Experiential avoidance (EA) has been documented to be a key factor in anxiety and depression. EA is the process by which people begin to have images or feelings that are distressing, and then try hard not to allow themselves to experience them. Such images might be sexual or aggressive or they might be failure or rejection related, but they generally are associated with pain, guilt or shame, which is what triggers the anxiety and that in turn motivates the individual to try to suppress and avoid the feeling or image. The problem is that the reaction creates a negatively reinforcing cycle where the avoidance is reinforced, but the anxious image is not integrated or habituated to. That means it stays active at some level and thus the individual must expend a bunch of psychic energy trying to NOT think of the thought. In addition, all of the energy invested in trying to suppress the thought reinforces the sense that the thought or image is very dangerous.
Probably the biggest treatment principle associated with anxiety is exposure. The earliest behavioral interventions developed by Joseph Wolpe for example, have been on trying to get individuals to be desensitized to feared stimuli. The two most known examples, systematic desensitization and flooding, are two long established treatments for phobias. Another common approach to anxiety is the cognitive approach which examines the beliefs individuals have about what they fear and attempts to coach them to alter more extreme and catastrophic interpretations with more adaptive and realistic interpretations. In the more recent, third wave iterations of CBT, mindful acceptance of one’s thoughts, feelings and experiences is recommended. I am trained in these and find them useful. However, I recently have developed a technique that is related to these traditions, but seems to combine them in a slightly different way than I have seen before and had some anecdotally positive results that I wanted to share.
The technique described below emerged out of a conversation I was having with a fellow PT blogger, Susan Heitler. She was advocating for “energy psychology” techniques and related approaches. My reaction was very skeptical, and so after our exchange, I began exploring some of the "energy psychology" techniques and found a recent review of the effectiveness of such techniques in Review of General Psychology. I felt this review was well done and believe that the effectiveness of some of the techniques must be seriously considered (if not the explanatory mechanisms for how they work).
To make a long story short, the techniques and findings got me thinking and I developed the following anti-anxiety intervention, which worked well in two cases I had in therapy, both of which were college age women dealing with significant problems with anxiety. I had tried traditional CBT interventions, but they were only mildly successful. I am calling the intervention Semantic Exposure with Distraction (SED). It is has a bit of EMDR, and is a bit like the ACT Milk exercise (see here).
Here is the set up. Both clients were college age White females and both had very emotionally evocative thoughts they tried frequently to avoid (and both struggled with anxiety and mood disorders). One was extremely frustrated with her academic performance. The other was having obsessive ruminations about her relationship. I had been working with them in an integrated manner, exploring key feelings, working on acceptance, identifying problematic catastrophizing, etc. The therapy had gone well in terms of insight, ego functioning and relationship functioning, but I was not getting as much reduction in anxious distress as I wanted. Then I tried this new form of exposure with both and got good results. Both reported that the intervention definitely helped and they found that they were using it outside of the therapy room. Here are the steps.
First, we identified the key anxiety provoking image and worked to put it in semantic form in a way that emotionally resonated as being a good expression of the feared thought. So, in one case, the thought was "No matter what I do, I will fail". For the other it was, "I will be rejected by X". Note that for both individuals, these were generally experienced as feared preconscious images and unwanted intrusive thoughts. That is, at the reflective, calm self-conscious level, they didn't strongly believe them. Nevertheless, the thought would intrude on them, especially under duress. Once the thought was identified put into words and tested (i.e., they said it and it felt both on target and scary), I then instructed them to do something that they could keep their attention on (this is the EMDR piece). For example, tapping their wrists, counting with their fingers, or tapping their foot.
I then instructed them to repeat the feared thought out loud, clearly, but while maintaining focus on the distraction, ten times. We then took a breath, centered and repeated the sequence 4xs (thus saying the feared thought over and over again, 50 times). In both cases, the result was the same. The first two or three sentences were hard. The thought evoked tears and they got a bit choked up. However, by the 30th or 40th repetition, they both chuckled a bit, and said it felt like the thought had lost its meaning (this effect is what the Milk exercise in ACT is after).
Doing a technique successfully with only two patients is not saying much. But I was struck by how easy it was to set up, the fact that they had not responded super well to traditional interventions, how broadly this intervention could be applied and how similarly and positively they both responded.
So, if you are treating someone with clearly anxiety producing, intrusive images that traditional techniques don’t seem to be working well or if you are someone who is struggling with anxiety producing images, you might consider trying the technique described here. For those who try it or are familiar with similar exposure techniques I would love to hear what you think.