Beyond avoidance of people, places, or activities, avoidance as a psychological process refers to the various ways a person distances themselves from intolerable thoughts, feelings, memories, wishes, fantasies, etc. If the avoidance is very effective at its job, then the whole process may be kept out of a person’s awareness for maximum self-protection. As a result, both patients and therapists are susceptible to avoidance dynamics in the therapy without recognizing it, especially if one or both individuals are in fact working very hard with good intentions, and therapy has the “look” of being productive. However, if the avoidance remains outside of awareness, that hard work will not lead to meaningful gains, leaving patient and therapist feeling stuck, confused, disappointed, and possibly resentful.

Thinking and Doing as Avoidance: The Patient

Therapy tends to include at least some elements of insight, psychoeducation, and supporting rational thought (thinking). Moreover, patients often benefit from various strategies like behavioral activation, engaging with fulfilling life activities, and maintaining physical activity (doing).

However, for some patients and some presenting problems, these useful elements and strategies function as avoidance-based coping, where the thinking and doing act as barriers to connecting with painful emotions or practicing healthy vulnerability and reliance on others. These patients may be very motivated, diligent with skills practice and homework, and eager to learn from the expertise of the therapist. Yet, if there is little to no change in the person’s quality of life despite these markers of positive engagement, it is a good sign to consider whether there are parts of the patient’s life and self that are being kept at bay by their “productivity.”

Patients who:

• tend toward emotional overcontrol (RO-DBT),
• are highly conscientious (Big 5 personality trait),
• who have an obsessive and/or compulsive personality style (psychodynamic conceptualization),
• who lean more toward a dismissive/avoidant attachment style,
• and/or who frequently use intellectualizing or rationalizing defenses

are more likely to fall into the trap of seemingly productive therapy.

Thinking and Doing as Avoidance: The Therapist

Therapists are not exempt from this type of avoidance. Just as the patient may enjoy the comfort of thinking and doing, therapists, too, may feel at ease in the realm of education and skills work and thereby participate in avoiding subjects and approaches that facilitate greater uncertainty, discomfort, and intimacy when necessary.

One study actually linked therapists’ anxiety, specifically death anxiety, to their preferred theoretical orientation, finding that therapists who experienced greater death anxiety preferred more rational and intellectual approaches than approaches that are more subjective, such as existential and humanistic therapies (Belviso & Gaubatz, 2013). Another study identified that therapists higher in experiential avoidance were less likely to recommend exposure treatment for obsessive-compulsive disorder (OCD; a “gold-standard” treatment) for patients who presented as clear candidates for the therapy (Scherr et al., 2015).

As such, it is crucial that therapists learn to recognize their own anxiety and defensive processes. Investing time for reflection and case conceptualization, consultation, supervision, and/or personal therapy are not optional activities for effective therapists. Processes within the therapist impact clinical decision-making, and thus, it is the therapist’s responsibility to make these processes unobtrusive to the work.

Places to Look for Therapeutic Inspiration

It is not within the scope of this post to offer a thorough consultation on how to therapeutically work with either the patient’s or the therapist’s avoidance; however, there are some modalities that may serve as initial inspiration to begin approaching avoidance dynamics.

Acceptance and commitment therapy (ACT), as its name implies, offers skills that promote approaching and accepting pain without getting “fused” with it or fruitlessly fighting to change it. Radically open dialectical behavior therapy (RO-DBT) was designed for emotionally overcontrolled individuals, whose difficulty with emotional experience and expression interferes with their relationships, self-esteem, and general functioning. Compassion-focused therapy (CFT) works to foster compassionate awareness of one’s pain and suffering and promotes the development of self-soothing capacities while easing issues with self-criticism and shame.

Of course, the wellspring from which all modern therapies have sprung, psychodynamic psychotherapy (PDT), and its specialized offspring (transference-focused psychotherapy [TFP], mentalization-based therapy [MBT], intensive short-term dynamic psychotherapy [ISTDP], and accelerated experiential dynamic psychotherapy [AEDP]) are naturally well-suited to uncovering and working with material that is kept out of awareness (avoided) to facilitate patients’ agency and well-being in relation to themselves and others, work, and play.