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.”)