Q&A with Dr. Luana Marques: Understanding avoidance

Luana Marques, Ph.D., is the Director of Community Psychiatry PRIDE at Massachusetts General Hospital (MGH), an Associate Professor of Psychiatry at Harvard Medical School (HMS), and author of Bold Move: A 3-Step Plan to Transform Anxiety Into Power. She grew up in Brazil, and immigrated to the U.S. where she earned her Ph.D. She focuses on helping people overcome discomfort to lead more fulfilling lives. She shared more about her work in an interview with Jamie Singleteary at the Within Summit.

You often speak about becoming comfortable with discomfort. How have you learned to do this in your own life?

I grew up in Brazil with a single mother, and moved in with my grandmother at 15. I faced a lot of adversity and trauma, and I managed it by running away from discomfort. My grandmother noticed my avoidance, took me to the mall, and had me talk to people. When I was training to become a psychologist and learned the principles behind exposure therapy, I immediately recognized the experience I’d had with my grandmother.

For those who aren’t familiar, can you describe what exposure therapy is?

Exposure therapy is a technique within cognitive behavioral therapy. When you’re experiencing psychological avoidance, your brain is interpreting everyday situations as threats. Once the amygdala identifies a threat, it triggers the fight, flight, freeze response. This is uncomfortable, so we tend to avoid these situations. In exposure therapy, we do the opposite: go toward a perceived threat, to train the brain not to fire in those moments.

What is “psychological avoidance,” when is it most likely to surface, and how it might feel in a person’s body?

I define psychological avoidance as any behavior designed to help us feel better that we become stuck in. When we perceive a threat and go into fight, flight, freeze, we all react differently.

For example, imagine you get an email that makes you anxious. You might respond with what I call a “react”—moving towards the threat and reacting without thinking, to try to eliminate discomfort. Others might see the email and retreat, walking away to try to distract themselves. Some freeze and just stare at the computer.

We all engage in psychological avoidance, because we’re wired to avoid threats, and sometimes, the brain misinterprets an email as a threat.

What’s the relationship between avoidance and anxiety?

Avoidance is a response to anxiety, which has three components. There’s the intellectual: black-and-white thinking, catastrophizing, predicting the worst. There’s the physiology of anxiety: dizziness, sweatiness, stomach pain. And there’s the behavioral component: feeling anxious and just not knowing what to do. Regardless of your experience of anxiety, most of us engage in psychological avoidance.

As a therapist, how do you feel like avoidance or psychological avoidance influences people’s approach to seeking care, support, and help?

People engaged in avoidance often create an alternative reality instead of confronting their own, and that denial can make it harder to ask for help. Also, because avoidance offers a quick fix that works momentarily, it can keep people from asking for help.

What are some of the barriers preventing vulnerable or marginalized people from accessing care and support, and what role do you think providers can play in helping to break down those barriers?

This reminds me of something my colleague, Dr. Maggie Alegria, said: providers must get out of our offices and listen to the communities we serve to meet their needs, instead of going in with our agendas and views.

There is significant stigma around mental health care in marginalized communities, and for good reason. It’s not just stigma, it’s reality. When I’m working with a person who says to me, “White psychologists don’t understand me,” they’re speaking their truth. It’s important to create a diverse workforce, and models that understand systemic racism.

I’ve found it to be effective to stay away from the idea of “therapy,” and think instead about skills. How can we teach people skills they don’t have?

How do you balance exposure therapy and encouraging people to engage with discomfort, with acknowledging that individuals may not be able to surmount some of these larger barriers entirely on their own?

Most of my role is training paraprofessionals to deliver skills to communities. I help providers understand what lane they can be in, and what lane they can’t. I was doing a workshop once, and I could see a paraprofessional was having what I believed to be a trauma response. So I had a conversation with them, and said: “Before you can do this work, you need to get additional support.” You have to be realistic and acknowledge where people are coming from.

What advice do you have for providers about guarding against burnout or managing their own trauma responses?

To treat trauma effectively, you must take care of yourself, which in this case means peer supervision, and awareness of whether the amount of trauma in your caseload is too much for you. Create a network of social support, and continue working to digest your trauma so you don’t add it to your caseload.

Are there any misconceptions you wish you could correct about the work you do?

Providers worry about things like anxiety, depression, and burnout. But while these things are painful, they usually aren’t the problem. The problem is how we react. Avoidance is the common denominator, and simplifying the narrative can help address the root of the issue.

When I’m working with communities of color, I often [encounter the] belief that I should be strong enough to do it by myself, and if I can’t, something’s wrong with me. What I say to my clients is, “If you could’ve fixed it yourself, you would have.” The brain is an organ, and it needs the same care as the heart, liver, and kidneys. I can’t treat my own heart, and you’re not trained to treat your [own] brain.