Therapists can help their patients think less catastrophically about being criticized, humiliated, and rejected by helping them enhance their self-esteem. They can do that by helping them develop reference points independent of their need for and the results of impression management. Patients can more clearly see the evidence for and against dark forebodings and disjunctive fears if they stop the self-spectatoring involved in attempting to constantly improve upon the grades they bestow on themselves in their own continuously self-administered interpersonal “report cards.” Avoidants can also helpfully ask themselves what it is about other people that makes it so necessary for them to actually hand out bad grades, trying to see, as is almost certainly the case, that “it’s their problem, not mine, because people these days only talk about themselves.” Avoidants can profitably ask themselves if the people actually humiliating, criticizing, and rejecting them are really important enough for their negativity to matter and take seriously to the point that it takes hold. And avoidants who have actually been personally “downgraded” and rejected can reassuringly tell themselves, when applicable, that “it’s their loss, not mine.”
Unfortunately, “illogical” cognitions can be resistant to corrective logic when there is enough reality to the so-called illogic to make full reality testing and reassurance difficult or impossible. Because planes do sometimes crash, it is not possible to offer blanket reassurance to phobic patients that flying is completely safe. Similarly, it is as impossible to completely dismiss the appropriateness of opening night jitters when performing before critics as it is impossible to completely dismiss the possibility of rejection when meeting new friends and lovers.
Because cognitive therapy inherently involves challenging how patients think, and because all challenges by their very nature are invariably critical, therapists should always do cognitive therapy in the context of a supportive holding therapeutic environment, where they offer patients countervailing comfort, reassurance, and understanding. They might repeat something supportive such as “most people share your anxiety and fears, at least to some extent” and “don’t blame yourself for making the thinking errors you make, for while it might be necessary for therapeutic purposes for me to speak as if you are entirely responsible for making the cognitive errors we discuss, we both understand that even your most unrealistic negative cognitions are, to some extent, particularly in a person as sensitive as you, set off by the antagonistic cognitions, and provocative behaviors, of others.”
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called my husband and said, “As hard as this is, we need to be on the same page about it.” When my husband comes home, he tells that kid that he would call the police on him if he ever acted like he did again. The kid then puts all his things into a large blanket, his computer and stereo into a box, and leaves. Said he would never come back and never wants to see us again.
I said I didn’t want him to go like this, that I wanted him to build to a point where he was ready to go, when he could afford a place. I told him I loved him very much, but that I saw him floundering and this was the age he needed to be working toward something.
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behavior; (6) improve their self-image; (7) make cognitive corrections/ rework aversive schemas; (8) use distraction methods such as positive social interaction; (9) increase contact to acquire critical social skills;
(10) try new experiences, which can help by enhancing and maintaining motivation and providing the opportunity to monitor behavior and correct maladaptive, automatic thoughts and irrational beliefs;
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learn to control fretful-expressive behavior while simultaneously
BEHAVIORAL THERAPY
Social Skills Training
Social skills that do not develop automatically as a consequence of changing one’s self-destructive thinking can be taught, leading, as the Quality Assurance Project notes, to “areas of increased social activities with decreased associated anxiety, a lessening of social isolation with diminished depression, and the loss of many irrational social beliefs.”4 Scattered throughout Anthony and Swinson’s book are direct suggestions to patients as to how they can better interact and communicate effectively with others. To paraphrase these authors, they suggest avoidants learn to listen, modify off-putting nonverbal communication, and develop conversational skills. They teach them how to go on job interviews; how to communicate assertively instead of too passively (hesitantly, shyly) or passive-aggressively; how to meet new people, make new friends, and date; and how to develop public speaking skills. They help them learn to control avoidant fretting in settings in which these behaviors are brought to the fore and lead to less than satisfactory human transactions.5 For example, they might teach them not to offer others a limp hand for an introductory handshake and to look people directly in the eye when they speak to them, instead of looking off into the distance, ostrich-like, thinking, “If I don’t see them, they won’t see me either.”
Graded Exposure
As noted throughout, behavioral therapists suggest patients perform individual tasks of graded difficulty geared to overcoming specific avoidant inhibitions. Thus Benjamin suggests that therapists help avoidants block maladaptive patterns with “desensitization to avoided social situations [by having the patient try out] successive approximations to more sociability.” She also emphasizes that therapists can best accomplish this if they give their avoidant patients “much reassurance in a context of competent, protective instruction.”6
Avoidants doing what makes them afraid in small increments must not let temporary setbacks unduly discourage them. As Rapee suggests, to become habituated to anxiety, avoidants need to “stay in a situation until [they start to] calm down,” and they must not let themselves “be discouraged by bad days.”7
Here are some ways a representative sampling of my avoidant patients underwent gradual exposure to feared situations:
They got out of the house and talked to strangers, saying hello to just one new person a day.
They responded to a stranger who said hello, instead of questioning the stranger’s intentions, then averting their eyes.
They stopped walking by people they saw, acting as if they didn’t see them.
They discussed a problem they were having with the person they were having it with, instead of retreating from or ignoring that person as “difficult.”
They went to work even when they didn’t feel like it, instead of calling out sick in order to have a “mental health day.”
They broadened their horizons, for example, by answering the phone, instead of letting the answering machine pick up the call. Though they did not have a partner, instead of staying home and eating all by themselves, feeling sorry for themselves, they went out to dinner alone. They bought a computer so that they could get e-mail from their friends, modified favored hobbies to do them with other people—collecting stamps in a group, instead of by themselves, or buying a book in a real bookstore, instead of in the remoteness of cyberspace. At work, they forced themselves to join in group conversations and sit with others in the cafeteria, instead of sipping coffee alone or taking their lunch to a park bench and eating it there in isolation.
They went to bars or onto the Internet for networking, meeting as many people as they possibly could, then slowly but surely winnowing relationships down perhaps to one significant other.