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 wheeclass="underline" 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.