Simultaneously, I attempt to handle the avoidant’s negative and positive resistances to therapy. Most avoidants start off wanting to be helpful to the therapist and to cooperate with treatment. At first, they work with the therapist in a joint endeavor meant to overcome their avoidance. They plead with the therapist to tell them what to do to meet people and how to overcome their relationship anxiety. Later in treatment, however, they almost always begin to balk. Positive transference resistances develop where they use the therapist as too much the substitute for a real relationship. Negative transference resistances develop where they test the therapist, often to the extreme. They disregard proffered advice and sometimes even deliberately disrupt viable outside relationships in order to make the therapist look defective and impotent. They seek self-understanding only to misuse it. They say, “I will change when I learn,” but either they never learn so that they don’t have to change, or they learn intellectually but not emotionally so that they can continue to get the gratification that comes from complaining, “See, I’ve got insight, but it doesn’t work.” Laboring in therapy under a poor self-concept, feeling guilty about, and fearful of criticism for, their thoughts and feelings, and constantly worrying about whether or not the therapist approves of what they say or do, they become overly cautious and hesitant to discuss important matters openly. Afraid of all closeness, they begin to distance themselves from the therapist by being vocally negative about therapy and about the therapist. Coming to see the therapist as a parent, they refuse to “get married just because you want me to, like my mother did” and otherwise fearfully turn an opportunity to grow into just another occasion to rebel. Finally, as Benjamin suggests, as easily injured individuals who readily “feel degraded or put down by any therapist suggestions [they often] boil . . . over and abruptly quit . . . therapy.”5
In short, they use therapy as just another opportunity to become avoidant. Therefore therapists must undercut their resistances both directly and indirectly. Undercutting resistances directly means working them out on a conscious level by pointing out who the therapist actually is and is not, for example, “I am not a controlling parent or rival sibling,” and by frequently and pointedly reminding patients that they should work with the therapist toward a common goal, not against the therapist toward developing just another avoidant relationship. Undercutting resistances indirectly means analyzing their unconscious origins with the goal of uncovering how present-day resistances are repetitions of old avoidant difficulties now reappearing with the therapist, and so not a thing to be accepted, tolerated, or condoned, but something to be subjected to the same corrective scrutiny as any other manifestation of avoidance occurring not only outside of, but also in, the treatment room.
This page intentionally left blank
CHAPTER 11
Psychodynamically Oriented Psychotherapy
The Quality Assurance Project asserts that “individual psychoanalytically oriented psychotherapy is the treatment of choice for [avoidant personality] disorder.”1 This is in contradistinction to most contemporary writings that advocate cognitive-behavioral therapy over all other forms of treatment for avoidant personality disorder (AvPD).
THE BASIC TECHNIQUE
In contrast to cognitive therapy, which emphasizes correcting, psychodynamically oriented (psychoanalytically oriented) psychotherapy emphasizes understanding. Psychodynamically oriented psychotherapy recognizes that the inner life of avoidants determines a good deal of their outer behavior. Its goal is to help avoidants understand the inner workings of their current removal behaviors through and through so that they can replace withdrawal with new, more comfortable, adaptive, satisfying, and mature interpersonal contacts, free of irrational, unconscious fear. As Millon notes, its method consists of “reconstructing unconscious anxieties”2 at the roots of the avoidance and exploring the avoidant’s anxiety-provoking fantasies as they occur in the patient’s present life as well as in his or her transference to the therapist.
INCULCATING INSIGHT
Psychodynamically oriented psychotherapists emphasizing the central role insight plays in attaining a cure focus on strengthening old and inculcating new self-awareness. Many avoidants do not discern that they are avoidant or the extent to which they suffer from AvPD.
A Case Example
An avoidant patient, though aware that he suffered from AvPD, was unaware of the extent to which he was inhibited and of how his inhibitions affected his life, compromising his own functionality and troubling those around him. In the realm of how his avoidance affected his life, he said he was pleased with the way his life was going, even though his fears kept him from leading a full, connected existence and instead forced him into the shadows of dark, anxiety-laden remoteness. But he failed to recognize how masochistically he was acting when he attempted to relate only in circumstances where he was assured that no relationship would develop, and how destructively he acted when he used the Internet not to meet someone, but to act out his avoidances: not advancing his case, but presenting his case history, putting himself in a negative light by offering bad presentations of his good qualities, as when he painted his preference for fidelity as clinging and his flexibility as desperation. Ambivalence of the “caring sharing, no one over 25” sort appeared in his Internet ads as his way not to expand horizons, but to eliminate good possibilities. Rigid preferences and the making of nonnegotiable demands led him to insist that for him, it was crucial that others have identical interests—something he called “compatibility,” though for him, it was a reason not for inclusion, but for exclusion. Particularly unwelcoming in his ads was his overemphasis on preferred age and body habitus that amounted not to suggestions about what he would like in someone, but to criticisms of what he disliked about everyone. Not surprisingly, few responded to his ads, and those who did made a date, then broke it, or kept the first date just so that they could break the second—sadistically building up his expectations now, the better to disappoint him later.
In the realm of how his avoidance affected the lives of others, he suspected that his perfectionism troubled and hurt other people who otherwise might love him. He knew, “When it comes to relationships, I hurt my chances by being so demanding.” But he failed to recognize how much he had become, to use his last girlfriend’s words, a “perfect snob,” who hurt others as he dropped someone already good enough, just to look for someone even better.
Other avoidants, though they discern that they are avoidant, deliberately, if unconsciously, downplay and cover up the extent of their avoidance and the degree to which it limits them socially. They paint this distorted picture of themselves to the therapist because they are terrified that the therapist—the very person from whom they seek help—will criticize them like everyone else, ridiculing and humiliating them by dismissing their problems; calling them “lazy losers, wallflowers, and wimps”; condemning them as bad instead of treating them as troubled; and rather than helping them get better, punishing them for being ill. So they censor crucial intimacies out of embarrassment and shame, or they reveal them but simultaneously excuse them as “not me,” closing off an in-depth discussion of their psychological problems by blaming their circumstances or other people, as when they present their inability to connect not as an emotional problem of theirs, but as a natural, expected, “anyone would feel that way” response to externals beyond their control. So we hear “you can’t meet anyone in this hick town/in a big city like New York,” or “none of the bars in this dump are any good,” or “my boyfriend is the problem,” or “my boss makes me work so hard that I am always too tired to socialize after work,” or “everywhere I go villains harass me sexually,” or “my parents defeat me at every turn,” or “my wife’s only goal in life is to torture me.” Often citing contemporary “do-your-own-thing” or “me-ism” philosophies, they blame the society in which they live for being a place where everybody encourages them to be avoidant. Frequently, they blame not their psychology, but their biology, and we hear “it’s inherited,” “I was born this way,” “it’s not me, it’s my chemical imbalance,” “I’m ugly,” “I have physical problems,” “I’m too old,” or “my genes hold the real secret of my inability to connect.” They also rationalize their avoidance as healthy, typically disguising it as a preference or taste. As an example, one avoidant who nightly dreamed that he wanted to, but was afraid to, meet people, daily rationalized his avoidance as follows: “I prefer to live alone because I can fill the refrigerator with what I want to eat, drop my clothes wherever I want to, play my sound equipment when and how loudly it suits me, and when I go to work and leave a can of soda cooling behind know it will be there just waiting for me when I return.”