This book was written to illuminate and clarify the pivotal role patterns of avoidance have on the development and maintenance of depression. All too often this author has seen both laypersons and professionals view and treat people suffering from chronic depression as if their condition is something they are simply born with, an attitudinal problem, or a condition caught like some type of disease. Consequently, their symptoms of depression tend to receive minimal or superficial treatment in the form of antidepressant medication or “pep talks” aimed at getting them out of their chronic state of discontent. Unfortunately, these simple answers to complex issues tend to miss the core causes of how they became depressed in the first place and/or what is preventing them from getting out of their misery. This book focuses on the common causes of chronic depression, including patterns of avoiding responsibility, stress, more realistic perspectives, acceptance of key aspects of living, as well as inappropriate escape patterns such as excessive use of drugs, eating disorders, compulsive gambling, etc. Research completed by the author on the relationship between patterns of avoidance and chronic depression is reviewed, along with pertinent case study examples of how his clients backed themselves into depression and either successfully emancipated themselves from this psychological prison or continued to languish within such. Finally, the critical roles of acceptance and purposeful living will be discussed, including 32 acceptance guidelines proposed by the author for those interested in self-help or application in the service of others. This book was written at a level appropriate for educated laypersons, undergraduate and graduate students in psychology and related fields, as well as people considering counseling or currently in psychotherapy. Additionally, it was written for practitioners in the mental health field who want a resource at a basic level which blends both traditional theories and therapies with more contemporary approaches, such as Acceptance and Commitment Therapy.
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How They Become and Remain Depressed
By Michael A. Church
AuthorHouseCopyright © 2016 Michael A. Church, Ph. D.
All rights reserved.
The Power of Avoidance Forces
Do you ever question why there are so many people taking antidepressant medication, many of whom seem to have pretty good lives? Do you wonder why some people linger with depression for so long, even though they have taken numerous medications? And, why do you think that some people bounce back from depression so well while others don't get up from what seems to be relatively weak blows? These and other related questions should not seem so vague and difficult to understand after reading this book. It took a very long time for medicine to abandon the idea that fever, bleeding, coughing, etc., were not the disease process. So too, psychology is now focusing more on the core causes of psychological distress and disorders, as opposed to symptoms such as depression. Although it is certainly tempting to view depression, anxiety, eating disorders, gambling and drug/alcohol abuse and other psychological problems as the "illness," more careful and closer examination reveals that these psychological difficulties are usually associated with consistent underlying causations, particularly patterns of avoidance and escape. In other words, these disorders are typically "side effects" of maladaptive coping styles inherent in personality functioning. The importance of this distinction cannot be underestimated because it guides how we interpret and treat various psychological problems. When we simplistically see symptoms as the psychological problem, there is a tendency to resort to short-term palliative treatments while failing to focus on core causations of the so-called disorder(s). We may view the gambler or alcoholic as a victim of being born with a disease. Or, we may simply see the sufferer as having to cope with genetically driven anxiety or depression which permanently affects their functioning, and is best treated with medication. Some might even view the depressed person as lacking the courage to change or adapt constructively. These orientations may not only help undermine responsibility and active coping on the part of the sufferer but, at the same time, suggest that superficial answers are the most appropriate way to perceive them. At best, medication is a general approach to specific problems and treats symptoms (Church & Brooks, 2010). Does anyone really believe that psychiatric medication goes to specific areas of the brain and fixes, repairs or adjusts the neurons or brain centers involved in various behavior problems? Moreover, medication often fails to produce positive effects and/or causes negative ones (e.g., side effects) while leaving the underlying cause(s) unexposed. Frequently, symptoms return when medication is curtailed.
A symptom-disease approach tends to be appealing to many physicians, patients, family members, and even some insurance and pharmaceutical companies. It seems cheaper in the short-run, convenient, tends to relieve feelings of responsibility on the part of the sufferer, offers a quick fix approach to the wishful thinker, and promises less effort up front. We know that insurance companies are under intense pressure to show profitability in the short run, leaving them less and less concerned about what is in the in the best long-term interest of the patient. Sadly, it often leaves the patient suffering with subpar and narrowly focused treatments. More to the point, treatment of effects rather than causes is likely to be superficial at best and, at worst, leads to more intense feelings of helplessness, hopelessness and demoralization while delaying treatment targeted at underlying causes of their problem(s). In some cases this type of ineffectiveness may even help facilitate suicide ideation and/or behavior (Church and Brooks, 2009).
After performing individual and group psychotherapy for several decades with people suffering from depression and many other psychological disorders, it became evident that traditional cognitive-behavioral psychotherapy was only minimally effective with some clients, particularly those suffering from chronic psychological disorders. Simply getting clients to substitute more rational and constructive thoughts and behaviors for presumably distorted, illogical or self-defeating ones was often ineffective or only yielded partial positive changes.
We are all aware of the power of motivation in both causing and sustaining our behavior patterns. We all experience the motivational conflict of both been drawn toward (approach) and away from (avoid) a goal or outcome. Clearly, we cannot obtain our desired outcomes when we are unable to approach and complete goal-directed behaviors. If this type of behavior pattern becomes consistent, then we are almost assured of being dissatisfied. Of course, it seems reasonable to ask why a person capable of logical and rational thought would routinely avoid seeking important goals. Fortunately, there is relevant research bearing on this question, some old and some new. Many decades ago, Dollard and Miller (1950) demonstrated that, as we get closer to a goal object, avoidance forces accelerate in strength faster than approach forces. The resulting effect of this phenomenon is that we may "chicken out" just prior to engaging in goal directed behavior, even in the face of something greatly desired. Another relevant and related research finding is that unpleasant events tend to be more powerful than pleasant ones (Baumeister, et. al., 2001). For example, it is been estimated that, generally speaking, for most people winning $1000 has about the same emotional intensity as losing $200. Thus, it becomes easy to see why we may be hesitant to approach goals that are associated with negative emotions, such as anxiety and fear. Although we have a strong desire to obtain certain goals, we can be overwhelmed by the anticipation of unpleasant feelings (e.g., anxiety) of stressful (e.g., fear) or painful events. To place this conceptual framework in another context, although we are social animals who desire affection and intimacy, the anxiety and fear related to rejection, embarrassment and/or disapproval renders many of us to loneliness, alienation and withdrawal. It is, of course, understandable that we usually try to avoid the unpleasantness caused by psychological and physical pain. Moreover, avoidance of pain is wired into our biology because it tends to enhance survival potential. Thus, we naturally tend to avoid fire, things that smell and taste horrible, people who could harm us, etc. However, when patterns of avoidance are inappropriate and/or excessive, the probability of psychological maladjustment increases and survival potential may very well decrease. Clearly, we need to know when it is imperative to confront painful experiences, even when our natural propensity is to avoid or escape (e.g., surgery). As will become clear, realistic confrontation of life stressors generally leads to development of better adaptive skills, more self-confidence, healthier relationships and greater life satisfaction. Contrariwise, excessive patterns of avoidance lead to opposite outcomes.
The critical significance of facing situations involving psychological pain helps us introduce an overlapping and key concept, acceptance. As will become clear throughout this book, we cannot untangle avoidance from acceptance. Fundamentally, we need to accept the realities of facing and enduring, as well as the negative outcomes that occur with excessive avoidance of such. A main theme of this book is that avoidance is the predominant cause and/or maintenance factor of most chronic psychological problems, including depression. Examples of this theme are seen in post-traumatic stress patients who do not want to discuss their dramatic experiences, drug/alcohol abusers who suppress their awareness of negative memories with psychoactive substances and other escape behaviors, eating disorder patients who displace their control issues with inappropriate and distracting food intake, gamblers who escape from their internal conflicts with compulsive acts, sexual compulsives who run away from intimacy and vulnerability, dependent personalities who continue to be indecisive and over rely on others, and people who escape into the world of the internet. The examples (contents) are almost endless but the themes (processes) are characteristically the same. That is, avoidance of some combination of thoughts, feelings and behaviors, along with associated lack of acceptance, combine as core issues which drive psychological disorders such as chronic depression. With respect to treatment, there will be clear articulations of how we can overcome persistent avoidance and lack of acceptance in the chapters to come.
What form does the lack of acceptance typically take? Generally, individuals engage in excessive lack of acceptance with respect to one or more of three aspects: themselves (Self), how they view and react to people (Others), and how they perceive living (Life). Certainly, it is expected that all of us will have trouble accepting some experiences. We hear about atrocities, learn a loved one has died, have relationship problems, etc. Clearly, it is natural to experience denial and/or a difficulty accepting stressful life experiences. Often, it takes a great deal of time and psychological work to truly accept traumatic realities at an emotional level. Most of us, most of the time, eventually come to accept the reality of our experiences and move on with our life in constructive ways and with more maturity. However, this process can be delayed significantly or indefinitely via inappropriate patterns of avoidance and lack of acceptance. In extreme cases we can become mired in dysfunctional patterns leading to chronic depression and cycles of self-defeating behavior. As implied above, this book will demonstrate how avoidance and acceptance issues are instrumental in causing and sustaining most psychological problems. Whereas the bulk of material will focus on chronic depression, the underlying themes of causation outlined in this book can be applied to many other common psychological disorders, such as those involving anxiety, personality, and substance abuse disorders which often co-occur in various combinations due to their shared core issues. Thus, although this book will concentrate on how depression tends to be caused and/or sustained, the underlying processes and causations discussed are relevant for many other disorders that can occur independently or in combination with depression.CHAPTER 2
The relevance of approach and avoidances forces in our daily lives was introduced in Chapter One. In Chapter Two we will expand on this topic and introduce associated research data. Dollard & Miller (1950) performed groundbreaking work on the relationship between avoidance and approach forces in terms of their effects on motivation and behavior decades ago. Briefly, they reasoned that the relative strength of these forces helps determine whether we approach or avoid goal directed outcomes. More specifically, they found that when motivation to approach a goal is stronger than the motivation to avoid it, then action towards achieving the goal prevails. They not only demonstrated these relationships in experiments but also found that, as we get closer to obtaining a goal, avoidance forces (anxiety and fear) go up at a faster rate than approach forces (desire). Moreover, when avoidance forces are stronger than approach ones it is predicted that the organism will discontinue goal directed activity.
For example, let's say that John wants to ask out a gal for a date next Saturday night. The Monday before he is likely to experience a great deal of positive anticipation but little anxiety because it is still a few days away from when he planned to pop the question. At this point in time, his approach forces are likely greater than his avoidance ones. He can imagine the fun and activities with which they could participate. However, as the time approaches for him to ask her out, the intensity of his feelings of avoidance are predicted to rise more steeply than approach ones. If his anxiety grows stronger than his desire before his asks her out, then he will almost assuredly engage in avoidant behavior and may even justify it (i.e., come up with some rationalization or excuse) in order to protect his self-esteem. In this type of situation, his avoidant behavior is under the principle of negative reinforcement because his avoidance of asking her out is followed with relief of anxiety or fear. Note that anxiety involves imaginary contact whereas fear involves the presence of the actual person or object. In this type of case his avoidant behavior is negatively reinforced (i.e., strengthened by the consequences that follow it); that is, relief from anxiety or fear. Since negative reinforcement, like positive reinforcement, is expected to increase response probability in similar situations, it is predicted that henceforth he will display avoidant behavior in like situations. This type of analysis helps explain why people with specific phobias and panic disorder, untreated or treated unsuccessfully, can develop more generalized conditions such as agoraphobia. Note also that because we evaluate our behavioral patterns, avoidant behaviors can have important implications for our self-concept. Thus, when people consistently avoid various stressors, responsibilities and desired outcomes, they can easily develop the self-perception of being weak or a coward. Once this type of self-concept orientation develops, it can mediate a whole host of related behaviors. In other words, it can generalize to other situations involving approach vs. avoidance forces wherein individuals are quick to run away without even evaluating their choices, since they perceive themselves as incapable of approaching certain stimuli. After all, they may think; "I can't do this because I lack the intestinal fortitude." In essence, some people come to see themselves as Avoiders. Of course, this can be a long and winding road toward self-defeat and one that, at least initially, they did not envision as landing them in a state of depression.
These opposing forces are inescapable parts of our evolution. They are designed for survival as opposed to helping make us happier and/or more content, although certain stimuli and responses naturally give us pleasure in the short run. Given that we are vulnerable to a multitude of factors that can lead to our demise, it is crucial we are careful to avoid certain stimuli and circumstances which can be dangerous. At the same time however, we are sometimes required to take risks and face painful situations in order to survive. We may need to consent to cardiac surgery or fight off someone who attacks us. Although the dividing line between prudent decisions to face versus avoid situations is not always clear, it is proposed here that people with chronic depression tend to habitually engage in avoidance of situations that either leads to self-defeating effects and/or lack of personal growth. Certainly, there are times when it is wise to avoid situations that will only cause us to waste energy and resources or risk serious injury or death. On the other hand, it is imperative we confront situations consistent with our values and priorities, particularly when we may not get another opportunity to do so or are simply putting off the inevitable (i.e., will have to face the stressful situation at some later date anyway), and delaying action only makes matters worse.
Contemporary research has found physiological support for Dollard and Miller's analyses via physiological mapping of our brains (Rogers, 2004). For example, in recent years research has not only made us more aware of the positive aspects of anger but, at the same time, located specific brain centers for approach vs. avoidance motivation with respect to these emotions. It seems surprising that it has taken us so long to be aware of the advantages of anger, given the assumption that it must have some evolutionary utility. Most likely, our view of anger is biased by the radical actions that some engage in when enraged, as well as the physiological and cognitive distress sometimes associated with this emotion. Nevertheless, research is revealing that anger can fuel optimism, foster leadership, increase focus on the practical issues, heighten creativity and ambition, enhance emotional intelligence, and facilitate understanding of others. As for the physiological bases of approach and avoidance, brain imaging and electrical studies have shown that the left frontal lobe is involved with approach behaviors toward desired goals and is rewarding in logical and rational ways. Avoidance behaviors are associated with activation of the right frontal cortex and entwined with a negative motivational system affiliated with inhibition and escape from punishment and threat. Brain scans reveal that anger leads to significant activation of the left anterior cortex, thereby facilitating positive approach behaviors. Thus, this area of research not only demonstrates physiological foundations for Dollard and Miller's concepts of approach and avoidance but, at the same time, provides evidence that anger can be a pleasurable experience when we believe it can help facilitate positive changes.
Excerpted from Avoiders by Michael A. Church. Copyright © 2016 Michael A. Church, Ph. D.. Excerpted by permission of AuthorHouse.
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