Thursday, November 1, 2012

Avoidance, my old friend

I recently became aware that I have been avoiding writing about avoidance.  I'd think about it occasionally.  And I had written (in my head) one rather glib start about how avoidance is a problem only because it works so well.  But then I realized I was avoiding all the feelings connected to avoidance, which is, of course, the purpose of avoidance in the first place.

One of my problems with the idea of PTSD is that the definition focuses exclusively on the emotion of fear.  But what's so special about fear?  Torn flesh and dead bodies produce disgust. (That's why we vomit.)  We feel the anguish of injured, missing, dead comrades.  Murderous rage abounds.  And I can't begin to enumerate the endless daily opportunities, big and small, for shame about what we've done, or what we didn't do that we felt we should have.  Fear is just one of several intense emotions we likely experience in war; why is it the only one that leads to "trauma?"  Why is it the only one seen as damaging?  While that's an important question I'll take up later, fear is uniquely important to avoidance because of it's relationship to any and all aversive human experiences.

We are "designed" to seek out those stimuli/situations/events we experience as pleasant or pleasurable and avoid those that we experience as aversive.  It's how organisms work; how they can be programed by evolution to seek and find those things necessary to survive and reproduce and avoid those that put that at risk.  Fear is the experienced affect that guides us avoid the aversive.  If we've come to learn a particular situation results in an aversive outcome (being shamed, for example) we will fear similar situations. These simple, obvious truths immediately reveals the complications of avoidance.

It is "natural" to avoid anything we find unpleasant.  So if you were attacked on one or more bridges where you suffered painful losses, it makes sense to drive miles out of your way to avoid going over a bridge in your hometown.  Seeing a bridge stirs the memories, and all the associated feelings, of what happened.  Even thinking about driving over it does.  Going out of your way to avoid it, while still somewhat anxiety provoking, is a lot better than what you know will happen if you try to drive over it.  Avoidance works.  Sitting with your back to the wall at a restaurant works (it lets you scan for danger).  So does avoiding crowds and, if you can't, carrying a weapon (e.g, a knife).

Avoidant responses to threatening situations protectect from vulnerability to harm.  But veterans also protect from vulnerability to loss/distress by avoiding family members, loved ones, or any real intimacy.  Avoiding shame is more challenging but veterans do so by avoiding situatiations in which their fears could be revealled (crowds, possibilities of loud noises [e.g., fireworks], being responsible for others).  They also avoid situations likely to stir their rage such as driving, working for demanding bosses, interpersonal conflict.

So you can see why a cabin in the wilderness provides the perfect solution.  No people to care about and thereby risk the anguish of another loss.  No people to threaten you.  No people to see and shame you for hitting the dirt when a car backfires.  No people to to see being turned into wet hamburger.  No wonder so many veterans express a longing for such a solution.

However, as always, our problems are the products of our solutions.  Avoidance is adaptive because it works.  But just because it works so well, it's likely to be retained even when no longer necessary.  Avoidance is self-reinforcing and hence, like drugs, addictive.  And, just like drugs, the price of the payoff ever increases.  As avoidance successfully lessens the fear of dreaded situations, more and more of life may get "roped into" an avoidant lifestyle

We know how to treat avoidance.  A combination of psycho-neuro education, some form of systematic desensitization or exposure therapy, and maybe some medications, all provided, of course, in the context of a theraputic relationship with a respectful, engaged, skillful therapist.  But that's not to say it's easy.  We avoid at the feeling level as well as the behavioral.  Even if the veteran has left the cabin in the woods the wall around his/her heart may long endure.  Dismantling the wall is no small task, especially with life all too often providing incentives to rebuild it.  What man hath put together even god (love) may labor to put asunder.  But let us try.

Roy Clymer

For the background and context for these remarks, please read my article on PTSD published in the Psychotherapy Networker which can be found here or see a copy of it found on this blog titled "The Puzzle of PTSD."

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