Experiential avoidance vs. acceptance
Much of applied clinical psychology is designed to help people reduce problems with depression and anxiety. Depression and anxiety involve negative feelings (affective states), thoughts (cognitive components), and somatic components. Because adaptive thoughts can be volitionally invoked, this has often been the point of intervention–many psychological interventions have been developed that help people change their thinking. Unhappy people are taught to think in more positive terms (cognitive restructuring). Psychological interventions have also been developed that encourage people to engage in behaviors that may reduce uncomfortable physiological arousal experienced as a part of anxiety. For example, people with anxiety are often instructed to enter and stay in (rather than avoid and escape) situations associated with anxiety for them, with the goal of allowing the anxiety to diminish. Cognitive restructuring and practiced physical relaxation techniques, such as deep breathing and progressive muscle relaxation, typically accompany these “exposure” efforts.
Even with research-tested approaches, difficulties can arise for a variety of reasons. The issue of client motivation has been a particular concern, and led to approaches such as motivational interviewing (helping clients resolve ambivalence and set goals[1]) and similar approaches (e.g., “paradoxical agenda setting” or “paradoxical inquiry”[2]), as well as harm reduction strategies (e.g., intersperse water and food with alcohol intake) that do not assume adherence to an ideal regimen. Additionally, special interventions have been developed for clients with very severe emotional symptomatology[3].
When treatment approaches do work, it may be due to factors unrelated to the theoretically effective components. Interesting findings have emerged in several treatment areas that suggest that benefits of treatment apparently may be tied in large part to the ability of the treatment to enhance the clients’ perceived control over problems, even when this does not involve actual control. For example, the use of biofeedback to reduce headache was shown to be effective even when false feedback was used. More broadly, so-called “placebo” effects are widely recognized, which enhance adaptive beliefs and in turn yield a variety of downstream benefits.
Closely tied to perceived control is the concept of acceptance. In stress management approaches, for example, problem-focused coping is augmented by emotion-focused coping. Whereas problem-focused coping involves attempted control over external stressors, emotion-focused coping enhances the ability to cope with negative affect. And although emotion-focused coping (emotional regulation) can involve increasing control over one’s emotions, it can also involve acceptance of undesirable situations and negative internal states. For example, some of the research on panic disorder that suggests that the difference between people with panic disorder and people without panic disorder is that although both groups experience unexpected and uncomfortable physiological arousal from time to time, the people with panic disorder become worried about it, and start taking steps to try to prevent another “panic attack”[4]. People with panic report difficulty accepting being upset, and a tendency to avoid unpleasant emotional experiences.
Acceptance of negative internal states has become an important tenet in newer cognitive-behavioral approaches[5],[6] such as Acceptance and Commitment Therapy and “mindfulness,” sometimes collectively called the “Third Wave of Behavior Therapy.” These approaches are considered more compatible with the acceptance aspects of 12-step programs and spiritual approaches than are traditional behavior therapies[7]. Acceptance is a key part of 12-step self-help groups (i.e., “to accept the things I cannot change,” in the Serenity Prayer). Wisdom traditions such as Buddhism advocate acceptance in order to cultivate a peaceful state of being. Some protestant Christian groups have traditionally encouraged members to accept current difficulties with an eye toward the hereafter. Acceptance of negative affective states is typically a more adaptive approach than many alternatives, such as addictive behaviors or self-harm, and more effective than other methods of emotional regulation, such as thought suppression.
However, some meta-analyses have found that although therapies using acceptance are better than placebo or waiting list control groups, they are not better than established therapies at treating depression and anxiety[5]. This is not an unusual finding in psychotherapy research (the so-called dodo bird effect, attributed to nonspecific factors). However, in this case it may reflect that measures of acceptance have not been appropriately specific[8]. The most important (negative) factor may be unwillingness to experience negative internal states[9]. This is a fascinating area of study, with lots of promise, and lots of exciting findings already. The experiential avoidance-experiential acceptance continuum is proving to be a very valuable dimension in psychotherapy research.
[1] Arkowitz, H., Westra, H. A., Miller, W. R., & Rollnick, S. (Eds) (2007). Motivational interviewing in the treatment of psychological problems. New York: Guilford.
[2] Burns, D. D., & Auerbach, A. H. (1992). Does homework compliance enhance recovery from depression? Psychiatric Annals, 22, 464-469.
[3] Linehan, M. M., & Dexter-Mazza, E. T. (2008). Dialectical behavior therapy for borderline personality disorder. In D. H. Barlow (ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed.; pp. 365-420). New York: Guilford.
[4] Tull, M. T., Rodman, S. A., & Roemer, L. (2008). An examination of the fear of bodily sensations and body hypervigilance as predictors of emotion regulation difficulties among individuals with a recent history of uncued panic attacks. Journal of Anxiety Disorders, 22, 750-760.
[5] Powers, M. B., Zum Vörde Sive Vörding, M. B., Emmelkamp, P. M. G. Acceptance and commitment therapy: A meta-analytic review. Psychotherapy and Psychosomatics, 78, 73-80.
[6] Sauer, S., & Baer, R. A. (2010). Mindfulness and decentering as mechanisms of change in mindfulness- and acceptance-based interventions. In R. A. Baer (ed.), Assessing mindfulness and acceptance processes in clients: Illuminating the theory and practice of change (pp. 25-50). Oakland, CA: Context Press/New Harbinger Publications.
[7] Wilson, K. G., Hayes, S. C. & Byrd, M. R. (2000). Exploring compatibilities between acceptance and commitment therapy and 12-step treatment for substance abuse. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 18(4). Retrieved from http://www.springerlink.com/content/q8l117087428434k/
individual differences in handling negative feelings
Someone recently asked me if I thought there were individual differences in how people handle negative affect, or if some people have simply been lucky enough to have experienced fewer negative events. I think it is clear that there are individual differences. Emotional regulation difficulties have been found related to a wide range of psychopathology. It is true that people who have trouble handling negative affect also report more past negative events, but there is evidence that recall is influenced by mood. Additionally, these folks describe events as traumatic that are objectively less so than events experienced by others who cope well. Stress happens when perceived threats exceed perceived resources, as Susan Folkman and Arnold Lazarus noted, and much of the individual differences in handling stress reflect differences in perceived behavioral control.
Although I view individual differences as being more important than past experiences, overall, when it comes to handling negative affect, early negative events may well set the stage for pessimism and depression over the long run. Neuro-anatomy is affected by sustained high levels of stress (e.g., increased sensitivity of limbic neurons and the norephinephrine system as suggested by Goddard’s work). If early stressors were psychologically unmanageable, an inability to handle future stressors may develop. Thus, people who have had substantial negative events in the past become biologically and cognitively different from those who have not. Thus there are individual differences in the ability to tolerate negative affect that correspond to personal history.
James Pennebaker and Susan Lutgendorf’s separate work on journal writing indicates that the key to therapeutic effects in writing about upsetting events is focusing on meaning. That fact bridges the gap between erroneous “boiler-pressure” psychodynamic models and the observed benefits of processing events in psychotherapy: It is not catharsis per se that is helpful; it is coming to understand the events in one’s life in a different way. As in forgiveness work, and cognitive therapy in general, it involves rewriting the narratives of our lives. We have been damaged by our past, and we must reinvent that past to begin to heal.
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