I recently read an article in The Washington Post by psychologist Luana Marques entitled “Avoidance, Not Anxiety, May Be Sabotaging Your Life.” The article wasn't about post-traumatic stress, per se, but as a therapist specializing in PTSD, which is a trauma- and stressor-related disorder, its contents rang all too true for me: One of the main ways in which trauma survivors cope with the anxiety that frequently accompanies remembering some part of their trauma is to avoid reminders of it altogether.
However, the effects of avoidance can be significant. Over time, you may end up getting more and more worried about the day when you might have to face what bothers you, because your mind is very good at coming up with bad things that could happen. (Remember that there may be a reason you entered the helping or service field that you did—your vivid imagination allows you to anticipate different bad things that can happen to people, strategize for them, and act to prevent them.)
Another reason why avoidance can increase anxiety is that staying away from a stressful situation can send a message to your brain and body that the situation is dangerous. A young child learns through experience to stay away from fire or a hot stove because he might have touched the stove and felt pain. Avoiding the stove afterwards reinforces an important lesson: It's not a good thing to get too close to.
The problem, of course, arises when we avoid things that aren't inherently dangerous. If you survived a shooting in which your attacker wore a black hat, that doesn't mean that the black hat was dangerous—just the particular person wearing it. So, you could be missing out on something when a potential business connection comes up to you wearing a black baseball hat, and you flinch and later avoid his calls.
Finally, people who avoid important opportunities can experience a drop in self-esteem. The message you might think, or on some level feel, is, I can't do hard things. That is sometimes the most insidious effect of avoidance, in my view.
Research bears out the potential harms of avoiding situations that trigger you, as well as the value of gradually approaching them. For example, one study of more than 1,000 military veterans receiving PTSD treatment found that those who used avoidance more frequently at the outset of treatment tended to have more severe PTSD symptoms at the end. Meanwhile, a study of 92 adults with chronic PTSD found that roughly half experienced significant reductions in distress associated with trauma reminders when they faced these reminders through treatment. These findings suggest that avoidance can help maintain PTSD symptoms, while learning to approach trauma reminders in a safe, structured way can help reduce them.
So what do I mean when I keep saying that you should approach and not avoid?
For one, some forms of therapy involve making a structured plan with your therapist to do things that you want to do, but cannot because they feel too scary or uncomfortable. For example, maybe you don't like taking your child to the playground because the sounds of children screaming with joy as they go down the slide remind you of children's terrified screams in Iraq.
I would probably not advocate that you “just do it,” or go right to the playground, à la Nike. But looking at pictures of the local playground on Google Maps for a minute—and then two, and three—could be a great start. From there, you might work toward visiting the playground when it's empty, and eventually when children are playing.
One process that can occur during this kind of gradual exposure is called habituation, or a reduction in distress as you encounter something repeatedly. Another important process is inhibitory learning: discovering through experience that something you associate with danger isn't necessarily threatening in the present. Your nervous system can gradually learn that the sound of children screaming on a playground is not the same as the sound of children screaming in a war zone.
There are many ways to approach instead of avoid, some of them doable right in a therapy session, by talking about what happened or processing memories of what happened through approaches such as Eye Movement Desensitization and Reprocessing (EMDR), for example. Different evidence-based PTSD treatments use different methods, but many help people reduce the power that traumatic memories and reminders have over their lives.
When you do decide to embrace approach over avoidance, the results can be life-changing. You can realize that what seemed dangerous is not necessarily so. You might become better able to distinguish between the past, when your trauma happened, and the present, when the same danger may no longer exist. And you might open up new opportunities for yourself, such as taking your child to the playground or pursuing a new job opportunity.
Finally, you might experience a renewed and strengthened sense of self based on the knowledge that you have done something challenging that once seemed impossible. Sometimes, this kind of change can contribute to what psychologists call post-traumatic growth, or positive psychological changes that emerge through struggling with the aftermath of trauma. Not everyone experiences post-traumatic growth, and it isn't a requirement for recovery. But regaining confidence in your ability to face difficult things can be profoundly satisfying.
And that is something I find especially rewarding to witness as a therapist.
About the Author: Andrea Mazzarino, LCSW-C, PhD, is a licensed clinical social worker and trauma therapist providing individual psychotherapy and mental health counseling to adults and adolescents in Maryland, Virginia, Washington, D.C., Florida, and Minnesota. Through her private practice, Windy Creek Therapy, she specializes in PTSD, trauma recovery, anxiety, and stress-related disorders, using evidence-based approaches including EMDR therapy, cognitive behavioral therapy (CBT), and mindfulness-based interventions. She offers in-person therapy in Montgomery County, Maryland, and online therapy for clients in states where she is licensed.
