Confronting Avoidance: Not So Easy

 

 

 

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.

 

 

See also….https://shirahvollmermd.wordpress.com/2010/02/10/avoidance

The No-Show Returns

Zach, having come consistently for a year, https://shirahvollmermd.wordpress.com/2010/07/16/the-no-show/, did it again. His standing appointment, every week, same time, comes around and  he does not show up. He does not call me. Hmmm, I think, what is going on here. Do I call him, I wonder. I do call, get his voicemail, continue to wonder. Did something happen? Somehow, I do not think so, but maybe. Is he doing his avoidance thing? I think this is the most likely. What is he avoiding, I ask myself. I think long and hard about our last session. There is the upcoming family reunion that he was dreading. Maybe he felt guilty about talking about how much he did not want to spend time with his family. This seems to make sense to me. I have a working hypothesis; a theory to test out when he returns. When will he call me to let me know what is going on? I notice that. Does he worry about me worrying? I don’t think so, but I wonder why not. Is he not used to people being concerned about him? Does he resist taking care of me in that way? The richness of the no-show comes alive. It gives me pause and deep thought that helps me understand Zach, or at least stimulates questions I have for Zach, in a way that showing up every week does not. At the same time, the frustration of not knowing what is going on lingers and is uncomfortable. It feels like the picture above. There is a missing piece, and I want to find it. Something terrible could have happened. I really hope not.

The Doorknob Comment

“There is one thing I want to tell you,” Vivian, sixty-two, says as we both look at the clock and know it is time to stop. I have a hunch that what comes next is the most pressing issue on Vivian’s mind. I suspect it is something like a confession; like she is about to tell me she is using too much medication, or that she has a hidden substance abuse problem. I wonder whether I should remind her that we are going to have to stop, or should I allow her a little more time to express herself. Vivian is handing me the classical doorknob comment; the comment that one says as they are about to leave the session. I could see this behavior as classic avoidance. She knows we will not be able to explore the issue in-depth on this day, but she also postponed telling me. Perhaps telling me at the last moment is a compromise; a balance between complete avoidance and meaningful exploration. In addition, maybe Vivien is pushing the boundaries. Maybe she is testing me to see if I will give her more time under these self-made critical circumstances. I am in a predictable bind. If I allow her to go over the time, then I am rewarding her avoidance. If I strictly adhere to my time limits, then I might seem rigid and uncaring.

I say, as Vivien knew I would, “I don’t mean to interrupt, but whatever you tell me, we won’t have time to talk about it very much today, and I am sorry about that since I suspect that what you are going to tell me is a challenging subject.” Vivien nods her head with understanding and proceeds to tell me that she just found out that her husband has been lying to her about giving money to his adult son, her step-son. Vivien is furious. “I can understand why you are furious, but why did you wait until the end to bring it up? I ask, thinking that Vivien struggles so much with her anger and her shame at being angry, that it is hard for her to be forthright. “No one likes being lied to,” I say, trying to help her shame, but also realizing that I did not let her answer my question, likely because I am feeling so rushed. “I wanted to mention it. Maybe it is not such a big deal.” Vivien says, with consistent defenses of  avoidance and minimization. “I think you left it to the end because it is a big deal.” I say, implying that her style is clear and self-injurious. It does not help her to minimize her pain in the way that she often does. I was surprised by the content, but not the method of delivery. The lay person might say it is “Vivien’s style” to be indirect and curvaceous in her communication. I would say that it is “Vivien’s coping mechanisms” to delay and avoid important subjects.  I suppose we are saying the same thing.

Traffic

Luigi, forty-two, hates to be late, but he also does not account for traffic in his calculation in coming to my office, despite the fact that I have seen him for ten years. One day, Luigi, frustrated with himself that he is fifteen minutes late, realizing that since he is unemployed he has time, says seemingly to himself “I could come early, get a cup of coffee, and that way I will never be late. I don’t know why I did not think of that before,” he says, as if the fog cleared. In the past, Luigi used to repeatedly say “if it were not for traffic I would have been here on time,” as if that explains his lateness. Luigi does not want there to be traffic so he acts as if it does not happen: denial. “Is pretending things not to be so, a theme in your life?” I wonder aloud. “I guess so,” he laughs. “Reality is hard to hold on to,” I say, thinking that that did not come out right. “Especially when we wish it were not so,” he finishes my sentence. “Yes, but coming here late hurts you,” I say, stating the obvious. “I know,” he says, “but leaving my house earlier somehow does not sit well with me.” “That is interesting. Instead of dealing with the realities of traffic, you pretend that you can make it here as if the freeways flowed smoothly, and then when the reality hits you, you get angry with yourself and you walk in here irritable,” I say, again, stating the obvious. “Maybe I am avoiding talking about other things, since we do spend a lot of time talking about the freeway,” he says, to my surprise. “Avoidance and denial do seem to go together. I can see how it is almost convenient to discuss the frustrations of traffic, given that it is a common irritant among Angelenos.,” I say, pleased that we can discuss how he has woven traffic into his therapy to protect him from talking about more sensitive issues. “I am going to get better at this on-time thing. You watch,” he says, as if to challenge himself and to surprise me. “That’s a deal,” I say, noting the enthusiasm and sense of renewal in his voice. Traffic might actually help us out.

“I Can’t Talk About My Mom”

Zach https://shirahvollmermd.wordpress.com/2010/07/16/the-no-show/ and https://shirahvollmermd.wordpress.com/2010/07/15/i-dont-speak-to-my-mom-what-is-wrong-with-me/,  comes back after missing his last appointment.  He opens the session. “I can’t talk about my mom. I am meeting my aunt in an hour and I have to be in a good mental space. I just can’t talk about her.” “That’s fine,” I replied. “You don’t understand,” he continues, “I will be a mess if I start to think about her.” “I can understand that,” I say. “I am afraid that I will fall  in the sink hole,” Zach says. “That is interesting,” I reply. “It seems like you made your own sink hole after we talked about her the last time, since you burrowed under the ground and you did not come up for a while. I can see why you think about sink holes, since it seems that your coping style is such that internal conflict makes you fall away.” “Just like Alice in Wonderland,” he quickly responds. “Alice fell into a world which did not make sense, and that is exactly your experience when you begin to piece together your childhood memories,” I quickly respond in turn. “No,” Zach says strongly. “I can make sense of my childhood. My mom was a nut job.” “That is a broad stroke,” I say. “The details of the ‘nut job’ is where things get messy. However, I am aware that we are talking about the very thing you said we should not talk about.” “That’s OK,” he says. “I need to talk about it.” “Yes, but what about how you are going to feel when you meet your aunt?” I ask.  “Oh, I will be OK,” he says dismissively.

The approach/avoidance dance was clear and painful. Zach wanted to talk about his mom so that he could metabolize his feelings; so that his feelings would not cause him to fall like Alice in Wonderland. On the other hand, the process of falling was terrifying. Maybe his feelings about his mom should be left unsaid, he thought; at least today when he had to keep himself together so that he could keep up some social graces. We began to talk about his mom; he engaged intensely in the discussion. He was riveted to my commentary. His fear subsided to the point where he was dismissive of my reminder that he cautioned me about talking about this subject at the very beginning of the session. Wrestling with how his mother made him feel as a child, along with how his mother makes him feel now, felt to me  like he came in as a dry plant, but now he was  finally getting a drop of water. His body changed; his attention to my words, conveyed a deep need to hear my point of view of his childhood. It seemed as though he had kept his feelings buried for so long that he was relieved when his childhood impressions came to the light of day. His protestation not to talk about his mother, in retrospect, appeared to be a plea to talk about her. The scales of his approach/avoidance feelings were tipped. Approach we did.

The No-Show

 

Zach, https://shirahvollmermd.wordpress.com/2010/07/15/i-dont-speak-to-my-mom-what-is-wrong-with-me/, https://shirahvollmermd.wordpress.com/2010/07/10/no-gravity-anxiety/, https://shirahvollmermd.wordpress.com/2010/04/14/prescription-drug-abuse/, leaves his appointment feeling bad that he does not speak to his mom. The next day, he calls me to tell me that he cannot make the appointment on Monday, but he will be seeing me in a “few hours.” I look at my calendar, confirming my thought that we do not have an appointment on Monday. I wonder. His appointment time comes and he does not come; he does not call. I wait five minutes, but I know he is never late. I wait another five minutes. Now, I am concerned. After fifteen minutes of waiting, I call him on his cell phone; I get his voicemail. Days go by, I still have not heard from Zach.

I have known Zach for ten years. Sometimes he is as reliable as a clock. Other times, he seems to evaporate from my atmosphere. Still, this is a new experience. My hunch is that it was so upsetting for him to talk about his mom, that he could not face another appointment. My hunch is also that this upsetting feeling which causes avoidance is unconscious, and as such, he will tell me that he got “caught up” with something and he lost track of time. I will of course, wonder why he did not call me, when he regained his sense of order. I will also wonder whether I should pose this obvious question to him, or whether I should let it be. I will want to pose my theory about his no-showing being connected to our difficult session, but as more time goes by, it will be harder to feel the heat of these moments. https://shirahvollmermd.wordpress.com/2010/02/10/avoidance/Avoidance works; temporarily.

Brain Fear

Jessica, twenty-two, recovering drug addict, history of multiple near-death experiences due to her prior drug use, comes in and says “so, have you seen The Matrix?” I say “no, and I know that disappoints you and it makes you feel like I don’t care about you.” She replies “no, it does not matter.” In a monotone she continues “my mom is having an affair; she left my dad, my dad is devastated. My single sister is pregnant.” I say, “your tone suggests that these are matter of fact events, but the content feels to me like these things could generate a lot of feelings. I think you are afraid of your brain; you are afraid to feel those feelings. ” I think about Avoidance Boy, https://shirahvollmermd.wordpress.com/2010/02/10/avoidance/, although with Jessica she is talking about emotionally laden issues, but she is avoiding the feeling aspects.

“Yep” she replies. “I am afraid of my brain.” “That is why you used substances for all those years” I responded. “Yep” she says again. “I can understand why your brain is a scary place. Since you have not wrestled with your feelings for a very long time, the uncertainty of what those feelings might be like is overwhelming.” “Yep”she says a third time. “So, what am I supposed to do?” she asks. I said “let’s return to you asking me if I saw The Matrix. In your mind that question, that first question that you asked me today, showed me that you were trying to reestablish a connection with me. You were hoping that we had common ground. You were hoping that you would feel cared about. Perhaps this suggest that you are searching for those feelings.” “Well, maybe” she says with a monotone. “Is it possible that I care even though I did not see The Matrix?” I ask. “Nope” she quips. We both laugh.

Like all fear, the fear of one’s feelings, of one’s brain,  is an uncomfortable place to be. We go ahead with baby steps; gently looking at the fear, moving slowly towards it. Humor helps. A good bond helps. Seeing the Matrix would help too.

Avoidance

Nancy, the subject of https://shirahvollmermd.wordpress.com/2010/01/23/friendly-fire/ came in, as she does every week, to talk about the love she feels from her children. Nancy has four kids, two from her first marriage and two from her current marriage. They all have their struggles, but Nancy feels so incredibly proud of them. She tells me how much each child has moved her in a particular way. She gets teary-eyed when she talks about how her adult children want to live near her. Her warmth and affection to them feels genuine and heart-felt. Yet, I ask myself, “why does Nancy come to therapy to discuss how much she loves her kids?” The short answer is that Nancy is avoiding talking about the more difficult part of her life, her marriage. Nancy has been married to Woody for ten years and for the most part, all ten years have been challenging. Nancy does not feel understood or appreciated. She feels that her work, both in the world and at home, goes largely unappreciated, especially by her husband. So, I wonder, why are we not talking about her marriage. I know the answer. If we begin to go down the road to discuss her marital problems, she will get scared that she will conclude she needs a divorce and she does not want to get near that path, so she comes to therapy to remind herself about all the warmth in her life.

Nancy used to view me as adversarial. In the past, she saw in me someone who wanted to take her down from her good feelings about her kids into the ugly world of a difficult marriage. After many years, Nancy has come to see that she has assigned me the role of wanting to make her feel bad by pressing her on the difficulties in her life. Now, she says with amazement that she sees me as trying to help her work through her problems. She marvels at how she used to believe that  I was trying to “take her down”.

Avoidance is a powerful defense. Nancy goes to the good things in her life to avoid the challenging things. For years, this was an unconscious process. Nancy had no idea why she would come to therapy to talk about how wonderful her children are. Now, she sees that just like a child who avoids doing his math homework  because he struggles in math, Nancy has avoided talking about the part of her life that needs work. Further, she used to feel that my wish to bring her difficulties to her attention was malicious. Fortunately, Nancy also knew that we had a long history of working together and although she felt in certain moments that I was trying to make her life worse, most of the time, she understood that I was there to help. Nancy’s mixed feelings allowed her to hang in there with me so that we could explore her avoidance behavior. Patience paid off.