The Essential Guide to Overcoming Avoidant Personality Disorder

CHAPTER 9 Development

EARLY PSYCHOLOGICAL ISSUES

Avoidant Disorder of Childhood

and Adolescence

The Diagnostic and Statistical Manual of Mental Disorders, third revised edition (DSM-III-R), describes a syndrome it calls “avoidant disorder of childhood and adolescence,” whose traits survive in the adult avoidant in the form of interactive problems that disrupt intimacy. This DSM-III-R syndrome is characterized by interpersonal anxiety manifest in a “desire for social involvement with familiar people, such as peers and family members,” associated with “an excessive shrinking from contact with unfamiliar people” so that the child is “likely to appear socially withdrawn, embarrassed, and timid when in the company of unfamiliar people and will become anxious when even a trivial demand is made to interact with strangers,” and may even become “inarticulate or mute.”¹

A Case Example

A 10-year-old has no friends of her age. Her only interpersonal contacts are her parents and a few of their adult friends. She never leaves her parents’ side, partly because the mother never lets her out of her sight, and partly because she is unable to go more than a few feet from home because she fears loud street noises, being stung by bees, and riding on public transportation (she fears she will drown when the train she is on crosses a bridge and falls off the tracks into the water), and partly because she fears strangers. (Her preoccupation with details—she is able to list 256 breeds of dogs as well as all the birds ever found in Colorado—suggests that she might be suffering from an associated Asperger’s syndrome.)

However, I have treated a number of patients who described their children as having emotional symptoms that seem to have been the opposite of those described in the DSM-III-R. In this non-DSM disorder, the child is both unable to relate outside the home and, while at home, makes the parents’ life into a hellish onslaught of disagreements and fights.

A Case Example

A patient of mine describes a son like this:

Last night, I drew the line and asked my husband to draw it with me, too, but I am still reeling in a mother’s desolation. There has been no movement in my eldest son’s life since the last time I asked him to start looking for a job so he could move out; his presumption was that he should live here forever not talking to us, find intermittent clerical jobs, and play tennis occasionally, while going to bars nightly, stumbling in in the wee hours of dawn.

I might have even put up with that, except for the fact that he never talked to me (or anyone), and when I talk to him, there is a particular anger toward me, which came out in full force yesterday.

The tension between us resurfaced Sunday night when he fed my dog a chicken leg (bone and all), and I was livid. He said I was acting crazy, all dogs eat chicken. Yesterday, when I was supposed to pick up my other son from school (he got out early that day), my electric garage door got stuck and wouldn’t open, so I knocked on my eldest son’s bedroom door (it was 10:30 a.m.; he usually gets up at 1 or 1:30 p.m . from his late nights) and said, “My garage door is stuck, would you go and pick up your brother with your car? He is waiting and there is no one there to give him a ride.” He said nothing, so I asked him again and then went to the front yard to rake leaves to the street curb for the collection. Next thing I know, my little dog had been set loose and was running toward me out onto the busy street. This kid comes out in his underwear and pulls open the garage door, berating me for not being able to do it myself. Trying to grab onto my dog before she gets squished by traffic, I yelled, “Asshole.” I felt terrible that that slipped out, but he almost seemed to be trying to harm the dog to get to me. His response was, “What a crazy bitch you are.

It’s only a dog,” and then, “If I’m an asshole, you go and get my brother yourself. Your door is opened.”

I was a nervous wreck. I said, “Son, this isn’t working. You don’t respect anyone in this house, you don’t pull your weight,

I asked you to rake the yard because your father has been sick (he had a bad flu last week and couldn’t move) and you refused to do it—this isn’t how a family is supposed to work. I feel terrible that you walk right by me every day without talking to me, and when you look at me you are always so hostile. I didn’t mean to call you an asshole, I was just nervous and trying to grab the dog while in the middle of traffic. I think it’s time for you to launch your life now, this isn’t working for either of us.”

R: Are you throwing me out?

T: I told you before, you can stay until you have a steady job, providing you work toward getting one, and in the meantime, you either pitch in with the chores or pay rent and treat all of us like we are human beings. You don’t need to be partying every night and staying in bed ‘til 1:00 p.m . every day when you could be looking for a job.

R: What do you think I want to be, a hermit like you, a 45-year-old loser with no friends, no job, who sits on her ass all day in front of a sewing machine?

T: Is this what you think of me after I spent my life loving and caring for you?

R: You never did a thing for me except get on my back. You have three kids who hate your guts. Do you think that’s us, or could it be you? ¹

He said, “You both hate me,” and started to cry. I said, “We both love you and want to try to make this relationship work while you stay here and work toward your independence. Can we try to be a real family who loves each other and helps each other out when we need it?”

He just shook his head. And cried. Then he left to go who knows where. And that is the last image I have of my son. I didn’t sleep all night.

Early Trauma

Avoidants avoid new situations and relationships that resemble old, traumatic ones. Avoidants who experienced incestuous sexual seductions, or who underwent severe punishment for trivial manifestations of their sexuality, steer clear of activities, places, or people that arouse these recollections. Thus a patient who, at age three, was severely whipped for “playing doctor” with the little girl next door became, as an adult, a celibate avoidant—his way to keep himself from being “whipped” once more by those who might once again censure him for having and even wanting sex. I have had a number of patients avoid commitment because it makes them feel tied down and smothered, just as they felt when in their first years of life when they underwent unpleasant operative procedures such as a tonsillectomy and adenoidectomy.

Early Parental Relationships

Millon speaks of how shyness develops out of early parental “rejection, humiliation, or denigration.”²

A Case Example

A shy, hypersensitive, avoidant patient felt uncomfortable meeting new people because he failed to distinguish making an insignificant social blunder from ruining himself socially completely. His fear of ruination originated with his parents turning on him when he made childish mistakes, which, of course, he predictably made because he was, in fact, still a child. It also originated in his relationship with a rejecting father, who paid little attention to him, hardly played with him, and never took him to the movies or museums, and in his relationship with his mother, who demanded absolute “apron string” fidelity in return for giving him any love at all.

Benjamin notes that patients with “AVD began the developmental sequence with appropriate nurturance and social bonding [giving the avoidant-to-be] a base of attachment that preserved normative wishes for social contact.” However, the AVD-to-be was “subject to relentless parental control on behalf of constructing an impressive and memorable social image. The opinions of others outside the family were given high value. Visible flaws were cause for great humiliation and embarrassment.” At the same time, the message was sent that “those outside the family were . . . likely to reject the AVD.” This led the AVD to be “concerned about public exposure” and to make “impression management” a priority. There was also “degrading mockery for any existent failures and shortcomings,” backed up by “shunning, banishment, exclusion, and enforced autonomy.” As a result, the AVD developed “strong self-control and restraint to avoid making mistakes that might be humiliating or embarrassing.” “When internalization [occurred the individual became] very sensitive to humiliation,” leading to defensive “social withdrawal in anticipation of rejection and humiliation” and an “unwilling[ness] to reach out unless there is massive evidence that it is safe to take the risk.”³

Those who suffer early in life from excessive parental control may grow up feeling as if every new adult relationship is a trap—as one patient put it, “an involuntary commitment.” Some of these individuals become excessively dependent avoidants, who give in, submit, and do exactly what they are told. But others become excessively independent avoidants who rebel and do only the opposite of what others expect of them. For example, though they want to get married, they refuse to do so just because it’s what their parents want them to do (and they see everyone as their parents).

Bruising parental criticism for being overly emotional can lead a child to grow up remote and unfeeling to spare himself or herself such further assault, for example, criticism for being a crybaby. Children who are told that “it’s bad to feel, and worse, to get at all angry” might, as adults, discourage all relationships in order to avoid subjecting their partners, and themselves, to their own angry outbursts. Children negatively compared to their siblings can grow up feeling devalued compared to everyone else and either retreat to avoid testing their unworthiness or attempt to feel more worthy by turning every new potentially loving relationship into a jealous, competitive, rival-rous situation, where winning to feel valued for the first time in their lives becomes the only thing, and all they care about.

Parents who infantilize their children in order to have them all to themselves can create an avoidant-to-be by keeping the child at home away from all his or her friends. In the case of the married couple, now separated, who lived apart in two connected houses (discussed in chapter 4), the mother would not let the daughter visit her father unaccompanied, even though they lived in a safe neighborhood and the father lived just down the porch. Instead, the mother insisted upon escorting the child from her house directly to the father’s door and watching until the child got safely inside. Infantilized children like this often pay the price, when they are still children, in the currency of defective relationships with siblings and compromised relationships with others outside the home and family. When they become adults, these children often pay another price: they become avoidants who have regressive relationships marked by an isolating dependency (codependency) on one, associated with a disinterest in, fear of, antagonism to, often based in jealousy of, all.

Parents who are themselves avoidant often create an avoidant child in their own image. They can do this directly, by vocally warning the child about the dangers of getting close, or indirectly, by criticizing just about everyone else for doing normal, nonavoidant things. In one case, parents who vocally criticized their own friends’ small indulgences, such as having cocktails each evening before dinner, helped create a child who avoided others because she believed that there was something “evil” about getting together with people, having a drink or two, and just enjoying oneself.

Paradoxically, early positive experiences can also lead to the development of avoidant personality disorder (AvPD). Healthy, nonavoidant parents can unwittingly create avoidant children should, as commonly happens, the child counteridentify with them to become a counterparental isolate. A child reluctant to break away from a pleasant home life and an early, pleasant, too-close relationship with the parent of the opposite sex can later in life develop an oedipal avoidant syndrome rooted in a desire to remain faithful to the parent, specifically manifesting as follows:

• staying single or picking a remote, unavailable partner to marry

• then having a poor or nonexistent sex life with him or her

• while longing to meet someone new and more romantic

• and seeking or having an affair

• yet picking a new partner who is equally avoidant, especially one who is also already married, so that the affair goes nowhere and leads to disappointment and regret, which is

• one’s comeuppance for cheating on one’s original partner and threatening to wreck or actually wrecking one’s own and the new partner’s marriage

A Case Example

I had a strange dream once when I was younger. My mother was young and maybe in her 30s. She was very beautiful, and always dressed to the nines, as she was in the dream. We were ready to go to the produce market with my father, but my mother (I was a kid in the dream) looked at me and said mischievously, “Why don’t I go without him this time?” My father hadn’t woken up yet, and I was afraid that he’d beat us if we went without him. Yet I wanted her to have her freedom, so I said, “Go, Mamma,” and she did: right out the door, beautiful, in a dress, high heels, pearls, her hair and lipstick just so, and she looked back at me and disappeared into the crowd. Then my father woke up and demanded to know where my mother was. I realized I hadn’t put my bra on yet; it was still in my hand for getting dressed, and I panicked trying to get past him, covering my chest, hoping he didn’t grab me as I ran around him into the bathroom. Then I woke up in a panic.

I know, it’s a Freudian field day. I just hope it is one of those false repressed memories. But I always was extremely afraid of him as a kid (he has mellowed now, thankfully) and always repulsed by the way he grabbed me and wouldn’t let me go when he had a few too many. Which probably explains why someone like my asexual husband would attract me when I was young. At least in my dream, my mother broke free of her imprisonment. I believe I picked a remote man due to my fear that any close relationship would be incestuous, then, in response, spent my whole marriage blaming him for being that way, having affairs that went nowhere, and fantasizing dumping him if one of my affairs “clicked.”

EARLY NONPARENTAL RELATIONSHIPS

Rosenthal, in the New York Times, describes studies that show how the early “interplay between young siblings exerts a powerful lifelong force” as people “keep the relationships they had when they were young—such as rivalry or bossiness . . . color[ing] all their interactions in the adult world.”⁴

Additionally, peers, teachers, entertainers, religious leaders, and the medical profession encourage avoidance directly or through the media by word and/or deed. Mill on emphasizes the role played by peer group ridicule in the development of AvPD.⁵ The media have a pro-avoidant effect on the adolescent when they extol the benefits of Zen withdrawal and do-your-own-thing philosophies that overstress the importance of freedom, independence, and individuality, while by implication, fully condemning that submission and deindividuation necessary to form close, loving relationships. Religious leaders who are excessively moralistic, and therapists who encourage and maintain avoidance through long, drawn out, harsh therapeutic regimens meant to ready the patient for having a full life that never comes, also belong in the category of “gurus,” whose so-called expertise in fact involves “expertly” encouraging avoidance.

BIOLOGICAL FACTORS

Ballenger views avoidance as a way to deal with anxiety/panic attacks that appear when a “brain alarm system . . . fires . . . too easily”⁶ so that the patient responds to the events of everyday life with excessive anxiety.

In some individuals, shyness is the product of constitution/tem-perament. Millon refers to “a genetic or hereditary . . . ‘interpersonal aversiveness’ ” displayed in early “hyperirritability, crankiness, tension, and withdrawal behaviors” in “easily frightened and hypertense babies who are easily awakened, cry, and are colicky [and who] rarely afford their parents much comfort and joy [but who rather] induce parental weariness, feelings of inadequacy, exasperation, and anger [accompanied by] parental rejection and deprecation.” Millon speculates that anatomical (an “ ‘ aversive center’ of the limbic system”) and hormonal-biochemical factors (“excess adrenalin and rapid synaptic transmission”) might account for this genetic interpersonal aversiveness.⁷

Kagan, according to Ruth Galvin, says that at one time, he assumed that “timidity was acquired through experience, the repeated avoidance of challenge strengthening a childhood tendency to withdraw. Now he . . . wonder[s] whether he had overlooked something: temperament.” He describes a “small group of people . . . who are born with a tendency to be shy with strangers and cautious in new situations,” a temperamental quality Kagan calls “inhibition,” which is related to shyness. He remarks how some children, like some puppies, are born inhibited and remain so throughout their lives. Kagan believes that this temperament is inherited. Kagan also notes that “although society sees [shy people] as underreactors, inhibited persons may actually have a stronger-than-normal response to novelty—too strong, in fact, for their brains to tolerate, with inhibition and shyness appearing as the self-protective result.”⁸

EVOLUTIONARY FACTORS

Becoming a civilized human being entails a degree of loss of “animal” warmth, spontaneity, and connectivity. The cat that, knowing that its owner is aggrieved, sits on a foot to offer sympathy, companionship, and comfort, with evolutionary “refinement,” becomes the human who responds to another’s suffering with “grin and bear it,” “cut it out,” or “go get professional help.” Thus a cat, after having lost her lifetime companion, another cat, became inconsolable, meowing all night, uncomprehending. When the cat’s owner died, the cat, not the family, was the first to notice that she had passed. The others were all in the kitchen, eating. The cat was at her owner’s side, howling.

Humans have normal primitive, protective “animal” avoidances such as a reflexive fear of mice and harmless snakes, a superstition of black cats crossing one’s path, a tendency to curl up in the fetal position when one feels overwhelmed or depressed, and, what is perhaps the ultimate biological avoidance of all, fainting “dead away” due to fright or in disgust. Even in such of our everyday expressions as “badgering,” “weaseling,” “outfoxing,” and “hogging,” we are reminded of the jungle origins of some of the most interpersonally aversive human behaviors. Some avoidants in their self-protective behavior remind us of a stray cat who, however hungry it may be, thinks twice before accepting a handout, and some of a raccoon who strikes a compromise with humans—not bothering them as long as they don’t bother it. Others remind us of dogs—pups who, thinking only of themselves, push others aside to get to an available teat; adult dogs who protectively roll over to beg for mercy, playing dead to retain life, or who retreat to a lair for safety, protection, and territorial advantage to avoid a fight; and older dogs who, when ill or about to die, remain transfixed within and become remote, perhaps to anticipate death—so that they can deny they love life.

One of my avoidant patients, a man with multiple social phobias, compared himself to his cocker spaniel, who developed a fear of blimps and had to scan the heavens for one before venturing out of doors—he speculated as a displacement from a fear of airborne predators. In her inability to walk near large objects like trash bins, he saw his own agoraphobia, and in her fear of walking over grates, he saw his own fear of being at the edge of a high cliff, in danger of falling, about to descend into nothingness.

PART TWO

THERAPY

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CHAPTER 10

A n Overview of Avoidance Reduction

Table 10.1

Eclectic/Holistic Avoidance Reduction

The analytic dimension: the therapist obtains information about and imparts insight into the dynamic aspects of the individual’s avoidances. The information is obtained from a study of the patient’s past life and of his or her current avoidant fantasies and behaviors, including transference ideation/behavior.

The cognitive dimension: the therapist identifies and corrects illogical, inappropriate, and often paranoid interpersonal negative thinking, partly to help the patient recognize and acknowledge the positive aspects of relationships the patient currently views as all negative.

The behavioral dimension: the therapist, informally or formally, asks the patient to perform a series of graded, nonavoidant, connective interpersonal tasks of progressive difficulty in order to approximate nonavoidance in a gradual, stepwise fashion.

The interpersonal dimension: the therapist identifies and understands specific avoidant interpersonal anxieties and shows avoidants how the outer manifestations of anxiety (anxiety equivalents) such as shyness can make others uncomfortable, leading others to react by thinking not “he is afraid of me,” but “she is too stuck up to talk to me.”

The educative dimension: the therapist enhances motivation by enumerating the virtues of relating over being isolated and teaches the patient the social skills that can lead to pleasurable and rewarding experiences, which in turn inspire further attempts at fuller social mastery.

The supportive dimension: the therapist provides the patient with a warm, reassuring, healing holding therapeutic environment within which the therapist attempts to reduce relationship anxiety directly, e.g., with such reassurances as “you will get over your anxiety if you patiently persevere.”

The pharmacotherapeutic dimension: the doctor prescribes selected patients antianxiety and/or antidepressant agents, always keeping in mind that many patients would prefer to at least try verbal therapy before taking medication. ^{2 3}

establishing and improving friendships; and (12) use indicated phar-macotherapeutic agents, such as beta-blockers, monoamine oxidase inhibitors, or serotonin uptake inhibitors, to reduce anxiety. Millon and Davis further recommend that these different therapeutic modalities take place in a supportive setting, where the therapist counters apprehension with “freehanded empathy and support,” the “therapist’s only recourse.”³

My approach is action oriented because it emphasizes doing as well as thinking. It goes beyond utilizing the more “passive” therapeutic techniques that rely exclusively on influencing and changing through understanding to emphasize the more “active” therapeutic techniques, particularly behavioral approaches where the therapist exhorts patients to convert from avoidance to nonavoidance by facing their fears now, as best they can, through exposing themselves directly to situations that make them anxious so that they can take that all-important leap from understanding what troubles them to actively doing something about it.

PSYCHODYNAMICALLY ORIENTED PSYCHOTHERAPY

Psychodynamically oriented (psychoanalytically oriented, insight-oriented) methods, a cornerstone of eclectic therapy, emphasize developing an understanding of the present manifestations of avoidance through identifying its anlage, that is, its developmental origins. Thus one avoidant’s present-day shyness was partly due to guilt about relating that originated in excessive closeness to a mother who discouraged her from getting involved with men by promoting the nonsensical belief that it was unthinkable for any daughter of hers to marry a stranger. A source of another’s shyness was a fear of humiliation originating in her early relationship with a father who went out of his way to spot when she accomplished something significant—just so that he could avoid keeping her from getting a swell head by paying her a compliment.

Psychodynamically oriented therapists also explore to relieve the patient’s present turmoil through developing an in-depth understanding of his or her current associations and fantasies in order to be able to fully answer such questions as, “Why exactly does asking a girl to dance make you so anxious?” The answers often come from asking other questions such as, “Is it that you fear she will reject you? And, if so, why should a stranger’s rejection matter so much?”

Most psychodynamically oriented therapists try to help soften their patients’ guilt feelings. They do that both by helping them become more accepting of impulses they currently renounce and by facilitating their use of healthier defenses to cope with guilt they cannot reduce or fully eliminate. Thus patients might better come to deal with feeling guilty about hating others by relinquishing projection of their hatred (“I don’t hate you, you hate me”) and instead denying and suppressing the hatred so that it shows less and therefore has less of a devastating effect on connectivity.

Psychodynamically oriented therapists regularly identify and attempt to understand avoidances as they appear in the patient’s negative actions with, based on transference to, the therapist, as when patients avoid an aspect of the therapeutic process, and even their therapist, by canceling appointments when something painful is about to surface.

How does understanding (insight) cure? In simplistic terms, patients make things right by learning to unlearn what went wrong. Though much of the literature about AvPD downplays the importance of insight, citing, as do Anthony and Swinson, the likes of the lack of evidence for the effectiveness of understanding (Freudian) dynamics,⁴ I believe that insight-oriented approaches, while not sufficient, are necessary, and synergize well with other approaches, particularly with cognitive-behavioral therapy.

COGNITIVE-BEHAVIORAL THERAPY

Eclectic therapists also use a cognitive-behavioral approach focused on exposing and correcting the illogical thoughts that lead patients to distance themselves from relationships due to forming and maintaining excessively fearful notions about being criticized, humiliated, and rejected. Cognitive-behavioral therapists correct thinking directly by reframing negative into neutral or more positive cognitions following the rules of evidence. They also correct thinking indirectly by suggesting behavioral interventions that consist of asking patients to do what makes them afraid in small, incremental steps as a way to slowly but surely reduce their anxious thinking (while simultaneously stirring up new anxious thoughts that the patients can bring back into therapy for further analysis and subsequent correction/integration).

Too, they employ exhortation (“I know you can do it” and “try living around your need to distance even before the fears that lead to your distancing have been fully mastered”) in order to goad patients into attempting successive approximations to healthy behaviors, hoping that they will gradually become habituated to the anxiety that predictably appears when they attempt to perform those very things that make them afraid.

Many therapists use a combination of psychodynamically oriented and cognitive-behavioral therapy.

A Case Example

A patient who complained about being afraid to go out on a second date benefited both from learning about how her past affected her in the here and now and from correcting her present misconceptions about dating directly so that she could feel calmer and act in a more productive fashion. For example, she once refused to have a second date with a man simply because he said that before making the next date with her, he had to check his schedule book. Correcting the cognitive error that “I will get back to you” equals “I have rejected you” was helpful, but not enough to change the emotional distortive thinking that came from deep within. To do this, we needed to go back to the beginning, when she first felt totally rejected over something similar, and equally insignificant. Now we discovered that her father was a man who, refusing to commit himself in advance to a specific time when they could get together, regularly told her when she asked him, “When can just the two of us have fun?” that, “I will get back to you about that,” then did not firm up a date for months, if at all. Understanding that “you view all new boyfriends as your procrastinating father” helped her see present relationships for what they were in the here and now, not as what she imagined them to be through the “ret-rospectoscope” of her past interactions with this parent. This insight acted synergistically with her new cognitive learning, the two together freeing her up to form a relationship that ultimately led to her getting happily married.

Though advocates for cognitive therapy rarely speak of its downsides, there are shortcomings and complications of cognitive therapy that can interfere with improvement or make matters worse. Cognitive therapy is inherently critical, for by definition, the therapist, however unintentionally, sends the patient two implied messages: “your thinking is wrong” and “you personally are wrongheaded”—not messages avoidants, already notoriously sensitive to lack of support and feeling/being devalued, necessarily want to hear. Also, resistances appear to this as to every other form of therapy. Two of these are the positive resistance of falsely reporting progress to please/humor a

therapist obviously trying to be of help and the negative resistance of stubbornly and even sadistically maintaining one’s psychopathology to spite a therapist too obviously pushing for change along lines the patient sees as predetermined and so deems to be controlling.

THE INTERPERSONAL APPROACH

Eclectic therapists also use an interpersonal approach, where they study the dyadic causes and manifestations of avoidance with a view to resolving distorted interpersonal perceptions that lead to maladaptive interpersonal behavioral patterns such as those that are the product of anxiety over intimacy. These therapists focus on the central interpersonal avoidant patterns and problems I emphasize throughout such as fears of humiliation, criticism, and rejection at the hands of others; low self-esteem that makes it difficult for patients to confidently relate to other people; and the belief that serious closeness means completely losing, rather than only partially compromising, one’s identity. Interpersonal therapists basically try to make it clear that avoidants’ expressed and secret interpersonal fears are excessive and their perception of the dangers associated with relating are overblown. They usually attempt to interrupt cycles of negative feedback where avoidants actively create some of the criticism they feel passively victimized by after provoking others to mistreat them less out of dislike and more out of fear.

SUPPORTIVE THERAPY

Eclectic therapists also use a supportive approach involving positive feedback from the therapist (“you are too good to fail,” “that’s great that you have succeeded,” “your low self-esteem is lower than by rights it should be”) and reassurance (“you can handle and overcome your anxiety”). When indicated, they give fatherly/motherly advice (“there are other places where you will be happier/more welcome/ more popular than in the suburbs”). Also, they often advise avoidants to seek succor from others who are potentially in a position to help— secret sharers, counselors, friends, family members, and lovers, who can, it is hoped, help the patient cope and feel better. And they use relaxation techniques such as teaching the patient to breathe deeply and more slowly; meditation; and when indicated, antianxiety pharmacotherapy. They do all these things, and more, within a comforting, therapeutic holding environment that serves as a kind of protective bubble for the patient attempting to venture forth into old and new anxiety-provoking interpersonal adventures.

THE EXISTENTIAL APPROACH

Eclectic therapists use an existential therapeutic approach consisting of reshaping the patient’s philosophy of life. Methods involve helping the patient rethink favored avoidant positions and goals through identifying with and emulating others the patient admires for their social prowess and reading self-help books that take valid nonavoidant positions such as “when looking for a partner, be flexible about type” and “don’t compare yourself to others.”

FAMILY THERAPY

Eclectic therapists might use a family therapy approach, hoping to resolve interfamiliar conflicts that interfere with an individual’s outside relationships. For example, they try to convince a smothering family to let go and stop infantilizing the patient by discouraging him or her from going out of the house, other, at least, than to go to work to support the family.

Some Case Examples

Family therapy made it clear to a shy avoidant that she had become a remote, formal, rigid, and inhibited adult because she feared acting on her positive impulses without first getting “parental” approval, and because she feared losing control of her instincts in the heat of passion and saying and doing things that she would later be ashamed of because what “her people” thought or might think of her, that is, her reputation within the family, had become more important to her than what she thought of herself and than her personal growth, happiness, and satisfaction. We traced her excessive need for approval to her parents’ continuing warnings that people frown upon friendly women for being sluts and look down on a woman who is at all outgoing as being “loose”—a warning that her parents, as it became clear during our sessions, continued to issue for their own selfish purpose: to keep her at home just so that she would always be around and available to take care of them in case they needed her.

She responded by entering a session wearing a T-shirt whose logo was “99% devil, 1% angel,” her way to tell her parents and me that she had finally begun to break free from her inhibiting need to find out and buy into what her parents thought about and expected of her, and to obtain parental approval before she acted, instead of acknowledging her own feelings, then seeking personal direction. Next, having become less dependent on what her parents, and anyone who reminded her of them, thought, she was able to brave the inevitable criticisms and rejections that everyone gets in this world without becoming discouraged to the point that she couldn’t do anything on her own without first having to ask for permission. Now she could try to connect with men without giving up easily, instead of fleeing out of a relationship at the first sign of closeness and, in retreat, figuratively going home again.

Family therapy made it very clear to one avoidant that he was threatened by closeness because he worried about what his parents thought of his romantic relationships. In treatment, he learned to ask of his parents, “What’s the worst that you can do to me?” then to answer his own question by telling them, “If you continue in your old ways, I will simply have to stop talking to you.” But still, his fear of parental disapproval persisted, making true intimacy with others impossible. So we next worked on helping him collect evidence on how the parental disapproval he so feared was less directed to him than it was the product of his parents’ own distortive thinking, and therefore being relevant to them only was not an indication of how he should view, and treat, himself.

In short, avoidant symptoms yield best to multiple approaches involving, first, getting to the bottom of things, then patching things up by making a variety of repairs. Though diverse approaches might at first appear to be mutually inconsistent, or even mutually exclusive, they can (and should) be used together, either alternatively or simultaneously. Because of the complex personality of the avoidant, a satisfyingly complete solution to the distancing problem can only be obtained through combined, multilayered therapeutic interventions.

Of course, not all avoidants should be treated exactly the same way. Different avoidants will need, desire, welcome, and respond to different treatment plans created to fit the individual’s specific problematic interactive anxieties. The presence/absence of comorbidity, parti cu-larly the presence of paranoid and depressive tendencies, must be taken into account. Also important in formulating a treatment plan are the individual’s personal preference for intellectual versus practical approaches; current circumstances and needs (patients with big supportive families often need less hand holding than patients whose avoidance has left them all alone); and the degree of desire to change, as determined by personal aspirations and individual goals and ambitions and ultimately influenced by therapist availability and cost.

In the realm of the patient’s personal problematic interactive anxieties, avoidants who are less fundamentally shy than fearful, such as commitment-phobic avoidants who would be outgoing, except for their long-standing, deeply ingrained interpersonal anxiety about becoming fully intimate, may benefit the most from exposure techniques combined with emotional support as they venture forth trying to overcome their all-the-world’s-a-stage fright. But patients who are temperamentally more shy and retiring than scared may benefit the most from an ongoing, long-term supportive relationship with a therapist meant to tide them over—as the therapist acts the part of a healer who the patient can rely on long term and cling to, as improvement, it is hoped, takes place, however slowly.

The more intellectually oriented avoidants do best developing insight first, then acting on what they learned next, while the less intellectually oriented avoidants do best first “doing,” with “understanding” coming next, if at all. The first group of patients likes to contemplate a journey before, during, and after embarking on it. The second group of patients is satisfied just to be handed a road map. While the first group often does well being told, “Face your fears of parties so that we can analyze those fears as they arise,” the second group often does well simply by being urged: “Go to parties for progressively longer periods of time in graduated ‘doses’ so that you will be able slowly but surely to get used to mingling.” Patients who tend to intellectualize do not take well to approaches that are exclusively total push, while patients who are more doers than thinkers feel stalled and cheated by therapists who seem only to want to talk first and expect action next, if at all.

In the realm of differing individual goals, many avoidants are content to work around, rather than attempt to fully overcome, their anxiety. Just as social phobics afraid of being trapped in the theater can simply go through life happily sitting on the aisle in the back row, and social phobics afraid of heights who cannot sit in the theater balcony can, if they can afford it, simply buy a comfortable seat in the orchestra or give up going to the theater altogether; patients with AvPD can seek a lifetime of partial, rather than full, relationships, such as relationships with friends rather than lovers, paid strangers such as waiters or prostitutes, or relationships organized around impersonal gratifications they make subsidiary to interpersonal pleasures such as the gratifications to be gotten from hobby clubs or group therapy. The therapeutic approach must also be geared to the individual’s style of relating. Some avoidants really like being isolated. Others are comfortable with a single codependent relationship, hopefully one that promises to last for a lifetime. Still others look forward to only moderate connectivity so they can have the best of both possible (avoidant and nonavoidant) worlds. And some look forward to leading a normal life with only modest compromise or, if possible, none at all.

As to what approach to use first, avoidants who are very anxious or depressed about their lives, especially those who have experienced a series of losses, need support and sometimes pharmacotherapy in the beginning of therapy, with uncovering reserved for later, when the patient’s realistic difficulties have become less, or less urgent, so that what suffering there is has now become primarily of an existential nature—not a matter of “what do I do to survive?” but of “how can I look at things differently so that I can feel more alive, connected, and joyful?”

My sessions fall naturally into the following pattern. We develop insight in one session; use the next session to develop a game plan for putting what we just learned into practice (via intersession exposure); have a session or two where we develop further insight, particularly into the anxiety aroused by this new exposure, with all sessions taking place in a setting of continuing support and reassurance along the lines of “you can do it” and “you will not faint or die when going out in public”; have another practice-oriented “game plan” session or two; and so on. A full working-through process comes later. Here we cover the same ground repeatedly and in different contexts, until it all “sinks in,” not only intellectually, but also affectively, that is, emotionally— and practice makes perfect.

Simultaneously, I attempt to handle the avoidant’s negative and positive resistances to therapy. Most avoidants start off wanting to be helpful to the therapist and to cooperate with treatment. At first, they work with the therapist in a joint endeavor meant to overcome their avoidance. They plead with the therapist to tell them what to do to meet people and how to overcome their relationship anxiety. Later in treatment, however, they almost always begin to balk. Positive transference resistances develop where they use the therapist as too much the substitute for a real relationship. Negative transference resistances develop where they test the therapist, often to the extreme. They disregard proffered advice and sometimes even deliberately disrupt viable outside relationships in order to make the therapist look defective and impotent. They seek self-understanding only to misuse it. They say, “I will change when I learn,” but either they never learn so that they don’t have to change, or they learn intellectually but not emotionally so that they can continue to get the gratification that comes from complaining, “See, I’ve got insight, but it doesn’t work.” Laboring in therapy under a poor self-concept, feeling guilty about, and fearful of criticism for, their thoughts and feelings, and constantly worrying about whether or not the therapist approves of what they say or do, they become overly cautious and hesitant to discuss important matters openly. Afraid of all closeness, they begin to distance themselves from the therapist by being vocally negative about therapy and about the therapist. Coming to see the therapist as a parent, they refuse to “get married just because you want me to, like my mother did” and otherwise fearfully turn an opportunity to grow into just another occasion to rebel. Finally, as Benjamin suggests, as easily injured individuals who readily “feel degraded or put down by any therapist suggestions [they often] boil . . . over and abruptly quit . . . therapy.”⁵

In short, they use therapy as just another opportunity to become avoidant. Therefore therapists must undercut their resistances both directly and indirectly. Undercutting resistances directly means working them out on a conscious level by pointing out who the therapist actually is and is not, for example, “I am not a controlling parent or rival sibling,” and by frequently and pointedly reminding patients that they should work with the therapist toward a common goal, not against the therapist toward developing just another avoidant relationship. Undercutting resistances indirectly means analyzing their unconscious origins with the goal of uncovering how present-day resistances are repetitions of old avoidant difficulties now reappearing with the therapist, and so not a thing to be accepted, tolerated, or condoned, but something to be subjected to the same corrective scrutiny as any other manifestation of avoidance occurring not only outside of, but also in, the treatment room.

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CHAPTER 11

Psychodynamically Oriented Psychotherapy

The Quality Assurance Project asserts that “individual psychoanalytically oriented psychotherapy is the treatment of choice for [avoidant personality] disorder.”¹ This is in contradistinction to most contemporary writings that advocate cognitive-behavioral therapy over all other forms of treatment for avoidant personality disorder (AvPD).

THE BASIC TECHNIQUE

In contrast to cognitive therapy, which emphasizes correcting, psychodynamically oriented (psychoanalytically oriented) psychotherapy emphasizes understanding. Psychodynamically oriented psychotherapy recognizes that the inner life of avoidants determines a good deal of their outer behavior. Its goal is to help avoidants understand the inner workings of their current removal behaviors through and through so that they can replace withdrawal with new, more comfortable, adaptive, satisfying, and mature interpersonal contacts, free of irrational, unconscious fear. As Millon notes, its method consists of “reconstructing unconscious anxieties”² at the roots of the avoidance and exploring the avoidant’s anxiety-provoking fantasies as they occur in the patient’s present life as well as in his or her transference to the therapist.

INCULCATING INSIGHT

Psychodynamically oriented psychotherapists emphasizing the central role insight plays in attaining a cure focus on strengthening old and inculcating new self-awareness. Many avoidants do not discern that they are avoidant or the extent to which they suffer from AvPD.

A Case Example

An avoidant patient, though aware that he suffered from AvPD, was unaware of the extent to which he was inhibited and of how his inhibitions affected his life, compromising his own functionality and troubling those around him. In the realm of how his avoidance affected his life, he said he was pleased with the way his life was going, even though his fears kept him from leading a full, connected existence and instead forced him into the shadows of dark, anxiety-laden remoteness. But he failed to recognize how masochistically he was acting when he attempted to relate only in circumstances where he was assured that no relationship would develop, and how destructively he acted when he used the Internet not to meet someone, but to act out his avoidances: not advancing his case, but presenting his case history, putting himself in a negative light by offering bad presentations of his good qualities, as when he painted his preference for fidelity as clinging and his flexibility as desperation. Ambivalence of the “caring sharing, no one over 25” sort appeared in his Internet ads as his way not to expand horizons, but to eliminate good possibilities. Rigid preferences and the making of nonnegotiable demands led him to insist that for him, it was crucial that others have identical interests—something he called “compatibility,” though for him, it was a reason not for inclusion, but for exclusion. Particularly unwelcoming in his ads was his overemphasis on preferred age and body habitus that amounted not to suggestions about what he would like in someone, but to criticisms of what he disliked about everyone. Not surprisingly, few responded to his ads, and those who did made a date, then broke it, or kept the first date just so that they could break the second—sadistically building up his expectations now, the better to disappoint him later.

In the realm of how his avoidance affected the lives of others, he suspected that his perfectionism troubled and hurt other people who otherwise might love him. He knew, “When it comes to relationships, I hurt my chances by being so demanding.” But he failed to recognize how much he had become, to use his last girlfriend’s words, a “perfect snob,” who hurt others as he dropped someone already good enough, just to look for someone even better.

Other avoidants, though they discern that they are avoidant, deliberately, if unconsciously, downplay and cover up the extent of their avoidance and the degree to which it limits them socially. They paint this distorted picture of themselves to the therapist because they are terrified that the therapist—the very person from whom they seek help—will criticize them like everyone else, ridiculing and humiliating them by dismissing their problems; calling them “lazy losers, wallflowers, and wimps”; condemning them as bad instead of treating them as troubled; and rather than helping them get better, punishing them for being ill. So they censor crucial intimacies out of embarrassment and shame, or they reveal them but simultaneously excuse them as “not me,” closing off an in-depth discussion of their psychological problems by blaming their circumstances or other people, as when they present their inability to connect not as an emotional problem of theirs, but as a natural, expected, “anyone would feel that way” response to externals beyond their control. So we hear “you can’t meet anyone in this hick town/in a big city like New York,” or “none of the bars in this dump are any good,” or “my boyfriend is the problem,” or “my boss makes me work so hard that I am always too tired to socialize after work,” or “everywhere I go villains harass me sexually,” or “my parents defeat me at every turn,” or “my wife’s only goal in life is to torture me.” Often citing contemporary “do-your-own-thing” or “me-ism” philosophies, they blame the society in which they live for being a place where everybody encourages them to be avoidant. Frequently, they blame not their psychology, but their biology, and we hear “it’s inherited,” “I was born this way,” “it’s not me, it’s my chemical imbalance,” “I’m ugly,” “I have physical problems,” “I’m too old,” or “my genes hold the real secret of my inability to connect.” They also rationalize their avoidance as healthy, typically disguising it as a preference or taste. As an example, one avoidant who nightly dreamed that he wanted to, but was afraid to, meet people, daily rationalized his avoidance as follows: “I prefer to live alone because I can fill the refrigerator with what I want to eat, drop my clothes wherever I want to, play my sound equipment when and how loudly it suits me, and when I go to work and leave a can of soda cooling behind know it will be there just waiting for me when I return.”

REDUCING GUILT

Psychodynamically oriented psychotherapists focus on understanding and reducing guilt that creates withdrawal due to rigidly prohibitive, critical, self-unaccepting and self-destructive attitudes, especially those relating to success and survival. Thus an avoidant believed that she should not marry until both a favorite aunt and all her sisters found themselves a husband. Unconsciously, she saw the world as a zero-sum place where getting something for herself necessarily meant hurting others by outshining them—and where getting anything at all meant taking an equivalent something away from someone else.

EXPLORING THE CHOICE OF EGO-IDEALS

Psychodynamically oriented psychotherapists also focus on discovering if avoidants’ relational ideals (ego-ideals) are chosen not by, but for, them, that is, if they originate in freewill or are determined by unconscious forces. In my experience, few people are avoidant, and hence alone, by choice. Even those avoidants who swear that they are truly happy in their loneliness and isolation, who insist that their isolation is splendid, and who affirm the wonders of being able to come and go as they please without that proverbial ball and chain around their ankle, really desire closeness and healthy dependency, not the complete freedom that they say they want. Instead, their desire to be free is, in fact, a compunction to remain unattached, and that is, in turn, largely the product of a rigid, self-punitive morality that leads them to be so preoccupied with matters of good and evil that they find themselves forced to squelch their human feelings in order to angle for sainthood and martyrdom, their way to deal with the shame they feel about their anger and to reduce the self-humiliation they put themselves through for having even the most modest of sexual desires.

DEALING WITH UNHEALTHY DEFENSES

Psychodynamically oriented psychotherapists focus on identifying unhealthy defenses so that they can help avoidants first, to relinquish them, and second, to put healthier defenses in their place. Healthier defenses include counterphobic defenses, to master anxiety by facing and meeting it head-on, “damn the torpedoes”; and resignation defenses, where avoidants learn to tolerate a small amount of anxiety and relax into their fears, instead of resolutely meeting them head-on, only to find that they have made things worse for themselves by trying to fight what is predictably going to be a losing battle.

DEALING WITH SECONDARY GAIN

Psychodynamically oriented psychotherapists routinely ask avoidants to relinquish the secondary gain they harvest from avoidant symptoms once formed. As I ask agoraphobic avoidants to relinquish the pleasure they get from always having a companion on street outings, and social phobics to relinquish the gratification they get from lazily avoiding giving a speech, I ask mingles avoidants to relinquish the gratification they obtain from sex good and plenty and instead seek greater gratification from closeness and commitment: quality over quantity.

DEALING WITH TRANSFERENCE RESISTANCES

Psychodynamically oriented psychotherapists are ever alert to the avoidant negative transference resistances that by highlighting their patients’ problems in microcosm serve as useful grist for the analytic mill. Avoidants often resist therapy by avoiding the therapist, the same way they avoid everyone else. They fail to show up for an appointment, call to make another one and break that, come late—calling to say, “I am just leaving from home” about the time their appointment starts or coming at the right time but on the wrong day—all the while apologizing, yet continuing to repeat their actions. Too often, they respond to eureka insight by becoming critical of the therapist who imparted it. Thus, one patient, each time she learned something meaningful, responded by devaluing the teacher (me) to render the teachings less troubling by damning them, and me, into insignificance. Another patient responded to interpretations that made her anxious by reviling me as a know-nothing, damned-if-you-do and damned-if-you-don’t doctor. Feeling I pushed her too far, too fast, she complained, “You are making me anxious,” yet feeling I was too accepting of her reluctance to try to meet people, she complained, “You aren’t doing your job.” She then attempted to reduce her anxiety by intensifying mine: by criticizing me personally, first for being lax, and then for being incompetent and unethical. Thus, on the days she thought that I was married, she accused me of having extramarital affairs and trying to seduce her, while on the days she thought I was single, she accused me of being a priestly celibate or a homosexual disinterested in her because I was disinterested in all women.

SUPPLEMENTAL TECHNIQUES

Psychodynamically oriented psychotherapy is rarely fully effective unless accompanied by supplementary methods employed to put the understanding obtained to use. Exposure techniques do more than just habituate the individual to anxiety directly. They also simultaneously facilitate the psychoanalytic process by releasing anxious thoughts that can then be brought back into therapy for discussion. Pharmacotherapy can help subdue fear and reduce guilt, and meditation and deepbreathing exercises can help the avoidant relax, putting him or her into a better frame of mind to work on understanding what went wrong in preparation for doing something to make it right.

A Case Example

A patient, an avoidant in both his professional and his personal lives, entered therapy complaining that he was too shy to meet old and make new friends, and certainly to meet someone to become his partner. At work, he volunteered for night duty so that he would not have to interact with too many coworkers or spend too much time with his family. In his personal life, he had one love affair when he was very young and never had another. Many years ago, when he was a teenager, he fell in love with the girl next door, but he was too shy to speak to her directly. The best he could do to make contact was to tie a romantic message for her on an arrowhead and shoot the arrow over the fence and into her yard. He thought that that was just the right flourish. Instead, he was surprised, and chagrined, to discover that the next phone call wasn’t from her, but from the police.

As an adult, he kept one or two old friends to satisfy his (minimal) attachment needs, and on those rare occasions when he agreed to go to parties, once there he stood in the shadows in a corner of the room looking longingly at, but unable to join in with, the people having fun. He scared off what few people he managed to approach, or who approached him, by putting them in no-win situations, rejecting them both if they acted friendly (because he feared people who got too close) and if they acted unfriendly (because he disliked people who kept their distance). Then he would leave for home early, and all by himself, to return to his small apartment, where he could watch television with the phone pulled and the intercom turned off (using a special switch he installed), accepting only e-mail because that way, “instead of being the passive victim of anyone who decides to call and bother me, I can pick up my messages when, and only when, I choose.”

On occasion, later in life, he was able to start a serious romance, only to pull back early in the game after telling himself that it would not work out. First, he brooded about all the mistakes he might make that, as he was convinced, would turn the other person off. Then he would perversely actually make those mistakes so that he could ensure that his gloomy predictions would come true because nothing could ever work out for him. Then he would think, “I already ruined things, so why bother continuing?” and in anticipation of complete disaster, he would become protectively remote and distant and bolt before a potential partner could, as he soon became convinced would happen, lose interest in him.

In reality, other people did not much take to him. His appearance made it difficult for him to connect with the very few people he felt comfortable knowing. As he said, “They call me ‘Skull’ because of my sunken eyes and cheekbones, ‘weird’ because my face is asymmetrical, and ‘peculiar’ because as I walk, I keep one shoulder higher than the other.” However, instead of doing what he could to improve his appearance, he confined himself to checking in the mirror from time to time—assessing flaws, overlooking virtues, and not really thinking about making those repairs that were both indicated and possible. Unconsciously, he held himself back because he actually wanted to look strange to others—so that others would continue to remain complete strangers to him.

Over the years, he developed a number of social phobias relating to different specific trivial prompts symbolizing a variety of deep, interpersonal terrors. In part, he had installed these phobias so that he could avoid getting close to people, his way to live out his motto, “If you fear visiting them, you won’t go, and if you don’t go, you won’t have to invite them back.” He could drive over bridges when he was not going to a date’s house, but when he was, he could not make it across due to the fear that he would faint, lose control of his car, hit an abutment, and have a fatal accident. Additionally, he was unable to take the train because he feared it would crash. He also developed a phobia of being in church. During the service, he had to sit near the exit door so that in case he should feel weak and faint, he could get out without calling attention to himself.

Eventually, he began to have some difficulty venturing out of doors at all. During the day, he had trouble going out because he feared being stung by flying insects, particularly wasps, and because he feared a repetition of an incident where a policeman had stopped him for no reason at all and asked him, in what he thought was an accusatory fashion, where he was going. Next, he completely stopped traveling from his home town to the city for all the reasons just mentioned and because he had become convinced that the second he got off the train, someone would approach him, pick his pocket, and strand him by taking the money he needed for the return trip.

In spite of these limitations, and the considerable suffering attendant upon them, he claimed that being an avoidant had many advantages.

As he, in essence, put it, “It’s great keeping my positive emotions in check. That way I can avoid humiliating myself by expressing feelings that I consider to be both so passionate as to be embarrassing and so common as to be trite. Besides, I do not really need other people. All I need comes from within. I enjoy my own company best. I like being isolated and get a great deal of pleasure from being able to go home, sit there surrounded by the things I love, and come and go as I please. I enjoy collecting things so much that I feel that the worst day at the flea market is better than the best day at the meat market, and anyway, my cat is my best friend, someone I can always count on—unlike everybody else I have met up to now.”

Our therapeutic work consisted in part of understanding in depth how his avoidances began. For example, we learned that his fear of criticism partly originated in his early relationship with a mother who savaged him when he did things wrong, without also complimenting him when he did things right, to the point that, as he put it, with a sort of humorous resignation, “She actually died before she could say even a single nice thing to or about me.”

We also uncovered, clarified, and analyzed the here-and-now fantasies that made up his current avoidant symptoms. We discovered that his shyness partly consisted of his staying away from people out of concern that he would take anyone he met away from someone else, much as his siblings took his mother away from him. An intense moral scrupulosity also led him to fear that others might criticize him for his sexual feelings. Too, he wanted to be a good role model for others he believed should, when it came to sexual relationships, follow his lead and be just as Spartan and abstemious as he was. As he described it, his was an advocacy for the highest level of morality, whose means of getting rid of temptation was not, as Oscar Wilde said, to yield to it, but, as he said, to get rid of the people who tempted him.

We discovered that for him, stinging insects symbolized his critical mother, as did the preacher in church and the policeman on the street. We further learned that he could not take the train because the moving train symbolized his impulses and train crashes the dreadful consequences of having and expressing them. Driving over the bridge symbolized his fears of forward movement and success—reaching the pinnacle, only to be mauled physically (i.e., castrated) as a consequence of soaring.

We analyzed his church phobia as due both to a fear of being submissive (“controlled by the proceedings”) and to a fear of being embarrassed publicly should he get too emotional about the service and lose control. The latter fear had some basis in reality, for on more than one occasion, just a small amount of alcohol released his inhibitions to the point that he acted aggressively in public and said nasty things to people he hardly knew—mostly, but not always, under his breath.

Such understandings gleaned over several years of therapy helped him deal with his relationship anxiety enough to form tentative, partially intimate relationships. He kept his old friends and developed a few new ones. He moved in with a woman he felt comfortable with, partly because she was an avoidant herself: an unassuming, undemanding person who desired little closeness and intimacy from him or from anyone else. They fought a great deal and threatened to leave each other on a regular basis, but that was only their way to reassure themselves, and each other, that neither was engulfing, or being engulfed by, the other.

On follow-up, he said that now was the happiest time of his life, although he recognized, “As my therapist, you are probably disappointed in me, thinking that the adjustment I made is somewhat less than ideal, at least according to what I consider to be your overly rigorous standards: particularly what I perceive (and you know that I am right!) to be your belief that everyone should get married, and that anything less than marriage represents an unsatisfactory adjustment to life, because by definition it represents a lesser way to live.”

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CHAPTER 12

C ognitive-B ehavioral Therapy

COGNITIVE THERAPY

Cognitive therapists identify, illuminate, and challenge avoidant logical distortions with the goal of correcting specific errors of thinking (avoidant ideation) likely to generate avoidant behavior. The therapeutic goal is to help patients think and act more rationally and productively so that they can more readily connect with others, and even commit to a long-term, lasting, loving relationship with someone special.

Along these lines, Beck elicits, challenges, and attempts to correct automatic thoughts, such as “others view me as socially inept and undesirable,” that lead to avoidant withdrawal, that in turn leads others to counter with “unfriendly . . . behaviors and actions.”¹ Beck reality tests these thoughts by asking avoidants to “apply . . . rules of evidence,” “consider . . . alternative explanations,” and solve interpersonal problems by “putting aside the subjective meanings they attach to a communication and focusing on the objective content”² so that, for example, avoidants can recognize that someone, merely by expressing a personal need, is not per se blaming them for not having gratified it.

Along similar lines, scattered throughout his book, Rapee offers cognitive-reparative approaches to treating shyness and social phobia. These can be paraphrased and summarized as follows:

• learn how to interpret and think about situations and other people more realistically, for example, through learning that feelings and emotions are directly caused by thoughts, attitudes, and beliefs, not by the things going on on the outside

• identify and change basic beliefs and unwritten laws such as “everyone must like me, and if I am not liked, I am worthless”

• identify and challenge basic fears—the things that make you anxious

• don’t overestimate the likelihood that bad things will happen in social situations

• ask, “What is the evidence for my alarmist expectations?” and reassuringly tell yourself, “If the worst should occur, so what?”

• Practice attention-strengthening exercises to help pay strict attention to the task at hand.³

A Case Example

A shy patient hesitated to leave the house because some of his neighbors did not say hello to him on his morning walk—he believed because they did not like him. I helped him reframe his conclusions about the supposedly noxious behavior of his neighbors so that he could become more realistic about this and other similarly terrifying interpersonal situations. I suggested that he apply the rules of evidence, consider alternative explanations, and pay strict attention to the task at hand—which involved focusing on the objective content of what his neighbors were saying, not on the subjective meaning he was attaching to their communications. I clarified that while some of his neighbors might dislike him, others were simply caught up in their own little world, thought he didn’t see them, or, if they did, did not want to call out his name because it was early in the morning and they were afraid of waking up the whole neighborhood. I clarified that his neighbors did not reject him because they thought that they were superior to him, and would not reject him even more when, getting to know him better, they saw his flaws more clearly. I also suggested that when making contact with people, he should monitor his anxiety to make certain that it does not exceed bearable limits, and if it does, he should pull back and try again the next time. For example, I suggested that to avoid creating internal unpleasantness, he should not, as was his habit, discuss politics and religion, but instead promptly switch the discussion to neutral issues such as the weather, or impersonal, unthreatening matters such as the real estate values in the neighborhood.

Some cognitive therapists stress the importance of spotting, identifying, and correcting cognitive errors as they arise in the transference. To illustrate, an avoidant who learned that her therapist was not being critical of her simply because she was correcting her cognitive errors thereby learned that her husband still loved her, even though he didn’t always agree with everything she said.

Some cognitive therapists use role-playing, where they ask patients to put themselves in others’ places for the purpose of developing truer assumptions about what others have in mind. In one case, a patient who felt he was being rejected because he didn’t get an immediate reply to an e-mail he sent was able, after putting himself in the (overworked) recipient’s place, to understand that the response was delayed simply because the person who received the e-mail was currently busy. (I describe role-playing, a predominantly behavioral technique, further later.)

Avoidants, especially those who snap at others in retaliation for imagined criticism, can also benefit from empathy enhancement, a technique that involves reducing transactional negativity through understanding where the other person is “coming from.”

Some Case Examples

Shortly after a man’s wife died, she received a notice from the internist who took care of her asking her to please come in for her annual physical examination. Her husband was outraged at first, but when I asked my patient to put himself in the doctor’s place to explore the possible reasons for the doctor’s confusion, the patient recognized that it was nothing personal and that the doctor, however misguided, was ultimately primarily concerned about his wife’s welfare. So instead of getting mad, and even, he called to tell the doctor’s office that his wife had died, to thank her doctor for treating her, and to commend the doctor for his continuing concern, however misguided, for the state of her health.

A psychiatrist felt passed over when an internist called not on him, but on a psychologist colleague, for a consultation with the internist’s patient. The psychiatrist remained angry until his own therapist pointed out that he, the therapist, knew (for personal reasons) that the internist was merely living out a positive relationship with his own psychotherapist, also a psychologist.

An avoidant vendor out of the morning newspaper reacted to the question, “Do you have any more of these newspapers?” with “It’s not my fault that I am out of them—why is everyone bugging me?” As his therapist, I suggested that he put himself in the place of his customers and see that they were expressing not a criticism of him, but a need of theirs, so that he should instead try a shorter, sweeter, less interpersonally divisive, more accommodating reply: “Sorry, no.”

Some therapists actively suggest positive thoughts patients can install to counter their negative cognitions. For example, a therapist first helped a patient who feared public speaking because he feared he would faint think less catastrophically about what might happen if he actually did faint, however unlikely that possibility. He next suggested that the patient hold a countervailing, distractive, reassuring thought while giving his speech: “my anxiety always dissipates a few minutes after I get started.”

Therapists often help patients think less catastrophically by supportively, soothingly reassuring them that anxiety almost always subsides shortly after a feared activity, such as going to a party or driving over a bridge, begins. What happens is that patients crest over what I call their “phobic hump,” at which time their anxiety diminishes or disappears, to be replaced by positive feelings of mastery, pride in accomplishment, joy in activity, and elated feelings both pleasurable in themselves and a source of motivation and courage to try again.

Therapists can help their patients think less catastrophically about being criticized, humiliated, and rejected by helping them enhance their self-esteem. They can do that by helping them develop reference points independent of their need for and the results of impression management. Patients can more clearly see the evidence for and against dark forebodings and disjunctive fears if they stop the self-spectatoring involved in attempting to constantly improve upon the grades they bestow on themselves in their own continuously self-administered interpersonal “report cards.” Avoidants can also helpfully ask themselves what it is about other people that makes it so necessary for them to actually hand out bad grades, trying to see, as is almost certainly the case, that “it’s their problem, not mine, because people these days only talk about themselves.” Avoidants can profitably ask themselves if the people actually humiliating, criticizing, and rejecting them are really important enough for their negativity to matter and take seriously to the point that it takes hold. And avoidants who have actually been personally “downgraded” and rejected can reassuringly tell themselves, when applicable, that “it’s their loss, not mine.”

Unfortunately, “illogical” cognitions can be resistant to corrective logic when there is enough reality to the so-called illogic to make full reality testing and reassurance difficult or impossible. Because planes do sometimes crash, it is not possible to offer blanket reassurance to phobic patients that flying is completely safe. Similarly, it is as impossible to completely dismiss the appropriateness of opening night jitters when performing before critics as it is impossible to completely dismiss the possibility of rejection when meeting new friends and lovers.

Because cognitive therapy inherently involves challenging how patients think, and because all challenges by their very nature are invariably critical, therapists should always do cognitive therapy in the context of a supportive holding therapeutic environment, where they offer patients countervailing comfort, reassurance, and understanding. They might repeat something supportive such as “most people share your anxiety and fears, at least to some extent” and “don’t blame yourself for making the thinking errors you make, for while it might be necessary for therapeutic purposes for me to speak as if you are entirely responsible for making the cognitive errors we discuss, we both understand that even your most unrealistic negative cognitions are, to some extent, particularly in a person as sensitive as you, set off by the antagonistic cognitions, and provocative behaviors, of others.”

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called my husband and said, “As hard as this is, we need to be on the same page about it.” When my husband comes home, he tells that kid that he would call the police on him if he ever acted like he did again. The kid then puts all his things into a large blanket, his computer and stereo into a box, and leaves. Said he would never come back and never wants to see us again.

I said I didn’t want him to go like this, that I wanted him to build to a point where he was ready to go, when he could afford a place. I told him I loved him very much, but that I saw him floundering and this was the age he needed to be working toward something.

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behavior; (6) improve their self-image; (7) make cognitive corrections/ rework aversive schemas; (8) use distraction methods such as positive social interaction; (9) increase contact to acquire critical social skills;

(10) try new experiences, which can help by enhancing and maintaining motivation and providing the opportunity to monitor behavior and correct maladaptive, automatic thoughts and irrational beliefs;

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learn to control fretful-expressive behavior while simultaneously