This piece was originally published in August 2018 as a blog post for Project Heal.
Summertime entails higher temperatures, more time spent outdoors, frequent social events, and ample opportunities to step out of one’s comfort zone. However, many people living with eating disorders prefer to remain within their comfort zones, and do so through the use of avoidance.
The concept of avoidance refers to preventing oneself from experiencing emotional discomfort by evading potentially distressing situations.
Avoidance comes in many forms. For instance, someone with a flying phobia may choose to travel exclusively by train in order to avoid a panic attack, which she anticipate she would experience if she were to board a plane. For those living with eating disorders, avoidance can be particularly problematic, in that continued avoidance of emotional discomfort actually serves to maintain disordered behavior. For instance, someone living with an eating disorder may skip a friend’s birthday party out of his desire to avoid the anxiety tied to encountering fear foods like pizza and cake, eating in front of others, and/or perceived body judgement from peers.
The more an individual engages in a given avoidant behavior, the more likely it is that this behavior will become habitual due to negative reinforcement. Negative reinforcement is the principle by which removing undesirable stimuli increases the likelihood of behaviors occurring again in the future. Due to negative reinforcement, the next time the previously mentioned individual is invited to a party, he will be even less likely to attend due to learning that avoiding the party prevented him from feeling anxious last time.
In sum, the ability to temporarily prevent anxiety through avoidance reinforces the power of the feared stimulus or situation.
In this sense, avoidance is actually quite adaptive. In general, most humans try to prevent themselves from feeling uncomfortable. Through evolution, we have learned to approach what is perceived as “safe” or life sustaining, and avoid what may be dangerous.
So, when we’re able to prevent ourselves from experiencing emotional distress by choosing not to participate in activities that cause discomfort, we may feel more in control of our emotions. In reality, if we base our choices on the belief that an anticipated emotional experience would be intolerable, doesn’t that mean our emotions actually control us? In fact, if we let the anticipation of anxiety at a birthday party prevent us from attending, our anxiety wins.
In contrast, if we instead make choices based on our values or goals, we may feel uncomfortable in the short-term, but much more satisfied with our behavior in the long-term. In the above example, the person skipping the party probably experienced a sense of relief once he decided not to attend. However, long-term, this individual likely experienced some regret due to missing out on a social event, and guilt tied to disappointing a friend in the process.
Now, let’s consider avoidance in the context of body image distress and summertime. Some seasonal examples of body avoidance might include: dodging mirrors, staying indoors, dressing in oversized clothing, refusing to wear a bathing suit, or choosing not to go swimming. If dressing in weather appropriate clothing (like shorts, tank tops, bathing suits) leads to feeling self-conscious, one may be able to temporarily prevent the experience of feeling self-conscious by dressing in larger clothing.
So, in this example, what’s wrong with avoidance? Many avoidant behaviors like this one are seemingly harmless. Individuals choosing to wear weather-inappropriate clothing may be thinking to themselves: “It’s not like I’m hurting anyone by wearing a sweatshirt in 90 degree weather August.” What many do not consider are the long-term cons of engaging in avoidance.
Long-term, there are many costs of avoidance. The first is fairly obvious. When we avoid situations that are potentially uncomfortable, we also miss out on many opportunities to engage in activities that are value-consistent, or otherwise enjoyable—like spending the day on the beach with family.
Secondly, research tells us that engaging in avoidance maintains the intensity of the emotional distress tied to whatever it is that you’re avoiding. From a neuroscience perspective, the experience of anxiety and fear is largely explained by lack of integration between neural networks. Ongoing avoidance maintains the lack of integration, thus maintains emotional distress. The left hemisphere of your brain even supports your avoidance through rationalizations such as, “who cares if I miss one lousy beach day with my family?” Ironically, in order to regulate the anxiety that we work so hard to avoid, we must challenge the thinking that enables avoidance, and learn to approach that which we fear.
Adopting an “approach” mentality leads to increased cortical processing, cognitive flexibility, and neural integration. Once our neural networks are integrated, we can better regulate our distress, thereby bringing us closer to the goal of gaining “control” over our emotions. Think of the common saying, “get back on the horse that threw you.” This advice captures the essence of the approach mentality by suggesting that we stop using avoidance to attempt to control our anxiety.
Now that we better understand the potential benefits of challenging avoidance, readers may be wondering what they can do to work toward this “approach” mentality. Understandably, the prospect of abandoning behaviors that provide us with the perception of control, and a subsequent sense of comfort, might sound intimidating or overwhelming-- but, there’s good news. Through working with a treatment team (such as a therapist, dietitian, and so on), clients can develop an exposure hierarchy. A hierarchy is a tool that allows clients to start gradually challenging avoidance through engaging in a series of manageable steps in the form of exposures—or “approach” behaviors.
By beginning with the least threatening item on the hierarchy, challenging avoidance patterns becomes less threatening, and more manageable. For instance, in the above example, one way to challenge the avoidant behavior of wearing oversized clothing in the summer might entail removing one’s sweatshirt in public for five minutes at a time to start, and eventually increasing the amount of time spent with the sweatshirt off. Eventually, overtime, the goal might be to leave the sweatshirt at home for a full day.
As clients navigate each item on their hierarchies and process their emotional experiences, their brains begin to recognize the ability to tolerate emotional discomfort, which eventually leads to an overall decrease in distress levels. In sum, the learned expectation of future relief from intense emotions improves the client’s ability to tolerate distress in the moment.
Sara Battista, LCPC, LPC is a therapist practicing in DC, and the founder of Greenhouse Psychotherapy.