Patrick J. Hart Psy.D.
Social Phobia:  Social Anxiety Disorder - Are You Phobic in Seattle?
Understanding Your Phobia: A Convergence of Views
Cognitive Behavioral Theory: Phobia & Social Avoidance

The below essay was adapted from the various papers written as part of my academic training and coursework. The summaries of theories and the ideas found below will give you a sense of how I help people resolve psychological problems. The below essays involve contemporary methods for treating phobia and social avoidance. Decidedly technical, I hope you find this interesting!

The Nature of Phobia: Origins and Maintenance
Experiential Avoidance: Phobia as Behavioral Immobilization

To illustrate the nature of experiential avoidance, acceptance 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 valued experiential outcomes and 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 (unwillingness) to take constructive action. This frequently has the paradoxical effect of maintaining the client’s misery.

Phobia: Dysfunctional Avoidance Maneuvers
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 avoidance maneuvers. Such a client might be noted to 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.

Phobic Avoidance of Psychological Distress:
Hayes (1994) contended that the culture at large, as well as many models of psychotherapy has “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 very supportive of avoidance practices involving the apparent control or suppression of private distress. For example, it is not uncommon for a person experiencing the sadness and loss to be advised to “think about something positive,” “forget it,” “cheer up,” and “get on with life,” or to otherwise avoid the aversive properties of an inherently aversive event.

Natural Struggles: Maladaptive Change Strategies
There are natural struggles and unavoidable tragedies in everyone’s life. In acceptance theory this kind of seemingly sensible advice, and the associated strategies of coping, represent an untenable and functionally defeating change agenda. This maladaptive change strategy is founded upon attempts toward experiential avoidance and struggles to control, or get rid of, negatively evaluated private events. Such tendencies toward control, escape, or avoidance of unwanted private experiences frequently generate harmful patterns of living and invoke the very problems for which clients present to psychotherapy (Hayes, 1994; Hayes et al., 1996).

Acceptance and Commitment Therapy for Phobia:
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 ones’ 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.

The Feel Good Agenda:
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 the acceptance 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 on Experiential Avoidance and PhobiaHayes 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 avoidance, 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 avoidance or 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 what is here described as experiential avoidance; “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 Feelings of Distress:
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 narrower is the range of behavior available for action within the environment.  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)

Experience Phobic: 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 ones 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. We 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 promoting acceptance 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).

Skilfully Bearing Pain: 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.

Turning Hassles Into Horrors: Low Frustration Tolerance
RET 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 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 [cognitions and affects] which they don’t approve” (p. 95), emphasis in original). Ellis and Robb noted that “Rational Emotive therapists had better, therefore, not only give clients unconditional acceptance but also actively-directivity 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 PhobiaAs 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 PsychotherapyTaken 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 AvoidenceHayes 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)

Acceptance and Commitment Therapy: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?

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