It is now believed that avoidant personality disorder patients are excellent candidates for treatment (as opposed to some of the other personality disorders - this is probably due to the healthy desire and longing for close relationships). Various psychotherapeutic approaches can be successful, depending on the patients goals, preferences, and psychological mindedness, and the clinician's expertise.
AvPDs may enter treatment via the criminal justice system or through self-referral. If they come in on their own, they are likely to be so apprehensive that any difficulty in the intake process will precipitate withdrawal. They will respond to kindness and positive regard but any indication of irritability or annoyance on the part of reception or intake personnel may prove intolerable. In mental health settings, these individuals may be drug-seeking if they have discovered the comfort that can be obtained through chemicals. Unfortunately, their pain is so apparent that many psychiatrists are more inclined to prescribe benzodiazepines for these individuals than people with any of the other personality disorders.
Unlike the other personality disorders in which denial, minimization, and externalization bring an illusory comfort and sense of personal justification, individuals with AvPD may well be motivated to seek change because the dynamics of their personality disorder are genuinely difficult to tolerate. They will frequently describe social and occupational problems; they will rarely have been able to develop a social network that is strong enough to help them through personal crises (DSM-IV, 1994, p. 663).
Treatment Provider Guidelines
Individuals who suffer from this disorder typically have poor self-esteem and issues surrounding any type of social interactions. They often see only the negative in life and have difficulty in looking at situations and interactions in an objective manner. This can also interfere with their self-report when they present for an initial evaluation, which can lead to important life history and medical information being missed (because the patient deems it and him or herself too unimportant to bother). It is necessary to take a more detailed evaluation than usual, while doing so in a relatively unobtrusive fashion. The clinician should be sensitive to nonverbal cues of the client during this session, to evaluate when information is being withheld. This is essential to making a differential diagnosis with similar-looking but vitally different disorders, such as someone who suffers from schizoid or borderline personality disorder. As with other personality disorder, the individual is not likely to present him or herself to therapy unless something has gone wrong in their life with which their dysfunctional personality style cannot adequately cope.
For individuals with AvPD,
developing trust in service providers is both essential and
difficult. They are hypersensitive and prone to feeling
criticized, judged, and injured by interpretation and
confrontation in the treatment process (McCann, Retzlaff, ed.,
1995, p. 146). They may well feel shame even while remaining
superficially compliant with treatment. They are inclined to
engage in testing behavior to see if they will be accepted and
supported (Kubacki & Smith, Retzlaff, ed., 1995, pp.
167-169). Accordingly service providers must make an extra effort
to establish rapport with avoidant clients. These individuals
will be less likely to flee the treatment relationships if
service providers are patient, nonthreatening, and sympathetic
(Donat, Retzlaff, ed., 1995, p. 49). If the service providers are
able to demonstrate that they are nonjudgmental, safe, and
patient, individuals with AvPD will be able to form an intense
and loyal treatment relationship (Benjamin, 1993, p. 305).
Clinicians need to recognize that individuals with AvPD tend to withhold or understate information that is relevant and be alert to the AvPD infectious helplessness, lack of attentiveness and firmly held negative beliefs (Sperry, 1995, pp. 50-51). Individuals with AvPD may initially elicit over-protectiveness and then exasperation. They must be encouraged to take risks or be allowed to diminish the potential quality of their lives if they cannot tolerate necessary changes. Service providers cannot take on the clients' own responsibilities (Dorr, Retzlaff, ed., 1995, p. 197) or attempt to push them further than they are willing or able to go. These individuals can recognize that other people find relationships rewarding (Donat, Retzlaff, ed., 1995, p. 49) and they are aware of their own pain; they may be motivated enough to change but will require patience for their hesitancy, avoidant behavior, and paralyzing anxiety. Once rapport and trust are developed, service providers must then be careful not to become "interpersonal methadone" and replace avoidant individuals' need to form outside relationships (Benjamin, pp. 305-306). Clinicians can become a safe haven for these clients and actually reduce their need for interpersonal connection in their social environment.
Service providers also need to remember that treatment progress for individuals with AvPD is usually quite slow; the process can be very frustrating for both the clients and the treatment providers (Beck, p. 280). Often, the belief that gradual change is both possible and beneficial must come from the clinicians. Individuals with AvPD are accustomed to defeat, self-deprecation, and withdrawal. They need someone else to believe in them while they begin the long process toward self-confidence and a sense of self-efficacy.
Termination of therapy is an important issue because a successful ending to therapy and the therapeutic relationship reinforces the possibility of new relationships.
Transference and Countertransference Issues
Transference for individuals with AvPD is usually anxious fearfulness of the rejection, humiliation, and exasperation of the service providers.
Countertransference involves the clinicians' reactions to the hypersensitivity and psychological fragility of these clients. They tend to elicit either overprotectiveness or excessive ambition on the part of service providers. Then, when the slow pace of discernible progress becomes frustrating, there may be an inclination for the clinicians to become the rejecting, exasperated, and judgmental people that individuals with AvPD feared they would be.
Another possibility for countertransference is an easy acceptance of and cooperation with the safety of the therapeutic relationship against a more dangerous external world. It may be appealing to service providers to be the trusted, admired, and depended upon "good parent" that these individuals never had. Part of the efficacy of group treatment modality is to allow individuals with AvPD to develop trust in others and in themselves without seeing the service providers as their only safety in a perilous world.