Experiential avoidance and its importance in psychopathology

Experiential avoidance refers to the phenomenon that occurs when an individual is unwilling to remain in contact with uncomfortable internal experiences such as thoughts, memories, emotions, physiological sensations and behavioural dispositions (Hayes et al., Reference Hayes, Wilson, Gifford, Follette and Strosahl1996). Experiential avoidance may be actively achieved via any number of unhelpful cognitive (e.g. suppression) or behavioural (e.g. procrastination) strategies, with the suggestion that experiential avoidance mediates the relationships between maladaptive coping responses and psychological distress (Chawla and Ostafin, Reference Chawla and Ostafin2007). For example, it has been reported that suppressing emotions not only leads to increased physiological arousal, but also does not provide relief from the subjective experience of that emotion (Gross and Levenson, Reference Gross and Levenson1997). Suppressing emotions may also result in cognitive impairment, unhelpful behaviours and interpersonal difficulties (Gross and Levenson, Reference Gross and Levenson1997), as well as contribute to increased anxiety, psychosomatic complaints and difficulties with substance use (Power, Reference Power and Power2010).

Indeed, experiential avoidance has been reported over recent years to be a transdiagnostic maintenance factor across a range of psychological disorders (Chawla and Ostafin, Reference Chawla and Ostafin2007; Michel et al., Reference Michel, Rowa, Young and McCabe2016). Difficulties with tolerating distress have been shown to be correlated with generalised anxiety disorder (GAD; Macatee et al., Reference Macatee, Capron, Guthrie, Schmidt and Cougle2015) as well as depressive and worry symptoms (Macatee et al., Reference Macatee, Albanese, Allan, Schmidt and Cougle2016). Similarly, a greater capacity for tolerating distress has been found to be negatively associated with anxiety sensitivity and intolerance of uncertainty, and therefore with GAD, social anxiety disorder (SAD) and obsessive-compulsive disorder (OCD; Laposa et al., Reference Laposa, Collimore, Hawley and Rector2015). Maladaptive attempts to avoid or suppress distressing emotions can lead to an increased experience of those emotions, resulting in a maintenance cycle which prevents helpful emotional processing or habituation (Barlow, Reference Barlow2011). Similarly, the acceptance of negative emotional experiences has been indicated as a potential protective factor against the development of depressive symptoms (Shallcross et al., Reference Shallcross, Troy, Boland and Mauss2010). Overall, emotional acceptance and expression have been linked to better coping and decreased distress even during times of adversity (Stanton et al., Reference Stanton, Danoff-Burg, Cameron, Bishop, Collins, Kirk, Sworowski and Twillman2000). In line with this, Macatee et al. (Reference Macatee, Albanese, Allan, Schmidt and Cougle2016) found that clients with depression and anxiety may benefit from interventions designed to improve distress intolerance.

The significance of experiential avoidance in CBT

A central tenet of cognitive behavioural treatment is to help the client reappraise unhelpful thoughts and behaviours that serve to maintain their psychological difficulties (Beck, Reference Beck1989). Whilst the cognitive-behavioural approach is widely supported by the evidence base across different psychopathologies, research tends to lack investigation into the effectiveness of specific cognitive-behavioural strategies (Bennett-Levy et al., Reference Bennett-Levy, Westbrook, Fennell, Cooper, Rouf, Hackman, Bennet-Levy, Butler, Fennell, Hackman, Mueller and Westbrook2004). Despite this, there is emerging evidence that those interventions that lack an experiential component are less effective than those that do (Bennett-Levy, Reference Bennett-Levy2003). For example, belief change has been found to be more effective when utilising behavioural experiments (i.e. testing a belief via active experimentation) as opposed to utilising verbal or written evaluation methods only (Bennett-Levy, Reference Bennett-Levy2003; McManus et al., Reference McManus, Van Doorn and Yiend2011). One explanation for these findings is that interventions which incorporate an experiential component (and therefore emotional activation) allow the client to process information at a deeper ‘implicational’ level (Teasdale, Reference Teasdale, Clark and Fairburn1997), rather than at an intellectual or rational level which may be less effective in facilitating change (Bennett-Levy et al., Reference Bennett-Levy, Westbrook, Fennell, Cooper, Rouf, Hackman, Bennet-Levy, Butler, Fennell, Hackman, Mueller and Westbrook2004). Essentially, cognitive-behavioural intervention should aim for a unification of ‘head and heart’, whereby the client not only knows an alternative perspective, but also believes it – a process achieved via experiential learning. Therefore, whilst CBT is not primarily conceptualised as functioning via emotional processes per se, there is growing evidence that emotional processing is fundamental to psychological change and recovery (Baker et al., Reference Baker, Owens, Thomas, Whittlesea, Abbey, Gower, Tosunlar, Corrigan and Thomas2012). This is supported by research demonstrating the efficacy of Barlow et al.’s (Reference Barlow2011) Unified Protocol (UP) (Carlucci et al., Reference Carlucci, Saggino and Balsamo2021), an emotion-focused cognitive-behavioural treatment which focuses on reducing emotional avoidance and facilitating appropriate emotional processing (Wilamowska et al., Reference Wilamowska, Thompson-Hollands, Fairholme, Ellard, Farchione and Barlow2010). Concordantly, reduced experiential avoidance has been shown to be significantly associated with reductions in anxiety as a function of CBT treatment (Eustis et al., Reference Eustis, Cardona, Nauphal, Sauer-Zavala, Rosellini, Farchione and Barlow2019), although less so than third-wave approaches such as acceptance and commitment therapy (ACT) which target this directly (Arch et al., Reference Arch, Eifert, Davies, Vilardaga, Rose and Craske2012; Niles et al., Reference Niles, Burklund, Arch, Lieberman, Saxbe and Craske2014). Implicitly, it may therefore be inferred that those clients presenting for CBT treatment who have difficulties with experiential avoidance are at risk of reduced benefit should this not be addressed as part of treatment.

What about therapist experiential avoidance?

Whilst there has been some investigation into the role of client experiential avoidance in maintaining psychological difficulties, until more recently there has been less focus on therapist experiential avoidance and how this might impede psychological treatments. Some authors suggest that in the same way that client beliefs about emotions can be problematic, therapist beliefs about emotions can also be detrimental to the therapy process (Leahy, Reference Leahy2016). The importance of therapists identifying their own schema and reflecting upon the potential impact on their therapeutic work with clients has been variously documented in the CBT literature (Haarhoff, Reference Haarhoff2006; Leahy, Reference Leahy2001; Presley et al., Reference Presley, Jones and Newton2017; Young et al., Reference Young, Klosko and Weishaar2003). Accordingly, the implementation of self-practice and self-reflection (SP/SR) has been more strongly advocated, with the experiential element of this shown to be particularly useful during CBT training (Bennet-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001; Bennet-Levy et al., Reference Bennett-Levy2003). For example, research suggests that engagement in SP/SR can improve the technical aspects of therapy such as CBT formulation skills (Haarhoff et al., Reference Haarhoff, Gibson and Flett2011) as well as interpersonal effectiveness (Bennett-Levy and Thwaites, Reference Bennett-Levy, Thwaites, Gilbert and Leahy2007).

Indeed, experiential learning is a fundamental component of adult learning theory (Kolb, Reference Kolb1984) which is integral to CBT training. This theory suggests that personal development is achieved via a four-stage process which includes active experimentation and felt experience, as well as more passive observational and conceptual modes of learning. The Declarative-Procedural-Reflective (DPR) model developed by Bennett-Levy (Reference Bennett-Levy2006) focuses on understanding therapist skills development specifically, with evidence that experiential learning is key to developing the ‘procedural’ or ‘professional artistry’ skills in particular (Bennett-Levy et al., Reference Bennett-Levy, McManus, Westling and Fennell2009; p. 573). In line with these theoretical conceptualisations, authors have suggested that therapist experiential avoidance is detrimental to their learning experience in training. For example, Lombardo et al. (Reference Lombardo, Milne and Proctor2009) suggested that therapist emotions are important in the process of learning and its transfer to practice, whilst Milne and Reiser (Reference Milne and Reiser2017) highlighted that supervision should include the same experiential methods that are fundamental to effective CBT treatment. It is noted that trainee therapists will likely experience anxiety as part of the training experience, for example due to feeling deskilled or having concerns about making mistakes with clients, but that these anxieties should be resolved via experiential learning strategies (Reiser and Milne, Reference Reiser and Milne2013) rather than collusion or avoidance (Milne et al., Reference Milne, Leck and Choudhri2009). Therapist experiential avoidance may therefore impede the learning process during training (for example by avoiding active learning opportunities such as role-rehearsal or direct observation of skills), in the same way that client experiential avoidance may impede their progress in therapy.

In addition to undermining the learning experience during training, therapists’ desire to avoid personal discomfort has been suggested as a contributing factor in poorer execution of key CBT skills such as homework setting (Haarhoff and Kazantzis, Reference Haarhoff and Kazantzis2007), as well as resulting in the avoidance of behavioural change strategies (Meyer et al., Reference Meyer, Farrell, Kemp, Blakey and Deacon2014) and the selection and implementation of evidence-based interventions such as imagery (Bell et al., Reference Bell, Mackie and Bennett-Levy2015), and exposure therapy in OCD (Scherr et al., Reference Scherr, Herbert and Forman2015), even beyond training. It has been proposed that CBT requires both the therapist and the client to tolerate a degree of uncertainty as part of the treatment process; therapists unable to do so may engage in safety behaviours which reduce their own anxiety, but also inadvertently impede their competence (Waller and Turner, Reference Waller and Turner2016). Moreover, Leahy (Reference Leahy2015) suggested that unhelpful therapist beliefs about emotions may result in problematic approaches to therapy such as over-emphasising rationality and implying that painful emotions are problematic. This may be accompanied by a didactic and lecturing interpersonal style contrary to effective guided discovery (Padesky, Reference Padesky1993), with inadequate session pacing to allow for emotional exploration (Leahy, Reference Leahy2015). This is supported by research demonstrating that therapist interactions laden with a high frequency of cognitive speech were found to be negatively related to emotional processing and treatment outcome (Anderson et al., Reference Anderson, Bein, Pinnell and Strupp1999). Interestingly, research to elucidate the frequency of therapists expressing their emotions by crying in therapy (TCIT) found that cognitive-behavioural therapists were significantly lower in TCIT tendency than all other therapeutic modalities investigated (Blume-Marcovici et al., Reference Blume-Marcovici, Stolberg and Khademi2013). Indeed, a noted limitation of CBT more generally is the propensity for intellectualising emotional experiences and favouring an educational approach rather than one that allows exploration of affect (Mackay et al., Reference Mackay, Barkham, Stiles and Goldfried2002); unhelpful beliefs about emotions resulting in therapist experiential avoidance may compound this notion as part of CBT training and beyond.

In summary, there are a number of assertions in the CBT literature which suggest that therapist experiential avoidance may impede learning opportunities during CBT training, and result in unhelpful approaches to CBT practice. It may therefore be that both of these factors impact upon therapist effectiveness across a number of key CBT competences. Despite this, there is a paucity of empirical research that directly examines the relationship between aspects of trainee therapist experiential avoidance and developing clinical competence in CBT skills. The aims of this preliminary study were therefore twofold:

1. (1) To estimate the incidence of experiential avoidance amongst a sample of trainee CBT therapists;

2. (2) To test the following hypotheses:

   1. (a) Therapist experiential avoidance is associated with overall observed clinical competence during CBT training;

   2. (b) Cognitive and behavioural aspects of therapist experiential avoidance are associated with observed clinical competence in specific CBT skills during training.