How does understanding (insight) cure? In simplistic terms, patients make things right by learning to unlearn what went wrong. Though much of the literature about AvPD downplays the importance of insight, citing, as do Anthony and Swinson, the likes of the lack of evidence for the effectiveness of understanding (Freudian) dynamics,4 I believe that insight-oriented approaches, while not sufficient, are necessary, and synergize well with other approaches, particularly with cognitive-behavioral therapy.
COGNITIVE-BEHAVIORAL THERAPY
Eclectic therapists also use a cognitive-behavioral approach focused on exposing and correcting the illogical thoughts that lead patients to distance themselves from relationships due to forming and maintaining excessively fearful notions about being criticized, humiliated, and rejected. Cognitive-behavioral therapists correct thinking directly by reframing negative into neutral or more positive cognitions following the rules of evidence. They also correct thinking indirectly by suggesting behavioral interventions that consist of asking patients to do what makes them afraid in small, incremental steps as a way to slowly but surely reduce their anxious thinking (while simultaneously stirring up new anxious thoughts that the patients can bring back into therapy for further analysis and subsequent correction/integration).
Too, they employ exhortation (“I know you can do it” and “try living around your need to distance even before the fears that lead to your distancing have been fully mastered”) in order to goad patients into attempting successive approximations to healthy behaviors, hoping that they will gradually become habituated to the anxiety that predictably appears when they attempt to perform those very things that make them afraid.
Many therapists use a combination of psychodynamically oriented and cognitive-behavioral therapy.
A Case Example
A patient who complained about being afraid to go out on a second date benefited both from learning about how her past affected her in the here and now and from correcting her present misconceptions about dating directly so that she could feel calmer and act in a more productive fashion. For example, she once refused to have a second date with a man simply because he said that before making the next date with her, he had to check his schedule book. Correcting the cognitive error that “I will get back to you” equals “I have rejected you” was helpful, but not enough to change the emotional distortive thinking that came from deep within. To do this, we needed to go back to the beginning, when she first felt totally rejected over something similar, and equally insignificant. Now we discovered that her father was a man who, refusing to commit himself in advance to a specific time when they could get together, regularly told her when she asked him, “When can just the two of us have fun?” that, “I will get back to you about that,” then did not firm up a date for months, if at all. Understanding that “you view all new boyfriends as your procrastinating father” helped her see present relationships for what they were in the here and now, not as what she imagined them to be through the “ret-rospectoscope” of her past interactions with this parent. This insight acted synergistically with her new cognitive learning, the two together freeing her up to form a relationship that ultimately led to her getting happily married.
Though advocates for cognitive therapy rarely speak of its downsides, there are shortcomings and complications of cognitive therapy that can interfere with improvement or make matters worse. Cognitive therapy is inherently critical, for by definition, the therapist, however unintentionally, sends the patient two implied messages: “your thinking is wrong” and “you personally are wrongheaded”—not messages avoidants, already notoriously sensitive to lack of support and feeling/being devalued, necessarily want to hear. Also, resistances appear to this as to every other form of therapy. Two of these are the positive resistance of falsely reporting progress to please/humor a
therapist obviously trying to be of help and the negative resistance of stubbornly and even sadistically maintaining one’s psychopathology to spite a therapist too obviously pushing for change along lines the patient sees as predetermined and so deems to be controlling.
THE INTERPERSONAL APPROACH
Eclectic therapists also use an interpersonal approach, where they study the dyadic causes and manifestations of avoidance with a view to resolving distorted interpersonal perceptions that lead to maladaptive interpersonal behavioral patterns such as those that are the product of anxiety over intimacy. These therapists focus on the central interpersonal avoidant patterns and problems I emphasize throughout such as fears of humiliation, criticism, and rejection at the hands of others; low self-esteem that makes it difficult for patients to confidently relate to other people; and the belief that serious closeness means completely losing, rather than only partially compromising, one’s identity. Interpersonal therapists basically try to make it clear that avoidants’ expressed and secret interpersonal fears are excessive and their perception of the dangers associated with relating are overblown. They usually attempt to interrupt cycles of negative feedback where avoidants actively create some of the criticism they feel passively victimized by after provoking others to mistreat them less out of dislike and more out of fear.
SUPPORTIVE THERAPY
Eclectic therapists also use a supportive approach involving positive feedback from the therapist (“you are too good to fail,” “that’s great that you have succeeded,” “your low self-esteem is lower than by rights it should be”) and reassurance (“you can handle and overcome your anxiety”). When indicated, they give fatherly/motherly advice (“there are other places where you will be happier/more welcome/ more popular than in the suburbs”). Also, they often advise avoidants to seek succor from others who are potentially in a position to help— secret sharers, counselors, friends, family members, and lovers, who can, it is hoped, help the patient cope and feel better. And they use relaxation techniques such as teaching the patient to breathe deeply and more slowly; meditation; and when indicated, antianxiety pharmacotherapy. They do all these things, and more, within a comforting, therapeutic holding environment that serves as a kind of protective bubble for the patient attempting to venture forth into old and new anxiety-provoking interpersonal adventures.
THE EXISTENTIAL APPROACH
Eclectic therapists use an existential therapeutic approach consisting of reshaping the patient’s philosophy of life. Methods involve helping the patient rethink favored avoidant positions and goals through identifying with and emulating others the patient admires for their social prowess and reading self-help books that take valid nonavoidant positions such as “when looking for a partner, be flexible about type” and “don’t compare yourself to others.”
FAMILY THERAPY
Eclectic therapists might use a family therapy approach, hoping to resolve interfamiliar conflicts that interfere with an individual’s outside relationships. For example, they try to convince a smothering family to let go and stop infantilizing the patient by discouraging him or her from going out of the house, other, at least, than to go to work to support the family.
Some Case Examples
Family therapy made it clear to a shy avoidant that she had become a remote, formal, rigid, and inhibited adult because she feared acting on her positive impulses without first getting “parental” approval, and because she feared losing control of her instincts in the heat of passion and saying and doing things that she would later be ashamed of because what “her people” thought or might think of her, that is, her reputation within the family, had become more important to her than what she thought of herself and than her personal growth, happiness, and satisfaction. We traced her excessive need for approval to her parents’ continuing warnings that people frown upon friendly women for being sluts and look down on a woman who is at all outgoing as being “loose”—a warning that her parents, as it became clear during our sessions, continued to issue for their own selfish purpose: to keep her at home just so that she would always be around and available to take care of them in case they needed her.