• simply agreeing to disagree in a relationship where change is unlikely, so that one or both partners can, through forbearance and compromise, live comfortably with dissention
• having an affair to solidify a marriage
• having an affair to rescue oneself, at least emotionally, from a difficult situation
• deciding to split up, ending a relationship with a partner who is too remote, too uncaring, and too unwilling to change
As an example of an expert advocating having an affair to solidify a marriage, Beavers says, “I believe that affairs can hold stuck marriages together probably as often as they rip them asunder. If reasonably gratifying, the affair may avert emotional illness in the involved spouse.”3
GROUP THERAPY
Benjamin recommends group therapy for some avoidants, noting that “new skills can be developed in the group [and] normal social development can follow.”4
When group therapy is done properly, avoidants undergo an encouraging and motivating experience in a nonpunitive setting, where, not feeling criticized and humiliated, they are comfortable relinquishing at least some of their shyness and remoteness. Unfortunately, I have never come across a therapeutic group specifically dedicated to treating sufferers from avoidant personality disorder (AvPD).
PHARMACOTHERAPY
Specific schema to help the physician determine which medication is better for which avoidant are beyond the scope of this text. Generally, I find pharmacotherapy most helpful for two groups of avoidants: shy avoidants who cannot initiate relationships and social phobic avoidants such as those afraid of attending a group gathering (an effect evident to those who have successfully palliated themselves with alcohol before entering a crowded room).
Medications found to be helpful for selected patients with AvPD include beta-blockers for stage fright, benzodiazepines, and two classes of antidepressants: serotonin reuptake inhibitors (SRIs) and monoamine oxidase inhibitors (MAOIs). Gabbard specifically advocates diminishing anger and guilt chemically.5 Marshall specifically recommends beta-blockers, MAOIs, and benzodiazepines as being most useful in the treatment of social phobia.6
Rapee, dissenting, discourages the use of all pharmacotherapy. He suggests, I believe irresponsibly, that with cognitive therapy, medication becomes unnecessary, and so “if you are taking medication that was prescribed by a doctor, you need to go back to that doctor and ask him or her to help you stop taking the medication.”7
Unfortunately, many of the medications recommended for AvPD have unwelcome side effects. They can variously becloud an avoidant who needs to concentrate on attaining nonavoidance, imparting a fuzzy feeling to an individual who functions better when bright and fully alert; sap energy needed for making friends and lovers; and make avoidants feel too well to sustain the motivation they need to solve problems: imparting a false sense of comfort that decreases the chances that they will work through their avoidance (and go out and meet people).
Therapists should not prescribe drugs just so that they don’t have to interact with their patients. One doctor, instead of talking at length with his avoidant patients, gave them all an activating medication for their withdrawal and a sedating medication for their anxiety and the anxiety-based somatic symptoms that often appeared when they tried to socialize. Another favored avoidant psychotherapists at his clinic by screening job applicants with the questions, “What drug do you give to an elderly lady who wants to leave a retirement community because she feels hemmed in there?” and “What drug do you give to a patient who wants to break away from his mother but cannot because should he do so, he would fear for her emotional health?” (In my opinion, in such cases, psychotherapy is likely to be the main, and often the only, mode of intervention.)
A TECHNIQUE OF LAST RESORT
Avoidants can, right from the start, simply accept their avoidance and decide to live with it, as if they can’t do any better. These avoidants
can be helped to build their avoidance into their daily routine. They can willingly, voluntarily, give up the pleasures and rewards of nonavoidance in exchange for remaining relatively anxiety-free. This, a solution of last resort, is best reserved for those situations where a realistic assessment of the patient’s possibilities and progress to date suggests that because some pessimism is indeed indicated, the therapeutic goals should be kept modest.
CHAPTER l6 The Ideal Therapist
Avoidants often contact me to ask if there is a central referral source for therapists treating avoidant personality disorder (AvPD). I get letters such as the following:
Hello, Martin. For many years I am spiraling deeper into isolation, and only yesterday I read about avoidant PD and discovered I fit on all counts. I am not sure what to do about it. I am 47, live in California. I decided to write to you and ask if you can recommend a group in our area I can join to work on this problem. I am scared to talk to people and my memory is weak. Thank you, JG
There is no such group that I am aware of, and of even greater concern is that while many therapists specialize in treating social phobia, few, if any, therapists specialize in treating AvPD. Therefore finding a satisfactory therapist generally involves vetting the therapist one already has, as you determine for yourself to what extent he or she is competent to treat you, and act accordingly, while at the same time trying to make his or her job a little easier by being as much the ideal, and as little the difficult, patient as possible.
The following are ideal ways for a therapist to deal with an avoidant.
RECOGNIZE THAT PUSHING AVOIDANTS TOO HARD, TOO FAST TO BECOME NONAVOIDANT IS COUNTERPRODUCTIVE
The ideal therapist recognizes that exposure to feared impersonal and interpersonal situations has to go at a rate that is comfortable for the individual. Becoming nonavoidant can take months or even years of stop and start movement toward that goal, for reasons (already discussed) I summarize (for purposes of convenience) here in table 16.1.
Some Case Examples
I told an avoidant patient, a man who was actually in satisfactory physical health, to “get out more, go to new places, meet new people, and get to know your son once again.” Instead of following any of my suggestions, he replied with a letter full of excuses:
Your prescription I cannot follow. In the first place, you are obviously not aware of my physical disabilities. My energy reservoir is very low, and just a few hours out simply exhausts me. Added to that is the fact that the severe arthritis in my left foot makes it impossible just to walk around the block. Furthermore, my urinary tract problems require frequent emptying of the bladder (anywhere from every 10 minutes to every half hour). So, besides the fatigue factor, I cannot consider long trips. But possibly the
Table 16.1
Why Becoming Nonavoidant Takes Time
Avoidants both like and need the way they are and fear the alternative too much to yield their problems up easily and immediately and just on the therapist’s say-so. For avoidance is in some ways like a favored philosophy, part of an entrenched and even somewhat beloved individual, very personal, value system. Avoidance is also a psychic mechanism that is treasured because it reduces anxiety. That means that unwelcome anxiety will predictably reappear when the therapist starts “tinkering” with the avoidant defense.
Between sallies toward mastery, avoidants, like anyone else, need to rest and regroup their forces in preparation for making their next move.
Nonavoidance, like all newly acquired behaviors, requires practice before it can become perfect and second nature.