Therapy for Social Anxiety, Social Phobia
and similar self defeating challenges.
“To dare is to lose one’s footing momentarily.
To not dare is to lose oneself. “
Self Regulation and Behavior Change
Patrick J. Hart Psy.D.
Social Phobia and Avoidance
Social Anxiety Disorder | Are You Phobic in Seattle?
Understanding Your Phobic Defenses | A Convergence of Views | Cognitive Behavioral Therapy of Phobia & Avoidance
The below essays were adapted from various papers written as part of my academic training and coursework. The summaries of theoretical ideas found below will give you a sense of how I help people resolve psychological problems that involve avoiding those situations or people or circumstances that cause distress. The ramblings below are derived form contemporary behavioral analytic methods for treating anxiety disorders, like panic, social phobia and similar human dilemmas. Some of this is decidedly technical, yet I hope you’ll find this interesting!
If you are not willing to have it . . .
. . . You’ve got it, bad!
The Origin and Maintenance of Phobia:
Experiential Avoidance & Phobic Behavioral Immobilization
To illustrate the nature of the problem, acceptance and commitment (ACT) oriented theorists might have us imagine an individual presenting for psychotherapy with complaints that involve “disabling fear of failure,” “immobilizing feelings of uncertainty,” or an “over-powering preoccupation with poor self-esteem.” This person’s clinical narrative might be noteworthy for complaints of intolerable symptoms like excessive anxiety, crippling frustration, and debilitating fear.
Fear as a Barrier to Goal Directed Behavior:
Suppose that this individual laments these distressing private events (fear, anxiety, and self-image), construing them as legitimate barriers to the initiation of potentially effective behavioral activities. Without the willingness to engage in functional, goal-directed behavior, this individual is unlikely to realize change his or her life experience or to achieve life-enhancing goals. Experiential avoidant individuals tend to assign these internal experiences a primary and causal role in creating behavioral immobility, which results in an inability (and an unwillingness) to take constructive action, which has the effect of maintaining the client’s misery.
Phobia: Dysfunctional Maneuvers to Avoid Fear
This person would construe distressing internal events as legitimate reasons, causes, or justifications for engaging in a wide range of dysfunctional and clinically relevant defensive maneuvers to avoid fear. Such a client might engage in various theoretically predictable escape or avoidance strategies directed toward the control, modification, or elimination of unwanted private events. Such a person would respond to distressing thoughts and emotions by attempting to control, ease, or eliminate them before engaging in risks, challenges, or actions that might serve personally valued outcomes. Furthermore, imagine that this individual held the conviction that such distressing internal events must be controlled or eliminated if therapy is to prove worthwhile. Acceptance theorists would describe this person as manifesting a strong tendency toward experiential avoidance.
Pathological Avoidance of Psychological Distress:
Hayes (1994) contended that the culture at large, as well as many models of psychotherapy have “inadvertently supported a kind of mass cultural illness, in which a main goal (often the main goal) of life is to have good feelings rather than bad feelings. Many healthy things in life do not feel good” (Hayes, 1994, p. 15).
Clearly, our culture can be naively supportive of avoidant coping practices that advise untenable control strategies in futile attempts to eliminate psychological “pain” and legitimate emotional distress. The common wisdom routinely encourages efforts to suppress or eliminate absolutely natural psychological turmoil. For example, it is not unusual for a person experiencing grief, anger, or fear to be kindly advised: “think about something positive,” “just put it out of your mind,” “let’s have a drink and forget about it.” Acceptance theorists hope that we will question the merits of such seemingly useful common advice.
Try a quick thought suppression experiment: Stop thinking — about not thinking — right now!
Natural Struggles and Maladaptive Change Strategies
There are natural struggles and unavoidable tragedies or losses in everyone’s life. In acceptance theory the above kind of seemingly sensible advice and associated strategies of coping represent an untenable and psychologically (functionally) defeating change agenda. Such maladaptive change strategies are founded upon attempts toward “experiential avoidance” and struggles to control, or get rid of, negatively evaluated private events. Contemporary research has revealed that such tendencies toward control, escape, or avoidance of unwanted private experiences frequently generate harmful patterns of living that invoke the very problems for which clients come to psychotherapy (Hayes, 1994; Hayes et al., 1996. cf. Wegner, 2010).
“Simple Phobia” or Experiential Avoidance?
ACT argues that experiential avoidance has the side affect of decreasing an individual’s ability to remain present with their own emotional reactions and behavioral responses. This interferes with one’s ability to remain on task, and choose functional behavioral responses in difficult circumstances. Distress and conflict need not be the enemy that defeats functional actions, even though many life events can be unpleasant to a gut-wrenching extreme. People will ultimately find themselves facing feelings of vulnerability, fear, frustration, hurt, or anger. Virtually inescapable, the pervasiveness of human distress proves certain. Distress does not, however, have to diminish your ability to cope with the situation effectively, nor is it harmful to your mental health.
The Feel Good Agenda: Etiology of Avoidance & Phobia
Psychological conflict, distress, and emotional discomfort are not experiences that people need appreciate or feel good about. Neither can such experiences be entirely escaped, nor can they be fully avoided. The acceptance model beckons the awareness that functional behavior does not require feeling great. The position taken here is that there are too many psychologically defeating ways to take shortcuts to “good feelings,” and these are accomplished with a cost to personal adaptation and healthy living. In this view, many forms of psychopathology are, at their core, an outgrowth of these shortcuts.
An Historical Perspective:
Relevant to Avoidance and Phobia |Convergence of Views
Hayes et al. (1996) asserted “experiential avoidance has been recognized, implicitly or explicitly, among most systems of therapy” (p. 1154). Various schools of psychotherapy have addressed this phenomenon, describing it from a variety of theoretical contexts and with a wide array of terminologies. Psychotherapists have been variously trained to work with avoidance-related defenses and coping strategies whereby humans attempt to (a) repress (Freud, 1924); (b) retroflect (Perls, 1969); (c) distort (Ellis, 1962); (d) deactivate (Beck, 1979); (e) disown (Rogers, 1951, 1961); or otherwise break contact with unwanted emotional and cognitive content.
The Freudian Tradition:
The Freudian tradition appears to have recognized the pathogenic nature of avoiding distress at all costs, prescribing psychoanalysis for the lifting of repressed experience, bringing threatening or painful psychic content to conscious awareness for interpretation (Freud, 1920/1966). More recently, Millon (1981) addressed repression in more contemporary terms, “repression thwarts the individual from ‘unlearning’ disturbed feelings or learning new, potentially more constructive ways of coping with them” (p. 101).
The Gestalt Therapists:
Gestalt therapists have also acknowledged the importance of working with distress; “to heal the suffering one must experience it to the fullest” (Bisser, 1970, p. 78). Gestalt theorists have long maintained that the foundation of many psychological problems lies in a client’s reluctance to make contact with distressing emotions and threatening experiences. Gestaltists have emphasized that psychological dysfunction occurs when emotions are interrupted, deflected, or retroflected before they can enter awareness and become useful toward organizing functional action (Perls, 1969).
Staying with Strong and Uncomfortable Feelings:
Psychological Acceptance: Cognitive Defusion and Behavioral Flexibility
A major outcome of many Gestalt interventions involves the suggestion that people attend to and stay with their current feelings so that functional actions can be mobilized (Perls, 1973). A variety of in-session experiments help people discover how awareness is blocked and how experience is avoided (Polster & Polster, 1973). When contact with emotional experience is avoided, the range of behavior available for action within the environment narrows. The “I” becomes more rigid and constrained, with fewer areas of legitimate operation, as more of the self’s capacities (feelings and actions) are rendered alien and thus unusable. (Kepner, 1987, p. 21)
Gestalt Therapy – Distress and Unpleasant Feelings:
Perls (1969) believed that much of the dysfunction in present society occurs because people have become experience-phobic, avoiding their feelings, especially unpleasant ones. Rogers’ (1951) client-centered therapy emphasized openness to experience and acceptance of feelings as an important therapeutic outcome. Rogers (1961) maintained that as a result of psychotherapy the client becomes more openly aware of his own feelings and attitudes as these exist in him at an organic level. . . . He is able to take in the evidence in a new situation, as it is, rather than distorting [or avoiding] it to fit a pattern which he already holds. (p. 115)
Client Centered Therapy:
Rogers (1951) noted that functional change occurs in people by moving from being distant from their experience to identifying with or owning their experience. Experiential approaches to therapy (Greenberg & Safran, 1989; Rogers, 1951, 1961) have long held that emotions give us information about events and help us to organize experience and behave adaptively in response to various life contexts.
Awareness: Adaptation and Problem Solving
Greenberg (1994) noted that by attending to the personal significance of emotional experience we are provided feedback about our behavioral responses. Such emotional attending “enhances adaptation and problem solving” (Greenberg, p. 53). People then need to accept their primary emotional experience because it provides them with adaptive information: “Living a healthy life then depends not on self [emotional] manipulation but on acceptance of one’s experiencing” (Greenberg, p. 54).
Behavior Analysis of Phobia:
Functional Analytic Psychotherapy (FAP) represents a behavior analytic model of therapy that is in alignment with the experiential avoidance perspective (Kohlenberg & Tsai, 1991). This model strongly advocates helping clients learn “toleration of emotions evoked by aversive stimuli” (Kohlenberg & Tsai, p. 125).
Emotional Distress Tolerance
In the presence of aversive stimulation a person often comes to feel distressing emotions, and then reflexively attempts to avoid, escape, or defensively attack such experiences. FAP therapists discuss various benefits to the client of promoting emotional toleration. I believe the benefits are many, including (1) increased contact with previously missed reinforcers, (2) increased potential for productive action, and (3) decreased negative arousal. Another benefit of accepting distress is that emotional toleration increases the possibility of productive action. (Cordova & Kohlenberg, 1994, p. 27)
Dialectic Behavior Therapy
Phobic Avoidance: Distress Tolerance and Radical Acceptance:
The Dialectical Behavioral Therapy (DBT) of Linehan (1993) also taught clients “distress tolerance” and discourages the pitfalls associated with experiential avoidance. Linehan’s (1994) method encouraged “Participating, in the context of mindfulness skills, entering completely into the activities of the current moment, without separating one’s self from the ongoing events [internal or external] and interactions” (p. 79).
Skillfully Bearing Psychological Distress:
Radical Acceptance and Doing What Works:
One focus of DBT is in helping clients learn to “bear pain skillfully” and “do what works.” Linehan (1994) explained “The automatic inhibition and/or avoidance of painful emotions, situations, thoughts etc., is viewed as an important component in psychological dysfunction and the prolongation of the very pain one is seeking to avoid” (p. 79).
Rational Emotive Behavior Therapy:
Rational Emotive Therapy (RET) is a cognitive-based method that also emphasizes the importance of accepting unwanted psychological experiences (Ellis, 1962). Rather than attempting to avoid disturbing cognitions and emotions, clients are taught to radically accept such experiences. Describing what has been called “neurotic discomfort anxiety,” Ellis and Robb (1994) noted that people can make themselves anxious about feeling anxious, and that people frequently engage in irrational attempts to avoid the experience of anxiety altogether.
Rational Emotive Behavior Therapy REBT:
Turning Hassles Into Horrors: Low Frustration Tolerance
REBT highlights the characteristic tendency of humans to manifest “low frustration tolerance,” and the human capacity to “make hassles into horrors.” Ellis and Rob pointed out that many people insist that annoying emotions “absolutely must not exist, that it is awful if they do, and that they can’t stand such experiences.” When therapists use rational emotive techniques, people are shown that they can “gracefully accept” uncomfortable emotional experiences.
Graceful Acceptance of Distress:
Ellis and Robb (1994) suggested that therapists help people “gracefully lump that which they do not like, instead of agreeing with the notion that people cannot accept those things [experiences and feelings] which they don’t approve” (p. 95). Ellis and Robb noted that “Rational emotive therapists had better, therefore, not only give clients unconditional acceptance but also actively-directively teach it to them, philosophically, emotively and behaviorally.” Furthermore, Ellis and Robb insisted that therapists “don’t have to do this to significantly help their clients. But they’d damned well better” (p. 95).
Cognitive Behavioral Psychotherapy and Phobia
As experiential avoidance has gained recognition, a number of contemporary cognitive behavioral therapies (e.g., Dougher, 1994; Ellis & Robb, 1994; Follette, 1994; Greenberg, 1994; Hayes et al., 1999; Hayes & Wilson, 1994; Jacobson, 1995; Linehan, 1993; Marlatt, 1994; S. M. McCurry & Schmidt, 1994; Strosahl, 1991) have developed treatment methods that target this psychopathological process. Although many of these approaches warrant empirical development, it is already clear that there is something of considerable value in acceptance-based methods.
Acceptance Oriented Therapies:
Acceptance-oriented therapists have addressed clinical contexts ranging from family therapy (Griffee, 1994; Metzler, 1994) to paraphilias (LoPiccolo, 1994), and from addictions (Marlatt, 1994) to personality disorders (Linehan, 1993, 1994; Strosahl, 1991). Marital and couples therapy (Jacobson, 1991; Koerner, Jacobson, & Christensen, 1994), geriatric care (S. M. McCurry & Schmidt, 1994), the sequelae sexual of abuse (Follette, 1994; Heard, 1994), frustration tolerance (Ellis & Robb, 1994), and quality of the therapeutic relationship (Cordova & Kohlenberg, 1994; C. McCurry, 1994) have also been considered from an acceptance perspective.
The Acceptance Movement In Contemporary Psychotherapy
Taken together, these therapeutic approaches represent what Hayes (1994) has termed: The Acceptance Movement in Contemporary Psychotherapy. Hayes (1994) noted: “there is a new wave of applied research into contextual, acceptance-based approaches . . . Some of our most intractable clients are now being moved; roadways are being laid across some of the widest intellectual bogs in applied psychology” (intro).
The Change Agenda: Acceptance vs. Change
Acceptance theorists argue that contemporary cognitive behavioral therapies have placed too much emphasis on changing, rather that accepting, unwanted private experiences. From an acceptance viewpoint these approaches may have unwittingly encouraged coping strategies that, in effect, promote the pathogenic process described here as experiential avoidance.
Traditional Behavior Therapy for Anxiety Phobia and Avoidence
Hayes et al, (1996) proclaimed: “Traditional behavior therapy fought anxiety with relaxation, whereas cognitive therapy challenged irrational beliefs with more rational ones. Essentially, better forms of experiential avoidance were systematically trained as modes of intervention. Even within these domains, however, emotional and other forms of experiential avoidance have been recognized as a problem, and such recognition appears to be increasing.” (p. 1154)
Lending momentum to acceptance-oriented clinical models, rational-emotive theorists have recently accentuated radical acceptance as an important outcome of psychotherapy (Ellis & Robb, 1994; Linehan, 1994). This trend was also highlighted by Neimeyer’s (1993) observation that modern cognitive therapy has been shifting to a position less interested in changing and controlling negative feelings, and more interested in interpreting negative affect as an essential and clinically informative aspect of human experience.
Although the rubric “experiential avoidance” is not specifically addressed or labeled as such, in many of the above systems of psychotherapy, each of the aforementioned approaches clearly address issues involving the psychologically unhealthy tendency for humans to avoid or suppress unwanted and threatening private events. These clinical methods have incorporated various acceptance-based strategies and techniques into their therapeutic procedures. Each of these approaches can be conceived to be working with the general phenomenon defined here as experiential avoidance (Hayes et al., 1994).
Dr. Patrick J. Hart
Are You Phobic in Seattle?
Seattle Evaluation and Treatment for Social Anxiety
Simple Phobia | Social Phobia | Avoidant Personality Disorder