experiences. We exist in a historical continuum and efforts to make thoughts, feelings, and memories go away don’t work very well (as talked about above). More important than the actual content of these tough internal experiences is our relationship to them. The more a trauma client can see them for what they are (e.g., “a thought is just a thought and can’t harm you in and of itself”), the less control they will have, and the more room they will find they have in their lives for experiences that are healthy, valuable and life-promoting.