The Trauma Paradox

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Whenever I give a client feedback that they meet criteria for a diagnosis of posttraumatic stress disorder (PTSD), I explain the four categories of symptoms that make up the disorder: intrusions, hyperarousal, negative changes in mood and thinking, and avoidance. I also explain that avoidance is the most paradoxical of the four categories. If memories of a trauma intrude on your everyday life, leave you feeling on edge, and dampen your emotions and thoughts, then of course you would want to avoid those memories. However, research suggests that individuals who heavily rely on using avoidance as a way to cope with distress are at higher risk of an increase in PTSD symptoms over time. Here’s why.

Fear conditioning and triggers

We are each equipped with an alarm system that allows us to respond quickly if our brain perceives a threat in our surroundings. When this alarm system goes off, our sympathetic nervous system becomes predominant, triggering what we often call the “fight, flight, or freeze” response. Our heart rate may increase and breathing may become more rapid and shallow as our hearts pump oxygen to our limbs. This prepares us to fight off a potential attacker, flee to safety, or brace ourselves to protect from an inevitable blow.

In those who have PTSD, fear conditioning can cause the sympathetic nervous system to become activated in situations that are not actually dangerous. Something that is relatively neutral becomes a “trigger” for a stress response because it is mentally paired with the memory of a past traumatic event. Literally anything can become a trigger: particular types of places, situations, people, sounds, smells, and objects. The problem is that each of these triggers may not actually be dangerous. While watching a TV show that depicts a car accident in the comfort of your home, you are not actually in danger of getting hit by another car. Similarly, bumping into someone in a busy train station does not mean that you are in imminent danger of being physically assaulted, and hearing New Year’s fireworks does not mean that you are about to encounter a loaded gun. Your mind and body, however, may respond as if these threats are real and impending.

Avoidance, escape, and safety behaviors

It is understandably common for people with PTSD to try to avoid or escape triggers. “Avoidance behaviors” refer to strategies to avoid traumatic stress altogether. For example, some people with PTSD may avoid ever riding in the passenger seat of a car because they don’t want to feel out of control. Others may avoid supermarkets at peak hours because of the possibility of a large, unpredictable crowd. “Escape behaviors” are actions intended to end any distress that has already started; for example, asking the driver to pull over and switch seats because of feeling overwhelmed, or abandoning a shopping cart full of unpurchased groceries because the supermarket has become crowded.

“Safety behaviors” refer to any behavior that is designed to protect oneself from a distressing, trauma-related emotion (often fear). In many situations, safety behaviors are done in far excess of what might actually keep one safe. Rather than just checking the locks once before going to bed, a safety behavior may involve checking the locks five or six times. Similarly, calling your child’s babysitter every 30 minutes to make sure she is okay may temporarily assuage anxiety, but is not going to actually keep her any safer while in someone else’s care.

Why is avoidance a problem?

There are two main reasons why avoidance, escape, and safety behaviors can create a problem in PTSD. The first is that they can get in the way of living the type of life that you want to be living. It is difficult to truly feel free when you have to plan your life around avoiding potential triggers. And asking loved ones to conform to your safety behaviors — even when those behaviors are designed to reassure you that your loved ones are safe — can leave them feeling trapped, and may degrade your relationship over time.

The second is that these behaviors mentally reinforce the idea that triggers are actually dangerous. Every time you engage in avoidance, escape, or safety behavior, the anxiety goes away temporarily. You check the security camera, you see that no one suspicious is approaching your home, you feel a little bit better. However, your sense of uneasiness may return and grow over the next hour until you feel the need to check the camera once again. Over time, there is a sense that the anxiety will never go away unless you check the camera. And because you keep checking it, you never get the chance to learn anything new: for example, that nothing bad will happen even if you don't look at the camera. Essentially, safety behaviors prevent you from deconditioning the fear response.

The beach ball analogy

Imagine that your trauma is represented by a shiny plastic beach ball, fully inflated. You would, understandably, really like to keep it underwater. If you used the full force of your weight and all of your muscular strength, could you keep the ball submerged? Perhaps, at least for a short time. But would you be able to keep the ball under water forever? Absolutely not. Eventually you would get tired, or distracted, or a wave would come and knock you off balance. And what would happen as your arms slipped from the ball’s smooth surface? It would shoot up into the air, with an equal and opposite force to that which you were using to hold it down.

This is also how avoidance of traumatic memories works. Yes, it is sometimes possible to successfully avoid the memories in the short term. You can distract yourself with work, an engrossing relationship, substance use, or a schedule chock-full of your child’s extracurricular activities. You can take back roads to avoid highways, you can order groceries online so that you don’t have to go to a crowded supermarket. But the unfortunate truth is that avoidance never fully works in the long term.

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Eventually, a memory of the trauma will inevitably come up. Perhaps this is at night when you lay down to sleep and suddenly have nothing to distract your mind. In addition, it is not possible to avoid external triggers indefinitely. As vigilant as you might be, at some point you are going to encounter a trauma trigger. Avoidance may be temporarily helpful, but it will not aid in long-term recovery from PTSD.

Healing From PTSD

Here’s the good news: you can heal from PTSD without relying on avoidance as your main coping strategy. Three psychotherapies are widely considered by international clinical treatment guidelines to have the strongest evidence for treating PTSD. Each uses a different strategy:

• Prolonged Exposure (PE) helps you to gradually approach trauma memories and triggers to restore your sense of self-efficacy.
• Cognitive Processing Therapy (CPT) teaches skills to help you change upsetting thoughts and beliefs related to your trauma.
• Eye Movement Desensitization and Reprocessing (EMDR) helps you process trauma-related memories, thoughts, and emotions.

The fact that all three have a strong evidence base means that you and your therapist can choose the one that seems like the best fit for you. Although these therapies take different approaches, each one guides you to metaphorically let the beach ball rest on the surface of the water. As it rests there, you are able to process it, and it loses its ability to pop up unexpectedly. The memory of the trauma may still exist, but it does so without the power to intrude on and control your everyday life. You can grow, you can move forward, and you can live in freedom.