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The Most Important Question in Therapy

Psychological pain often arises from attempts at avoidance.

Key points

  • Clients benefit from gaining new insight into their patterns of thought, emotion, and behavior.
  • New insights in therapy may emerge either abruptly or gradually, over time.
  • Psychological pain often results from attempts at pain avoidance. Therefore, exploring clients' avoidance habits may yield important insights.
Jill Wellington / Pixabay
Source: Jill Wellington / Pixabay

As a result of writing this blog, I am often contacted by journalists and podcasters for interviews about issues I may have raised here. In one recent interview, a journalist asked me about a-ha moments in therapy—those instances in which the client gains new insight about their difficulties and themselves.

I noted that counter to popular beliefs and movie depictions, a-ha moments are not necessary for progress in therapy. Often, clients know full well what the source of their trouble is and how to fix it; people who ask for advice are rarely clueless about what needs to be done. What they lack is self-confidence, support, and guidance in acting on their knowledge. This is one reason why psychologists often answer a client’s “What should I do?” with "What do you think you should do?”

Additionally, when a-ha moments do happen, they mark not the end of the recovery process, but its beginning. In other words, while popular entertainment—and the classic Freudian narrative—depict insight and catharsis as the culmination of the therapeutic journey, in real life this is generally not the case.

To yield real change, moments of insight must be followed by arduous work to change old, ingrained habits and establish new, healthy ones. Becoming aware of the solution to your problem does not in itself solve the problem. The solution must be implemented.

Moreover, a-ha experiences often emerge not at once or fully formed but slowly, piecemeal and over time, resembling less the flipping of a switch and more the slow turn of a dial. In other words, a-ha moments are not always moments. New insights sometimes dawn slowly over the course of therapy, as clients gradually recognize, sometimes in retrospect, subtle changes that had occurred over time.

To wit: Reflecting on her office behavior over the past few months, a client gradually notices that she is becoming more assertive and hence more effective. That realization leads to another: that her previous beliefs that she’d be rejected if she asserted herself are in effect being refuted, and can be discarded and replaced by more accurate and constructive self-talk.

The journalist then asked me what kind of questions tend to elicit a-ha moments or experiences in therapy. I replied that there was no formula. Any moment—even a moment of silent contemplation—has the potential to yield discovery, regardless of the specific nature of a given question or whether a question had even been posed. Each client's journey is different, and generalizations are risky.

Moreover, different schools of therapy may rely on different types of questions. For example, cognitive psychologists often use the "So what?" question to probe a client's irrational, catastrophic beliefs (client: "I'm afraid people will dislike my presentation." Therapist: "Let's assume they do: so what?"). The "questioning process" employed by reality therapists poses a set of useful questions: "What do you want? What are you doing (to get what you want)? Is it working? If not, what else can you do?"

Solution-focused therapists often use the so-called miracle question: "If a miracle happened tonight and the problem was solved, what would be the first thing you’d notice that would indicate that a miracle had occurred?” Exception questions, such as "When do you not have the problem?" and "What do you do that is different then?”) are also used in this tradition to identify the client's strengths and coping resources.

Yet if pressed, I said, I’d suggest that clarifying moments in therapy often happen when we focus on the client’s avoidance habits. Experiential avoidance (EA) may be broadly defined as an “unwillingness to remain in contact with distressing thoughts, feelings, memories, and other private experiences.” In other words, it is an attempt to avoid distress.

Recent research and theorizing in psychology have increasingly pointed to the fact that such avoidance is a central feature in many different psychological disorders: Phobias involve avoiding certain places or objects; panic disorder involves avoiding the fear sensations in the body; OCD rituals constitute avoidance of the discomfort brought about by disturbing obsessive thoughts; PTSD involves avoidance of experiences that trigger terrifying traumatic memories; depression involves avoiding attempts to find rewards in an environment that had previously proven non-responsive (aka "learned helplessness"); substance abuse involves an attempt to numb distress, guilt, shame, or physical pain, etc.

In all these cases, the avoidance habit, presenting itself as an effective short-term solution, proves ineffective and destructive in the long run to the individual’s health and functioning. Psychological distress, in other words, is caused by misguided attempts to avoid psychological distress.

The mechanisms underlying this process hinge on the fact that avoidance is a short-term solution offering immediate relief. Life, however, is long-term, and short-term fixes tend to collapse over time. Specifically, avoidance prevents the development of coping skills and hinders learning and problem solving, since all avoidance teaches you is how to avoid more. It also tends to generalize over time: The more you avoid tolerating discomfort, the more difficult tolerating discomfort becomes.

By way of analogy, a habit of avoidance is akin to substance addiction. At first, taking a drink alleviates (lets you avoid) your distress. But over time, drinking becomes your main source of distress.

This idea, that avoiding pain now leads to more pain later, is not new. Freudian psychoanalysts note how defense mechanisms, designed to reduce the distress of anxiety, also distort our perceptions of reality; Gestalt theory cites the problem of “contact avoidance,” or an inability to remain aware in the living moment, as the source of psychological suffering; behaviorists have studied how avoidance prevents new learning, and hence behavior change; cognitive theorists have noted how avoidance perpetuates cognitive distortions through the failure to note and consider disconfirming evidence.

Evidence of the destructive power of avoidance can be found in the literature attesting to the therapeutic power of its opposite: exposure. Research has shown that facing one’s fears and processing difficult emotions lead to improved mental health, facilitating the acquisition of coping skills and a sense of psychological empowerment, and refuting inaccurate beliefs. In fact, as I have argued here before, exposure work, which involves in effect countering avoidance, is the most potent weapon in any therapist’s arsenal, and all therapy is in part exposure therapy. Therapy works when the client learns to face, manage, tolerate or change what they had previously learned to avoid.

A complication here is that avoidance often does not appear as such but operates under various guises. In fact, avoidance often masquerades as action. People often will continue performing a destructive habit because they fear that not doing so will result in greater destruction. A client continues to speak nonstop to avoid the self-reflection offered by silence—which they find scary. A client's continuous labor at people-pleasing is an attempt to avoid the distress of potential rejection, which they perceive as unbearable. People with chronic worry often fret incessantly about impending catastrophes, believing that such worry constitutes action when in fact, such worry hinders their ability to take problem-solving action. Worrying is avoidance masquerading as action.

The cunning of avoidance is one reason why many clients are unaware that their pain is being caused by their attempts to avoid pain. Thus, the questions that are most likely to facilitate the a-ha process in therapy will often aim to illuminate this truth. Once we identify the destructive, painful, or ineffective behavior pattern the client wants to change, the most useful question is some version of: “What does this current behavior allow you to avoid?”

In discovering what a dysfunctional habit lets us avoid, we discover what we need to face in order to heal.

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