Shirah Vollmer MD

The Musings of Dr. Vollmer

Confronting Avoidance: Not So Easy

Posted by Dr. Vollmer on April 30, 2012




The art of psychotherapy, the sense, the intuitive sense, that a patient’s chief complaint, may in fact be a diversion away from a more touching issue, comes from years of practice deciphering whether there is congruence between content and affect. Then, even if one accurately detects avoidance, the question arises as to how best to talk about something that is not on the surface. Patients have taught me to say “hmmm….” in a way which suggests suspicion, without directly saying that it feels like something really important is not being talked about. There is Jerry, the fifty-two year old massively unhappily married man, who never talks about his marriage, but mentions at the end of every session how he is going to leave his wife. There is Susan, thirty-six, who appears deeply concerned about her sixteen-year old son, but she dominates our time with issues regarding her fourteen-year daughter who is doing very well. There is Larry, sixty, who consistently comes twenty minutes late to every appointment, but insists that traffic was “particularly bad today.” My sense of this form of denial is that these folks carry a tremendous amount of internal pain, which one day, hopefully soon, will come to the surface, so that we can process it together. It seems that the longer the pain is pushed away, the harder it will be to wrestle with it. The harder one tries to keep these demons in the closet, the more forcefully they will pour out, when the time comes. This time will usually be at a point where the person can no longer hold that door shut. Jerry’s wife will likely one day leave him. Susan’s son will collide into trouble at school or with the law, or both. Larry will ultimately come to understand that he is wasting his time in psychotherapy if he comes twenty minutes late. At these points, the flow of emotions will be massive. As with so many things in life, I can see the pain coming, but I don’t know when the patient will be able to feel it. It is like seeing cracks in the earth and knowing there will be an earthquake, but not knowing when. There is controversy in the field, whether a clinician should wait for the person to experience pain, such that the pain is a springboard to exploration, or whether the clinician should point to the avoidance before the patient has conscious awareness of his behavior. My solution is to decide this issue while I sit with a patient. As I said, this is the art of psychotherapy.



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13 Responses to “Confronting Avoidance: Not So Easy”

  1. Shelly said

    If Jerry is consistently unhappy in his marriage and speaks about leaving his his wife, then why can’t you begin the next session about his doorknob comment about his wife? If Susan speaks about her wonderful daughter, can’t you ask about her troublesome son? And Larry’s consistent lateness to your sessions together probably are symptomatic of tardiness to other aspects of his life as well…work, social functions, etc…perhaps he would be open to a discussion about how all of that fits in together? I definitely see how you need to take your lead from your patients, however if your patients trust you, they should know that you only have their complete and total health and welfare in mind.

    • Hi Shelly,
      I absolutely can bring up issues which are “doorknob” comments at the next session, but as avoidance is a defense mechanism, then the patient often avoids my question. There is a journey of dodge ball until the time is ripe to talk about it. This time is usually a crisis point in which the defense mechanisms are forced to be altered by overwhelming external forces. Thanks, as always, for deepening my thinking on this subject.

  2. jo said

    As a patient, I appreciate it when my therapist pushes the envelope or introduces something she thinks I may have overlooked (or that I am avoiding). She doesn’t do it very often, but when she does, it gives me a lot to look at. She’s a lot more patient than I am … waiting for me to work things out in my own time.

  3. Hi Jo,
    Thanks for chiming in. Her patience, speaks to the art of therapy. It is helpful to hear your experience. Thanks again.

  4. Ashana M said

    It’s always a choice, isn’t it? The status quo has its own pain. Making changes has a different pain. One can wait until the pain of the status quo becomes unmanageable, or one can look for ways to make the pain of change more manageable. Sometimes it comes down to both.

  5. Shirah said

    Yes, I understood your question, and yes, I think the therapist has to be patient with the understanding that with patience, and motivation from the patient, over time, the relationship will deepen, and there will be a greater sense of safety in which the patient can then slowly approach the difficult issues which he had previously been avoiding.

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