Psychodynamically Oriented Psychotherapy
SUPPLEMENTAL TECHNIQUES
Psychodynamically oriented psychotherapy is rarely fully effective unless accompanied by supplementary methods employed to put the understanding obtained to use. Exposure techniques do more than just habituate the individual to anxiety directly. They also simultaneously facilitate the psychoanalytic process by releasing anxious thoughts that
can then be brought back into therapy for discussion. Pharmacother-apy can help subdue fear and reduce guilt, and meditation and deep-breathing exercises can help the avoidant relax, putting him or her into a better frame of mind to work on understanding what went wrong in preparation for doing something to make it right.
A Case Example
A patient, an avoidant in both his professional and his personal lives, entered therapy complaining that he was too shy to meet old and make new friends, and certainly to meet someone to become his partner. At work, he volunteered for night duty so that he would not have to in-teract with too many coworkers or spend too much time with his fam-ily. In his personal life, he had one love affair when he was very young and never had another. Many years ago, when he was a teenager, he fell in love with the girl next door, but he was too shy to speak to her directly. The best he could do to make contact was to tie a romantic message for her on an arrowhead and shoot the arrow over the fence and into her yard. He thought that that was just the right fl ourish. In-stead, he was surprised, and chagrined, to discover that the next phone call wasn’t from her, but from the police.
As an adult, he kept one or two old friends to satisfy his (minimal) attachment needs, and on those rare occasions when he agreed to go to parties, once there he stood in the shadows in a corner of the room looking longingly at, but unable to join in with, the people having fun.
He scared off what few people he managed to approach, or who ap-proached him, by putting them in no-win situations, rejecting them both if they acted friendly (because he feared people who got too close) and if they acted unfriendly (because he disliked people who kept their distance). Then he would leave for home early, and all by himself, to return to his small apartment, where he could watch television with the phone pulled and the intercom turned off (using a special switch he installed), accepting only e-mail because that way, “instead of being the passive victim of anyone who decides to call and bother me, I can pick up my messages when, and only when, I choose.”
On occasion, later in life, he was able to start a serious romance, only to pull back early in the game after telling himself that it would not work out. First, he brooded about all the mistakes he might make that, as he was convinced, would turn the other person off. Then he would perversely actually make those mistakes so that he could ensure that his gloomy predictions would come true because nothing could ever work out for him. Then he would think, “I already ruined things,
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so why bother continuing?” and in anticipation of complete disaster, he would become protectively remote and distant and bolt before a potential partner could, as he soon became convinced would happen, lose interest in him.
In reality, other people did not much take to him. His appearance made it diffi cult for him to connect with the very few people he felt comfortable knowing. As he said, “They call me ‘Skull’ because of my sunken eyes and cheekbones, ‘weird’ because my face is asymmetrical, and ‘peculiar’ because as I walk, I keep one shoulder higher than the other.” However, instead of doing what he could to improve his ap-pearance, he confi ned himself to checking in the mirror from time to time—assessing fl aws, overlooking virtues, and not really thinking about making those repairs that were both indicated and possible. Un-consciously, he held himself back because he actually wanted to look strange to others—so that others would continue to remain complete strangers to him.
Over the years, he developed a number of social phobias relating to different specifi c trivial prompts symbolizing a variety of deep, in-terpersonal terrors. In part, he had installed these phobias so that he could avoid getting close to people, his way to live out his motto, “If you fear visiting them, you won’t go, and if you don’t go, you won’t have to invite them back.” He could drive over bridges when he was not going to a date’s house, but when he was, he could not make it across due to the fear that he would faint, lose control of his car, hit an abutment, and have a fatal accident. Additionally, he was unable to take the train because he feared it would crash. He also developed a phobia of being in church. During the service, he had to sit near the exit door so that in case he should feel weak and faint, he could get out without calling attention to himself.
Eventually, he began to have some diffi culty venturing out of doors at all. During the day, he had trouble going out because he feared being stung by fl ying insects, particularly wasps, and because he feared a repetition of an incident where a policeman had stopped him for no reason at all and asked him, in what he thought was an accusatory fash-ion, where he was going. Next, he completely stopped traveling from his home town to the city for all the reasons just mentioned and be-cause he had become convinced that the second he got off the train, someone would approach him, pick his pocket, and strand him by tak-ing the money he needed for the return trip.
In spite of these limitations, and the considerable suffering attendant upon them, he claimed that being an avoidant had many advantages.
As he, in essence, put it, “It’s great keeping my positive emotions in check. That way I can avoid humiliating myself by expressing feelings that I consider to be both so passionate as to be embarrassing and so common as to be trite. Besides, I do not really need other people. All I need comes from within. I enjoy my own company best. I like being isolated and get a great deal of pleasure from being able to go home, sit there surrounded by the things I love, and come and go as I please.
I enjoy collecting things so much that I feel that the worst day at the fl ea market is better than the best day at the meat market, and anyway, my cat is my best friend, someone I can always count on—unlike ev-erybody else I have met up to now.”
Our therapeutic work consisted in part of understanding in depth how his avoidances began. For example, we learned that his fear of criticism partly originated in his early relationship with a mother who savaged him when he did things wrong, without also complimenting him when he did things right, to the point that, as he put it, with a sort of humorous resignation, “She actually died before she could say even a single nice thing to or about me.”
We also uncovered, clarifi ed, and analyzed the here-and-now fanta-sies that made up his current avoidant symptoms. We discovered that his shyness partly consisted of his staying away from people out of concern that he would take anyone he met away from someone else, much as his siblings took his mother away from him. An intense moral scrupulosity also led him to fear that others might criticize him for his sexual feelings. Too, he wanted to be a good role model for others he believed should, when it came to sexual relationships, follow his lead and be just as Spartan and abstemious as he was. As he described it, his was an advocacy for the highest level of morality, whose means of get-ting rid of temptation was not, as Oscar Wilde said, to yield to it, but, as he said, to get rid of the people who tempted him.
We discovered that for him, stinging insects symbolized his criti-cal mother, as did the preacher in church and the policeman on the street. We further learned that he could not take the train because the moving train symbolized his impulses and train crashes the dreadful consequences of having and expressing them. Driving over the bridge symbolized his fears of forward movement and success—reaching the pinnacle, only to be mauled physically (i.e., castrated) as a consequence of soaring.
We analyzed his church phobia as due both to a fear of being sub-missive (“controlled by the proceedings”) and to a fear of being em-barrassed publicly should he get too emotional about the service and
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lose control. The latter fear had some basis in reality, for on more than one occasion, just a small amount of alcohol released his inhibitions to the point that he acted aggressively in public and said nasty things to people he hardly knew—mostly, but not always, under his breath.
Such understandings gleaned over several years of therapy helped him deal with his relationship anxiety enough to form tentative, par-tially intimate relationships. He kept his old friends and developed a few new ones. He moved in with a woman he felt comfortable with, partly because she was an avoidant herself: an unassuming, undemand-ing person who desired little closeness and intimacy from him or from anyone else. They fought a great deal and threatened to leave each other on a regular basis, but that was only their way to reassure them-selves, and each other, that neither was engulfi ng, or being engulfed by, the other.
On follow-up, he said that now was the happiest time of his life, although he recognized, “As my therapist, you are probably disap-pointed in me, thinking that the adjustment I made is somewhat less than ideal, at least according to what I consider to be your overly rig-orous standards: particularly what I perceive (and you know that I am right!) to be your belief that everyone should get married, and that anything less than marriage represents an unsatisfactory adjustment to life, because by defi nition it represents a lesser way to live.”