She responded by entering a session wearing a T-shirt whose logo was “99% devil, 1% angel,” her way to tell her parents and me that she had finally begun to break free from her inhibiting need to find out and buy into what her parents thought about and expected of her, and to obtain parental approval before she acted, instead of acknowledging her own feelings, then seeking personal direction. Next, having become less dependent on what her parents, and anyone who reminded her of them, thought, she was able to brave the inevitable criticisms and rejections that everyone gets in this world without becoming discouraged to the point that she couldn’t do anything on her own without first having to ask for permission. Now she could try to connect with men without giving up easily, instead of fleeing out of a relationship at the first sign of closeness and, in retreat, figuratively going home again.
Family therapy made it very clear to one avoidant that he was threatened by closeness because he worried about what his parents thought of his romantic relationships. In treatment, he learned to ask of his parents, “What’s the worst that you can do to me?” then to answer his own question by telling them, “If you continue in your old ways, I will simply have to stop talking to you.” But still, his fear of parental disapproval persisted, making true intimacy with others impossible. So we next worked on helping him collect evidence on how the parental disapproval he so feared was less directed to him than it was the product of his parents’ own distortive thinking, and therefore being relevant to them only was not an indication of how he should view, and treat, himself.
In short, avoidant symptoms yield best to multiple approaches involving, first, getting to the bottom of things, then patching things up by making a variety of repairs. Though diverse approaches might at first appear to be mutually inconsistent, or even mutually exclusive, they can (and should) be used together, either alternatively or simultaneously. Because of the complex personality of the avoidant, a satisfyingly complete solution to the distancing problem can only be obtained through combined, multilayered therapeutic interventions.
Of course, not all avoidants should be treated exactly the same way. Different avoidants will need, desire, welcome, and respond to different treatment plans created to fit the individual’s specific problematic interactive anxieties. The presence/absence of comorbidity, parti cu-larly the presence of paranoid and depressive tendencies, must be taken into account. Also important in formulating a treatment plan are the individual’s personal preference for intellectual versus practical approaches; current circumstances and needs (patients with big supportive families often need less hand holding than patients whose avoidance has left them all alone); and the degree of desire to change, as determined by personal aspirations and individual goals and ambitions and ultimately influenced by therapist availability and cost.
In the realm of the patient’s personal problematic interactive anxieties, avoidants who are less fundamentally shy than fearful, such as commitment-phobic avoidants who would be outgoing, except for their long-standing, deeply ingrained interpersonal anxiety about becoming fully intimate, may benefit the most from exposure techniques combined with emotional support as they venture forth trying to overcome their all-the-world’s-a-stage fright. But patients who are temperamentally more shy and retiring than scared may benefit the most from an ongoing, long-term supportive relationship with a therapist meant to tide them over—as the therapist acts the part of a healer who the patient can rely on long term and cling to, as improvement, it is hoped, takes place, however slowly.
The more intellectually oriented avoidants do best developing insight first, then acting on what they learned next, while the less intellectually oriented avoidants do best first “doing,” with “understanding” coming next, if at all. The first group of patients likes to contemplate a journey before, during, and after embarking on it. The second group of patients is satisfied just to be handed a road map. While the first group often does well being told, “Face your fears of parties so that we can analyze those fears as they arise,” the second group often does well simply by being urged: “Go to parties for progressively longer periods of time in graduated ‘doses’ so that you will be able slowly but surely to get used to mingling.” Patients who tend to intellectualize do not take well to approaches that are exclusively total push, while patients who are more doers than thinkers feel stalled and cheated by therapists who seem only to want to talk first and expect action next, if at all.
In the realm of differing individual goals, many avoidants are content to work around, rather than attempt to fully overcome, their anxiety. Just as social phobics afraid of being trapped in the theater can simply go through life happily sitting on the aisle in the back row, and social phobics afraid of heights who cannot sit in the theater balcony can, if they can afford it, simply buy a comfortable seat in the orchestra or give up going to the theater altogether; patients with AvPD can seek a lifetime of partial, rather than full, relationships, such as relationships with friends rather than lovers, paid strangers such as waiters or prostitutes, or relationships organized around impersonal gratifications they make subsidiary to interpersonal pleasures such as the gratifications to be gotten from hobby clubs or group therapy. The therapeutic approach must also be geared to the individual’s style of relating. Some avoidants really like being isolated. Others are comfortable with a single codependent relationship, hopefully one that promises to last for a lifetime. Still others look forward to only moderate connectivity so they can have the best of both possible (avoidant and nonavoidant) worlds. And some look forward to leading a normal life with only modest compromise or, if possible, none at all.
As to what approach to use first, avoidants who are very anxious or depressed about their lives, especially those who have experienced a series of losses, need support and sometimes pharmacotherapy in the beginning of therapy, with uncovering reserved for later, when the patient’s realistic difficulties have become less, or less urgent, so that what suffering there is has now become primarily of an existential nature—not a matter of “what do I do to survive?” but of “how can I look at things differently so that I can feel more alive, connected, and joyful?”
My sessions fall naturally into the following pattern. We develop insight in one session; use the next session to develop a game plan for putting what we just learned into practice (via intersession exposure); have a session or two where we develop further insight, particularly into the anxiety aroused by this new exposure, with all sessions taking place in a setting of continuing support and reassurance along the lines of “you can do it” and “you will not faint or die when going out in public”; have another practice-oriented “game plan” session or two; and so on. A full working-through process comes later. Here we cover the same ground repeatedly and in different contexts, until it all “sinks in,” not only intellectually, but also affectively, that is, emotionally— and practice makes perfect.