«MARTIN KANTOR PRAEGER Distancing Distancing Avoidant Personality Disorder, Revised and Expanded MARTIN KANTOR Library of Congress ...»
Avoidant Personality Disorder,
Revised and Expanded
Library of Congress Cataloging-in-Publication Data
Distancing : avoidant personality disorder / Martin Kantor. — Rev. and expanded p. cm.
ISBN 0–275–97829–X (alk. paper)
1. Avoidant personality disorder. 2. Avoidance (Psychology). 3. Remoteness (Personality trait). I. Title.
RC569.5.A93K35 2003 616.85 8—dc21 2003052894 British Library Cataloguing in Publication Data is available.
Copyright 2003 by Martin Kantor All rights reserved. No portion of this book may be reproduced, by any process or technique, without the express written consent of the publisher.
Library of Congress Catalog Card Number: 2003052894 ISBN: 0–275–97829–X First published in 2003 Praeger Publishers, 88 Post Road West, Westport, CT 06881 An imprint of Greenwood Publishing Group, Inc.
www.praeger.com Printed in the United States of America The paper used in this book complies with the Permanent Paper Standard issued by the National Information Standards Organization (Z39.48–1984).
Let us not forget that the motives behind human actions are usually inﬁnitely more complicated and various than we assume them to be in our subsequent explanations...
—Dostoyevsky, The Idiot Contents Preface ix Part I: Description 1 1 Why Has Avoidant Personality Disorder Received So Little Attention? 3 2 The Literature 11 3 The Mental Status Proﬁle 33 4 Types of Avoidants 51 5 Healthy Avoidance 59 6 Avoidant People 65 7 Sociocultural Manifestations 75 8 Course 77 9 Comorbid Disorders: Comorbidity with Schizotypal, Schizoid, and Affective Disorders 87 10 Comorbid Disorders: Comorbidity with “Neurotic” Spectrum Disorders 101 11 Comorbid Disorders: Comorbidity with Other Personality Disorders 127 12 Cause: An Overview 149 viii Contents Part II: Therapy 13 An Overview of Avoidance Reduction 169 14 Psychodynamically Oriented Psychotherapy 185 15 Cognitive-Behavior
In today’s world, avoidance, distancing, removal and isolation have become so widespread that people assign greater importance to their possessions than they assign to their relationships. This is not surprising.
What will startle us, however, is the extent to which laypersons, clinicians, and researchers alike have overlooked, misunderstood, or downplayed avoidance, even though, like sex or hunger, it serves as a primary determinant of behavior, creates as much interpersonal difﬁculty as schizoid remoteness, depressive withdrawal, and borderline ambivalence, and causes as much social distress as ignorance and poverty. Avoidants themselves (I use the term avoidants to refer to patients with an Avoidant Personality Disorder) think they are happy as things stand, or, if they feel unhappy, blame their unhappiness on their stars or on their fate. Victims of avoidants remain convinced that something is wrong with them, and try to do better, when it is the avoidant who has the problem and should be the one making the improvements. Psychotherapists treating avoidants often have too narrow a view of what causes and constitutes avoidance.
In the realm of what causes avoidance, they often focus exclusively on the avoidant’s fear of criticism, humiliation, and rejection, without considering other equally important reasons to be avoidant, such as the paranoid tendency to assume criticism, humiliation and rejection in their absence, or the histrionic tendency to rage mightily over the most insigniﬁcant and unimportant of interpersonal events. In the realm of what constitutes avoidance, they focus almost exclusively on two groups of avoidants: individuals who are timid and shy in their relationships, and individuals with a Social Phobia such as public speakers with stage fright. Virtually
x Prefaceoverlooked are avoidants whose social anxiety is displayed in other ways.
Particularly overlooked are those avoidants who are neither shy nor phobic but who form unstable relationships characterized by a fear of closeness, intimacy, and commitment.
In its turn the scientiﬁc literature overlooks much of the valuable work already done on avoidance, often simply because it is otherwise labeled.
For example, what scanty literature there is on avoidance fails to mention that as early as 1945 Otto Fenichel described a group of individuals who suffer from “social inhibitions consisting of a general shyness... [that may lead to withdrawal] from any social contact [because] they anticipate possible criticisms to a degree that makes them hardly distinguishable from persons with paranoid trends” (p. 180), or that in 1953 Harry Stack Sullivan devoted substantial portions of his text The Interpersonal Theory of Psychiatry to the subject of avoidance. Karen Horney’s contribution to the concept of Avoidant Personality Disorder (as outlined in Chapter 2) is generally downplayed, and Eric Berne’s (1964) Games People Play, although it describes a number of what are essentially avoidant transactions substituting for real intimacy, is not as renowned as it should be as a treatise on interpersonal distancing. As usual, although Sigmund Freud has done much of the seminal work on avoidance, he gets little, or none, of the credit. For example, in Totem and Taboo, Freud (1950) was one of the ﬁrst to use the term “avoidance,” trace the “ancient history” or “phylogenetic” origin of “avoidance” (his word), and analyze “avoidance,” in this case as it took the form of that notorious negativity we so often see between a man and his mother-in-law.
My book Distancing makes a break from tradition in order to provide a fresh, in-depth descriptive, dynamic and therapeutic look at avoidance and Avoidant Personality Disorder (AvPD). Descriptively, I delineate four types of avoidants. Collectively, all primarily suffer from social or relationship anxiety leading to distancing. Individually, each is distinguished by the speciﬁc way they distance.
Type I avoidants are removed avoidants who distance by withdrawing.
There are two subtypes depending on the speciﬁc nature of the withdrawal: shy social isolates and social phobics. Shy social isolates stay at home living by themselves or with their family, either rarely socializing or socializing but within limits—making a few distant contacts and keeping a few old friends while having great difﬁculty meeting new people and even more difﬁculty sustaining close, intimate relationships. As Theodore Millon and Roger D. Davis (1996) say, these are the “conﬂicted avoidants [who] would like to be close and show affection but anticipate experiencing intense pain and disillusionment” (p. 268). Therefore they “precipitate disillusionment through obstructive and negative behaviors” (p. 268). In contrast, social phobics package their social anxiety into discrete quanta. Their anxiety appears in speciﬁc situations where they are Preface xi called upon to perform, for example, when they are called upon to speak in public. They then withdraw, but they do so only in these special circumstances, in the main sparing other, more intimate, aspects of their relationships. As Millon and Davis (1996) say, these phobic avoidants “disposed to ﬁnd highly speciﬁc phobic precipitants” (p. 269) “turn their attentions to ﬁnding a symbolic substitute, some object or event onto which they can displace and funnel their anxieties” (p. 270) by “a psychic displacement and condensation of [their] internal and generalized anxiety onto a symbolic external object” (p. 270).
Type II avoidants are ambivalent avoidants who distance by having numerous superﬁcial but few or no close intimate relationships. Typical Type II avoidants include my mingles avoidants, serial daters who meet new people easily but have difﬁculty sustaining and developing old relationships due to a fear of closeness, intimacy, and commitment.
Type III avoidants are also ambivalent vacillating avoidants who, however, distance by ﬁrst forming what at least appear to be satisfactory relationships that seem to do well (if only superﬁcially) and last. Then, after a shorter or longer period of time, they do an about-face and demean, devalue, and disavow those relationships—even when, or just because, they seem to be working. These are the seven year itch avoidants who form a long-term relationship with a lover, then one day announce “I need a hiatus from this relationship.” Or they get married, then one day either ﬁle for a divorce out of the blue or just disappear forever out of the life of a signiﬁcant other, often one who truly loves them.
Type IV avoidants are dependent individuals who distance by becoming deeply involved with, or immersed in, a regressive relationship with one other person or with a closed group of individuals. These individuals are exempliﬁed by the codependents described by Melody Beattie (1987).
Their goal is to get close to one in order to reduce or eliminate worldly contact with all. (All of these types and subtypes will be discussed more fully in Chapter 4.) Dynamically, I view the distancing of Type I–IV avoidance as the product of multiple social/relationship anxieties—not just one. In addition to anxiety about criticism, humiliation, and rejection (the ofﬁcial avoidant dynamic), avoidants suffer from anxiety about being ﬂooded by outof-control instincts rushing out should they open up their inner Pandora’s box full of dark sexuality and anger; anxiety about being depleted of lifeenergy as a result of letting go of their feelings; and, the opposite of anxiety about rejection, anxiety about the possibility of acceptance. This latter anxiety—a most important, and often downplayed, anxiety—is in turn due to one or more component anxieties: anxiety about becoming dependent; anxiety about being controlled, and as a result being overwhelmed by, trapped in, and engulfed by the closeness and intimacy of a committed relationship; and anxiety both about winning (a fear of success)
xii Prefaceand about losing (a fear of failure). My deﬁnition of AvPD is therefore
much broader than the narrow deﬁnition of AvPD found in the DSM-IV:
“AvPD is a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation... present in a variety of contexts” (p. 662).
In Distancing I supplement clinical material gleaned from the avoidant in the therapist’s ofﬁce, on the structured psychological test, and in the research lab to include a perspective on the avoidant that the serious student of personality disorder too often discounts because of its informal, anecdotal, and so supposedly unscientiﬁc nature—a study of the avoidant in the real world, in his or her native habitat, in a place where he or she acts spontaneously, thereby producing material useful for bringing the scientiﬁc approach to the patient into line with the normal proband. I observe avoidant behavior in everyday life. I watch avoidants doing real, avoidant things without necessarily being aware that they are being studied. This way they reveal themselves without posing and without playing up to an audience, presenting a ﬂeshy and true picture, not one that is suitable only for framing. I observe avoidants at home, on the dock on a summer’s day in a singles’ resort, at the rail on a winter’s morn in a singles or gay bar, and in the supermarket, missing the people around them as they obsessively shufﬂe their two-for-one coupons. I also observe them in the gym, doing precisely three sets of twelve reps each, deliciously contemplating how their body will look six months from now when they should be even more deliciously contemplating the person at hand, the one right before them, the one waiting impatiently for the machine. I watch them ﬁght for the machine, not for the person about to take it away from them, as they tell the interloper, “Go away and come back when I’m done,” instead of turning the situation around to their nonavoidant advantage by saying, “Come here; let’s not ﬁght over gym machines; let’s talk about us, and our getting together for a date, perhaps tonight.” My goal is to evolve a dedicated, eclectic, holistic, action-oriented therapeutic approach to treating the avoidant/AvPD patient, a therapeutic approach I call avoidance reduction. My therapeutic approach is dedicated because it is focused on the distancing process in all its aspects. It is eclectic and holistic because it deals with a broad range of core avoidant issues, including but not limited to the developmental, psychodynamic, cognitive-behavioral, interpersonal and existential-philosophical basis of avoidance, that is, it covers the main components of avoidance that go into making up the whole avoidant picture—the avoidant gestalt. It is action-oriented because it emphasizes doing as much as thinking. It goes beyond the more passive techniques such as those that emphasize developing understanding into the psychodynamics of avoidance, its developmental origins, and its basis in cognitive illogic, to include and emphasize the more active techniques such as exhorting patients to conPreface xiii vert from avoidance to nonavoidance by facing their fears now, as best they can, by exposing themselves directly to situations that make them anxious so that they can make that all-important leap from understanding to action.
My approach contains little that is new. I have scanned the various schools of thought for proven techniques that might be helpful for isolated remote patients having difﬁculty becoming meaningfully interrelated. I have come up with a compendium of relevant methods and techniques borrowed from the major schools of psychotherapy in use today, and cut and pasted them together to form a collage dedicated to helping patients become less shy, more outgoing, and increasingly comfortable with closeness, commitment and intimacy.
My text is intended for at least three audiences: