Acceptance and Commitment Therapy for Anxiety Disorders

Chapter 4. Controlling Anxiety Is the Problem, Not a Solution

Two mice fell into a bucket of cream. Immediately, each began to struggle frantically in an effort to get out. Around and around they went, but without success. Growing tired, one mouse had had enough. Believing that the situation was hopeless, she ceased to struggle and eventually drowned. The other mouse, determined to get out of the bucket, kept swimming and swimming against all odds. This mouse would not give in to her fate. So, on and on she went, though deep down inside she had every reason to believe that she was wasting her time. What happened next came as a complete shock to the little mouse. With each stroke, the cream began to stiffen, and shortly thereafter turned into butter. The mouse then climbed on top of the butter and out of the bucket to safety.

It may seem that this simple story only has two messages. The first message is that continued struggle is generally the way out of life’s hardships. The second message is that giving up always leads to death. Here is a third one: Struggle can keep us safe and alive when we are responding to real danger and threat. Yet the crucial question to ask is: Can anxiety ever turn into sweet butter so long as one desperately struggles to get out or away from it? None of us would choose to be thrown into a situation like the two little mice found themselves in. Yet, most of us can probably see a bit of ourselves in how the two mice responded to it. Animals prefer controllable aversive events and will act to maintain a sense of control, and to regain it if it’s lost, in the wake of uncontrollable aversive events.

Humans do this too. Under most circumstances, this is a highly adaptive and workable strategy. For instance, if we can act to reduce the possibility of real pain and suffering, then it makes sense to do so. There is comfort in knowing this and responding accordingly. Our direct and indirect experiences with the world tell us as much, and a voluminous psychological literature supports the benefits of a control posture in the promotion of psychological health and physical well-being (Barlow, 2002; Chorpita & Barlow, 1998; Zvolensky, Lejuez, & Eifert, 2000). Life may not always be fair, but we can and should do something about it to make things right.

Managing and overcoming life’s daily challenges often requires hard work, effort, and persistence. Success and happiness never come easy, and never come at all for those who wait, give in, or do nothing. We have all heard variations of this credo from a very young age and are in some sense guided by it. Though there is no guarantee that these coping strategies will produce desired outcomes, they are valued and useful precisely because they tend to produce desired outcomes more often than not.

Persons suffering from anxiety disorders are all too familiar with the mantra of struggle and control. By the time they enter therapy, most have tried numerous strategies in the struggle to manage and control their anxiety, unwanted thoughts, worries, and physical sensations. Unfortunately, the success of the strategies has typically only been limited. Like the mice in the opening story, individuals are stuck in a bucket with their anxious thoughts and feelings and are desperately swimming around trying to find a way out. They may even feel powerless, hopeless, and alone. It does not occur to them that the bucket may be their friend, not their enemy.

The goal of this chapter is to describe anxiety-control efforts and why they are largely unworkable as a means to cope with anxiety. We will also indicate that control efforts are related to another “toxic” process, which has to do with not accepting our reality and an unwillingness to experience what we have, when what we have is aversive to us. At first, some of these ideas may sound a bit odd to you. In your clinical work, you have been very much involved in your client’s struggle with anxiety, actively trying to help them cope. At a more basic level, you may also wonder how control can work so well as a strategy to handle the demands and strains of the world, and yet be so ineffective when applied to unwanted anxiety-related thoughts and feelings inside the skin. Anxiety is an aversive emotional state that brings with it suffering, right? Should it not be controlled? Is it not your task to help your client be more successful in their control endeavors? As you will see, control efforts have a more insidious side as a solution to anxiety, and can make the anxiety and the client’s life worse, not better. Anxiety never turns into sweet butter if one is unwilling to have the experience of anxiety.

Examples of Control Efforts

Control means quite literally to order, limit, instruct, or rule something or someone’s actions or behavior. Control is, by definition, purposeful and effortful. It requires an investment of time, energy, and resources and deliberate action directed toward some outcome or goal. For example, if you no longer like some of your clothes, you can simply take those tops, pants, or shoes and throw them away or pass them on to someone who may actually like them. Likewise, if you are in a job that you do not like, you can simply quit that job, go to a different employer, and work there. If you are fed up with the color of the walls in your bedroom, then you can paint the walls red, green, blue, or whatever color your heart desires. The common element of these examples is that they all involve situations where control is possible because they involve objects and events in the external world (the world outside our skin). We can literally use our hands and feet to manipulate and physically change those objects and events. These kinds of actions can work well in the external world and often have a positive impact on our lives.

When Does Control Work?

One of the main psychological purposes of control is to manage our world, our behavior within it, and at times the behavior of others. This strategy works so successfully in most spheres of life that it only makes sense to apply it deliberately to manage emotional and physical pain, and in some instances, this strategy leads to desirable outcomes. For instance, control may be directed to prevent or manage external sources of pain while maximizing contact with pleasant activities and outcomes. Thus, we tend to avoid situations that may result in physical injury or death, and we act to escape from them when and if they occur.

For example, if we see a previously hidden car approaching us as we cross the road, we run for safety. If another person or an animal threatens to attack us, we take evasive, defensive, or offensive action to the best of our abilities. As we indicated in previous chapters, this type of fear-related behavior is adaptive and works to our advantage. Controlling or reducing our fear by responding to an identifiable cause in the external world is a workable solution. There is nothing dysfunctional about this form of control.

Now let us consider the case where control behavior is directed to prevent or minimize internal sources of physical and emotional pain (e.g., illness, unpleasant thoughts, feelings). This latter form of control is also quite common, may work, and again can be quite functional. For instance, you may take an aspirin for a headache, see a doctor for an illness or injury, take time to relax so as to feel more energized, and exercise regularly and watch what you eat and drink so as to promote health and feel better about yourself.

When Does Control Not Work?

Problems arise when either of these control strategies is taken to the extreme— when control efforts become overly intense and rigid and when they are applied in situations where they do not work. An example would be the young woman who becomes so fearful of gaining weight that she restricts her eating and exercises for three hours every day to control her weight and how she feels about herself. In the case of anxiety disorders, problems arise when control efforts are applied in circumstances where they simply do not work, either because they do not produce the outcome desired by the client (anxiety reduction), or because the partial relief they offer restricts the person’s life.

Take the case of Susan. Susan had a full-blown panic attack in her car while making a right-hand turn. To control subsequent panic attacks, she would avoid making right-hand turns while driving. Although this tended to reduce Susan’s anxiety somewhat, she paid a high price for her relative comfort. Even short trips to work or to run errands became convoluted, difficult excursions requiring a map, careful planning beforehand, and constant vigilance. Spontaneous drives on unfamiliar routes were out of the question. It seemed that controlling anxiety—maximizing feeling good while minimizing pain and emotional suffering—had become the focus and purpose of Susan’s life. Yet, this strategy left her neither panic free nor feeling good. Far from it. Susan’s life was lived in the service of controlling panic, and it became more restricted as a consequence. A related example is the man with a history of panic attacks who quits his job and stays at home for fear of having more panic attacks if he leaves the house. In these and other examples, control efforts are typically life constricting, not life expanding.

As in Susan’s case, control efforts often end up becoming a way of life for persons suffering from anxiety disorders. Anxiety is, in many respects, an unpleasant emotional state. So it is understandable when people simply say, “Anxiety is bad” or “I don’t like anxiety.” Most people without anxiety disorders do not like experiencing anxiety. Yet, not liking anxiety does not make it a problem. If this were true, then many of us would likely suffer from anxiety disorders.

Instead, anxiety becomes problematic when an individual experiences anxiety in the absence of real threat or danger and acts “as if” anxiety is a cause of suffering and misery. Statements like “I cannot do ABC or go to XYZ because I have anxiety” imply that “If I did not have anxiety, I would be able to do ABC or go to XYZ.” From this posture, anxiety needs to be managed and controlled like other external sources of pain and misery in order for a person to be happy and healthy and to have a good quality of life. Yet, there is good reason to believe that control over anxiety is not particularly workable as a solution and may actually be part of the problem. Although your clients can probably sense that control is not working as a solution to their anxiety, they may not yet see how it has become problematic.

Why Anxiety Control Is Problematic

Control efforts are intimately fused with our evaluations of the world. We make an effort to have more of what we like. What we dislike, we often try to avoid or escape from. This strategy works to the extent that the good and unpleasant in life are, in fact, within our control.

Emotional Control Is Often Illusory

One of the greatest illusions about control is that we have it most of the time. Yet, many life experiences, both pleasant and unpleasant, happen outside our control. A simple example is the weather. A bitter cold wind blowing at our face can cause some discomfort. A natural reaction in this case might be to turn our backs to the wind. This act may provide some relief, but it will not stop the wind or the cold. Cursing the cold wind will likely not do much good either. We would like to think that the situation is different when it comes to controlling our own emotional reactions and thoughts, and the behavior of others. Yet, control in such circumstances is typically, at best, only partial.

Consider a somewhat humorous example of John’s younger brother Kevin. As a child, Kevin loved having spaghetti and meatballs for dinner. It was his favorite meal and he would request it often. This all changed shortly following Kevin’s fifth birthday. During the summer of that year, Kevin had been playing outside in the dirt with some friends. One of the kids found a worm and then tossed it in the air. The worm happened to land on Kevin’s shirt collar and then slipped inside his shirt and down his back. Kevin screamed and cried to have the worm removed. A few days following this event, Kevin once again sat down to a spaghetti dinner with his family. Remember, this was his favorite meal! Before they started eating, one of Kevin’s older brothers jokingly said, “Hey, the spaghetti noodles look like worms.” From that point on, Kevin would not eat spaghetti or noodles in any form. He had made an arbitrary association (spaghetti = worms = disgust/aversion). This association, in turn, was established by a sequence of events that occurred outside of Kevin’s control. This example illustrates the subtle forms of conditioning that we all experience on a daily basis as well as the great illusion of control, namely that we should always act to have and maintain control when it comes to unpleasant thoughts and feelings. One of the main psychological challenges for all of us, and particularly persons with anxiety disorders, is to learn that this need not be so and is indeed a myth.

We Cannot Turn Emotions On and Off

Human emotions are a good example of events that cannot be readily controlled, either by turning them on or by turning them off. Emotions have no on/off switch. Emotions happen to us as a consequence of our interactions with the world. They are not something we deliberately do apart from that world. To illustrate, try making yourself extremely happy. Go ahead and try it now. If you were successful, then you likely induced the state as a response to something else (e.g., a memory of a pleasant past experience or by thinking about something you like or an event you are looking forward to). Yet, this is not what we were asking of you. We want you to feel exuberant for the sake of it, not as a response to something that may help make you feel that way. Now, try to do the same by making yourself feel really anxious or afraid. We want you to try really hard. Again, the point is that controlling our emotions is extremely difficult. This is actually a useful exercise to do with clients, and we will come back to it later.

Persons suffering from anxiety disorders often come to therapy believing anxiety should be controlled in the same way that many other aspects of human experience can be controlled. Implicit in this is the notion that anxiety is bad. And, like other bad things in life, one should act to not have it, or to diminish the probability of having it, because we simply must not and cannot have it. Ellis (2004) has written extensively about this human tendency that we all share to some degree and how it can get us into trouble (Ellis & Robb, 1994). So we should not fault persons suffering from anxiety disorders for doing what appears to come naturally for many, if not all of us. Westernized notions of personal happiness and success are intimately bound up with feeling good, not bad. Thus, being able to control unpleasant thoughts and feelings would seem like a sensible strategy in order to be happy and successful. This assumption, as we described in an earlier chapter, is at the core of many empirically supported psychosocial interventions for anxiety disorders. It is also part of the “dark side” of emotional control.

The Dark Side of Emotional Control

Our reference to the dark side of emotional control is based on an increasing amount of solid research evidence. Several independent lines of research suggest that attempts to suppress and control unwanted thoughts and feelings can result in more (not fewer) unwanted thoughts and emotions (Clark, Ball, & Pape, 1991; Gold & Wegner, 1995; Lavy & Van den Hout, 1990; Wegner, Schneider, Carter, & White, 1987; Wegner, Schneider, Knutson, & McMahon, 1991; see also Purdon, 1999, for a recent review). This is possible because the human body is a closed system with a series of built-in feedback loops. Within this system, therefore, trying not to have anxious thoughts and feelings will contain aspects of the unwanted event and other events to which it might be related. Thus, reacting to our own reactions can actually amplify those reactions in a vicious self-perpetuating cycle.

For example, a person suffering from obsessive-compulsive disorder may try not to think about shouting out profanities during a church service. Yet, trying not to think about yelling profanities is itself a thought about profanities. Here the very act of suppressing the thought may bring about the very unwanted thought and emotional experience exactly when it is most unwanted, such as during a church service. Kevin tried this too. He tried to suppress the thought of worms so that he could eat spaghetti. Yet, it only made things worse. This is quite like the activity of trying not to think about a pink elephant. It is hard to do because not thinking about a pink elephant is itself a thought of a pink elephant.

CONTROLLING EMOTIONAL EXPERIENCE VERSUS BEHAVIOR

We do not wish to imply that all emotional regulation is problematic. In fact, in many cases it is the failure of emotional regulation that is a problem. It is important, however, that we clearly distinguish between regulating the experience of emotions and regulating the actions that are associated with that experience. For instance, anger and rage are examples where emotional regulation is highly desirable because uninhibited outbursts of verbal and other anger and rage-related behavior can be very destructive. Even in such cases, however, the initial experience of anger feelings cannot be controlled. The emotional experience of anger, just like fear, may show up in a fraction of a second. What can be controlled is how individuals respond to their felt anger. For example, individuals can learn to choose whether they respond with attack, avoidance, or compassionate understanding when anger shows up. The first step in this process is to notice anger and accept its presence. The next step involves making a choice about how one responds to it.

The point here is that emotional experience can be inhibited and controlled only to a point. Attempts to do so often do not work and may actually make matters worse. Gross and Levenson (1997), for example, found that attempts to suppress either a positive or a negative emotion do not provide relief from the psychological experience of that emotion. In fact, just the opposite occurs. The emotion becomes stronger and more salient. We are much better at controlling what we do with our hands and feet in response to unwanted emotional experiences than we are at controlling the emotional experiences themselves. Paradoxically, the first step toward healthy emotional regulation is letting go of our attempts to control unwanted emotional experience and accepting what we have for what it is; that is, to acknowledge the presence of fear, anxiety, worry, sadness, and anger. This stance puts us in a much better position to exert control where we do have it—how we respond to our ecmotions.

THE EFFECTS OF CONTROL VERSUS ACCEPTANCE

In our own research lab, we have seen firsthand the problem of trying to control uncontrollable emotional experiences (Eifert & Heffner, 2003). In this study, we compared the effects of creating an acceptance versus a control treatment context on avoidance behavior and reported fear in women scoring high in anxiety sensitivity. All women were asked to breathe carbon dioxide–enriched air for two ten-minute periods. This challenge procedure reliably produces involuntary and largely uncontrollable physiological sensations that are similar to those experienced by people during panic attacks. Thus, participants really had no control over their reactions to the challenge. Through the use of an interactive metaphor, we taught women in the acceptance context not to fight their symptoms and to accept them instead. Women in the control context were taught a special breathing skill and were encouraged to use the breathing skill to control their paniclike symptoms.

Nearly half of the participants instructed to conquer their fear worried that they would lose control. Interestingly, quite a few of them (20 percent) actually did lose control—they dropped out of the study altogether. In contrast, acceptance-context participants were less avoidant behaviorally. They also reported less intense fear and fewer catastrophic thoughts during the panicogenic carbon dioxide (CO2) inhalations. In short, participants who accepted the annoying (but harmless) panic sensations without trying to fight them did not worry about losing control. None of them dropped out of the study. Paradoxically, by giving up their efforts to gain control, they actually had more control!

Our results were replicated in a study examining the effects of accepting versus suppressing the effects of a panicogenic CO1 challenge in clients with panic disorder (Levitt, et al., 2004). Clients in that study were simply instructed to either accept or suppress their responses to the CO1 challenge. This study found an almost identical pattern of results as we did. The acceptance group was significantly less anxious and less avoidant than the suppression or no-instruction control groups. Yet, the groups did not differ in terms of self-reported panic symptoms or physiological responses. It is important to reiterate that people in these studies, just like people with panic attacks in natural life, had no choice about having or not having the physical sensations. People cannot learn or choose not to have the sensations. What they can learn and control is what to do when they have them. That is, people can accept and be with their psychological and emotional experiences, or they can fight them.

There are also multiple clinical studies suggesting that client attempts to control anxiety may have paradoxical negative effects (Ascher, 1989). For example, Wegner (1994) found that attempts to control anxiety in the face of ongoing stress exacerbate physiological arousal. Increased tension during relaxation training was also reported in a study by Heide and Borkovec (1983). Likewise, studies suggest that adding slow diaphragmatic breathing (“breathing retraining”) might not increase the effectiveness of interoceptive exposure treatment for panic disorder (Craske, Rowe, Lewin, & Noriega-Dimitri, 1997). In fact, breathing retraining even led to poorer outcomes compared to treatment without such training (Schmidt et al., 2000).

In a more general way, active coping efforts that attempt to minimize the experience of anxiety may, paradoxically and unintentionally, maintain pathological anxiety and increase the anxiogenic effects of interoceptive stimulation (Craske, Street, & Barlow, 1989). For instance, Spira, Zvolensky, Eifert, and Feldner (2004) found that avoidant coping strategies such as denial, mental disengagement, and substance abuse predicted more frequent and intense CO1-induced physical and cognitive panic symptoms than acceptance-based coping strategies. These findings are consistent with earlier studies showing that attempts to avoid aversive private events are largely ineffective and may be counterproductive (Cioffi & Holloway, 1993; Pennebaker & Beall, 1986).

Collectively, these studies suggest that hiding, actively suppressing, escaping from, or avoiding negative thoughts and emotions are all unlikely to help one feel better in the long term. In fact, purposefully trying to control feeling anxious may, in turn, increase the very anxiety one wants to control (Gross & Levenson, 1997), while also increasing the probability that unwanted emotional responses will recur again, often in more severe form, in the future (Cox, Swinson, Norton, & Kuch, 1991; Hayes, 2004a; Hayes et al., 1996). Worse yet, anxiety suppression and control efforts also act to decrease positive emotional experiences (Gross, 2002). The result is more anxiety, not less, which will likely be followed by more effort to control the anxiety, in a self-perpetuating cycle.

Experiential Avoidance and Control

The lack of control over life stress, whether real or imagined, is thought to function as a core diathesis and risk factor for anxiety disorders (Barlow, 2002). If one starts from this perspective, then it makes perfect sense to teach clients new ways to manage and control anxiety and the circumstances that give rise to this feeling. In one form or another, most contemporary cognitive behavioral treatments for anxiety disorders attempt to do just that. In effect, such treatments are playing into the struggle and control agenda that is familiar to all of us, and particularly to individuals who have been suffering from anxiety disorders.

Nonacceptance and Rigid Control Efforts Make Anxiety Disordered

Let us suppose that control itself is not the issue and that control is merely one of several manifestations of a more basic and toxic underlying diathesis (i.e., a predisposition or vulnerability). We will describe that diathesis in a moment, but for now consider a person who is fully willing to experience a full range of human emotions, even intense anxiety and fear, without acting to control them. Those feelings and associated thoughts are welcomed and experienced just as they are, and are acknowledged as such. This person neither acts to reduce, avoid, or escape from them, nor does she let them get in the way of important and meaningful life activities. At first glance, one might think such a person is the exception, not the rule.

Yet even in Westernized societies where the culture of feel-goodism is the rule, there are many people who do not let anxiety rule their lives—recall the data presented in chapter 2 on the number of people with panic attacks who never develop panic disorder or the majority of people who experience trauma but never develop PTSD. There is nothing disordered about people feeling anxiety and the accompanying physical sensations. There is nothing harmful or disordered about anxious or “negative” thoughts. They are what they are, thoughts and feelings, nothing more or less; they do not harm or kill; they are, in a very real sense, what makes us fully human.

Now consider anxiety in the context of someone who does not accept it and is unwilling to have it. Anxiety in this context is not just a feeling, it is a bad, even dangerous, feeling and necessitates a response. Now, anxiety is no longer just anxiety. It is a problem that cannot be had and must go away. Thoughts are no longer thoughts, they are bad thoughts. Anything associated with anxiety or the likelihood of experiencing anxiety is now a problem. Anxiety is now likely to be responded to with anxiety, and fear with fear. What follows are efforts to manage anxiety and the circumstances that give rise to it. As we have seen, such efforts are unlikely to be successful in the long term. Instead, these apparent “solutions” create a host of life problems.

Linehan (1993) succinctly defined suffering as pain plus nonacceptance. In other words, what turns adversity and emotional pain into suffering is the nonacceptance of such pain. Sadness after a loss is pain. Fear, humiliation, and shame after experiencing repeated sexual assaults is emotional pain. Life unfortunately serves up these events, and it is normal and appropriate when we respond to such events with sadness and fear and make efforts to remedy the situation. Pain turns into suffering when we do not accept our emotional reactions to painful events. When we do not accept our feelings of apprehension and instead struggle to get rid of them, the pain of normal anxiety may turn into the suffering associated with disordered anxiety. Such suffering occurs when we don’t want to be hurt or fearful. Suffering manifests when we do not acknowledge and accept the reality of such experiences and instead act to avoid or escape from them. This leads us to become fearful about having fear and to experience sadness about being sad, and we start doing things to avoid our feelings.

Types of Control-Oriented Strategies

The following chart gives examples of control-oriented strategies that usually do not work in the long run. Such strategies are a natural consequence of unwillingness, and make little sense as a response to anxiety and fear in the context of willingness. They represent forms of experiential avoidance that may turn normal fear and anxiety into disordered fear and anxiety. We’ve included technical and nontechnical definitions for each strategy.

control-oriented strategies

Experiential Avoidance and the Anxiety Disorders

Anxiety disorders are characterized by experiential avoidance, which is defined as a tendency to engage in behaviors to alter the frequency, duration, or form of unwanted private events (i.e., thoughts, feelings, physical sensations, and memories) and the situations that occasion them (Hayes, 1994; Hayes et al., 1996). Unlike acceptance, experiential avoidance reflects a cutting off from human experience (both good and bad) and a commitment to follow a change agenda where it is not workable; namely in the realm of thoughts and emotions (Hayes, 2004a; Hayes et al., 1994).

Examples of Experiential Avoidance in the Anxiety Disorders

The lives of those suffering from anxiety disorders are replete with examples of experiential avoidance or nonacceptance. This common element may take different forms, but its function is the same across disorders, namely to not have anxiety. Clients with post-traumatic stress disorder, for example, often avoid or escape from physical sensations, reminders of the trauma, memories, and the effects of those events (i.e., flashbacks, dissociation, numbing, increased arousal, tension, disrupted interpersonal and occupational functioning), in an attempt not to have or experience them. Similarly, persons with specific phobias often “rationally” acknowledge that they should not be afraid and yet still avoid any verbal, physical, or other reminders of the phobic stimulus because they “must not” experience the fear that would be elicited by such stimuli.

Persons with panic disorder likewise respond to their own intense and benign symptoms of arousal (e.g., heart sensations, sweatiness) by fighting and resisting them as if they were threatening or dangerous and must not be had under any circumstances. Such individuals are quite literally fearful of experiencing their own fear. As a consequence, they often do everything they can to not experience fear by engaging in agoraphobic avoidance or by using anxiolytics and other drugs. Persons suffering from social phobias and generalized anxiety disorder also are unwilling to experience what are otherwise normal physical and emotional reactions. Concerns about social evaluation and failure or worries about everyday life problems, even when they are intense and exaggerated, are normal. They are normal so long as we allow them to be there and continue to do what needs to be done in our lives. Problems arise when we do not accept negative affect associated with those concerns and worries as they are, and instead act to avoid them. The same is true of persons struggling with obsessive-compulsive disorder, where the issue shifts to unwanted thoughts and needless rituals. As indicated in chapter 2, most people with OCD realize that their rituals are excessive and unreasonable. Yet they continue to engage in behavior that is designed to control or reduce their unwanted thoughts because they want to reduce the negative affect associated with them.

Thus, all the anxiety disorders have at least one fundamental thread in common; namely, persons do not like how they think and feel. As a result, they engage in behaviors to reduce, control, or avoid their anxious thoughts and feelings. The paradox, however, is that persons can never truly escape from or avoid their bodies or their psychological experiences. For instance, a man who panics in a mall and escapes outside takes his unwanted thoughts and emotional experiences outside with him. A woman with PTSD who experiences flashbacks seeing a man in the street who faintly resembles her abuser, and then turns around and runs to her car, takes her unwanted images and emotional experiences into the car with her.

Costs Associated with Experiential Avoidance

Experiential avoidance is a potentially self-destructive process that is associated with significant costs, the least functional and most significant of which is the taking of one’s own life. Suicide is the deliberate and purposeful act of terminating one’s life to escape pain and suffering. There is no good evidence that nonhuman species commit suicide (Hayes, Strosahl, & Wilson, 1999) nor any evidence that relief from pain follows suicide. Most major religions teach as much. Suicide will be met with eternal suffering in the afterlife, not bliss. There is no perspective taking, no relief, even for those who do not hold any religious beliefs. You are alive, and then you are dead.

There is ample evidence that humans, unlike nonhuman animals, will take their own lives to end pain and suffering, with suicide ranking as the eleventh leading cause of death in the United States (Centers for Disease Control, 2002). Though suicide rates in the anxiety disorders have been inconsistent across studies, a recent meta-analysis suggests that the risk may be greater than previously thought (Khan, Leventhal, Khan, & Brown, 2002). In fact, the rate appears to be over ten times greater in patients with anxiety disorders, regardless of the type of anxiety disorder, than age-adjusted rates found in the general population, which are .01 percent (= 1 in every 10,000 persons; Centers for Disease Control, 2002). These data point to the need to evaluate suicide risk in anxiety disorder patients. That risk, from an ACT perspective, increases as a person more rigidly and pervasively engages in experiential avoidance behavior.

Most anxious persons will not resort to suicide to end their struggle with anxiety and fear. Instead, they will live in the world and not fully participate in it. Avoidance and escape behavior gives the impression to an outsider that persons with anxiety disorders wish they were not fully part of the world. Yet this is typically not the case. Clients with anxiety disorders do want to go out and live a full, meaningful life. It is just that they are not willing to take their anxiety along with them on this path.

To illustrate, we saw a woman in our clinic who had been struggling unsuccessfully to control her worry and physical tension. Initially she viewed her worry, physical tension, and nervousness as the main problem in her life and the reason why she could not be happy and do the things she previously enjoyed doing. She was, however, an avid baker. Over the course of therapy, the therapist used the client’s baking activities to undermine her struggle to control and avoid by directly challenging this agenda in session.

Therapist: You said that you love to bake and that you are quite good at it.

Client: Oh yes, I’m quite a good baker.

Therapist: You also said that your worry and tension have been getting in the way of several meaningful activities in your life.

Client: Yes … It has been brutal … I wish I could get rid of it and move on with my life.

Therapist: From the sounds of it, I bet that your worry and anxiety must keep you from baking too. Also, I’d bet, given what you’ve said, that if I made you really anxious and worried you couldn’t bake a thing.

Client: Like hell! Nothing can keep me from baking when I want to.

Therapist: I see … So you can bake and think what you think and feel what you feel. Yet, somehow you can’t do other things because of how you think and feel. Is that true?

Client: Well … uh … not really.

From this point on in therapy, our client began to see her former solutions to her problems as problems in themselves, and eventually committed herself to doing the things she wanted to do and taking whatever thoughts and feelings she had along with her. A variety of experiential exercises, such as in vivo and imaginal exposure, were included to facilitate this process. Such exercises were used to help our client more fully experience her thoughts and feelings for what they are. In so doing, such exercises also likely had the indirect effect of changing the aversive functions of such events and, more importantly perhaps, her responses to them. As she told us during a six-month follow-up visit, “I used to cross bridges before I got to them. Now I don’t cross those bridges until there is a real bridge to cross. Then, I just deal with it and move on.”

The life problems that persons with anxiety disorders experience are, in one form or another, a direct consequence of the tendency for humans to suppress and avoid suffering. As indicated in the previous chapter, evaluative thinking and destructive language conventions largely fuel this tendency. Perhaps, humans do have an innate tendency to believe that we absolutely must not have discomfort, as Albert Ellis (2004) so vehemently states. In any case, avoidant-style coping is associated with a range of negative outcomes, including weakened immune system functioning, illness, and impairment in interpersonal, social, and occupational domains, overall poorer quality of life (Gross, 2002; Hayes et al., 1996; Pennebaker & Beale, 1986), and even greater mortality risk (Denollet et al., 1996). Impairments in social, interpersonal, and occupational functioning are manifestations of this struggle and control agenda and often the main reasons why persons with anxiety problems seek professional help. For example, a socially anxious person may avoid social interactions as a means to decrease anxiety. Typically, this strategy will result in temporary relief from anxiety, but it also comes with a more delayed cost of long-term social isolation (Leary, 1986). Experiential avoidance is a life-constricting type of behavior precisely because humans cannot avoid their psychological experience of the world. Our emotions and thoughts do not force us to behave in certain ways, they only make it more likely that we will do so (Gross, 2002). It is what we do with them that counts!

Unwillingness to Struggle

Below is a very simple metaphor that illustrates the negative consequences that follow from being cut off from the experience of pain and struggle. Your clients may see a bit of themselves in this story, particularly in how they may rely on others to help them control their experience of anxiety and fear. Here, however, the issue is not about fighting back, but rather about allowing struggle to occur as a normal process underlying health and wellness.

The Moth Metaphor

A man found a cocoon of an emperor moth. He took it home so that he could watch the moth come out of the cocoon. __On the day a small opening appeared, he sat and watched the moth for several hours as the moth struggled to force its body through that little hole. Then it seemed to stop making any progress. It appeared as if it had gotten as far as it could and it could go no farther. It just seemed to be stuck. __Then the man, in his kindness, decided to help the moth. So he took a pair of scissors and snipped off the remaining bit of the cocoon. The moth then emerged easily, but it had a swollen body and small shriveled wings. The man continued to watch the moth because he expected that, at any moment, the wings would enlarge and expand to be able to support the body, which would contract in time. Neither happened! In fact, the little moth spent the rest of its life crawling around with a swollen body and shriveled wings. It never was able to fly. __What the man in his kindness and haste did not understand was that the restricting cocoon and the struggle required for the moth to get through the tiny opening was the way of forcing fluid from the body of the moth into its wings so that it would be ready for flight once it achieved its freedom from the cocoon. Freedom and flight would only come after the struggle. By depriving the moth of struggle, he deprived the moth of health.

Experiential Avoidance Differs from Our Typical View of Avoidance

Experiential avoidance is thought to function as a core psychological diathesis—a way of relating with oneself and the world—underlying the development and maintenance of several forms of psychopathology and human suffering more generally (Blackledge & Hayes, 2001; Hayes et al., 1996; Hayes & Wilson, 1994). It is a process related to how we go about influencing the emotions we have, when we have them, and how we experience and express them. As such, experiential avoidance is best described as one of several emotion regulation strategies (see Gross, 2002). As we describe below, experiential avoidance helps make the normal emotion of anxiety disordered and functions to maintain disordered experiences of anxiety and fear. That is, avoidance is both a risk factor for the development of anxiety disorders as well as a consequence of having anxiety disorders.

Avoidance as a Consequence of Anxiety Disorders

Most of us tend to think of avoidance as a response-focused emotion regulation strategy (Gross, 1998, 2002) that develops as a consequence of having an anxiety disorder. As such, avoidance serves to maintain anxiety-related problems by preventing opportunities for corrective emotional learning that would come about via direct experience (Dollard & Miller, 1950; Eysenck, 1987; Mower, 1939, 1960; Rachman, 1976; Solomon & Wynne, 1954). For instance, almost all persons suffering from anxiety disorders engage in activities designed to avoid, escape from, or limit the probability, intensity, and duration of experiencing anxiety and the contexts that occasion it (Barlow, 2002). As escape and avoidance behaviors tend to reduce anxiety (at least temporarily), they are thought to maintain and exacerbate anxiety-related problems via the process of negative reinforcement, thus setting up a vicious self-perpetuating cycle (Bouton et al., 2001). This is why exposure techniques are at the core of all cognitive behavioral therapies of anxiety disorders. Such techniques are designed to counteract covert and overt forms of avoidance and escape behavior by promoting approach behaviors in a structured way. The general goal is to provide a context for corrective emotional learning (Forsyth & Eifert, 1998a).

Avoidance as a Diathesis for Anxiety to Become Disordered

Within the traditional cognitive behavioral account, avoidance follows from anxiety disorders. As we indicated in chapter 3, negative reinforcement maintains this cycle, in part, because it reduces the probability of experiencing aversive feelings and seemingly provides relief from such feelings following escape from situations that evoke them. This account makes sense if one starts from the perspective that too much anxiety, fear, and the like are problematic and need to be reduced. Now consider the possibility that a tendency toward experiential avoidance may be learned and may itself be problematic. Consider also that this tendency may function as a psychological diathesis that binds with anxious thoughts and feelings to send human beings down the road to an anxiety disorder.

The question, then, is why do we avoid feelings and thoughts as if they are the enemy? The learning of such avoidance starts very early, is pervasive, and is fundamentally built into the very nature of human language and cognition. In Westernized societies, the typical and acceptable response to unpleasant thoughts and feelings is often to change or get rid of them (Blackledge & Hayes, 2001). Our culture (parents, schools, the media) teaches that some thoughts and feelings (happiness, pride) are good and that other thoughts and feelings (anxiety, sadness) are bad and should be eliminated or at least minimized. From the time we are little children, we are taught that we can and should control what we think and how we feel, particularly those negative thoughts and feelings. For instance, the little boy who cries on the playground is told, “Pull yourself together; don’t be a baby.” Just think of how many times you have heard parents or teachers saying things like, “Don’t worry, there’s no reason to be afraid,” or “Stop crying, or I’ll really give you something to cry about.” The crying child now learns to be a mute child, and to hide emotional pain. What we are left with is a silent child who may be suffering inside. Through these and other experiences, children and adults quickly learn to regulate the experience and expression of their emotions in the eyes of others. Emotion regulation tendencies do not emerge in the absence of other people. The sky, the earth and the objects and animals that inhabit it have no stake in what humans think and feel at any moment—only humans do.

From an ACT perspective, social learning creates a context where forms of experiential avoidance and nonacceptance can thrive (Hayes, Strosahl, & Wilson, 1999). Here, the stakes are quite high. Emotional regulation is used as evidence of maturity, emotional stability, health and wellness, success, fulfillment, and happiness. We typically do not question what life might be like if unpleasant emotions and thoughts were treated simply as events to be experienced as part of being fully human, and not as “things” to be managed and controlled (cf. Blackledge & Hayes, 2001). We do not question the cultural mandate that equates failures of emotional regulation with suffering and misery. We leave unchallenged the generally accepted cultural view that connects “positive” thoughts and feelings with an ability to engage life to its fullest. In this cultural context, anxious thoughts and feelings become obstacles to living and the achievement of valued goals. They are reasonable justifications for inaction and are quite often fused with our sense of self-worth (e.g., “I’m not good enough,” “Something is wrong with me,” “I’m an anxious person,” “I am broken”). Thus, the feelings and thoughts must be managed and controlled, even if that control comes at significant cost to the individual.

Emotional avoidance is a natural outcome of this process and represents a predisposition that people use to cope with anxious thoughts and feelings, some more so than others. As we describe in later chapters, this is the general system or diathesis that an ACT approach seeks to undermine. The strategies used to “not have” anxious thoughts and feelings are the problems. This, by the way, may include use of medications and psychosocial treatments for anxiety (including some of the skills taught in cognitive behavioral treatments) that aim to help clients reduce or eliminate unwanted anxiety and fear. Such treatments, from an ACT perspective, are part of a larger problem-solving control-oriented strategy that does not work as a long-term solution (Hayes et al., 1996). Remember, it is what we do with anxiety and fear that counts!

Anxiety Disorders Are Experiential Avoidance Disorders

From an ACT perspective, anxiety becomes disordered when persons:

§    do not accept the reality that they will experience certain emotions, thoughts, memories, or physical sensations they do not like;

§    are unwilling to be in contact with such emotions, thoughts, memories, physical sensations, and behaviors as they are;

§    take deliberate steps to alter their form and frequency or the circumstances that occasion those experiences; and

§    do so rigidly and inflexibly even at significant personal and interpersonal cost (cf. Forsyth, 2000; Forsyth & Eifert, 1996, 1998a; Friman et al., 1998; Hayes et al., 1996).

These four behavioral predispositions, and the verbal-cognitive processes that guide their regulation, are at the core of understanding the development and maintenance of anxiety disorders and figure prominently in the ACT approach to treatment. Anxiety becomes problematic when we do not accept its presence, when we are unwilling to have it, when actions are geared toward not having it, and when such actions disrupt or impede movement toward valued goals (Blackledge & Hayes, 2001; Wilson & Murrell, 2004). This sequence is illustrated somewhat humorously in figure 2. It nicely captures the ACT model of psychopathology and the essence of an ACT approach.

road to the mountains

The road to the mountains depicts going in the direction of what is important in life for the client. You can actually show clients this picture when you talk about the effects and costs of experiential avoidance: “Imagine you are driving through life on a long winding road toward a mountain. Let’s call this mountain your ‘Value Mountain.’ It represents everything you care about in your life and what you want to be about as a person. This is the place you want to go. Suddenly anxiety jumps out and blocks the road. You slow down, and try to avoid hitting anxiety. So, you quickly turn right, and find yourself on the ‘emotional avoidance’ detour. Note how experiential avoidance functions here. You are trapped in a loop, going round and round, and getting nowhere. You are sidetracked, stuck, and miserable as a consequence.”

This loop is disruptive precisely because it neither works as a solution to anxiety (e.g., it doesn’t make it more bearable, go away, or less likely to recur) nor is it a way most persons would choose to live. As we outline in later chapters, ACT attempts to undermine this struggle and change agenda by breaking the cycle of avoidance and control. All ACT strategies promote greater psychological flexibility, that is, a willingness to participate in life fully and a commitment to go in the direction of personal values. Note that controlling, getting rid of, and replacing anxious thoughts and feelings play no part within the ACT model of treatment. Clients can take them, along with other thoughts and feelings, on their ride through life.

Evidence Supporting Experiential Avoidance as a Toxic Diathesis

To show that emotional avoidance functions as a behavioral diathesis and risk factor for anxiety-related pathology, it is important to demonstrate that this predisposition functions to exacerbate aversive emotional responses in individuals with no known history of psychopathology. Consistent with this view, we have shown that greater predispositions toward emotional avoidance (as assessed using the Acceptance and Action Questionnaire; Hayes, Strosahl, et al., 2004), including the deliberate application of instructed emotion regulation strategies (i.e., emotion suppression), result in more acute emotional distress, but not greater autonomic reactivity (Feldner, Zvolensky, Eifert, & Spira, 2003). This study is important, for it is the first to show that emotional avoidance and emotion regulation strategies potentiate experimentally induced acute episodes of emotional distress (i.e., induced via panicogenic inhalations of 20 percent CO1-enriched air). Most notably, such effects were shown in healthy individuals with no known psychopathology.

We have since replicated these findings and found that emotional avoidance, but not other psychological risk factors for panic (e.g., anxiety sensitivity), tends to covary with more severe panic response, even in healthy individuals (Karekla, Forsyth, & Kelly, 2004). After several trials of inhaling CO1-enriched air, individuals high in experiential avoidance reported more panic symptoms, more severe cognitive symptoms, and more fear, panic, and uncontrollability than their less avoidant counterparts. Interestingly, as in all previous studies we conducted in our labs, the magnitude of autonomic responses did not discriminate between groups. Only one study that we know of has shown a relation between experiential avoidance and physiological reactivity to pleasant, unpleasant, and neutral film clips. In that study, persons with a greater predisposition toward experiential avoidance tended to experience their positive and negative emotions more intensely, but also showed greater heart rate suppression to unpleasant stimuli relative to their less avoidant counterparts (Sloan, 2004). These studies provide further strong evidence that experiential avoidance exacerbates aversive emotional responses and may constitute a risk factor for the development and maintenance of anxiety disorders.

Collectively, the work discussed above and other related studies (Hayes et al., 1996) suggests that a rigid repertoire of emotional avoidance may constitute an important psychological diathesis and risk factor for the development, maintenance, and potential exacerbation of anxiety-related problems. Simply put, “If you don’t want it, you’ve got it.” It is for this reason that experiential avoidance and control efforts must become a primary treatment target.

Summary of Key Concepts

This chapter began with a simple metaphor of two mice trapped in a life-or-death struggle. We end with the view that this struggle, when applied to unpleasant thoughts and feelings and the circumstances that might occasion them, is the toxic process that underlies a good deal of human suffering. Nonacceptance and the struggle with anxiety are, in a real sense, what makes anxiety disordered. Addressing this struggle head-on is what an ACT approach to treatment is about. In the process, clients learn how to experience their anxious thoughts and feelings in a new, less frightening way, as they are. The therapeutic prize here is to foster greater psychological flexibility and choice and a willingness to contact a full range of human experience as it is, always with an eye on helping clients move in valued life directions. As clients learn to give up the struggle and control change agenda, they are no longer owned by it or their unwanted experiences. They are free to live. This somewhat counterintuitive notion builds upon the model we outlined earlier, where feeling good is not a necessary requirement for living good.