MASTER DISSOCIATION
Avoidants need to stem dissociative flights from the possibility or actuality of acceptance where they fail to respond to positive gestures and laugh off a serious approach—as they become defensively aloof in order to reflexively squelch feelings they perceive to be dangerous and forbidden, doing so by the pathological expedient of distancing themselves from the people who elicit those very feelings.
OVERCOME BOREDOM AND RESULTING NEOPHILIA
Avoidants need to relinquish protective boredom that, in effect, says not “I am afraid you find me uninteresting and reject me,” but “I find you uninteresting and reject you”—one of those negative responses that disrupt intimacy along the lines of “don’t say hello once and it will be overlooked; don’t say hello twice and you will be overlooked.”
HELP OTHERS BECOME LESS AVOIDANT
Helping others become less avoidant is a royal road to helping oneself along similar lines. Avoidants might try each day to convince one previously avoidant person to stop rejecting and to accept people instead. Avoidants might also consider working to create a less avoidant society—for example, supporting or joining groups dedicated to overcoming such (always avoidant) bigotry as gay bashing, and spousal abuse.
MAINTAIN YOUR PHYSICAL HEALTH AND IMPROVE YOUR PERSONAL APPEARANCE
I often recommend a complete cessation of smoking, limiting one’s use of alcohol, and using only prescribed medications in as low a dose as one’s physician will agree to. When necessary, I refer my avoidant patients for an appearance makeover, perhaps to an exercise guru or cosmetic expert, and suggest that patients watch makeover TV shows such as those on what to wear.
EVALUATE AND REEVALUATE YOUR NEED FOR THERAPY OR ANY THERAPY YOU MAY ALREADY BE RECEIVING
Since avoidance is an interpersonal problem, the solution may require not only self-help, but also supplemental professional help from a flesh-and-blood therapist.
Avoidants need to be certain that their therapists have made the right diagnosis. There are relatively few therapists familiar with AvPD, and I have gotten many letters from patients complaining that their therapists called them depressed or paranoid, when they were in fact avoidant. Because avoidants need to face their fears gradually, but inexorably through graded exposure, before they can obtain full, useful self-understanding, the most effective therapists are action oriented, rather than purely intellectual healers; that is, they do not rely exclusively on imparting insight then expect avoidants to attempt, and be able to take, nonavoidant action simply because they understand themselves. Effective therapists also do not rely solely on cognitive-behavioral therapy alone, without simultaneously employing insight-oriented, interpersonal, and supportive methods. The latter methods are often criticized in the cognitive-behavioral literature as inadequate—for example, Anthony and Swinson say, “As for other psychological therapies, although they certainly have a place for treating certain types of problems, they are not proven when it comes to treating social phobia and other anxiety-related conditions.”5 But this so-called inadequacy is often not the product of the methods themselves, but due to the therapist relying on them exclusively.
Avoidants often need to do their own research and ask their therapists specific questions about indications and contraindications, adverse effects, and the risks and rewards of being medicated for anxiety and depression. Many individuals with AvPD benefit from pharmacotherapy to reduce anxiety and depression. On the positive side, prescribed benzodiazepines and antidepressants can help avoidants become less anxious and fearful, while antidepressants can help relieve an avoidant’s depression. But on the negative side, both can interfere with relationship formation and maintenance. Both can create a chemical nirvana that removes motivating anxiety and depression, which warn avoidants to do something with their lives before it’s too late; take a needed edge off the socially useful protective paranoia that allows avoidants to determine if there is anything wrong with, or even dangerous about, certain others; soften the “craggy neurotic profile” an avoidant needs to be interesting, not bland/pedestrian/ordinary; and lyse the pro-social interpersonal (hyper-) sensitivity and capacity for empathy that so often originates with, and depends for its continuance on, being anxious, depressed, and paranoid.
SUMMING IT ALL UP AND PUTTING IT ALL TOGETHER
Avoidants should apply the lessons learned as often as they can, and preferably on a daily basis, ultimately bringing all helpful therapeutic methods to bear on each and every troublesome interpersonal encounter, effectively using multiple approaches to chip away at the avoidant problem and reduce relational anxiety to the point that it becomes sufficiently tolerable to allow them to feel comfortable and fearless enough to be transactionally active and interpersonally venturesome.
Throughout, avoidants should continue to expose themselves to one feared situation after another, until they prove to themselves that relationships are in fact, if not entirely safe, then at least less dangerous than they fear. To keep moving forward and keep their avoidance from coming back, taking hold, and escalating once again, they should constantly review, rethink, and rework what they learned and practice the remedies over and over again, until practice makes perfect. As their fear and anxiety subside, they can begin to think more clearly and take on more and more challenges, until they have attained the level of nonavoidance that is both possible and right for them.
Getting over avoidance is a lifetime job. Avoidance can be more easily reduced than entirely eliminated. Therefore, every day of their lives, avoidants have to be on the alert for distancing, and every time they detect that the distance between themselves and others is resurfacing and increasing, they should repeat the step-by-step remedies outlined in this chapter and in the rest of this book, until they can cope with and master their anxiety and avoidance and so change themselves and their lives in the direction that they, not their psychopathologies, want things to go.
Notes
PREFACE
1. Oldham, J. M., & Morris, L. B. (1995). New personality self-portrait: Why you think, work, love, and act the way you do. New York: Bantam Books, p. 200.
2. Dalrymple, K., & Zimmerman, M. (2007, October). Social anxiety disorder and comorbid depression; challenges in diagnosis and treatment. Psychiatric Times, p. 27.
3. PDM Task Force. (2006). Psychodynamic diagnostic manual. Silver Spring, MD: Alliance of Psychoanalytic Organizations, p. 54.
CHAPTER 1
1. Fenichel, O. (1945). The psychoanalytic theory of neurosis. New York: W. W. Norton, p. 180.
2. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author, pp. 662-665.
3. Quality Assurance Project. (1991). Treatment outlines for avoidant, dependent and passive-aggressive personality disorders. Australian and New Zealand Journal of Psychiatry, 25, p. 410.
4. Francis, A., & Widiger, T. A. (1987). A critical review of four DSM-III personality disorders. In G. L. Tischler (Ed.), Diagnosis and classification in psychiatry. New York: Cambridge University Press, p. 280.