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Working With the Avoidant Client

7 tips to help those diagnosed with APD - 'avoidant personality disorder'


A diagnosis of avoidant personality disorder is a starting point, not a finishing line.

“Pain in this life is not avoidable, but the pain we create avoiding pain is avoidable.

– R.D. Laing

I’m not one for labelling people. Therapy should, I feel, help clients transcend their labels.

And yet an understanding of differing personality types is vital for any therapist. When we understand personality diversity, we can avoid the trap of assuming other people are fundamentally the same as us in all ways. This helps us avoid being continually surprised/shocked/disappointed/unduly impressed when they behave differently to us.

Humanity shares some common characteristics, certainly, but within that greater pattern certain people share commonalities with certain other people based on their personality type.

There’s another important point here.

No one has to fatalistically assume that personality type will unalterably determine the course of our lives.

An introvert, for instance, can learn to be more outgoing. Someone naturally prone to neuroticism can, over time, learn to be much calmer.

So yes, we all tend to fall broadly into distinct personality types. Most people will have more or less stable patterns of inner and outer experience. Perhaps they’ll be open to new experiences, or conscientious, or extroverted, or agreeable. Or perhaps not!

So the idea of personality type is potentially useful as long as we don’t limit people by viewing them only through the lens of what we assume they (or we) must be like.

And so we come to the concept of personality disorders.

Dealing with disordered minds

Personality is a constellation of individual traits, experiences, and behaviours that are stable over time. A personality disorder is a stable collection of personality traits that cause the person and the people in their lives ongoing problems. This is not at all to say (and I hope this goes without saying) that having problems means you have a personality disorder!

When many people consistently find a particular person ‘difficult’, when a person consistently runs into problems, and when those problems seem to be self-manufactured (whether the person recognizes that or not), that person may have a personality disorder. At least from a psychiatric perspective.

Another way of looking at things might be that someone labelled as suffering a personality disorder might be simply not meeting their emotional needs, or even their physical needs – as the tale of the thirsty king so beautifully illustrates.

Anyway, I think looking at some people through the frame of personality disorders can be useful, as long as we don’t fall into the trap of not seeing the unique individual behind the label.

Personality disorders, of which 10 are currently recognized,1 include borderline, antisocial, histrionic, and narcissistic personality disorders.

It’s important to remember that people seldom fall into neat diagnostic boxes, and that one and the same person may glide in and out of many different diagnostic categories at different times. Comorbidity is said to be common among those with personality disorders. For example, those diagnosed with borderline personality disorder may also have traits of histrionic personality disorder, or even narcissistic personality disorder, and so on.

So with these caveats in place, in this piece I’ll focus on helping clients with so-called avoidant personality disorder (APD). I’ll describe what it is and how to recognize it, and offer a few ideas of my own that I hope will give you some fresh ways to help someone who exhibits signs of APD.

But first… what is avoidant personality disorder?

Hiding away

I worked with Jane over many months. She had reached the point where she hid away from the world completely, wanting to just curl up and not be seen or judged by others anymore. She was terrified of meeting me because of how I might judge her.

In our fourth session she finally told me, with some embarrassment, that she’d previously been diagnosed with avoidant personality disorder.

“Does that diagnosis mean I can never change?” she asked me plaintively.

I reassured her that all human personality is mutable and we can alter, sometimes radically, elements of how we feel and what we do.

I suggested: “A diagnosis is perhaps a starting point, not a finishing line.”

Diagnosis is not treatment, of course, but it can be a starting point for some.

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Anyway, Jane did show signs of many of the classic avoidant personality indicators. She:

  • was extremely sensitive to perceived rejection or criticism
  • longed for but avoided social connections and intimacy
  • feared ridicule
  • was easily embarrassed and ashamed
  • assumed others would dislike or disapprove of her
  • felt unattractive and uninteresting to others
  • was extremely shy and timid
  • avoided new situations and stuck to her ‘safe’ routine, and
  • had extremely low self-esteem.

So, as far as what I had observed and what she had disclosed about herself, the diagnosis did seem to fit.

Jane wasn’t unsociable. She wanted friends, and even a partner one day. But she felt unable to engage with people without feeling intensely fearful of rejection. She had also become extremely pessimistic that things could ever be better for her.

Here are seven strategies I used with Jane. They might prove useful for you.

Tip one: Imply there’s a time limit on their suffering

If someone is essentially shy and timid, they may have come to believe that’s just who they are. If they’ve been diagnosed with APD, this sense of unchangeable negative identity may feel even stronger. We can use the language of change to imply (without being too crassly contradictory) that things can and will alter for them. For example, with Jane I made statements such as:

“What’s the worst thing about having been so shy and scared of rejection?”

Here I framed the shyness and fear of rejection in the past tense, with the implication that it doesn’t have to persist indefinitely. Of course, a single statement makes no difference, but if we continually use the language of change it can start to alter how the client themselves comes to view the problem.

When we use this kind of language a lot, we build an implicit sense that change is possible without having to say it explicitly. But we can go further.

If we continually use the language of change it can start to alter how the client themselves comes to view the problem. We build an implicit sense that change is possible without having to say it explicitly.Click To Tweet

Tip two: Remove the symptoms of APD from your client’s core sense of identity

I also used questions like the following with Jane:

As a thought experiment, what kinds of things will you be doing as the shyness drops away a bit?”

Notice here I slip in a sense of things in the future being better in the form of a question, avoiding the need to make it explicit. But I also remove the shyness from her core identity by suggesting it can “drop away”. So rather than ‘you are shy’, we imply that shyness isn’t you, and can actually fall away from you. It is not the real you.

Tips one and two can be useful in unpeeling any sense of being stuck with being an unalterable type or having a permanent disorder.

How we use language is so important with our clients. But just as fundamentally, we need to find out fast just what fearful social timidity has been preventing a client from getting.

Tip three: Work out what needs the client isn’t meeting

As always, we need to discover what primal emotional needs our client is currently not meeting. To what extent is their difficulty a way of trying to deal with an unmet need (or even a sloppy unconscious attempt at meeting a genuine need for, say, security or attention), and to what extent does the condition prevent their needs from being met?

So you can talk to your client about the needs we all share, and help them find ways to meet those needs.

Part of any therapy session consists in locating client resources. Sometimes we can do this by asking the famous exception question.

Tip four: Discover exception times

I asked Jane:

“What times can you think of where you were with someone and you didn’t worry about what they thought of you? Where you felt relaxed and connected?”

In other words, was there an exception to the problem? A time where it might have been expected to occur but it just didn’t? This is a very useful question when working with any client.

Jane thought for some time.

“Well, I knew this woman in my first job. She had such a way about her and she actually seemed to like me! We just got on really well. I always felt relaxed with her…”

Later, during hypnotic work, I helped Jane evoke being with that co-worker and amplify that feeling of being in company and relaxed.

We then had her hypnotically experience having that feeling much more of the time with many different kinds of people. So we began to exercise transferring the resource. She found this exercise particularly useful.

I also discovered times where she’d tried new things spontaneously, We explored times that flew in the face of her diagnosis rather than just focusing on times that supported it.

Sometimes a client will tell you there have never been any exception times, but usually when you look hard enough you’ll find them. Sometimes when you ask, the client’s mindset is not aligned to seeing positive exceptions so they will just not recall them – but they may ‘accidentally’ tell you about one later. And if not, you can simply begin to build a picture of what the experience of relaxing with others would be like.

Often, too, of course, we need to help the avoidant client undo emotional memories that may be maintaining their current avoidant style.

Tip five: Undo past conditioning

Jane feared being rejected, ridiculed, belittled, and even hated, despite the fact that she was an agreeable and decent person. I asked her why she thought she was like that.

“Well, both my parents would shout at me a lot. I think that’s where I get the nervousness from. I was often told no one would like me if I did this or didn’t do that. Like it was a threat. I was also quite badly bullied at school, and in my first job.”

I ascertained that some of the feelings Jane had when confronted with meeting new people or going into a new situation were very similar to the feelings she’d had when being yelled at by her mum and dad and also when being bullied. I worked to help take the sting out of those memories so she could develop new, calmer, more adaptive emotional templates.

So certainly we may have to help undo past emotional conditioning.

Okay, now here’s a question for you. What do you call someone who ‘has’ avoidant personality disorder when they no longer avoid things?

Tip six: Set behavioural tasks

Many years later, I answered that very question for Jane:

“You know, if you don’t avoid things so much you can’t really be said to have an avoidant personality… you’re just left with…”

“Personality!” She finished my sentence.

“Yes, you have personality!” I said. “And a good one at that!”

I set Jane behavioural tasks – to meet up with one person she trusted once a week, and to do one new thing (even simply walking back from her job a different way).

I had her do these tasks hypnotically in her mind initially, to maximise the probability she’d feel more natural about actually doing them.

Bit by bit, we added to the tasks and they became more daring. Soon she was seeking out, not running from, many kinds of experiences that she would previously have avoided.

She began to widen her life to the point where more of her intrinsic needs could now be met.

Taking all the above approaches will tend to have, as a happy side effect, a positive effect on self-esteem. But we can also work on this directly.

Tip seven: Work on their self-esteem

As we’ve seen, low self-esteem tends to be a feature of the avoidant client. This may be a cause of their avoidance but also a consequence of it. If we avoid others, we might then start to feel we are alone because we are unlikeable or unlovable. Jane lived with loneliness every day when she first came for therapy, but as we progressed she began to see people enough to shrink her sense of isolation right down.

I helped Jane envisage being more relaxed in the face of perceived criticism and around people she found to be ‘scary’, and we also worked on her self-esteem more directly, helping her build up a more positive sense of who she was and what she was able to do. We looked at typical self-esteem issues, such as the feeling of not ‘deserving’ good things in life.

Jane was never going to be the world’s most gregarious, outgoing, or adventurous person. But in time she began to meet her needs for social connection – and even intimacy, with a man she met.

“I’m happy with having a bit of personality,” she smiled towards the end of our final session, “but I’ll ditch the disorder I think.”

Create change by subtle implication

As therapists we know how difficult it is to help clients change by giving them advice. Explicit instructions are often challenged, avoided or simply discarded. Taking a more subtle approach to undermine limiting beliefs and inspire hope of change can be much more fruitful, which is why Mark created his online course Conversational Reframing – click to read more.

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Mark Tyrrell

About Mark Tyrrell

Psychology is my passion. I've been a psychotherapist trainer since 1998, specializing in brief, solution focused approaches. I now teach practitioners all over the world via our online courses.

You can get my book FREE when you subscribe to my therapy techniques newsletter. Click here to subscribe free now.

You can also get my articles on YouTube, find me on Instagram, Amazon, Twitter, and Facebook.

Notes:

  1. American Psychiatric Association (2013). “Alternative DSM-5 Model for Personality Disorders”. Diagnostic and Statistical Manual of Mental Disorders (5th ed.), pp. 234-236. doi:10.1176/appi.books.9780890425596.156852. ISBN 978-0-89042-555-8.

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