Humans have normal primitive, protective “animal” avoidances such as a reflexive fear of mice and harmless snakes, a superstition of black cats crossing one’s path, a tendency to curl up in the fetal position when one feels overwhelmed or depressed, and, what is perhaps the ultimate biological avoidance of all, fainting “dead away” due to fright or in disgust. Even in such of our everyday expressions as “badgering,” “weaseling,” “outfoxing,” and “hogging,” we are reminded of the jungle origins of some of the most interpersonally aversive human behaviors. Some avoidants in their self-protective behavior remind us of a stray cat who, however hungry it may be, thinks twice before accepting a handout, and some of a raccoon who strikes a compromise with humans—not bothering them as long as they don’t bother it. Others remind us of dogs—pups who, thinking only of themselves, push others aside to get to an available teat; adult dogs who protectively roll over to beg for mercy, playing dead to retain life, or who retreat to a lair for safety, protection, and territorial advantage to avoid a fight; and older dogs who, when ill or about to die, remain transfixed within and become remote, perhaps to anticipate death—so that they can deny they love life.
One of my avoidant patients, a man with multiple social phobias, compared himself to his cocker spaniel, who developed a fear of blimps and had to scan the heavens for one before venturing out of doors—he speculated as a displacement from a fear of airborne predators. In her inability to walk near large objects like trash bins, he saw his own agoraphobia, and in her fear of walking over grates, he saw his own fear of being at the edge of a high cliff, in danger of falling, about to descend into nothingness.
PART TWO
THERAPY
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CHAPTER 10
A n Overview of Avoidance Reduction
Table 10.1
Eclectic/Holistic Avoidance Reduction
The analytic dimension: the therapist obtains information about and imparts insight into the dynamic aspects of the individual’s avoidances. The information is obtained from a study of the patient’s past life and of his or her current avoidant fantasies and behaviors, including transference ideation/behavior.
The cognitive dimension: the therapist identifies and corrects illogical, inappropriate, and often paranoid interpersonal negative thinking, partly to help the patient recognize and acknowledge the positive aspects of relationships the patient currently views as all negative.
The behavioral dimension: the therapist, informally or formally, asks the patient to perform a series of graded, nonavoidant, connective interpersonal tasks of progressive difficulty in order to approximate nonavoidance in a gradual, stepwise fashion.
The interpersonal dimension: the therapist identifies and understands specific avoidant interpersonal anxieties and shows avoidants how the outer manifestations of anxiety (anxiety equivalents) such as shyness can make others uncomfortable, leading others to react by thinking not “he is afraid of me,” but “she is too stuck up to talk to me.”
The educative dimension: the therapist enhances motivation by enumerating the virtues of relating over being isolated and teaches the patient the social skills that can lead to pleasurable and rewarding experiences, which in turn inspire further attempts at fuller social mastery.
The supportive dimension: the therapist provides the patient with a warm, reassuring, healing holding therapeutic environment within which the therapist attempts to reduce relationship anxiety directly, e.g., with such reassurances as “you will get over your anxiety if you patiently persevere.”
The pharmacotherapeutic dimension: the doctor prescribes selected patients antianxiety and/or antidepressant agents, always keeping in mind that many patients would prefer to at least try verbal therapy before taking medication. 2 3
establishing and improving friendships; and (12) use indicated phar-macotherapeutic agents, such as beta-blockers, monoamine oxidase inhibitors, or serotonin uptake inhibitors, to reduce anxiety. Millon and Davis further recommend that these different therapeutic modalities take place in a supportive setting, where the therapist counters apprehension with “freehanded empathy and support,” the “therapist’s only recourse.”3
My approach is action oriented because it emphasizes doing as well as thinking. It goes beyond utilizing the more “passive” therapeutic techniques that rely exclusively on influencing and changing through understanding to emphasize the more “active” therapeutic techniques, particularly behavioral approaches where the therapist exhorts patients to convert from avoidance to nonavoidance by facing their fears now, as best they can, through exposing themselves directly to situations that make them anxious so that they can take that all-important leap from understanding what troubles them to actively doing something about it.
PSYCHODYNAMICALLY ORIENTED PSYCHOTHERAPY
Psychodynamically oriented (psychoanalytically oriented, insight-oriented) methods, a cornerstone of eclectic therapy, emphasize developing an understanding of the present manifestations of avoidance through identifying its anlage, that is, its developmental origins. Thus one avoidant’s present-day shyness was partly due to guilt about relating that originated in excessive closeness to a mother who discouraged her from getting involved with men by promoting the nonsensical belief that it was unthinkable for any daughter of hers to marry a stranger. A source of another’s shyness was a fear of humiliation originating in her early relationship with a father who went out of his way to spot when she accomplished something significant—just so that he could avoid keeping her from getting a swell head by paying her a compliment.
Psychodynamically oriented therapists also explore to relieve the patient’s present turmoil through developing an in-depth understanding of his or her current associations and fantasies in order to be able to fully answer such questions as, “Why exactly does asking a girl to dance make you so anxious?” The answers often come from asking other questions such as, “Is it that you fear she will reject you? And, if so, why should a stranger’s rejection matter so much?”
Most psychodynamically oriented therapists try to help soften their patients’ guilt feelings. They do that both by helping them become more accepting of impulses they currently renounce and by facilitating their use of healthier defenses to cope with guilt they cannot reduce or fully eliminate. Thus patients might better come to deal with feeling guilty about hating others by relinquishing projection of their hatred (“I don’t hate you, you hate me”) and instead denying and suppressing the hatred so that it shows less and therefore has less of a devastating effect on connectivity.
Psychodynamically oriented therapists regularly identify and attempt to understand avoidances as they appear in the patient’s negative actions with, based on transference to, the therapist, as when patients avoid an aspect of the therapeutic process, and even their therapist, by canceling appointments when something painful is about to surface.