Cory Newman, Ph.D.
Reducing anxiety by avoiding anxiety-evoking situations is a powerful reinforcer. Avoidant patients stubbornly refuse our admonitions to confront anxiety-evoking situations and try out new skills. On June 27, forty-eight NJ-ACT members heard Dr. Cory Newman describe a cognitive approach to working with avoidant patients.
Cory began by describing avoidant patients. They tend to quit, procrastinate, leave early, fail to show up, change the subject, work and sleep at odd times, avoid new experiences, act unassertively, and abuse alcohol and drugs in order to reduce their anxiety. These maladaptive behaviors are maintained by dysfunctional beliefs such as: I cannot bear to be disliked or rejected; I cannot tolerate discomfort; I lack the necessary skill (low self-efficacy); I will feel better if I don’t think about upsetting things; I’ll do it someday/later; or people will not like the “real me.”
Avoidant patients experience little enthusiasm, pride, joy, or courage. They present for therapy with excesses of anxiety, panic, guilt, regret, and/or envy.
A critical treatment objective with avoidant patients is teaching them to pursue goals to their conclusion in spite of setbacks and obstacles. More specific goals include: reducing catastrophic fears of failure, increasing self-efficacy, increasing assertiveness, and improving time management. Treatment should also encourage expressions of effectiveness -- “I can,” “I think,” and “in my opinion” – and decrease expressions of ineffectiveness -- “I don’t know,” “I’ll try,” or “whatever you want.”
Role-playing is an especially important technique with avoidant patients, and modeling coping with anxiety is more effective that modeling mastery of anxiety. Many repetitions will be necessary, but remind avoidant patients that the first exposure to anxiety-evoking situations is the worst.
Cory recommended cognitive restructuring of patients’ morbid fears of failure and rejection, plus behavioral experiments to test the validity of these fears. Other helpful techniques include addressing the avoidant patient’s in-session behavior and hypothesizing about similarities between the patient’s relationship with you and the patient’s relationships with others.
Cory pointed out that doing homework is correlated with successful outcome, but avoidant patients avoid homework. Therapists should explain the rationale for homework, give clear instructions, and never stop assigning homework, even if patients never complete a single assignment. Homework can be almost anything from traditional thought records to keeping a journal to listening to tapes of sessions. Some patients are more cooperative if homework is called “lab work” or “field work.” Letting them choose the assignment or doing the assignment in session may improve compliance.
Premature termination is a common problem with avoidant patients. Never assume that these patients want to return for another session -- ask them. Empathize with the unpleasant aspects of being in therapy and draw links between patients’ feeling overwhelmed in therapy and in similar life situations. Address lateness, missed sessions, and superficial discussion, but always, always, always use a gentle, accepting tone.
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