Back in November I wrote about how the field is shifting its thinking on complicated grief and some of the controversy surrounding the changes to grief as an exclusionary criterion for depression in the DSM. I still agree that the change was a step in the right direction and with that in mind, we’re going to look at how CBT can be useful in addressing avoidance behaviors within the context of complicated grief.
Individuals who struggle with complicated grief may engage in avoidance behaviors as a way of dealing with the distress caused by situations connected to the loss. Behaviors may include avoiding family gatherings, isolating during certain times of the year, avoiding certain family members, avoiding places that have a connection to the loss – the list can be long or short. Avoidance behaviors carry two big price tags, the first being that they make the distress related to the situation worse in the long run. To understand why this happens it might be useful to understand the culprit behind the behavior namely, faulty thinking.
Avoidance behaviors are generally driven by catastrophic hypotheses . By engaging in the avoidance behavior we get immediate relief from the distress because we avoid whatever catastrophic event we believe may happen if we were to confront or face the situation- this is the hook. In avoiding the situation we rob ourselves of the opportunity to test the hypothesis. Because negative thinking surrounds the situation we are seeking to avoid, our beliefs about the situation become more catastrophic as more time passes between the present and our last successful exposure to the situation. This increases the likelihood that we accept the hypothesis as fact without evidence.
Let’s say a hypothesis someone may have looks something like,
“If I attend a family function I will go crazy.”
Things get even more complicated if the last exposure to the situation actually did involve an unpleasant or uncomfortable experience; there may be historical evidence to support the belief that the hypothesis is correct. So…
“If I attend a family function I will go crazy.”
Feeds into or is based on…
“Last time I went to a family event I had a panic attack and embarrassed myself in front of everyone.”
By not accepting the invitation, the distress associated with the invitation probably drops down rather quickly. However, the long term impact may involve an increase in the distress they experience when thinking about or faced with the prospect of attending family functions in the future. As this spiral progresses, negative core beliefs the person has about themselves in relation to the loss may either get reinforced or introduced…
“I’m a bad [uncle, cousin, son] because I abandoned my family after the loss.”
Which brings us to the second price tag; sometimes avoidance behaviors cause us to push away from supports and activities that can actually help us through the grieving process. By burning both ends of the candle through avoidance, increasing the distress associated with triggers connected to the loss AND isolating from supports that can help us cope with the loss, we are significantly reducing our overall capacity to adaptively grieve.
The most effective way to reduce the distress associated with triggers is to test the hypothesis but that may be a tall order and, in some situations, even counterproductive for someone who experiences really high levels of distress. One small step that may increase comfort and motivation to change the behaviors is to really examine history.
True, there may have been times when things did not go well when confronted with a situation connected to the loss but can you think of other times when things did not turn out so poorly?
What could you learn from the “bad exposures” that may be helpful to you in future exposures?
Were there other circumstances contributing to the negative exposure that no longer exist?
On the whole, in what ways are you better now than you were then?
What are the real costs and benefits to keeping things the way they are?
What are the real costs and benefits to changing?
Even if the worst happens how can confronting the trigger still be beneficial?
Would you judge someone you cared about as harshly as you are judging yourself? What evidence do you have to support the belief that your family members are any different?
Hopefully, examining the record of history and putting the “worst” in perspective will help reduce the amount of anticipatory distress to a point where you feel capable of taking a few more steps forward.
One tool that can help you cope with avoidance is a fear ladder which can break down the event you are avoiding into small pieces. Each piece will trigger different levels of distress; the trick is to begin confronting those aspects of the situation that bring up the least amount of distress. So a person who isolates may begin by emailing family members they have been avoiding. Typically friends and family members will be glad to hear from the person and the feedback received may test the hypothesis further or challenge the core belief. As you work on the lower rungs you may notice that the pieces on the higher rungs may also shift down.
Something else to keep in mind is that the anticipatory distress of a triggering situation usually drops off after a period of time during the exposure. Sure, there may be a bit of a spike from anticipation to exposure but eventually the distress drops below the level prior to the exposure as a result of testing the hypothesis and/or surviving the situation despite it not going as well as you would have wanted.
Although we used family gatherings as an example throughout this post we can really apply this thinking and skill set to anything we avoid as a result of the loss – photo albums, restaurants, sections of town, etc. Although exposure is effective, it is not advisable for every situation. For example, I would never encourage an individual who struggles with a gambling addiction to hang out in a casino. Also, it is very important to remember that exposure can make matters worse if not done correctly and so if there are concerns about safety or fears that exposure may lead to a worsening of symptoms, it is probably best to seek professional assistance.