The Essential Guide to Overcoming Avoidant Personality Disorder

BEHAVIORAL THERAPY

Social Skills Training

Social skills that do not develop automatically as a consequence of changing one’s self-destructive thinking can be taught, leading, as the Quality Assurance Project notes, to “areas of increased social activities with decreased associated anxiety, a lessening of social isolation with diminished depression, and the loss of many irrational social beliefs.”⁴ Scattered throughout Anthony and Swinson’s book are direct suggestions to patients as to how they can better interact and communicate effectively with others. To paraphrase these authors, they suggest avoidants learn to listen, modify off-putting nonverbal communication, and develop conversational skills. They teach them how to go on job interviews; how to communicate assertively instead of too passively (hesitantly, shyly) or passive-aggressively; how to meet new people, make new friends, and date; and how to develop public speaking skills. They help them learn to control avoidant fretting in settings in which these behaviors are brought to the fore and lead to less than satisfactory human transactions.⁵ For example, they might teach them not to offer others a limp hand for an introductory handshake and to look people directly in the eye when they speak to them, instead of looking off into the distance, ostrich-like, thinking, “If I don’t see them, they won’t see me either.”

Graded Exposure

As noted throughout, behavioral therapists suggest patients perform individual tasks of graded difficulty geared to overcoming specific avoidant inhibitions. Thus Benjamin suggests that therapists help avoidants block maladaptive patterns with “desensitization to avoided social situations [by having the patient try out] successive approximations to more sociability.” She also emphasizes that therapists can best accomplish this if they give their avoidant patients “much reassurance in a context of competent, protective instruction.”⁶

Avoidants doing what makes them afraid in small increments must not let temporary setbacks unduly discourage them. As Rapee suggests, to become habituated to anxiety, avoidants need to “stay in a situation until [they start to] calm down,” and they must not let themselves “be discouraged by bad days.”⁷

Here are some ways a representative sampling of my avoidant patients underwent gradual exposure to feared situations:

They got out of the house and talked to strangers, saying hello to just one new person a day.

They responded to a stranger who said hello, instead of questioning the stranger’s intentions, then averting their eyes.

They stopped walking by people they saw, acting as if they didn’t see them.

They discussed a problem they were having with the person they were having it with, instead of retreating from or ignoring that person as “difficult.”

They went to work even when they didn’t feel like it, instead of calling out sick in order to have a “mental health day.”

They broadened their horizons, for example, by answering the phone, instead of letting the answering machine pick up the call. Though they did not have a partner, instead of staying home and eating all by themselves, feeling sorry for themselves, they went out to dinner alone. They bought a computer so that they could get e-mail from their friends, modified favored hobbies to do them with other people—collecting stamps in a group, instead of by themselves, or buying a book in a real bookstore, instead of in the remoteness of cyberspace. At work, they forced themselves to join in group conversations and sit with others in the cafeteria, instead of sipping coffee alone or taking their lunch to a park bench and eating it there in isolation.

They went to bars or onto the Internet for networking, meeting as many people as they possibly could, then slowly but surely winnowing relationships down perhaps to one significant other.

They accepted dates arranged for them, instead of protesting based on preconceived notions that reflected preexisting avoidances, turning “blind dates” down for purported philosophical reasons that were little more than rationalizations of self-defeating motives.

Patients can expose themselves not only to uncomfortable external, but also to uncomfortable internal sensations (interoceptive exposure) so that they can learn to better tolerate their inner anxiety experiences. For example, they can learn to tolerate dysphoric feelings by conjuring up frightening fantasied situations in their mind, starting with the mildest anxieties and ratcheting up to the most frightening, letting these all work their way through their thoughts and emotions. The self-analysis of their dreams can provide new and helpful self-discoveries.

Exposure therapy works in part because it helps avoidants achieve minor successes, which reduces full despair about complete social failure. Success breeds success because real accomplishment enhances self-esteem by promoting self-pride that increases self-confidence, which leads to improved functionality that further enhances motivation (for motivation comes as much from doing as the other way around). Avoidants who relate at all successfully discover that relationships make them feel good about themselves; feeling good about themselves makes them feel more worthy of relating; and feeling more worthy of relating helps them relate even better. Additionally, actually being in a positive relationship helps reduce negative symptoms—as the positive energy from real-life friendships flows back into reducing underlying maladaptive, automatic thoughts and irrational beliefs, allowing fuller, more satisfactory human transactions to occur, while providing support and structure that predictably reduce avoidant anxiety. For example, a patient was unable to ride on a train until she decided to force herself to visit a potential partner she met on the Internet. Now, feeling enveloped in his protective warmth, she was able to make the trip and to do so virtually anxiety-free.

This said, avoidants who are both patient and highly motivated can bypass the need for incremental, step-by-step exposure and deal with the worst first in an attempt at instant mastery, deliberately increasing their anxiety to a painful (but supportable) level, hoping to break through to health all at once, instead of gradually, and before all their deep fears of closeness have been definitively resolved.

Manipulation

A phobic pass or other talisman can help those avoidants who are impressionable enough to believe in magic. Some therapists give an avoidant afraid of going to a party a signed slip of paper that reads, “Pocket and hold on to this and you will be okay on your date tonight.” Others give a social phobic afraid of public speaking a slip of paper that says, “You will be able to get through your speech without having your voice crack, or passing out.”

Role-Playing

This helps patients spot specific relationship problems so that they can begin to relate in new, less tentative, more effective, less selfdestructive ways. Videotapes of avoidants interacting with others with the avoidant speech and behavior patterns edited out to create a new, more nonavoidant performance can show avoidants what exactly they can do now to act less avoidant in the future.

Injecting the Therapist’s Personal

Nonavoidant Philosophy

Once, hoping to teach a patient how relationship difficulties can be overcome through yielding, compromise, and positivity, I quoted W. H. Auden’s 1957 poem, “The More Loving One”: “If equal affection cannot be / let the more loving one be me.”⁸

Paradoxical Therapy

Jay Haley’s paradoxical therapy is a form of behavioral treatment that is, in some ways, the opposite of exposure therapy. Here patients are asked, or told, not to do the very thing that they should be doing—that very thing that makes them most anxious. The therapist counts on the patient’s native stubbornness and oppositionalism to surface and lead to fearless counterphobic and hence healthy action.⁹ For example, one therapist suggested a patient take a vacation from relationships, anticipating that as a stubborn, resistant avoidant, he would do exactly the opposite of what the therapist advocated—relate to others, just to defy the therapist!

Paradoxical approaches are particularly helpful for sexual avoidants because they almost predictably lyse inhibitions by evoking the lure of the forbidden. Sexual avoidants often experience an enhancement of sexual desire plus an urge to actually have the prohibited sex they were formerly unable to have simply because now, told to cease and desist, they feel tempted to sneak around and start having it against the therapist’s wishes and behind the therapist’s back.

Enhancing Motivation

Therapists can enhance an avoidant’s motivation to relate by enumerating the benefits and rewards of relating, hoping to convince the patient that such rewards are sufficiently great to make it worthwhile to experience the discomfort involved.

Urging Patience

I remind patients that they will not be better by tomorrow because they did not become avoidant overnight. Also, most avoidants both like and need the way they are and fear the alternative too much to become instantly nonavoidant just on a therapist’s say-so. For in one sense, avoidance is a philosophy, an entrenched, much-beloved, personal value system, and in another sense, patients need their avoidance because it is a defense that reduces anxiety, if only by offering breathing room in interpersonal crises—an opportunity to regroup forces in preparation for making the next, terrifying move. Too, nonavoidance, like almost all new behaviors, requires practice before it can become perfect and second nature. Finally, pushing oneself too far, too fast into feared encounters can lead to such intense anxiety that in response, avoidants may quit therapy or stay in treatment but, therapeutically speaking, drag their feet to reestablish their comfort level.

Journaling

Journaling/workbooking can clarify and critique one’s avoidant positions and firm up what needs to be done to better reposition oneself interpersonally. Journaling is discussed further in chapter 20.

Relaxation Techniques

Deep breathing and muscle relaxation can help induce a state of calm and control the hyperventilation that often accompanies interpersonal anxiety.

Creating Right-Brain Activity

Right-brain activity (the product of emotions) can blot out left-brain activity (characterized by faulty, worrisome thinking). For example, an avoidant anxious about public speaking can blot out stage fright by thinking about a joyous celebratory dinner to come “if I get through this.”

Having Joint/Group Exposure

Avoidants can get together with ex-avoidants to consult with them to find out how these ex-avoidants became nonavoidant. They can also join in with other active avoidants to egg each other on as powerful allies in a joint program to conquer relational panic.

Of course, certain avoidant problems are more amenable to behavioral therapy than others. The shy patient who fears meeting someone new at a party can attempt trial connecting, but the more outgoing patient who can start but not see a relationship through to its conclusion cannot be reasonably expected to attempt trial committing.

Behavioral cures can unfortunately backfire, leading to increased isolation. For example, although avoidance can be made more tolerable with hobbies, it is usually a better idea to make hobbies more tolerable with nonavoidance so that avoidants don’t while away lonely hours keeping busy, instead of busying themselves making the hours less lonely. So often, solitary hobbies increase isolation by acting as reminders of how much one is missing. So the often given behavioral remedy “get a hobby if you can’t relate” should be corrected to “relate, so that you don’t have to get a hobby.”

CHAPTER l3

Interp

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Sullivan places the focus of therapy on interpersonal anxiety¹; that is, he studies old and new interpersonal distortive fantasies in order to correct resultant transactional removal behaviors that keep patients from getting close and developing anxiety-free intimate relationships. Frieda Fromm-Reichmann describes the goals of treatment as a “potential freedom from fear, anxiety, and the entanglements of greed, envy, and jealousy . . . actualized by the development of [the] capacity for self-realization, [the] ability to form durable relationships of intimacy with others, and [the ability] to give and accept mature love.”² Millon and Davis emphasize having “a ‘corrective emotional experience’ with the therapist,” with the therapist serving as a mirror for everyday relationships and offering a positive experience that it is hoped would “generalize to [other] contexts outside of the therapy hour.”³ I focus on the dyadic unit as a way to understand one or both of its individual members. I identify avoidant interactive behaviors, bring them to the patients’ attention, and study their conscious and unconscious meanings. I try to learn about the special circumstances under which interpersonal withdrawal actions appear, that is, the “when,” or the exact moment, that the avoidant begins to pull back from others, and to learn about the “why,” that is, the reasons for the retreat. Do avoidants become anxious in some situations but not in others, and withdraw from some but not from all people? Do some feel comfortable with a person “of their own kind,” but withdraw from people who are significantly unlike themselves, for example, “beneath them” or “better than I am,” or of a different color, race, religion, or social status? Or is it just the reverse: do they feel uncomfortable with a person of their own kind and seek, almost compulsively, someone as much unlike themselves as possible?

I also correct interpersonal cognitive errors, for example, I suggest avoidants stop exaggerating relational dangers so that closeness equates to commitment, entrapment, and fatal smothering. I ask avoidants to stop overestimating the degree to which others are being negative to them, turning a cancelled dinner date into a catastrophic signal that all relationships will henceforward be troubled and doomed. I ask avoidants to try only to react fully positively in safe situations with family, chums, and potential or actual partners who are warm, yielding, permissive, and available, and to react with at least some caution in dangerous situations such as those where the possibility of fulfillment is weak. I especially warn them not to attempt to get close to others who are by nature distant, unfeeling, forbidden, and unavailable such as people who are already taken, like “almost divorced” men who promise to leave their wives but have no intention of ever doing so.

I teach avoidants specific interpersonal skills. In particular, I ask them to identify and reduce the contribution they make to the distancing process, where they create relational negativity by behaving in a way that others will predictably find off-putting, if not openly insulting.

I strongly suggest that avoidants routinely exercise their power of positivity—striving to be nice and generous to, and less overly demanding of, others so that they come to act in the same healing way toward other people that they would want other people to act toward them. Being nice is always good practice for avoidants, and that usually involves becoming less critical and demanding of, and more forbearing toward, others, and failing that, if they must feel and behave negatively about and to others, doing so in as restrained a manner as possible so that they can at least leave the door open to making amends—apologizing after the fact, then going back. Being nice also involves being generous—giving others something without expecting to get something in return. That often starts with reducing excessive expectations of others to avoid disappointment that can lead to punishing those who have done one a good-enough good deed.

A Case Example

A student wrote to me asking how he could get a copy of my book on writer’s block, which he wanted to read but couldn’t afford on his small allowance. I guided him, I thought graciously, on how to get the book out of the library, only to have him criticize me and the library as follows: “I’ll order a document copy mailed out (I don’t fully understand what the hell this is, to be honest; you’d think they’d make it clear, operating a service and all . . . I mean, they won’t loan me the book by mail order, but they’ll photocopy every page and mail them to me? I mean . . . seriously, who would do that?). I’ve read your book on paranoia, by the way, not because I’m paranoid. It just seemed interesting, and I like to read a lot, y’ know. I’m not really interested in self-help stuff, to be brutal, I tend to think things come and go, are what they are, so to speak, and if you’ve got a pretty good handle on yourself, you know when to turn a page—forward or back. Y’ know what I mean?”

I also suggest avoidants, such as the student I just quoted, be em-pathic: not getting sidetracked onto how others make them feel to the extent that they lose focus on how they make others feel, as they address only their own emotional needs and not those of the people around them. I advise avoidants that they can best be empathic if they appreciate the good in others, and they can do that by better understanding others’ feelings, needs, and motivations as well as by seeking benign explanations for others’ presumably bad behaviors, forgiving their small transgressions, and thus giving others an opportunity to save face, and themselves the opportunity to retain the possibility of making repairs.

Finally, I ask avoidants to give up their need for full identity maintenance. I remind avoidants afraid of relinquishing any aspect of their identity to a significant other that as the singer Joni Mitchell said, when it comes to love, “some loss of self is inevitable.”⁴ I also emphasize that new and often more pleasurable identities emerge in close, intimate relationships, particularly the identity of being a happily partnered/happily married individual. I also point out that avoidants can, if they like, compensate for any loss of personal identity they will probably incur in a relationship by developing a new and stronger professional identity independent of, and supplemental to, the personal identity that they are so often highly terrified of losing completely.

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CHAPTER 14 Supportive

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Supportive therapy for avoidant individuals consists of what Benjamin calls “generous doses of . . . empathy and warm support . . . delivered without a hint of judgmentalism or rejection . . . providing] evidence of a safe haven” where acceptance rules. Benjamin also notes that in therapy, “the AVD’s [avoidant’s] pattern is an especially intense version of the ‘generic’ patient position. He or she wants to be accepted and loved, and ‘holds back’ because of poor self-concept and fears of humiliation. The ‘generic’ therapist position addresses this ‘generic’ patient position,” gradually helping the AVD share “intimacies and feelings of inadequacy or guilt and shame,” while the therapist’s “benign and nonjudgmental acceptance of the AVD helps the AVD begin to accept himself or herself [and] as the therapy relationship strengthens, the patient can begin to explore his or her patterns.”¹

Following are three important cornerstones of my own supportive therapy approach to avoidants.

LIKING AND RESPECTING THE PATIENT

Patients who perceive that their therapist likes and respects them feel that the therapist truly wants to help, leading them to feel accepted, rather than rejected—a healing therapeutic response that can persist long after psychotherapy is over, as the patient carries the therapist’s positivity around inside, with the therapist having become at least the one person in the avoidant’s life different from rejecting mother, emasculating father, and all the other hurtful and cruel people that inhabit the world of the avoidant’s scary past, frightening present, and dreaded future.

OFFERING THE PATIENT REASSURANCE

Here are some reassuring messages that I give my anxious avoidant patients.

Everyone Experiences a Degree of Social Anxiety

Avoidant patients who feel uniquely troubled, or uniquely bad, often find it reassuring to learn that they are not alone—because almost everyone gets anxious in social situations. Indeed, a big difference between a healthy and an avoidant response is the willingness to accept and tolerate a degree of social anxiety and continue to function in spite of it.

Social Anxiety Can Be Overcome

Avoidant patients almost always benefit from hearing that their prognosis is good, for they have the gift of relating already inside, and “all” they have to do is unwrap it.

All of Us (Even Avoidants) Have Some Control

over What We Allow Others to Do to Us

Avoidants, like everyone else, have the option of staying away from, or getting out of, relationships with difficult avoidogenic individuals (those who would make anyone anxious and drive just about everyone away) without feeling guilty or being criticized or stigmatized for doing so.

Criticism Is Rarely FAtal

Most of us survive the criticism that all of us get from time to time, no matter who we are or what we do. For example, most of us get through being put in can’t-win situations similar to that of the woman who was criticized for being a slut for showing her sexual feelings, then criticized for being cold, unavailable, and unresponsive for hiding them.

There Are Ways to Make Even Devastating

Criticism More Tolerable

Avoidants can find strength and approval from within by refusing to calculate their self-worth by their so-called reputation. It helps to recognize how often not us, but our critics, are the ones who deserve censure for elevating their own self-esteem by lowering the selfesteem of others. Furthermore, there is often a bright side to being criticized, as people identify, sympathize with, and move in to support the underdog. Dealing with criticism is discussed further in chapter 17.

Fears Are Worries, Not Realities

Avoidants can be reassured that there is little or no justification for many of their fears. Flooding by and depletion of one’s life force due to letting strong feelings loose can occur, but it is almost always mild and transitory, consisting of a mere passing sensation of fatigue. And while there are documented cases of grooms and best men passing out during a wedding ceremony (but with few to no real consequences), I know of only a relatively few documented cases of public speakers actually fainting (at least for emotional reasons) while giving a speech or appearing on TV.

Guilt Is Almost Always an Overresponse

Guilt over minor peccadilloes is mostly the product of distortive thinking about one’s past and present behavior, leading to inappropriate low self-esteem that breeds self-criticism and hence even more guilt.

Anxiety Almost Always Subsides Shortly

after Starting an Activity

Cresting over a phobic hump occurs as a result of denial and habituation so that anxiety disappears, to be replaced by a feeling of mastery, pride in accomplishment, joy in activity, and sense of general elation— all of which are both pleasurable in themselves and a source of courage to try again.

A Case Example

A patient afraid to drive over a bridge at first refused to try because he was generally too anxious to leave home and because of specific fears that something terrible might happen if he got behind the wheel: he would faint, lose control of his car, and, bumping and crashing into other cars, die and kill others in a fiery crackup. One day, he nonetheless forced himself to drive over a bridge. Predictably, anxiety began as soon as he got near the base of the bridge and increased as he ascended; then, as he crested, his anxiety turned into a feeling of euphoria due to delight in accomplishment—happiness about his triumph both over the obstacle bridge and his need to avoid it, and ecstasy over his having successfully mastered his bridge terror. (However, the entire cycle began once again the next time he tried to drive over the same bridge.) Things were much the same for him when he forced himself to attend a party. He felt anxious at the beginning of the evening. The anxiety worsened as the evening progressed. However, after an hour or so, the anxiety peaked and began to diminish, to the point that he was able to introduce himself to one or two people. Now he felt quite pleased and delighted with himself and began to function almost normally. This feeling lasted for the rest of the evening (once again, only to restart the next time he went to a party).

GIVING THE PATIENT GOOD ADVICE

Pinsker generally discourages giving patients specific advice. He tells them that “for $11.98, you can buy books that tell you what to do.”² Instead, he prefers to outline general principles. I feel that outlining general principles, while an excellent idea for treating most patients, may be wrong for those avoidants who misinterpret handsoff approaches as a lack of caring on the part of an unconcerned therapist.

This said, therapists who give advice should explain that taking it does not make one a dependent pushover. They should also caution patients to do what works for them, and not to do something simply on the therapist’s say-so (or on the basis of myths currently in circulation). They should also avoid too specifically telling patients exactly what to do in situations where different reasonable options exist, for here individual choice must reign. I personally feel most comfortable giving avoidants advice on how to develop social skills and overcome specific avoidant pathology. For example, I feel comfortable suggesting that Type I avoidants try to overcome their shyness by “getting out there and meeting new people,” while listing some places they might actually go to do just that. But I believe it would be presumptuous of me to decide who among those they actually meet are right, and who are wrong, for them.

Not all avoidants are candidates for the same advice. Therapists giving advice should respect the level of nonavoidance a given individual wishes to achieve—how much closeness and intimacy he or she wants out of life and is capable of attaining. Some so-called avoidants truly want to be loners. Still others long for a close but not a fully intimate relationship. For some, marriage is the right and only goal; others fear it will ruin their and their partner’s lives. Each avoidant has to determine for himself or herself what, on a continuum from social isolation to full closeness and intimacy, is desirable and possible and suggest the therapist intervene accordingly. And the therapist should always ascertain how much sacrifice an individual is willing to make for relationships in the way of the inevitable negative accoutrements of meaningful connecting: some loss of self and a diminution of autonomy and independence.

Here are some examples of advice I have given to avoidants that they subsequently told me they found to be helpful.

Develop a Nonavoidant Outlook

Avoidants should recognize that the downsides of being alone are far greater than the anxiety associated with closeness, intimacy, and commitment.

Seek Consensual Validation

Avoidants can benefit from confiding how anxious they feel to others. Doing so avoids their seeming to reject others, for most people predictably mistake personal shyness for disdain targeted at them, leaving others less sympathetic and more antagonistic.

Learn the Art of Positivity

As emphasized throughout, avoidants should try to act as positively as they can toward others, becoming kind, generous, and forgiving, instead of being testily unwilling to extend themselves halfway and refusing to negotiate and compromise. They should become empathic as they eschew narcissistic self-preoccupied pulse taking, thinking only of “my anxiety,” without also considering others’ feelings, needs, and motivations. Sensitively addressing others’ emotional needs, not only one’s own, consists of being as apologetic, supportive, generous, and unsadistic as one’s anxiety and need for withdrawal will allow, while whenever possible offering others an explanation of one’s avoidance: “I am not being antagonistic; I am simply feeling afraid.”

Think Twice before Hooking Up with Truly Antagonistic Individuals

Examples of individuals best avoided follow:

• those who serve as bad examples because they themselves are seriously avoidant and proud of it, such as people who put things before people, like fussy housekeepers who won’t invite anyone over to the house because they fear that they will ruin the furniture

• rationalizers of their own inappropriate aggressiveness as mere assertiveness

• pessimists who tout tragic fiction and sad songs to affirm their belief that few, if any, relationships ever work out—one reason why “life sucks”

• paranoids who can neither trust nor be trusted

• hypermoral individuals who condemn as sinful anything spontaneously and characteristically human, especially human sexuality

• infantilizing individuals who encourage staying home all of one’s life to devote oneself completely to taking care of faltering children, needy siblings, or elderly parents

• friends who attempt to act as substitutes for romantic relationships—particularly devastating are “close” companions who, when they find their own intimate relationship, dump the avoidant suddenly and without warning. For example, a psychiatrist leaned heavily on and formed a codependent relationship with a psychologist friend who willingly listened to her troubles for many years. Then, when the psychiatrist got married and no longer felt so needy, she told the psychologist, “I am out of the shrink realm and into the art realm, so because now we no longer have anything in common, I won’t be seeing you anymore.”

• jealous individuals who ensnare then guard avoidants, luring them into isolating groups, like therapeutic support groups, whose members too readily substitute themselves for individual relationships, then demand group cohesion at the expense of individual freedom and group loyalty before personal achievement and fulfillment. Thus in a group house on Fire Island, whenever the members of the house sensed that one of the roommates was about to connect, the other members suggested that they all go to the local ice cream parlor and look for men: a place significantly called “Unfriendly’s.” Other isolating groups are those whose members espouse a Zen-like philosophy of removal as the best or only way to reduce interpersonal anxiety; advocate antisocial behavior, as do some rumbling motorcycle club members; or advocate bigotry by word or deed, for example, putting seriously exclusionary by-laws into place to keep out others they deem unacceptable because of their race, religion, ethnicity, or sexual orientation.

Don’t Stay Overlong in a Relationship

That Isn’t Working

Doing that is a particularly bad idea when it is being done out of an excessive sense of guilt about leaving and a masochistic need to change the minds of those very others who are most set against one.

Never Use Sex as a Vehicle for Expressing

One’s Avoidance

Hypersexuality should not become a way to display one’s fundamental unrelatedness or a way to rebel against a society believed oppressive.

Never Use Sex as a Vehicle for Overcoming

One’s Avoidance

Sex should not be a masochistic, self-punitive begging, where one reluctantly submits sexually just to retain a relationship along the lines of “I’ll do anything you want me to if only you will love me and not leave me.” Nor should avoidants make “good sex” the sole criterion for pursuing a given relationship, especially if they are planning all along to abandon the relationship when the sex loses its luster.

When Involved in a Committed Sexual

Relationship, Try to Practice

ioo Percent Fidelity

Especially for avoidants, cheating tends to be more an avoidant problem than a nonavoidant solution—something that puts distance between people by creating personal guilt and partner resentment, even in partners who at first seem willing to go along. Therefore avoidants should confine their “extramarital relationships” to incomplete relationships selected to supplement, not replace, “spousal” relationships: a relationship with a pet (where the nonhuman aspect makes the closeness both acceptable and tolerable); a nonsexual relationship with a friend (especially a member of the same sex in a heterosexual marriage/opposite sex in a homosexual marriage); a nonsexual relationship where, additionally, age differences are reassuring (so that homosexuals/heterosexuals may more comfortably adopt an older man/woman as a close companion than a younger one or one of the same age); and close family relationships as distinct from equally close relationships with strangers. To avoid distancing, avoidants who have any strong outside relationships should always emphatically reassure their partners that “I will not allow this person to come between us or take me away from you.”

Avoidants often ask me as their therapist whether they should try to meet people in singles bars or attempt to connect over the Internet. I advise avoidants that, used appropriately and in moderation, these places of approach can help the avoidant find a lasting relationship—but only if avoidants first overcome their avoidance enough to “mingle” and work any contacts creatively—looking not for quick sex or a merger, but trying to network with the long-term view in mind. Networking involves slowly but surely, and patiently, making as many acquaintances as one can, deliberately spreading oneself thin in the beginning, making multiple contacts, developing a circle of acquaintances, then narrowing the newly developing wide band of relationships down to one significant other, the most important individual in one’s new life: Mr. or Ms. Right.

Needless to say, avoidant behaviors can be as disruptive in singles bars, or on the Internet, as they can be anywhere else. Thus an avoidant man I finally convinced to go to a bar to try to meet women “accidentally” negated my advice by carelessly saying loudly and convincingly, “There isn’t anyone in this bar that I would sleep with”—thinking he was just talking to one of his friends, only, as he knew from experience might happen, to find that as he spoke, everyone else fell silent so that “the whole world heard what I said.”

Because all contact is by nature nonavoidant, avoidants desiring to network need only begin somewhere, almost anywhere, for starters forming distant relationships in anticipation of gradually getting closer as their anxiety subsides. Avoidants can start by being nonavoidant in some small respect, such as by saying hello to strangers. They can also form experimental “practice” (transitional) relationships that serve the purpose of loosening up, conditioning themselves not to fear rejection, advertising their availability, and getting a nonavoidant reputation via showing others “I want, and am willing, to accept people.”

Avoidants should take care not to fall for the come-ons of dating services that offer miracles in the form of alluring advertisements virtually guaranteeing to provide them with suitable mates. Disappointment and an unwillingness to try again is their fate, as it is of the avoidants who buy into books and embrace gurus that tell them how to succeed relationally, effortlessly, and in short order, promising an immediate and easy solution to a complex problem that will almost certainly take time and effort to solve.

AVOID GIVING PATIENTS BAD ADVICE

Bad therapeutic advice includes advice best reserved for nonavoidants such as “do your own thing”; “get your anger out”; “play hard to get”; “don’t say yes when you mean no”; and “make complete honesty your best policy.” Avoidants need to become more, not less, connected by keeping their anger in to develop and cement relationships; by generally playing easy, not hard, to get; by sometimes saying yes when they mean no—being cooperative, compromising, and even submissive, if only to temporarily reduce tension; and instead of always expressing themselves and speaking freely and indiscriminately, by being very careful of what they say and do in the recognition that most times they are only one of many hypersensitive people in any given room.

As mentioned earlier, therapists should not routinely give avoidants advice about who specifically is right or wrong, good or bad for them, leading the avoidant on to condemn specific relationships prematurely, and on some trivial and principled but unhelpful grounds. Along similar lines, an avoidant should seek not a compatible partner based on his or her answers to an Internet questionnaire, but a simpático partner, who, whatever his or her specific personality profile happens to be, is motivated to make a relationship work, willing to change if necessary, and especially loath to validate avoidant fears of being rejected by others by actually being rejecting.

SUPPLEMENTAL APPROACHES

At times, I refer my avoidant patients for an appearance makeover, to an exercise guru, or to another physician for needed medical care for physical ailments.

I sometimes suggest tricks avoidants can use to master the anxiety associated with giving a speech or meeting people at a social gathering.

Public speakers can help deal with the fear of fainting associated with stage fright by reassuring themselves that they are not losing consciousness by moving about in place, wiggling toes, tightening the thighs and buttocks in a symbolic attempt to get the blood to flow back to the brain, sucking on a mentholated cough drop or sugar candy to refresh themselves, or having a sip of ice water to “shock” themselves back into focus. They can also make their audience seem less frightening by demeaning them, for example, by imagining them in a ridiculous pose so that the audience looks as ridiculous to the speaker as the speaker feels he or she looks to the audience.

I often recommend the following “healthier” defenses as potentially salutary substitutes for defensive withdrawal (healthy defenses are also mentioned in chapters 11 and 20):

• Healthy avoidance, which allows patients to retreat from unimportant, uncomfortable relationships in order to prevent discomfort in these relationships from spreading to contaminate and destroy potentially productive social and personal contacts (healthy avoidance is specifically discussed in chapter 3)

• Healthy denial and counterphobia, to cope with criticism and rejection and to overcome anxiety about becoming intimate—short of becoming an extensively frantic, gregarious hypomanic who pushes too hard and acts too precipitously to master his or her terror of doing anything at all

• Healthy projection, involving an “it’s you, not me” philosophy (particularly useful in an emergency where one’s self-esteem has fallen and badly needs a temporary lift through a reduction of self-blame via blaming others)

• Healthy identification, becoming like others who are less fearful and less guilty, more self-tolerant, and more self-assertive. While this is controversial, therapists can, in selected cases and in a limited way, become identification figures through sharing personal experiences by telling their patients how the therapist warded off or actually resolved his or her own problems with avoidance, doing this in the hope of encouraging his or her patients to identify with the nonavoidant therapist. However, sharing experiences, life stories, life problems, and personal triumphs, while likely to be effective with dependent avoidants, who hang on a therapist’s every word, and with obsessive-compulsive avoidants, who are so paralyzed when it comes to making any interpersonal progress that they beg to be told what to do (even though, at their most resistant, they plan not to do it, or to do the opposite), is likely to be a bad idea for paranoid avoidants, who suspect their therapists of wanting to steal their money by talking about themselves on their time, and “dime,” and for alarmist histrionic avoidants, who see any signs of avoidance in the supposedly healthy therapist as indicative of the complete hopelessness of their own situation, and as a bad sign for the outcome of their therapy.

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CHAPTER 15

Oth er Forms of Therapy

VIDEO

Bandura has described a process that he calls “observational learning,” a form of modeling through which avoidants and others can learn how to form healthy interrelationships by imitating people who are interacting with the appropriate level of intimacy.¹ Buggey uses a special method of observational learning that employs video self-modeling (VSM)—a relatively new technique for modifying behavior using positive examples of interactions created through the editing of videos, where avoidants can view themselves performing a task just beyond their present functioning level. ² In VSM, the therapist videotapes avoidant patients interacting with others, then edits out the problematic interactions so that the avoidant patients can watch themselves doing better. This has been found to be an especially powerful way to learn nonavoidance since people imitate models they are similar to, and who is more similar to us than ourselves?

MARITAL/COUPLE THERAPY

Marital or couple therapy is a form of interpersonal therapy dedicated to helping two individuals basically committed to each other repair their relationship.

A review of the literature and an informal sampling of therapists reveals that marital therapists do not always agree on the best way to help couples in which one or both members of the dyad are avoidant work out their problems. Possible methods include the following:

• reducing unilateral or mutual avoidances through abreaction and other techniques meant to relieve contributory emotional tension and pressure

• undergoing psychodynamically oriented psychotherapy to resolve marital problems through the development of insight into what is going on individually and interpersonally

• simply agreeing to disagree in a relationship where change is unlikely, so that one or both partners can, through forbearance and compromise, live comfortably with dissention

• having an affair to solidify a marriage

• having an affair to rescue oneself, at least emotionally, from a difficult situation

• deciding to split up, ending a relationship with a partner who is too remote, too uncaring, and too unwilling to change

As an example of an expert advocating having an affair to solidify a marriage, Beavers says, “I believe that affairs can hold stuck marriages together probably as often as they rip them asunder. If reasonably gratifying, the affair may avert emotional illness in the involved spouse.”³

GROUP THERAPY

Benjamin recommends group therapy for some avoidants, noting that “new skills can be developed in the group [and] normal social development can follow.”⁴

When group therapy is done properly, avoidants undergo an encouraging and motivating experience in a nonpunitive setting, where, not feeling criticized and humiliated, they are comfortable relinquishing at least some of their shyness and remoteness. Unfortunately, I have never come across a therapeutic group specifically dedicated to treating sufferers from avoidant personality disorder (AvPD).

PHARMACOTHERAPY

Specific schema to help the physician determine which medication is better for which avoidant are beyond the scope of this text. Generally, I find pharmacotherapy most helpful for two groups of avoidants: shy avoidants who cannot initiate relationships and social phobic avoidants such as those afraid of attending a group gathering (an effect evident to those who have successfully palliated themselves with alcohol before entering a crowded room).

Medications found to be helpful for selected patients with AvPD include beta-blockers for stage fright, benzodiazepines, and two classes of antidepressants: serotonin reuptake inhibitors (SRIs) and monoamine oxidase inhibitors (MAOIs). Gabbard specifically advocates diminishing anger and guilt chemically.⁵ Marshall specifically recommends beta-blockers, MAOIs, and benzodiazepines as being most useful in the treatment of social phobia.⁶

Rapee, dissenting, discourages the use of all pharmacotherapy. He suggests, I believe irresponsibly, that with cognitive therapy, medication becomes unnecessary, and so “if you are taking medication that was prescribed by a doctor, you need to go back to that doctor and ask him or her to help you stop taking the medication.”⁷

Unfortunately, many of the medications recommended for AvPD have unwelcome side effects. They can variously becloud an avoidant who needs to concentrate on attaining nonavoidance, imparting a fuzzy feeling to an individual who functions better when bright and fully alert; sap energy needed for making friends and lovers; and make avoidants feel too well to sustain the motivation they need to solve problems: imparting a false sense of comfort that decreases the chances that they will work through their avoidance (and go out and meet people).

Therapists should not prescribe drugs just so that they don’t have to interact with their patients. One doctor, instead of talking at length with his avoidant patients, gave them all an activating medication for their withdrawal and a sedating medication for their anxiety and the anxiety-based somatic symptoms that often appeared when they tried to socialize. Another favored avoidant psychotherapists at his clinic by screening job applicants with the questions, “What drug do you give to an elderly lady who wants to leave a retirement community because she feels hemmed in there?” and “What drug do you give to a patient who wants to break away from his mother but cannot because should he do so, he would fear for her emotional health?” (In my opinion, in such cases, psychotherapy is likely to be the main, and often the only, mode of intervention.)

A TECHNIQUE OF LAST RESORT

Avoidants can, right from the start, simply accept their avoidance and decide to live with it, as if they can’t do any better. These avoidants

can be helped to build their avoidance into their daily routine. They can willingly, voluntarily, give up the pleasures and rewards of nonavoidance in exchange for remaining relatively anxiety-free. This, a solution of last resort, is best reserved for those situations where a realistic assessment of the patient’s possibilities and progress to date suggests that because some pessimism is indeed indicated, the therapeutic goals should be kept modest.

CHAPTER l6 The Ideal Therapist

Avoidants often contact me to ask if there is a central referral source for therapists treating avoidant personality disorder (AvPD). I get letters such as the following:

Hello, Martin. For many years I am spiraling deeper into isolation, and only yesterday I read about avoidant PD and discovered I fit on all counts. I am not sure what to do about it. I am 47, live in California. I decided to write to you and ask if you can recommend a group in our area I can join to work on this problem. I am scared to talk to people and my memory is weak. Thank you, JG

There is no such group that I am aware of, and of even greater concern is that while many therapists specialize in treating social phobia, few, if any, therapists specialize in treating AvPD. Therefore finding a satisfactory therapist generally involves vetting the therapist one already has, as you determine for yourself to what extent he or she is competent to treat you, and act accordingly, while at the same time trying to make his or her job a little easier by being as much the ideal, and as little the difficult, patient as possible.

The following are ideal ways for a therapist to deal with an avoidant.

RECOGNIZE THAT PUSHING AVOIDANTS TOO HARD, TOO FAST TO BECOME NONAVOIDANT IS COUNTERPRODUCTIVE

The ideal therapist recognizes that exposure to feared impersonal and interpersonal situations has to go at a rate that is comfortable for the individual. Becoming nonavoidant can take months or even years of stop and start movement toward that goal, for reasons (already discussed) I summarize (for purposes of convenience) here in table 16.1.

Some Case Examples

I told an avoidant patient, a man who was actually in satisfactory physical health, to “get out more, go to new places, meet new people, and get to know your son once again.” Instead of following any of my suggestions, he replied with a letter full of excuses:

Your prescription I cannot follow. In the first place, you are obviously not aware of my physical disabilities. My energy reservoir is very low, and just a few hours out simply exhausts me. Added to that is the fact that the severe arthritis in my left foot makes it impossible just to walk around the block. Furthermore, my urinary tract problems require frequent emptying of the bladder (anywhere from every 10 minutes to every half hour). So, besides the fatigue factor, I cannot consider long trips. But possibly the

Table 16.1

Why Becoming Nonavoidant Takes Time

Avoidants both like and need the way they are and fear the alternative too much to yield their problems up easily and immediately and just on the therapist’s say-so. For avoidance is in some ways like a favored philosophy, part of an entrenched and even somewhat beloved individual, very personal, value system. Avoidance is also a psychic mechanism that is treasured because it reduces anxiety. That means that unwelcome anxiety will predictably reappear when the therapist starts “tinkering” with the avoidant defense.

Between sallies toward mastery, avoidants, like anyone else, need to rest and regroup their forces in preparation for making their next move.

Nonavoidance, like all newly acquired behaviors, requires practice before it can become perfect and second nature.

Avoidants routinely perceive excessive therapeutic zeal as an attempt to dominate and control them. Therefore pushing them prematurely into feared encounters can make them anxious, depressed, and negativistic to the point that they bridle and may either leave treatment in order to reestablish comfortable distance from the therapist or stay in treatment but resist it to restore their own sense of being in control and their feeling of personal mastery.

severest problem is my unpredictable physical instability (dizziness, loss of balance, etc.). This is due to a cerebral deterioration, the onset of which I expect will be proved on the CAT scan I am to have shortly. While it is true, as you suggested, that I would like to live on the Upper West Side of Manhattan, because of the easy access to many cultural events, a goodly number of them free, such as the Juilliard concerts and the weekly library concerts at Lincoln Center, a hop skip and a jump there and back would have no benefit for me, even if it were physically possible. Furthermore, my contact with the son you suggest I see regularly is, to say the very least, tangential. So even if he were inclined to eke out a couple of hours for a visit, the event would be both superficial and painful.

The following is my comeuppance for pushing a patient with AvPD too far, too fast to get married.

A patient who complained that she couldn’t meet men and get married said she had begun to meet them, but “forgot” to tell me that they were all already married. When I discovered and exposed this avoidant ploy, instead of meeting married men, she met a single man and actually married him—someone, though, sadly, she had selected for being close to death from cancer.

Generally speaking, the ideal therapist reserves total push techniques for shy and phobic Type I avoidants, who, already pushing themselves, accept others pushing them as well, and even welcome being urged to expose themselves to situations that make them anxious. However, the ideal therapist uses these techniques with caution, if at all, for ambivalent Type IIa avoidants who one day wish to be pushed “to get out and meet people” yet another day, resenting that, resist and rebel, and for seven-year-itch Type IIb avoidants, who need not be urged to form a new relationship but to stay where they are in the old one—for what such individuals require is not more, but less action, and not less, but more reflection.

DO NOT PRESENT TRIVIAL OR UNHELPFUL REMEDIES AS EFFECTIVE

Simple behavioral conditioning, such as “make a list of all the things that frighten you about people, then master your fears by tearing up the list,” or more complex behavioral interventions, such as videotaping the patient and confronting him or her either with the raw results (to illustrate what needs to be changed) or with the results edited to make him or her look better (to illustrate goals) often makes more supplemental than effective primary therapeutic modalities, for several reasons. First, a characteristic of mental illness is the inability to learn from experience. Second, as I discovered from having treated many veterans with posttraumatic stress disorder, few avoidant individuals can, through conscious effort alone, rid themselves of the traumatic imprints that figure heavily in their fearful withdrawal. Therefore I make a point unlike the one made by behaviorists who criticize all psychoanalytic approaches as unproven: some behavioral approaches, while proven, are simplistic, and while they do lead to change, it can be trivial and often gradually wears off as conflicts return and once again take hold, making it difficult to get therapeutic results to satisfactorily and permanently generalize outside of the “lab.” Third, approaches that use videotaping overlook how difficult it can be to convince some avoidants to be filmed in the first place. This is partly because avoidants imagine a critical implication to filming that threatens the more sensitive, more paranoid avoidants, who interpret being filmed as being watched, and being watched as being criticized and humiliated—as one avoidant put it, “rubbing my nose in my misbehavior.”

DO NOT TREAT AVPD AS IF IT IS SOCIAL PHOBIA

As discussed throughout, the ideal therapist differentiates these two disorders as having different therapeutic requirements. He or she treats social phobia as a phobia/confluence of phobias, but treats AvPD as a personality disorder.

DO NOT GIVE AVOIDANTS PREMATURE, ILL-ADVISED REASSURANCE

Creating too much hope can lead to excessive disappointment later on. However, the ideal therapist does not foster too little hope either. Too often, therapists, in an attempt to be reassuring, tell their patients something like, “Being alone, being by yourself, isn’t so bad, there are worse things than being alone, I even envy you your going alone to camp out in the country under the stars.” But without realizing it, they are thus implying that avoidance is so chronic and untreatable that their patients will never improve. They are also coming across as belittling, for by reassuring their patients that “things as they stand are not so bad after all,” they are effectively saying, “You are entitled to very little, can expect even less, and anyway your problems aren’t that momentous in the first place.”

DO NOT BE CRITICAL OF THE PATIENT

A number of observers point out how often therapists criticize their patients in the guise of treating them and suggest that all therapists, not only analysts, instead respond to patients in a consistently positive way, instead of being rejecting, disapproving, and controlling.

DO NOT CREATE MORE AVOIDANCE THAN YOU CURE

Sometimes avoidance creation is an unavoidable complication of even well-done psychotherapy. Often treatment has to be so lengthy and involving that it cannot help but encourage the patient to let current relationships deteriorate and put forming new ones on hold. Treatments like short-term psychodynamically oriented psychotherapy and cognitive-behavioral therapy (the latter is, by design, almost always time limited) help solve the problem of overinvolvement, for as short-term interventions, they do not act so much the substitute for real living and do not tend to encourage the patient to waste good years of his or her life in the therapist’s office on the couch, preparing for a future that may never come. However, so often avoidance creation is not due to the length, but to the content of therapy. For example, too often therapists create more avoidance than they relieve by siding with the patients’ interpersonal antagonisms after hearing only their one side of the story. Thus one therapist encouraged a patient to have her alcoholic husband not let off on psychiatric grounds, but sentenced to jail for a behavioral peccadillo, reasoning that “it isn’t wise for him to constantly evade the consequences of his behavior.” The therapist said that what she did was a good thing, but it was only good in theory. For it is true that alcoholics must face the consequences of their alcoholism—but in this case, the patient’s real intent was to rid herself of her husband, and her husband knew it. So as a result of this “therapeutic” intervention, the husband started drinking again and, unable to forgive his wife for being heartless, filed for divorce.

Therapists often encourage/create avoidance by telling avoidants to “keep busy” as a way to deal with their lonely isolation. For most avoidants, “get a hobby (or a pet, particularly a dog) and you won’t miss not having friends” should be changed to “get a friend or partner and you won’t miss not having hobbies or a pet.” Like pets, hobbies are suitable for supplementing, not for replacing, relationships with other human beings. Although avoidance can be made more tolerable with hobbies, it is usually a better idea to make hobbies more tolerable with nonavoidance so that avoidants don’t while away lonely hours keeping busy by themselves, instead of busying themselves working toward making the hours less lonely. Solitary activities can also increase the distress of isolation by acting as constant reminders of how much the patient is missing. The next “hobby” in such cases can become increasing preoccupation with one’s own body, leading to further isolating somatic symptoms/hypochondriasis. (Besides, the therapist who tells the patient to get a hobby is often perceived to be a defeatist, whose true unsaid message is “since that is the best you can do.”)

The most untherapeutic therapists create more avoidance than they relieve by offering themselves up as substitutes for real relationships. A therapist who needs to fill his or her practice and bring in enough money to live on might unconsciously discourage “outside” relationships in very subtle, almost creative ways. For example, one therapist, advised by a patient that she planned to marry a man her junior and stop therapy, replied, “Men that much younger than you are only interested in your money”—in this case, clearly a projection.

DO NOT BE OVERLY INTELLECTUAL AND IMPRACTICAL

What some avoidants really need is a directive, nuts-and-bolts lecture on what the therapist believes constitutes being avoidant and how and why to change that. Therapists who avoid “lecturing” their avoidant patients, whether they do so by overanalyzing; overcorrecting thinking; overmodifying behavior; overgiving drugs on the assumption that the problem is biological, not psychological; or doing bio, instead of giving positive feedback, should consider the avoidant’s cry of “I’m afraid of rejection” as an opportunity to say something trite but true, like “it’s better to have loved and panicked than to have never loved at all.”

DO NOT DO FAMILY THERAPY WHEN INDIVIDUAL THERAPY IS INDICATED

With avoidants, the advantages of family therapy are often outweighed by the disadvantages. In particular, in family therapy, it is difficult for the therapist to take the family’s side, even when indicated, since avoidants regularly misinterpret the therapist’s in any way siding with family members in interfamily disagreements as a criticism of or an abandonment of them, the primary patients.

DO NOT BECOME IMPATIENT WITH AVOIDANTS

Some therapists find avoidants frustrating. Perhaps therapy is going too slowly and the therapist is tempted to lower expectations in a rush to see some movement and terminate. Perhaps the patient is deliberately being stubborn in order to provoke the therapist to declare, “Impasse, let’s take a vacation from therapy” or “Let’s quit, I’ve done all I can do for you.” The therapist suggests marriage is the goal and the patient counters that he or she instead prefers a long-term committed relationship because marriage isn’t right for everyone; or the therapist suggests a long-term committed relationship before, or instead of, getting married, and the patient counters either that all he or she wants is a circle of friends and acquaintances, not anything more intimate, or that marriage is his or her goal, and that by suggesting otherwise, the therapist is trying to humiliate and defeat the patient. Impatient therapists at best cut corners, cow patients into saying they feel better, dismiss ill patients from therapy before they are better, or, at worst, as happened in one case, essentially “throw the patient out of treatment” without notice, and in the middle of a session, because “we aren’t getting along very well and it’s better if we cut our losses and I don’t waste your money; but I will ask you to pay for this entire session since I can’t fill the time on such short notice.”

DO NOT TAKE AVOIDANT NEGATIVITY PERSONALLY

Too many therapists come to dislike and become overly critical of avoidants as their response to taking the patient’s negative transference personally. Patients who, with very little justification, complain, “You are criticizing me” make some therapists uncomfortable because they make them feel like a critical parent or an errant child. Patients who disagree with everything the therapist says, damning it into oblivion by responding with faint praise, foot dragging, or lack of movement to brilliant, apt, insightful, and decisive formulations, make some therapists feel like misguided fools wasting their time and the patient’s money. At times, avoidants’ guilt about their sexual instincts arouses like feelings in the therapist, enhancing the therapist’s sheepishness about having a body and sexual desire. Some therapists feel that all avoidants are too distant and remote for their taste; and I have even spoken to therapists who view the avoidant patient as a “cry baby” because “most of them are unable to suck it up and tolerate even a little social anxiety.”

Therapists often act out their feeling critical by using deep interpretations to hurt, as in “You are as hostile to others as your mother was hostile to you.” They blame the patient for actively causing every rejection he or she in actuality experienced passively. Too often, they refer to avoidant “misanthropy” when it would be less confrontational, and truer, to refer to avoidant “fear.”

DO NOT BECOME OVERLY SYMPATHETIC TOWARD THE AVOIDANT “PLIGHT”

Overly sympathetic therapists view avoidants solely as the innocent victims of less than ideal inner and outer circumstances and even conceptualize the patient’s avoidance as a “disease over which you, the sufferer, has no control.” They should instead ask avoidants to take some responsibility for themselves and their actions. Blaming early trauma exclusively for the avoidant’s present plight is common, but it has the effect of excusing avoidants for being avoidant. That, in turn, supports their desire for the world to change when they are the ones who need to work on making many of the changes in their world.

CHAPTER 17

Hel ping Avoidants O vercome Their Fear of Criticism

As the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, suggests, avoidants hesitate to look for interpersonal intimacy because of an extreme sensitivity to criticism that leads them to fear being “exposed, ridiculed, or shamed” and subject to “mockery or derision.”¹

Avoidants do not feel criticized only when they haven’t been; they also deny that they have been criticized when they have been. In the latter case, instead of registering criticism consciously, they perceive it, but subliminally, or suppress it completely, thus allowing it to fester to the point that it leads to unmanageable, seething anger, and stuck just below the surface, it causes ongoing divisive resentment, ultimately outing to wound or destroy their interpersonal relationships.

It helps if avoidants recognize that so often, when it comes to being criticized, the problem lies not with something that they, but something that their critics, did wrong. To this end, avoidants can profitably understand what motivates their critics to be critical: their presumptuousness, their prejudice, and their distortive cognitions, all of which render their criticism too impersonal to be taken personally. Thus most critics

• are judgmental people prone to getting easily upset and, when upset, to hurling random epithets that predictably hit avoidants, individuals already guilty and hypersensitive, particularly hard

• are in an irrational transference to their subjects, mistaking them for a prying mother, controlling father, or competitive sibling

• have identified with their own shrill, harsh, hurtful parents and now are abusing people in the present the same way their mothers or fathers abused them in the past

• are basically talking about themselves, that is, criticizing themselves in the act of criticizing others. For behind all criticism of others lurks a self-criticism as critics routinely project onto, then humiliate and demean, others for traits they dislike in themselves. Therefore avoidants should reframe the negative things critics say about them as negative self-statements on the part of the critics, displaced outwardly, with criticizing another being just the critics’ way to criticize themselves, with the “you” being a “for example,” and so the formulation “it takes one to know (and criticize) one” here holds a special truth.

• are suffering from mild to severe psychopathology. Most avoidants find it comforting to spot specific pathology in their critics. As Keating suggests, avoidants can lessen their “difficult feelings . . . by understanding some of the syndromes of difficult people [who] may be feeling depressed, guilty, fearful, etc., and refus[ing] to admit such feelings even to themselves.”²

Such understanding helps avoidants affirm themselves, develop a semiscientific method of self-defense, and even, if they like, improve their relationships with their critics by responding to the critics’ emotional ranting in a therapeutic fashion, as a therapist might respond, say, reassuring fearful histrionic critics that all is not lost, or suspicious paranoid critics that the danger they believe themselves to be in is minimal to nonexistent.

Avoidants should also attempt to understand where they themselves are coming from, in the sense of what motivates them to respond so fearfully and negatively to criticism. Why, for example, do they value others’ negative opinions about them over their own more positive opinions about themselves, and continue to do so even when they know that their critics are misguided? Perhaps it is a combination of submissiveness to almost everyone, plus a global self-punitive, self-negating attitude that leads them to be a “sucker for authority”—parentalizing critics, and everyone else, as omniscient, good, and omnipotent mother or father clones, while simultaneously treating themselves as unknowing, bad, little children too small and weak to even consider challenging others’ negative views. Perhaps they have become “compliment junkies” because when they were children, they were either criticized too much or loved too extensively and now as adults need to sustain a compensatory or harmonizing, habitually unflawed self-image that can only come from always getting 100 percent positive feedback from others, without which they respond in a predictably negative way, and as predictably, catastrophically.

Perhaps it is jealousy that causes avoidants to become overly sensitive to criticism. In his 1922 paper “Certain Neurotic Mechanisms in Jealousy, Paranoia, and Homosexuality,” Freud divided jealousy into competitive or normal, projected, and delusional types. The first is connected with a sense of loss and narcissistic wound as well as enmity against the successful rival; the second involves a projection of one’s own temptations (that may have been repressed) with flirtations as a safeguard against actual infidelity; and the third is associated more specifically with projection of repressed homosexuality.³ Competitive or normal jealousy leads avoidants already sensitive to feeling as if they are second best to too readily feel that they are being criticized and rejected because they don’t match up; projected jealousy leads avoidants already feeling sheepish about being amoral to too readily feel that they are being criticized and rejected because they are sinners; and delusional jealousy leads avoidants already questioning their sexual orientation to too readily feel convinced that they are being criticized and rejected because they are queer.

Avoidants can be taught to respond to criticism in a healthier way. They can learn to

• ignore as much as possible those negative people who reject them

• remind themselves that no matter who they are, not everyone is going to like them or approve of what they do

• harden themselves to criticism they cannot avoid, developing a thick skin, turning off that alarm bell in their heads, and always remembering that being criticized is rarely catastrophic and that what seems so important today often turns out to be unimportant tomorrow, for most matters in life are not matters of life and death

• develop a sense of humor, putting both unjustified and justified criticism into perspective by lightening up and seeing the amusing and, in the infinite scheme of things, unimportant side of what at first looks to be an interaction of tragic proportions. Thinking macrocosmic thoughts can help. For some avoidants, looking up at the stars and realizing what is a big and what is a small thing puts passing ill-considered or even justified criticism into perspective.

• tell themselves when they do get criticized and rejected that it is not the end of the world, but a part of, not an unfortunate complication of, being involved in a relationship

This said, there are times, to be determined by the individual, when avoidants should meet criticism head-on, mustering as much strength as possible to respond to criticism not like a turtle pulling back into its shell (flight), but like a lion turning on those who trouble it (fight). Now having in effect “identified with the aggressor,” they turn tables and, instead of cowering, become as aggressive to the critic as the critic has just been to them. Too often, avoidants are the recipients of advice along the lines of “just let it pass, don’t become so defensive; I wouldn’t even give them the time of day, it just encourages them.” As a result, they have (wrongly) come to fear that being assertive with their critics, for example, aggressively setting limits on them, will predictably ensure further criticism and rejection. In truth, assertion can help avoidants reduce criticism and rejection and develop and retain a more positive self-image. Avoidants who tell their critics straight out, “You do not know what you are talking about,” or “You are one, too,” or “You did it first,” or “It is not a matter of who will accept me, but a matter of who I will accept” at least won’t withdraw from their critics after saying or doing nothing in response. They will instead respond forcefully, actively, and productively, effectively neutralizing the attack on them with a valid, effectual counterattack. Thus a patient of mine remembers a stranger telling her not to let her dog on the beach when in fact the dog was on the sidewalk bordering the sand. She felt less cowed when, instead of replying “sorry” then seething in retreat, she said, “I haven’t given you permission to talk to me.” Avoidants can profitably plan their repartee in advance of an anticipated attack. I often advise my avoidant patients to make and hold on to a list of their positive points so that when they are actually attacked, they are prepared to reel these off along the lines of, “This is what I like best about myself.”

Those avoidants who have difficulty responding to their critics assertively need to discover the reasons why. These are, with remedies implied, as follows:

• the belief that submissiveness offers protection along the lines of exposing the underbelly as a sign of abject, protective surrender (in fact, submissiveness gives many critics, who are invariably sadists, carte blanche, then a second chance, condoning and encouraging them, for most critics, as sadists, perceive submissiveness as weakness, implying vulnerability, which inspires further attack)

• an excessive need to develop and maintain a positive self-image based on being nice and cooperative at all times, even in the face of intense, unjustified, and irrational negativity from others

• low self-esteem that leads avoidants to feel too unworthy even to attempt to mount an effective self-defense

• a fear of failure: “It won’t work”

• a fear of success: “I will go too far”

• some = all thinking characterized by the inability to distinguish setting limits from getting annoyed, getting annoyed from getting angry, and getting angry from committing murder

• an excess of empathy and altruism, where, after putting themselves in their critics’ shoes, they use their own terror-stricken responses to others’ criticism to judge how devastated others would presumably feel in response to criticism coming from them

Particularly helpful is aggressively living well as the best revenge: having an extremely pleasurable life to spite all those who seem to want one to be miserable.

Sometimes avoidants can actually have a rational discussion with their critics. They can start by simply refusing to accept global criticism—roughly the equivalent of name calling—and instead ask for details, telling their critics, “Only if I know exactly what I am being criticized for can I respond in a meaningful, considered way and so adopt the best possible defense, point-by-point, with facts, not out of my emotions.”

Avoidants can also learn how to manipulate their critics to get them to lay off. They can make their critics feel guilty by acting as if they love them back, no matter how harshly they treat them, saying something like, “That’s OK; the negative things you say about me don’t cause me to feel less positively about you,” however ingenuous that statement might be. Alternatively, they can make their critics feel guilty by beating them over their heads with their own bloody bodies (“Look what you have done to me”), or they can successfully disarm their critics by saying, “Mea culpa,” that is, “getting back” with a selfcriticism, as in “you are right, I know that’s the way I am, but, pity me, what can I do about it, I don’t seem to be able to change.” Manipulations work especially well with those critics who unconsciously want to be loved but go about getting that love in a paradoxical way, via criticizing others as a test to see if, nonetheless, they still love them, with all their heart, under the most inauspicious circumstances.

Avoidants can almost always reduce the negative impact criticism has on them by putting third parties between them and their critics. Third parties can support avoidants by advising them how to avoid criticism in the first place and how to cope with and recover from criticism that they were unable to escape. As supportive confidants, third parties can take the avoidants’ side at times of stress—offering them a retreat, a place where they can go to be reassured that they are not as bad as their critics say they are, while being reminded, when applicable, that it is the critic, not the avoidant, with the big problem. E-mail support from friends can be particularly valuable for avoidants who otherwise might have to face their anxiety completely alone. And as Benjamin Franklin said, applicable here, at times of stress the best things to get you through are “three faithful friends—an old wife, an old dog, and ready access to cash.”⁴

Having private demeaning fantasies toward their critics can also help avoidants feel less cowed. Thus avoidants can help overcome a fear of public speaking by thinking of the audience as fools, perhaps in the nude.

Sometimes the best idea is to just walk away from criticism physically and emotionally, completely shunning troublesome people and instead focusing on one’s most fervent admirers and one’s truest and most loving friends.

Avoidants should certainly lose interest in meeting only the difficult challenges of life, in only winning the hard games, and in only meeting and making the tough conquests, as they make the difficult, critical people in their lives the very ones who count the most and only set out to appeal to, by changing the minds of, those that are most set against them.

Some Case Examples

One artist reacted to criticism with the thought, “They criticize me with such conviction and knowledge that they must be right.” He spent his early years depressed, hoping “for the big reward, more important than the Tonys and the Oscars—having the New York Times say something nice about me.” His mental state improved when, instead of hoping to get the Times to reverse its position, he developed a healthy disdain for its opinion and went about his business, closing the eye formerly always open to what “Daddy thinks of me.”

A doctor’s megalomaniac colleague continually put him down. For example, once he confessed to this colleague, “I don’t like this person,” only to be told, “I happen to know that the feeling is mutual.” Another time, after he bragged to this colleague that “if I wanted to, I could always get a job at a certain organization,” the colleague told him, “What makes you think they would want you?” This colleague also put the doctor down medically, no matter how accurate and clever the doctor’s formulations. Indeed, the more accurate and clever they were, the more he challenged them. The doctor felt that his ideas were being quashed or ignored. Yet he kept trying, and kept failing, to please and impress. Each night, he would go home feeling depressed, his self-esteem lower than the night before, and each morning, he would go back for more, trying to get his depression to lift by bringing this man around in an attempt to feel supported and accepted, instead of attacked, humiliated, and rejected. Finally, he realized the senseless nature of this commitment and sensibly simply stopped talking to the colleague—beyond a curt good morning and a discussion of any business that had to be transacted. His therapist, in supporting his new approach, added, “Don’t think you are supposed to get along with someone just because you work with him.” Now the doctor’s self-esteem returned, his depression lifted, his creativity and cleverness reappeared, and his work performance improved markedly.

Of course, avoidants should not completely harden themselves to ignore or minimize the utility of constructive criticism. Instead of becoming automatically and reflexively defensive in the face of any and all criticism, they should distinguish constructive from destructive criticism, then reexamine themselves to see if any constructive criticism is deserved, accept it if it is, and change accordingly. That doesn’t mean seeing themselves as bad. It just means trying to be and do better the next time by turning the criticism into a positive, creative, growthenhancing experience, making the criticism work for them by taking it somewhat to heart, doing better, and most important, making certain that their critics hear all about how well they have done, are still doing now, and plan to do in the future.

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