Therapy

Although the avoidant is one of the most common personality disorders encountered in clinical practice, many factors combine to make its prognosis unusually poor. The most basic characteristics of the avoidant run counter to the basic requirements of psychotherapy. Simply put, avoidants avoid. So intense is their desire to flee shame and humiliation that many employ defensive strategies designed to block such feelings from their own self-awareness. In contrast, effective therapy requires that thoughts and emotions be discussed openly, at least at some point, which in turn requires a focus on the self and its perceived deficiencies. Just considering the very first question of therapy—"What is it about me that I would like to change?"—may prove to be extremely terrifying for more severe cases, many of whom never present for therapy or drop out after just a few sessions. As we saw with Sean, perceived defects can be difficult to discuss, even with someone whose role it is to help.

Therapeutic Traps

Avoidants require tremendous patience and care. Because almost everyone in avoidants' lives is perceived as a painful fountain of negative evaluation, avoidants are extremely reluctant to share themselves openly. Accordingly, they need to know that the therapist is different and that the therapeutic relationship will be different. Reassurance, pacing, and acceptance are essential. When avoidants sense impatience, they feel judged, criticized, and attacked, and their immediate impulse is to withdraw. Conversely, avoidants are often so afraid of disappointing others that they may fake real progress or report what they believe the therapist wants to hear, effectively setting themselves up to simply drop out when further expectations cannot be met. This often leaves the therapist in a state of confusion and astonishment.

Avoidants need to know that they can say, "You're pushing me too hard right now" without destroying the relationship or incurring the wrath of those they respect. Every other relationship in their lives operates on the assumption that disclosure will be punished. The therapeutic relationship should be perceived as safe enough and authentic enough that avoidants can assert themselves without fear of being condemned, as Sean eventually did. This is an index of progress, but it is also true that such levels of trust constitute a breakthrough for many patients, one that grows out of the total process of therapy. Many avoidants find any discussion of transference and countertransference too threatening, at least at first.

Because trust is such an important issue, avoidants have ways of testing those they encounter to determine who can be trusted and who cannot. Minor frustrations may be imposed on others as a means of gauging their reaction. They may find an excuse to cancel appointments, reschedule at an inconvenient time, or just not show up. Here, the questions behind these behaviors are: How easily or willingly will this individual become an extension of my own punitive superego? Will he or she seek to punish me like everyone else? Or can he or she be trusted as safe? Becoming critical, hostile, impatient, or indifferent fails the test.

Therapeutic Strategies and Techniques

Trust will likely remain an issue throughout therapy, but the therapist will have more freedom to focus on difficult problems once a basic sense of safety becomes established. The inept self-image of avoidants, their interpersonal fears of exposure and rejection, and their defensive use of distraction to diffuse the pain of mere self-conscious awareness, of just being themselves, are all deeply connected.

Working from a cognitive perspective, Beck et al. (1990) suggest that once this modicum of safety is established, feelings of low self-worth can be addressed by actively disputing automatic thoughts, such as, "I am no good, inadequate. I am defective. Others will mock me." This helps patients discover errors in thought that they commit in the course of everyday living that contribute to their own painful feelings and problems. In addition, most avoidants possess a variety of admirable traits that get lost in their relentless focus on their own faults. Global feelings of worthlessness can be moderated and counterbalanced by integrating these positive characteristics into a fuller and more balanced sense of self. An objective assessment of Sean, for example, would emphasize his excellent grades and his ample computer talents, things of which he can be proud. If these can be integrated into his self-schema, his esteem should rise and, with it, his willingness to experiment socially.

Other techniques mix cognitive and behavioral elements. Tolerance to interpersonal situations can be increased by imagining social situations that evoke negative emotions and exploring them together with the therapist in the privacy of the therapy room. Automatic thoughts (Beck et al., 1990) can be elicited and tested along the way. This technique combines cognitive and interpersonal elements and can be used to try out new behaviors that prediffuse feelings of anxiety before the behaviors are implemented in the outside world. After the avoidant begins to feel more comfortable with these experimental rehearsals, an entire hierarchy of anxiety-provoking topics can be constructed and the subject can be asked to predict exactly what will happen in each situation.

Ideally, each of these predictions is eventually reality-tested by the patient, with the results discussed in session. The avoidant moves forward as comfort with each succeeding step grows. If subjects are reluctant to test their predictions, they can be asked to role-play, with the therapist assuming the part of the other person. To aid in preventing relapse, avoidants can be taught to use anxiety as a signal that automatic thoughts are active, to keep logs of avoidant thinking, to actively discredit their own irrational beliefs, and to plan realistic coping strategies in advance of difficult situations. This approach would probably be particularly effective with Allison because anxiety is so much a part of her life.

Finally, because cognitive techniques implicitly involve disagreeing, interrupting, or redirecting the subject, transference feelings created as a result of these activities should probably be explored at the very beginning. Otherwise, the avoidant may paint the therapist as critical or rejecting and conclude, "I'm so defective that I can't even do therapy right." Beck et al. (1990) suggest that patients rate feedback from their therapist on a trust scale ranging from 0 to 100%, thus providing very specific information that allows progress in this area to be charted concretely. All such activities work to increase social competence while falsifying the automatic thoughts that any amount of embarrassment at all will be too painful to bear.

The social detachment that avoidants employ to defend against criticism works to confirm their pessimistic expectations. From an interpersonal perspective, Benjamin (1996) stresses the internal experience of avoidants, its basis in their developmental history, and its effect on the therapeutic process. She again emphasizes that the poor self-concept of avoidants makes them vulnerable and easily hurt by the therapist. For example, Sean or Allison would probably be more comfortable with Carl Rogers than with Albert Ellis.

Unlike other formulations, however, Benjamin also suggests that beneath a surface of reluctance and unease lies a deep reservoir of anger. Because of their hypersensitivity, even minor suggestions may be viewed as put-downs. Afraid to share these hurts, avoidants hold them inside until the day they simply boil over. According to Benjamin, the antidote to this pattern is accurate empathy and uncritical support. Because the covert interpersonal message to the avoidant during childhood was, "Do not trust others. You are so defective only your family could love you," these subjects may experience feelings of disloyalty when sharing details of their family history. Presenting therapy as a warm sanctuary helps avoidants express these feelings safely.

Family, couples, and group therapy can be beneficial in breaking patterns that perpetuate avoidant behavior. Frequently, one spouse functions as an enabler who interacts with the world at large, allowing the avoidant the freedom to restrict social contacts to a bare minimum with no adverse consequences. Enablers must understand their role in reinforcing avoidance behavior. After years of encouraging avoidant spouses who suddenly quit jobs for no reason or burst into anger without first sharing feelings of resentment, many partners are themselves under considerable stress. Avoidants are hypersensitive to rejection even from their most intimate partners and readily become involved in triangulated relationships, including extramarital affairs (Benjamin, 1996). These relationships are considered safe in that they provide the intimacy of sexual relationship but also a degree a distance. As Benjamin notes, couples therapy cannot be conducted while such secret relationships are active. The secret lover who provides comfort and protection when the spouse is angry or withdrawn must be given up to improve the marital relationship.

Because avoidants are especially fearful of social situations, group therapy conducted in a context of acceptance and support can be invaluable if the group is sensitive to the individual's fears and can respond empathically. Warm acceptance from a variety of people in a group provides a strong counterpoint to early rejection from the family. Moreover, groups can often be effective in identifying positive characteristics in avoidants that they cannot see in themselves or simply devalue. Avoidants should not be forced into interacting but rather should be allowed to observe from the sidelines until they feel ready to risk exposure. Such groups allow the person the unique opportunity to acquire and practice behavioral and social skills in a microcosm of the social world. Given the subject's needs, groups with members who are critical for no reason are probably to be avoided (Millon, 1999).

Psychodynamic theories see avoidant behavior as being driven by the shame of not measuring up to the ego ideal. By this formulation, avoidants fear the opinions of others because they fall short of their own internalized standards and see themselves as weak, defective, or even disgusting, sometimes even to the point of dissociation as an escape from the pain of basic self-conscious existence. Treatment emphasizes a strongly em-pathic understanding of the experience of humiliation and embarrassment and insight into the role of early experiences in creating present emotions. Childhood memories are analyzed to clarify the roots of the disorder. Because avoidants use fantasy as a major coping mechanism, they often bring rich interpretive material to the therapeutic process. Fantasies of success, acceptance, and self-actualization can be contrasted with their present life and related to early childhood recollections. Feelings of embarrassment may be seen as deriving from a comparison of the self against the standards of a harsh, punitive superego. Accordingly, particular attention must be given to the role of parental figures in creating patterns of self-condemnation. Avoidants need to separate from such vicious introjects. Allison and Sean may have problems, but their families provided the toxic environment in which these problems could take root and grow.

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