What role does avoidance have in PTSD? And how can we begin to challenge avoidance?

In my private practice I am always struck by the challenge that avoidance can present.

When people first attend a session, they are often going to great lengths to avoid thinking about their past traumatic experiences. It makes total sense, if you don’t think about the past then you won’t have to deal with the pain of it right? Or if you avoid anything that may be triggering then you may safeguard yourself from remembering what happened? Except it doesn’t work. In fact, it does the opposite, avoidance maintains the cycle of PTSD. This blog sets out to explore the role of avoidance in PTSD, what avoidance looks like and how you can start to overcome it.

Understanding PTSD:

PTSD is a complex psychological condition that can develop in the aftermath of traumatic experiences. Whether it's a single traumatic event such as an accident, traumatic bereavement, birth trauma or a series of distressing occurrences, such as abuse and distressing childhood events.

According to the The International Classification of Diseases – 11th Revision (ICD-11) produced by the World Health Organisation (WHO) the following three symptoms indicate a diagnosis of PTSD:

1.     Hyperarousal - these symptoms lead to a feeling of always being ‘on guard’ and having a heightened sense of alertness, anxiety, and irritability. This can lead to issues with sleep and concentration and leave people unable to relax due to experiencing exaggerated startle responses.

2.     Intrusions & Re-experiencing - these symptoms include intrusive memories, flashbacks, and nightmares associated with the traumatic event. People describe feeling like they are stuck in the past and are reliving something traumatic.

3.     Avoidance - these symptoms mean that people actively avoid reminders of the traumatic event – including thoughts, feelings, places, people, and discussions related to the trauma.

The Role of Avoidance in PTSD:

 Avoidance is a natural response to the distressing and often overwhelming symptoms of PTSD. It serves as a coping mechanism to shield you from the pain of your traumatic experiences. However, while avoidance may provide temporary relief, it can perpetuate the cycle of PTSD and limit your ability to lead a fulfilling life.

At the beginning of therapy people often say to me that they didn’t realise how much they were avoiding, or they are shocked when we explore some of their behaviours and coping mechanisms and they involve a certain level of avoidance.

There are many ways in which people find they develop a pattern of avoidance. These may include:

Avoidance of Places and People: Many individuals with PTSD avoid places or people associated with their traumatic events. This often includes avoiding all relationships to ‘protect’ themselves.  This can mean that a person’s life becomes very limited and can lead to social withdrawal and profound isolation.

Avoidance of Discussing Traumatic Experiences: Talking about the traumatic event may be too distressing for some individuals, causing them to avoid these conversations at all costs. This can hinder their ability to process their feelings and experiences. In fact, unprocessed trauma can lead to many physical issues such as chronic pain, gut issues and memory problems.

Busyness and Overcommitment: Some people turn to excessive work or other activities to keep their minds occupied, leaving little time for introspection, or processing the past. They may find that they spend so much of their time keeping themselves busy that they become exhausted and burnt out but feel unable to allows themselves to stop for fear of re-experiencing their trauma.

Substance Abuse and Self-Medication: Alcohol and drug use, as well as oversleeping and overeating, are often used as ways to numb the emotional pain associated with PTSD. While they may offer temporary relief, they are not healthy and can lead to physical long-term issues.

Self-Care: People often begin to neglect their basic needs following trauma and find they avoid doing activities they previously enjoyed. Often clients will say to me that they feel too overwhelmed to exercise regularly or go out and see friends or create a space for themselves. However, they find that their mood becomes worse as they become more isolated, and simultaneously more afraid of engaging in previous self-care activities.

Why avoidance is a problem:

While avoidance may provide short-term relief, it can have serious consequences in the long run. Avoidance behaviours can lead to a person living a limited life with increased isolation, strained relationships and unable to engage in activities they used to enjoy.

Ultimately avoidance perpetuates the cycle of fear and anxiety and reinforces the belief that the world is a dangerous place. Avoidance limits one's ability to engage in life and hinders the natural healing process.

For illustration purposes I have written an example of avoidance due to PTSD (this is a fictional client)

Dave is a 35-year-old man who lives in a small village in the UK with his partner. He works full time from home. He was recently in a serious car crash where he broke his leg and thought he was going to die. He has been experiencing nightmares and flashbacks of the event since. He also notices that when he sees a car’s headlights that he starts to feel sick and panicked.

Since this event he has decided that getting into a car is too dangerous, so he has stopped driving and getting in any cars. He thinks if he ever gets into a car again that he will die. However, this means that he is limited to friends and family visiting him in his village. Initially this wasn’t a problem but over time he has begun to feel trapped as he cannot really leave the village because there is no other transport available. His partner is also beginning to express frustration as they are having to do all the shopping and are fed up with always being at home and not being able to go out together. He is worried his relationship is breaking down. Dave has begun to feel more isolated and frustrated. Over time his family and friends have started to visit less and he has started to feel lonely and angry with himself.

One of the challenges for Dave is that he now has not been in a car for six months and so he has become even more frightened. Dave begins some therapy sessions and together they agree that Dave is going to do some graded exposure. He initially starts with sitting in a car with his partner, then alone, then driving for a minute with his partner, then longer and then alone. Through challenging this avoidance, Dave begins to realise that cars can be dangerous, but they are not always dangerous. That he can be a driver or passenger in a car and that does not mean he will die. Dave begins to increase the amount he drives and begins to engage in activities he used to enjoy including going out with his partner. This leads to him regaining his confidence and independence and he begins to notice his relationship improving.

Although the above is a brief example of avoidance in PTSD, it clearly shows some of the development of avoidance behaviours and how problematic these can be.

 Challenging Avoidance:

Breaking avoidance is a crucial step towards healing and recovery. It's essential to recognise that while avoidance may provide temporary relief, it ultimately perpetuates the cycle of trauma. Challenging avoidance can feel overwhelming and needs to be done slowly and safely.

The most important step in breaking avoidance is seeking professional help. A therapist with experience in treating PTSD can provide the necessary tools and therapies to address avoidance behaviours. They will work with you to identify some of your avoidance behaviours and what your goals are for treatment. They may suggest the following:

Gradual Exposure: Exposure therapy is an evidence-based approach that involves gradually facing the situations or stimuli you've been avoiding. With the guidance of a therapist, you can develop a hierarchy of feared situations and work through them systematically.

Mindfulness and Grounding Techniques: Practicing mindfulness and grounding techniques can help individuals stay present in the moment and reduce the urge to avoid. Breathing exercises, meditation, and sensory grounding techniques can be valuable tools in managing distress.

Talking Therapy: There are different therapeutic modalities that can be used to treat PTSD but the most important thing is to make sure your therapist is specialised in working with trauma. In the UK the current main trauma talking therapies are – Trauma Focused Cognitive Behaviour Therapy (TF-CBT), Eye Movement Desensitisation Reprocessing (EMDR) therapy and Narrative Exposure Therapy (NET). Always make sure the clinician you decide to work with has official training in what they are offering.

If you do not feel quite ready to begin trauma therapy, then there are some things that you can do to start challenging avoidance:

Build your support system: Connect with friends and family who understand your condition and can offer emotional support. Support groups can also be valuable in sharing experiences and coping strategies.

 Self-compassion: Develop self-compassion by being kind and patient with yourself. Understand that healing from PTSD is a journey, and it's okay to have setbacks. Avoid self-criticism and practice self-care.

 Education and Empowerment: Educating yourself about PTSD, its symptoms, and available treatments can empower you to take control of your recovery. The more you understand your condition, the better equipped you are to confront avoidance.

Set Realistic Goals: Set small, achievable goals to gradually reintegrate into activities and situations you've been avoiding. Celebrate your successes, no matter how small they may seem.

Conclusion:

Overcoming avoidance is a vital step on the path to healing from PTSD. While avoidance may initially offer a sense of safety, it ultimately hinders recovery and limits the ability to live a fulfilling life. By seeking professional help, gradually confronting avoidance behaviours, and prioritising self-care, individuals with PTSD can gradually break free from the cycle of avoidance and regain control over their lives. It's a challenging journey, but one that holds the promise of healing and renewed hope.