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James D February 21st, 2006 07:18 AM

Avoidant PD
Hi all,
I have been working with an Avoidant Personality Disorder (AvPD) client (55 y.o.) for some time now. She has made gradual progress and has enrolled in a course at a local educational instution - a big step given the high level of social anxiety she experiences and will confront each time she attends the school.

I'm interested in people's experience of working with AvPD, time it takes to start observing noticable changes, and strategies that have proved useful. I believe I read somewhere that progress is typically quite slow.

Also, this client and another client with strong AvPD traits find it very difficult to close their eyes and keep them closed for relaxation sessions. Is this a feature particular to this group of clients? The client mentioned above feels she has to sit with her back to a wall and states she feels out of control if her eyes are closed; she needs to know what is going on. This also makes getting to sleep difficult at night.

So, i'm also interested thoughts and suggestions on this topic as well.

Many thanks,
James D

Janene Cowlishaw February 23rd, 2006 01:11 PM

Re: Avoidant PD
have you thought of assessing her for high shame-proneness. It would definately fit with D. L. Nathansons' Compass of Shame where one of the four poles are avoidance. Does she tend to attack others (verbally) when pushed to 'the wall' rather than attack self. If she is also living in the pain and fear of high or global shame, it would account for her problems with closing her eyes during therapy - because the site of shame is the face - it would be unbearable to think you might (and would be - to her) looking at her face when she cannot see you - because you might spot her reality that she is actually flawed and a fraud as a person with no right of existence.

James Pretzer February 27th, 2006 08:57 PM

Re: Avoidant PD
If you haven't already read the discussions of Avoidant Personality Disorder in Clinical Applications of Cognitive Therapy (second edition) and in Cognitive Therapy of Personality Disorders (second edition), I'd recommend both of them.

It can be quite useful to help the client recognize the drawbacks to avoiding unpleasant emotions (especially anxiety and embarassment) and to help them recognize the value of persistently facing situations and emotions that they have been avoiding.

James Pretzer February 27th, 2006 09:05 PM

Shame in Avoidant PD
I don't remember seeing many discussions of dealing with shame in CBT but this is something that can be quite relevant to treating Avoidant PD. There is the option of pinpointing and modifying dysfunctional thoughts that elicit shame and the option of using "shame-attacK exercises" as in REBT. I also like to have the client (gradually) fill me in on whatever it is that they are terribly ashamed of and what the client thinks others would think "if they knew."

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