They accepted dates arranged for them, instead of protesting based on preconceived notions that reflected preexisting avoidances, turning “blind dates” down for purported philosophical reasons that were little more than rationalizations of self-defeating motives.
Patients can expose themselves not only to uncomfortable external, but also to uncomfortable internal sensations (interoceptive exposure) so that they can learn to better tolerate their inner anxiety experiences. For example, they can learn to tolerate dysphoric feelings by conjuring up frightening fantasied situations in their mind, starting with the mildest anxieties and ratcheting up to the most frightening, letting these all work their way through their thoughts and emotions. The self-analysis of their dreams can provide new and helpful self-discoveries.
Exposure therapy works in part because it helps avoidants achieve minor successes, which reduces full despair about complete social failure. Success breeds success because real accomplishment enhances self-esteem by promoting self-pride that increases self-confidence, which leads to improved functionality that further enhances motivation (for motivation comes as much from doing as the other way around). Avoidants who relate at all successfully discover that relationships make them feel good about themselves; feeling good about themselves makes them feel more worthy of relating; and feeling more worthy of relating helps them relate even better. Additionally, actually being in a positive relationship helps reduce negative symptoms—as the positive energy from real-life friendships flows back into reducing underlying maladaptive, automatic thoughts and irrational beliefs, allowing fuller, more satisfactory human transactions to occur, while providing support and structure that predictably reduce avoidant anxiety. For example, a patient was unable to ride on a train until she decided to force herself to visit a potential partner she met on the Internet. Now, feeling enveloped in his protective warmth, she was able to make the trip and to do so virtually anxiety-free.
This said, avoidants who are both patient and highly motivated can bypass the need for incremental, step-by-step exposure and deal with the worst first in an attempt at instant mastery, deliberately increasing their anxiety to a painful (but supportable) level, hoping to break through to health all at once, instead of gradually, and before all their deep fears of closeness have been definitively resolved.
Manipulation
A phobic pass or other talisman can help those avoidants who are impressionable enough to believe in magic. Some therapists give an avoidant afraid of going to a party a signed slip of paper that reads, “Pocket and hold on to this and you will be okay on your date tonight.” Others give a social phobic afraid of public speaking a slip of paper that says, “You will be able to get through your speech without having your voice crack, or passing out.”
Role-Playing
This helps patients spot specific relationship problems so that they can begin to relate in new, less tentative, more effective, less selfdestructive ways. Videotapes of avoidants interacting with others with the avoidant speech and behavior patterns edited out to create a new, more nonavoidant performance can show avoidants what exactly they can do now to act less avoidant in the future.
Injecting the Therapist’s Personal
Nonavoidant Philosophy
Once, hoping to teach a patient how relationship difficulties can be overcome through yielding, compromise, and positivity, I quoted W. H. Auden’s 1957 poem, “The More Loving One”: “If equal affection cannot be / let the more loving one be me.”8
Paradoxical Therapy
Jay Haley’s paradoxical therapy is a form of behavioral treatment that is, in some ways, the opposite of exposure therapy. Here patients are asked, or told, not to do the very thing that they should be doing—that very thing that makes them most anxious. The therapist counts on the patient’s native stubbornness and oppositionalism to surface and lead to fearless counterphobic and hence healthy action.9 For example, one therapist suggested a patient take a vacation from relationships, anticipating that as a stubborn, resistant avoidant, he would do exactly the opposite of what the therapist advocated—relate to others, just to defy the therapist!
Paradoxical approaches are particularly helpful for sexual avoidants because they almost predictably lyse inhibitions by evoking the lure of the forbidden. Sexual avoidants often experience an enhancement of sexual desire plus an urge to actually have the prohibited sex they were formerly unable to have simply because now, told to cease and desist, they feel tempted to sneak around and start having it against the therapist’s wishes and behind the therapist’s back.
Enhancing Motivation
Therapists can enhance an avoidant’s motivation to relate by enumerating the benefits and rewards of relating, hoping to convince the patient that such rewards are sufficiently great to make it worthwhile to experience the discomfort involved.
Urging Patience
I remind patients that they will not be better by tomorrow because they did not become avoidant overnight. Also, most avoidants both like and need the way they are and fear the alternative too much to become instantly nonavoidant just on a therapist’s say-so. For in one sense, avoidance is a philosophy, an entrenched, much-beloved, personal value system, and in another sense, patients need their avoidance because it is a defense that reduces anxiety, if only by offering breathing room in interpersonal crises—an opportunity to regroup forces in preparation for making the next, terrifying move. Too, nonavoidance, like almost all new behaviors, requires practice before it can become perfect and second nature. Finally, pushing oneself too far, too fast into feared encounters can lead to such intense anxiety that in response, avoidants may quit therapy or stay in treatment but, therapeutically speaking, drag their feet to reestablish their comfort level.
Journaling
Journaling/workbooking can clarify and critique one’s avoidant positions and firm up what needs to be done to better reposition oneself interpersonally. Journaling is discussed further in chapter 20.
Relaxation Techniques
Deep breathing and muscle relaxation can help induce a state of calm and control the hyperventilation that often accompanies interpersonal anxiety.
Creating Right-Brain Activity
Right-brain activity (the product of emotions) can blot out left-brain activity (characterized by faulty, worrisome thinking). For example, an avoidant anxious about public speaking can blot out stage fright by thinking about a joyous celebratory dinner to come “if I get through this.”
Having Joint/Group Exposure
Avoidants can get together with ex-avoidants to consult with them to find out how these ex-avoidants became nonavoidant. They can also join in with other active avoidants to egg each other on as powerful allies in a joint program to conquer relational panic.
Of course, certain avoidant problems are more amenable to behavioral therapy than others. The shy patient who fears meeting someone new at a party can attempt trial connecting, but the more outgoing patient who can start but not see a relationship through to its conclusion cannot be reasonably expected to attempt trial committing.
Behavioral cures can unfortunately backfire, leading to increased isolation. For example, although avoidance can be made more tolerable with hobbies, it is usually a better idea to make hobbies more tolerable with nonavoidance so that avoidants don’t while away lonely hours keeping busy, instead of busying themselves making the hours less lonely. So often, solitary hobbies increase isolation by acting as reminders of how much one is missing. So the often given behavioral remedy “get a hobby if you can’t relate” should be corrected to “relate, so that you don’t have to get a hobby.”