REDUCING GUILT
Psychodynamically oriented psychotherapists focus on understanding and reducing guilt that creates withdrawal due to rigidly prohibitive, critical, self-unaccepting and self-destructive attitudes, especially those relating to success and survival. Thus an avoidant believed that she should not marry until both a favorite aunt and all her sisters found themselves a husband. Unconsciously, she saw the world as a zero-sum place where getting something for herself necessarily meant hurting others by outshining them—and where getting anything at all meant taking an equivalent something away from someone else.
EXPLORING THE CHOICE OF EGO-IDEALS
Psychodynamically oriented psychotherapists also focus on discovering if avoidants’ relational ideals (ego-ideals) are chosen not by, but for, them, that is, if they originate in freewill or are determined by unconscious forces. In my experience, few people are avoidant, and hence alone, by choice. Even those avoidants who swear that they are truly happy in their loneliness and isolation, who insist that their isolation is splendid, and who affirm the wonders of being able to come and go as they please without that proverbial ball and chain around their ankle, really desire closeness and healthy dependency, not the complete freedom that they say they want. Instead, their desire to be free is, in fact, a compunction to remain unattached, and that is, in turn, largely the product of a rigid, self-punitive morality that leads them to be so preoccupied with matters of good and evil that they find themselves forced to squelch their human feelings in order to angle for sainthood and martyrdom, their way to deal with the shame they feel about their anger and to reduce the self-humiliation they put themselves through for having even the most modest of sexual desires.
DEALING WITH UNHEALTHY DEFENSES
Psychodynamically oriented psychotherapists focus on identifying unhealthy defenses so that they can help avoidants first, to relinquish them, and second, to put healthier defenses in their place. Healthier defenses include counterphobic defenses, to master anxiety by facing and meeting it head-on, “damn the torpedoes”; and resignation defenses, where avoidants learn to tolerate a small amount of anxiety and relax into their fears, instead of resolutely meeting them head-on, only to find that they have made things worse for themselves by trying to fight what is predictably going to be a losing battle.
DEALING WITH SECONDARY GAIN
Psychodynamically oriented psychotherapists routinely ask avoidants to relinquish the secondary gain they harvest from avoidant symptoms once formed. As I ask agoraphobic avoidants to relinquish the pleasure they get from always having a companion on street outings, and social phobics to relinquish the gratification they get from lazily avoiding giving a speech, I ask mingles avoidants to relinquish the gratification they obtain from sex good and plenty and instead seek greater gratification from closeness and commitment: quality over quantity.
DEALING WITH TRANSFERENCE RESISTANCES
Psychodynamically oriented psychotherapists are ever alert to the avoidant negative transference resistances that by highlighting their patients’ problems in microcosm serve as useful grist for the analytic mill. Avoidants often resist therapy by avoiding the therapist, the same way they avoid everyone else. They fail to show up for an appointment, call to make another one and break that, come late—calling to say, “I am just leaving from home” about the time their appointment starts or coming at the right time but on the wrong day—all the while apologizing, yet continuing to repeat their actions. Too often, they respond to eureka insight by becoming critical of the therapist who imparted it. Thus, one patient, each time she learned something meaningful, responded by devaluing the teacher (me) to render the teachings less troubling by damning them, and me, into insignificance. Another patient responded to interpretations that made her anxious by reviling me as a know-nothing, damned-if-you-do and damned-if-you-don’t doctor. Feeling I pushed her too far, too fast, she complained, “You are making me anxious,” yet feeling I was too accepting of her reluctance to try to meet people, she complained, “You aren’t doing your job.” She then attempted to reduce her anxiety by intensifying mine: by criticizing me personally, first for being lax, and then for being incompetent and unethical. Thus, on the days she thought that I was married, she accused me of having extramarital affairs and trying to seduce her, while on the days she thought I was single, she accused me of being a priestly celibate or a homosexual disinterested in her because I was disinterested in all women.
SUPPLEMENTAL TECHNIQUES
Psychodynamically oriented psychotherapy is rarely fully effective unless accompanied by supplementary methods employed to put the understanding obtained to use. Exposure techniques do more than just habituate the individual to anxiety directly. They also simultaneously facilitate the psychoanalytic process by releasing anxious thoughts that can then be brought back into therapy for discussion. Pharmacotherapy can help subdue fear and reduce guilt, and meditation and deepbreathing exercises can help the avoidant relax, putting him or her into a better frame of mind to work on understanding what went wrong in preparation for doing something to make it right.
A Case Example
A patient, an avoidant in both his professional and his personal lives, entered therapy complaining that he was too shy to meet old and make new friends, and certainly to meet someone to become his partner. At work, he volunteered for night duty so that he would not have to interact with too many coworkers or spend too much time with his family. In his personal life, he had one love affair when he was very young and never had another. Many years ago, when he was a teenager, he fell in love with the girl next door, but he was too shy to speak to her directly. The best he could do to make contact was to tie a romantic message for her on an arrowhead and shoot the arrow over the fence and into her yard. He thought that that was just the right flourish. Instead, he was surprised, and chagrined, to discover that the next phone call wasn’t from her, but from the police.