What is avoidance in PTSD?
Avoidance, one of the symptom clusters of PTSD (APA, 2013), refers to persistently avoiding internal and/or external reminders of a traumatic event(s). Those reminders can bring up intense and uncomfortable emotions, thoughts, and memories. It makes sense that we try to avoid them – it’s our way of trying to protect ourselves from pain.
For more information about PTSD, check out www.melissagoldsmithphd.org/blog/what-is-ptsd
Types of avoidance in PTSD
1. Avoiding internal reminders
Avoiding internal reminders of a traumatic event includes avoiding or trying to avoid distressing memories, thoughts, or feelings about the trauma(s) (APA, 2013).
Some examples of avoiding internal reminders:
- Avoid thinking about what happened
- Working too much or staying extremely busy to try not to think about what happened
- Pushing away feelings of anger, sadness, or fear about the traumatic event whenever they come up
- Trying to distract or shut out feelings of guilt and shame when they pop up
- Using food, alcohol, substances, etc. to distract or numb from the distressing thoughts, feelings, and memories
2. Avoiding external reminders
Avoiding external reminders of a traumatic event includes avoiding or trying to avoid external reminders that bring up distressing memories, thoughts, or feelings about the traumatic event(s) (APA, 2013). These external reminders can be:
- People
- Places
- Conversations
- Activities
- Objects
- Situations
Some examples of avoiding external reminders:
- Avoid unfamiliar people
- Avoid loud noises
- Avoid having your back to a wall, door, or people behind you
- Avoid watching certain TV shows or movies
- Avoid intimacy – physical, sexual, or emotional
- Avoid sights, sounds, smells, etc. that remind you of the traumatic event(s)
Here’s the heart of the struggle: The paradoxical effect of avoidance
Avoidance works in the short-term: we feel relief at that moment. But, avoidance doesn’t work long-term. Avoidance intensifies distress and exacerbates symptoms in the long run.
Avoiding thoughts, emotions, memories, etc. about traumatic event(s) can make PTSD symptoms much worse. Emotions, especially fear, sadness, anger, guilt, and shame, amplify. As the symptoms increase and emotions intensify, the internal list of what you “used to do” before the traumatic event(s), but now avoid grows. That can include withdrawing from activities and interacting with others in your daily life. That long list of what you avoid can leave you feeling stuck. Avoidance takes you further away from your goal of recovery.
Overcoming avoidance in PTSD
What you need to know
1. Are you willing?
The fear of facing the memories, thoughts, and emotions about past traumatic event(s) is understandable. However, recovery is possible when 1) your desire to break free from the traumas outweighs your fear, and 2) when you are willing to sit with temporary distress and discomfort, so you can begin to reclaim control of your life instead of PTSD controlling it.
2. Treating avoidance in PTSD
I strongly recommend working with a licensed mental health clinician trained in evidence-based trauma-focused therapy for PTSD, such as Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE) Therapy to help you face past traumatic experiences. CPT and PE are two of the gold-standard treatments for PTSD. Research has shown that they can significantly reduce PTSD symptoms, including avoidance, short-term and long-term (Cusack et al., 2016; Kline et al., 2018; Resick et al., 2012).
Read more about CPT and PE here: www.melissagoldsmithphd.org/blog/deal-with-ptsd
You are likely aware of some examples of what you avoid internally and externally. (Remember that list of what you “used to do” before the traumatic event, but don’t do now?) You and your clinician can work together to identify any additional ones. Some examples of avoidance can be obvious, whereas others can be very subtle.
Facing past traumas in a healthy way to move forward
Overcoming avoidance in PTSD is a key step toward recovery. Although avoidance provides temporary relief, it ultimately reinforces distress and intensifies symptoms over time. Facing internal and external reminders of trauma can be challenging; however, with the right support and evidence-based trauma-focused treatments like Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) Therapy, recovery is possible. Working with a trained mental health professional can help you gradually face your memories and thoughts and process your emotions. By choosing to face your traumatic experiences, you can move forward with greater self-confidence and focus on living in the present.
In my Ohio-based private practice, I provide evidence-based trauma-focused treatments, like CPT and PE, to adults who are willing to face their past traumas, so they can move forward with confidence and a greater sense of control in their daily lives. I am committed to delivering treatments that have shown long-term results.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Cusack, K., Jonas, D. E., Forneris, C. A., Wines, C., Sonis, J., Middleton, J. C., Feltner, C., Brownley, K. A., Olmsted, K. R., & Greenblatt, A. (2016). Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Clinical Psychology Review, 43, 128-141. doi: 10.1016/j.cpr.2015.10.003.
Kline, A. C., Cooper, A. A., Rytwinski, N. K., & Feeny, N. C. (2018). Long-term efficacy of psychotherapy for posttraumatic stress disorder: A meta-analysis of randomized controlled trials. Clinical Psychology Review, 59, 30-40. doi: 10.1016/j.cpr.2017.10.009.
Resick, P.A., Williams, L. F., Suvak, M. K., Monson, C. M., & Gradus, J. L. (2012). Long-term outcomes of cognitive–behavioral treatments for posttraumatic stress disorder among female rape survivors. Journal of Consulting and Clinical Psychology, 80, 201-210. http://dx.doi.org/10.1037/a0026602
