Ep. 80 - Avoidant Personality Disorder
Is your loved one an expert ghoster or the first one to run from a social situation? People with avoidant personality disorder (AVPD) are not just shy or a little aloof, but avoid relationships and social situations in order to hide a deep sense of inadequacy. In this episode, we describe what AVPD is, how it's different from similar disorders like social anxiety, how it's treated, and tips for loved ones of people with AVPD.
If you need help dealing with a loved one that struggles with avoidance, we're here to help. Sign up here for a free 30 minute consultation to learn how co-host Dr. Kibby at KulaMind can support you.
Read more about AVPD here: Weinbrecht, A., Schulze, L., Boettcher, J., & Renneberg, B. (2016). Avoidant personality disorder: a current review. Current psychiatry reports, 18(3), 1-8.
If you have a loved one with mental or emotional problems, join KulaMind, our community and support platform. In KulaMind, work one on one with Dr. Kibby on learning how to set healthy boundaries, advocate for yourself, and support your loved one. *We only have a few spots left, so apply here if you're interested.
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Speaker 1: Welcome back little helpers. As the holidays approach, we always like to talk a little bit about loneliness. And so today we're moving out of Cluster B disorders into Cluster C, which is the fearful anxious thinkers, basically. And today's episode is on avoidant personality disorder. This is probably a personality disorder that very few of you have heard of before, but it's actually just as common as the other personality disorders. And it is marked by having very few relationships, feeling pretty socially inept, and it results in a lot of loneliness. And so we just like to talk about this when the holidays come out, because it can be really, really tough time to be lonely and to feel like you just don't have much of community around you. So we're going to talk about what AVPD is, how it is similar and different from very kind of similar disorders like social anxiety disorder and treatment and tips. So just to start out, AVPD or avoidant personality disorder needs to have at least four of the following criteria. So these people avoid occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection. So that's really important. It's not that they just don't like other people, it's that they're really afraid of being rejected or criticized. Second criteria is an unwillingness to get involved with people unless they are certain of being liked. Third is showing restraint within romantic or sorry, within intimate relationships because of the fear of being shamed or ridiculed. So it might be really difficult for them to get truly close or vulnerable with somebody that they have been in a relationship with for years, or maybe with family members. They're preoccupied with being criticized or rejected in social situations. Really what this is getting at is they spend a lot of time worrying about this. This takes up a lot of their mental space. They're inhibited in new interpersonal situations because of feelings of inadequacy. So this is a little bit different from the kind of fear of criticism. So this is like a real belief that, wow, I might not be as good as other people. They view themselves as socially inept, personally unappealing, or inferior to others. So pretty kind of global assessment of their character overall, and they're unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing. So Kibbe, this sounds a lot like social anxiety disorder. Can you talk to us about how those two disorders are similar and how they're different?
Speaker 0: It's super hard to tell them apart.
Speaker 1: I know, because I've tried so many times, and I find it so hard to diagnose differently.
Speaker 0: Yeah, it really is. I mean, what we're talking about is the people in your loved ones or even yourself who are just terrified of social situations, right? They don't want to go to a party. They don't want to ask someone out on a date. And they're just so scared because they're afraid of rejection, right? There's like a group of people who are like that, and we're all like that in certain points. But again, personality disorders, remember that it's something different than just a disorder. So first of all, social anxiety disorders sometimes come and go, right? It's like episodic. You'd be socially anxious for a part of your life, and then you get a little bit better. People with AVPD, this is how they are for most of their adult life across different situations and time. So when you ask and you really get someone with AVPD, they really feel like they're inferior no matter what.
Speaker 1: If.
Speaker 0: They feel like they're inferior at work and in romantic situations, they don't feel like they're as attractive. They're not as smart. They just feel that they're just worse than everyone else, and they really avoid as much as they can. And that doesn't always look like they're hermits. They're not always like sitting at home. They're really – they could even just put on a really good show and act really cool and calm and collected, but they really avoid intimate relationships and getting closer and vulnerable with people. So it's just a matter of pervasiveness, like how long and how much are they like this? But I could describe a little bit more clinically because I've worked with people with SAD and with social anxiety and AVPD. It's this feeling that I have with people with PDs. It's like they walk in a room and you just feel it. Something that feels different is that they really are just terrified of intimacy for people with AVPD. So what that feels like is that even as you're getting closer to them as a therapist or even in a romantic setting or any kind of setting, you feel them pulling – like they want it so badly. You feel like they just have this yearning for that, but at the same time they pull away. So it's actually for me when I'm working with someone with that, it's really enticing. I'm drawn to be like, if I give them more warmth and more reassurance, then they're watching someone be thirsty for that. But yet they're drawing away from any fountain, any water, right? So it's like this push-pull feeling. Whereas people with anxiety disorders, they're terrified, but they can start to settle into intimacy a little bit more. They have people in their life they feel more comfortable with. So it has this like deeper feeling. It's not very good. But there was some research showing that AVPD people do have more deficits in intimate relationships. They're more emotionally guarded, even with the people they're closest to. Whereas people with SAD, with social anxiety, not necessarily.
Speaker 1: Yeah. There's some debate I was reading that maybe AVPD should just be considered the severe end of the social anxiety spectrum rather than a personality disorder of its own. But the writers of this paper at least were arguing that it had enough differentiating factors to warrant its own diagnosis. But I do think that that's a good question because diagnosing this, it's so tricky to pull them apart. Because people with social anxiety disorder, they avoid social situations. They have fear of rejection and criticism. They're really afraid of embarrassing themselves. They can come across as aloof and uninterested because they're just trying to hold it together and not show their vulnerability and embarrassment. And, yeah, when I would consider an AVPD diagnosis, I'm looking at things like, do you only have one close friend? But that could be an extreme form of social anxiety disorder, like, you know, or, yeah, it seems like this global kind of character assessment is the most different, it's the most compellingly differentiated.
Speaker 0: Part for me. That's it. I think what we're talking about is like a disorder versus your whole identity. Because if you have a whole lifetime, I mean, let's say social anxiety disorder is often diagnosed like if you're afraid of social situations, but mostly because you're afraid of people seeing how nervous you are, like that's kind of like woven into the understanding of social anxiety. Like I'm afraid to go to a party or give a talk and people are going to see that I'm shaking or my face blushes, right? So they're afraid of being seen for this, like, how nervous they are. People with AVPD are afraid of being seen for who they are. They're like, I'm fundamentally unlovable and inferior and people are going to see that and hate me. So arguably, if you have a whole lifetime of being socially anxious, doesn't that eventually change the way you see yourself, right? Your identity?
Speaker 1: I know. Another good question. Yeah. I think it's so people with SAD are afraid of being seen by others seeing how nervous they are. And they're afraid of messing up because of how nervous they are saying something stupid, forgetting lines in their speech, etc. Which just it does feel categorically different than like people are going to see me as defective in an act, you know, or just like ugly.
Speaker 0: Yeah.
Speaker 1: Because that's who I believe myself to be. And that just sounds like such an awful way to live your life.
Speaker 0: Yeah. Yeah. It's a it's linked with a lot of depression. It's linked to other personality disorders, too. But it's just like so fundamentally lonely. I mean, I always think about one patient that I had with I think the full blown diagnosis. And he it was just so heartbreaking. All he wanted was to be loved. All he wanted was that we like to actually be connected. And there's also this like fantasizing they have this obsessive fantasies about belongingness. So he would always like, every time just talk about how he just like watch friends or watch TV or read something about having a group of friends and just that's all he wanted. And so we'd work on it. But he just it just was like, he felt like he was yet the way he described the loneliness was that he would he would look whenever people would be hanging out, he would look be looking like as if he's behind a glass like he would describe it like a fishbowl he was looking into this world where everyone was connecting and loving and being intimate and sharing and he just was watching it and wanted it so wanting to be part of it so badly but just really just couldn't this really this felt like this was a world that was just just outside of his grasp that he wasn't didn't have access to so it's just really painful.
Speaker 1: Yeah, that's really tragic. And I mean, it's really sad, too, because you know that like, probably from other people's perspective, you know, he might seem a little odd because he's so withdrawn, but other people aren't seeing him as inadequate or defective in the same way that he is. So it just feels like an invention. That's just keeping him trapped.
Speaker 0: Yeah, I mean, he and other people I know who have traits of it are sometimes even very, very socially skilled in some ways, like they're able to talk and chit chat and and do things that look like they're engaging, but they're really far removed emotionally, or they like are hiding them true their true self. So some of them will avoid in that way where they just like are put on a mask. Yeah, I mean, I just keep thinking there's this one. This one podcast episode with this interview, talks about someone with AVPD. And it was really interesting, because this person was like the life of the party, but like, you know, came in, everyone assumed that he was well liked, but he would come in be funny, charming, and then just not have anyone close to him. So yeah, so it can, it could, it could be deceiving in that way. But the loneliness, like deep, deep loneliness as the core of their self concept, concept is like a big thing.
Speaker 1: I mean, what was this person like? And did he have a girlfriend? I mean, family, any close friends at all? Like, what?
Speaker 0: My patient?
Speaker 1: Yeah, yeah.
Speaker 0: I mean, that's, that was the strange thing. He was married, had kids had a job was constantly that's the one thing that was interesting. The I mean, actually, now thinking about the criteria, he was only in scenarios that constantly gave him reassurance, but it still wasn't enough. So it kind of felt this bottomless pit. His wife, his co workers, me as a therapist, were constantly telling him, you're actually great. We actually care about you. We're actually here for you, please, like, open up, you know. So there's, it's almost like everyone around him was begging to give him what he what he said he wanted, but he still like jumped back from it. So if you probably saw him on the street and saw him in his workplace, you wouldn't even think about it.
Speaker 1: Yeah, this idea of, you know, if I let somebody see me for who I really am, they're going to leave me, they're going to hate me or no one is going to see that I'm unlovable. It's so interesting, because it's kind of like, what are the characteristics of someone that would be like that? And I can think of someone who secretly wanted to, like, you know, kill their pets and maybe their children, like, I would leave that person, you know? But it's not like there's this set of traits that's just unpalatable to everyone that isn't psychopathic. And yet, it's something that so many of us buy into.
Speaker 0: I know shame is such a big thing in our in our culture, a culture that doesn't actually make sense to have as much because, I mean, we could see that there's all sorts of public figures and feel like that you can kind of find your people anywhere in America, most places. But yeah, unless you're like, killing and eating other people, I feel like there's a lot of, there's a lot of forgiveness to the, you know, these deeper traits that we're afraid is unlovable. But I think it's, I mean, the literature on AVPD, kind of like other PDs we've seen, parents are neglectful, maybe emotionally neglectful, abusive, or just like, unaccessible. And also, people with AVPD have parents who have low social abilities. So there might be, I don't know, they might be kind of socially deficient on their own. So they don't know how to show feedback or love for somebody as well. Yeah. So it's so hard, though, when when you grow up with a parent who isn't able to show you that you're worthy or loved, how that just, like, is an earworm that just gets inside you. And you could be a completely normal average person that just goes around believing that about themselves.
Speaker 1: Well, I mean, it just shows how important those early developmental years are, with the caveat that this also has very, very high heritability. So 0.67, again, it was like the exact same, right? With histrionic personality disorder.
Speaker 0: Yeah, it is crazy how like, if yeah, how likely it is that if you have a personality disorder, your kids are most likely going to have a personality disorder. So I mean, I think that takes a lot of the blame out of the environment and like parenting exactly right.
Speaker 1: I mean, it might or it's that you model the behaviors that then, you know, develop in your kid. I mean, if you are, I mean, we know that, like, shame and mentalization develop around the same time. So early, early beginnings of two, but really kind of coming, like, really fully developing more forward and onwards. And if the people in your life neglect you and treat you like you're not important, and that is your universe, then yeah, you're gonna develop with the idea that like, Oh, other, other people don't like me. They don't care about me. So I mean, I would say, if you know any parents like that in your life, even you showing love to that kid could be really a great intervention.
Speaker 0: Yeah, that's actually that reminds me of something else I read that compared to other personality disorders. People with AVPD have fewer other parents, other adults in their life. So people with, you know, borderline personality disorder or narcissistic personality, they'll have like a parent who's abusive or neglectful, but they might have other people in their lives. For some reason, AVPD, like they, they don't have as many people that maybe are more isolated in general.
Speaker 1: Because their parent has AVPD.
Speaker 0: Right, exactly. So it's a really, truly lonely, intergenerationally lonely disorder where you get this feedback from one person, you're not lovable or valuable. And then you don't really have any, as much other feedback from anyone else to kind of counteract it. So yeah.
Speaker 1: Yeah. I know. I mean, it's just so it's just so sad. And then, you know, the disorder itself manifests the consequences that you're afraid of, you know, if you can't allow yourself to be vulnerable with another person, then you're never going to feel loved, because you're never going to feel like they're seeing who you really are. You're never going to get that belief challenged. You're going to go on hiding. And other people might find you difficult to get close with. So you don't have any close friends.
Speaker 0: Yeah, I wonder, I wonder if personality disorders get so sticky, because there's this research showing that people really try to confirm their self views.
Speaker 1: They really self verification theory.
Speaker 0: Yeah, they really try to seek out situations to confirm their the way they see themselves. So they are pushing away people and being like, see, people leave me, right? Right.
Speaker 1: Do we know why that is? I mean, I don't know, I was actually talking to Zach about this, and he kind of disconfirmed this hypothesis. But I'm like, is there? Is there more comfort in having consistency in your identity?
Speaker 0: Than there is in change? Yeah, I was doing some research on self esteem. And generally, people want people either look for situations that boost self esteem, or they look for situations that confirm they don't look, obviously, for ones that are lower it. So there's competing theories, like do people try to see themselves better than they are, or they try to see themselves as similar. But I would, I would think that just change in general is hard, right? If you grow up thinking you're, you know, operating and thinking and in one way about yourself, it's really hard to be in a situation that really upends, like, all the things you think about yourself, right? Like to even invite the possibility that you are worthy means that then you would have to go out and try and like, actually make a connection and risk rejection. And that might just be too much for someone to handle.
Speaker 1: Even though then confirm. I mean, it's it's such a wild theory. It's really cool in a dark way. I mean, I imagine too, like if they do get disconfirming evidence, they might meet that with a lot of distrust. Like you are pretending to love me.
Speaker 0: Exactly. Yeah, I wish there was more written about the difference between people with AVPD and social anxiety, because I think this is way more common than people think, but they don't know how to differentiate. So I'm thinking about like, working with my patient, one thing that stuck out with me was every week we would, he would come in with obsessing about a situation where someone said something or talked to him in a different way. And he was like, that just shows that they hate me. An example was like, someone mentioned, oh, I think you have anxiety. I think that you're struggling with anxiety. And then we had, like, literally three sessions focusing on how that person was judging them and thinking poorly of them.
Speaker 1: Right.
Speaker 0: And, and, first of all, the thing that struck me about that was how deep that is. There's many people I work with social anxiety that if they were told you, I think you have anxiety, they'd be like, yep, I definitely do. But this person just took that as such a deep character attack that they were just obsessing over it. And, and couldn't get over it. And then we would also map on like, kind of get some insight on how that person, like how this is something that that is like a bias from them, how they're almost like looking for criticisms and other people, like kind of be like, is part of the way you see things. It's like, part of your cognitive model, see, let's map it out. And they'd be like, oh, my gosh, that's right. So maybe people won't don't actually see me this way. And then next week, it was like, we're starting from square one. So that that feeling of having to like, keep like, the insight kept disappearing is definitely part of the literature that says that people with AVPD have issues with like, self reflection and theory of mind and insight that people with social anxiety don't, they might even have too much self awareness. So yeah,
Speaker 1: PDs seem to be pretty consistently associated with mentalization difficulties.
Speaker 0: Yeah.
Speaker 1: And I guess maybe that speaks to the natural inflexibility in personality disorder. I mean, you can't have a PD that is that's flexible. Inflexibility is built in because it has to be persistent and pervasive.
Speaker 0: Yeah, I still I was obsessed with this idea in grad school. And I still am into it that people with PDs might have this almost like a learning deficit of taking social information and adapting your the way you see yourself based on that, right? They're like, I'm unlovable. And then you could be like, No, I love you. They're like, Nope. I don't believe you. So it's just kind of like, they're unable to change with like new information, you know?
Speaker 1: Yeah. Yeah. So it's a relatively poorly studied condition. Do we know anything about treatment?
Speaker 0: Yeah, treatment. I really wish there were more studies about this. Like this is a call for anyone listening who's in research, please do more. Actually, but they're not going to come out. They're avoided. So they're not going to come and volunteer for research. This is why this is so hard. But the few research that I saw says that cognitive behavioral therapies are really good for this disorder, more than psychodynamic therapy. That's just one study. So but CBT is definitely more helpful. So any kind of therapies that challenge their beliefs about themselves, and, and of course, behaviors. So the CBT is for this disorder tend to focus on it's what's called the malignant self regard. So they just hate themselves. They like it's not just as I would kind of we're hammering this, this idea home, but it's not just that they are afraid someone's going to think they're dumb because they blushed. But it's like they see themselves as fundamentally bad. Actually, which is people with vulnerable narcissism also have so they might be related.
Speaker 1: We can talk more about that. Maybe.
Speaker 0: Yeah, I mean, this is just I've just heard this anecdotally as like people who worked with different disorders, but people they might they think some personality disorder therapists think that some people with AVPD also have vulnerable narcissism, because it's like the other end of the grandiose part, right? They just like, they just think that they're the worst and they, they hate themselves. Yet they kind of draw attention to themselves, like they get that reassurance all the time. Right? But it's like this fundamental self esteem problem, right? They're like swinging to this extreme self hatred. And obviously, that's getting reinforced in some way.
Speaker 1: Yeah, I mean, it's interesting, because anybody who hates themselves, and then interacts with other people is probably going to bring up their self hatred at some point, they're probably going to blame their misbehavior on something global about the self and people who are not disordered, generally can't stand to hear that. They can't just be like, Oh, okay, that's, that's why it's because you're a shitty person. Defective. Oh, okay, well, that explains everything. No, they're gonna reassure, they're gonna say, No, my god, no, it's not that. And that can be a process. But okay, so there's this malignant self image.
Speaker 0: Yeah. So basically, the CBTs will work on the self belief that's so sticky, this like malignant self regard, and the feeling and these beliefs that they have to subjugate their their needs. So basically, they have to control and suppress their deeper, deepest desires from from social relationships. And they also feel like they're going to be abandoned. So and then the behaviors in response are the avoidance, right, they like cope with that really painful feeling that malignant self regard by avoiding social situations. So they're just they're just hiding. They're hiding from other people. They're hiding from the risk of getting rejected. So CBT is like, it's going to be a really slow, painful process to treat this. It's like, probably very baby steps towards like helping these people kind of open up. I'm just thinking about my patient and working with him. It was so hard. This actually, I mean, I remember in internship interviews, they ask us what give us an example of a case that didn't go really well. And he was the one that I always thought of. Because it's just this fundamental problem of connection, right? This person so desperately wants to be loved and almost keeps you at arm's length. So it doesn't allow you to love, which was really hard for me. So it was this painstaking, like little small, as I'm saying, we will work on one issue for like three weeks. You know, they were called anxious. And so three weeks was focusing on that. And we did really, really small, gradual behavioral task of like, okay, when you're picking up your kids from school, why don't you like smile at someone because it was like the goal of trying to make new friends. So it's like, okay, why don't you try to smile at someone and see how that goes? That was a several week process. It was really hard to do. Or how about you ask for feedback from your bosses about what you're doing? Well, and so we took that feedback. And it was like, a bunch of sessions of just digesting the feedback and battling with the kind of what you're what you said, like, if you get positive feedback, to like, not just assume it's wrong, or that they're lying or actually rejecting you. So yeah, it was just like, he got this pot like super positive work review. And there was like one constructive feedback. I think it was actually a long level of like, you're too hard on yourself. And he fixated on that. It's like, see, they think that I'm terrible. They think that I'm this. And I was like, wait, but there's paragraphs of how you did well. And that one sentence saying that it's something you could work on. They like technically have to put that in. So just really painstaking. But it didn't go well. Because I mean, I felt like you always feel like you're walking on eggshells. This is probably this goes into the tips for people with loved ones with AVPD, you might always feel like you're on eggshells. You're constantly showing love, love, love, reassurance, reassurance. I'm there. I care for you. You're great. You're great. And you're just you start to watch everything you're saying around them, because everything is taken as a rejection, right? And so I really felt like I was inhibited myself. I couldn't say what I really felt. I couldn't say I had to be happy all the time and loving and warm, and any falter that would have been bad. So, you know, there was a time when I was tired, and I didn't smile as much. And then we had to talk about that. But that was a really painful process. Um, yeah. And the the actually the thing that went wrong was that he had a really went through something really hard in his personal life came in and was like inconsolably crying and was like, see, I'm unlovable. No one loves me. No one cares about me. I I'm worthless. I'm alone. I'm married, but I'm alone. And I try to counteract that. I tried to, you know, in CBT terms, try to provide counter evidence. I was like, but didn't your wife say that she really cares about you in that conversation? Yeah, but it doesn't matter. She's lying. She's just saying it. I was like, but right now, I'm telling you, I really care about you. I really enjoy our work together. I really like our connection. I think we have a good working relationship. What is it like for you to be here with someone actually telling you that they care about you? Yeah. And he just shut down and closed his eyes was shaking his head inconsolable. It's like, no, no, you just have to because you're a therapist. You don't actually. And I kept pushing back on that. I kept thinking if I just leaned in with more warmth, then like it will break through. He stopped therapy after that. Yeah, he wrote and said, I need to take a break from therapy. It's a little bit too much for me. And then I, gosh, I consulted with a with my supervisor. And they always mentioned like, okay, if someone if someone says they don't want therapy, you have to give them the policy that they skip a certain amount. They're technically out of treatment and have to re-engage like just something right administrative. So I had to write that in the email. And I said, Okay, just letting you know if you miss X amount then. And he was like, and he wrote back like, does that mean you're kicking me out? You're kicking me out because I'm a bad, bad patient, aren't you? I knew it. And then I never heard from him again.
Speaker 1: Wow.
Speaker 0: So yeah, and so like, that is that stands out for me. And I was so and I, I looped over everything I said and everything I did. And I regret I still regret this to this day, even though I know it's part of his disorder. But what I would do differently, like people ask me what do I do differently is that with these people, if they're not ready, they're not ready to be challenged on their malignant self regard, right? They're not ready to they, it's almost organizing and calming for them to get some to get like push people away and get some confirmation of how much they hate themselves, right? And to lean in and try to push and be like, No, you're wrong. You are cared for. That's just, they want intimacy so badly, but intimacy in itself is terrifying. So I leaned in with something that was just like, terrifying to them. So yeah, I wish I kind of like held my ground a little bit more and didn't lean in so much with my feelings and just like, help them explore in that moment. So I.
Speaker 1: Mean, that's really acting opposite to what feels natural, though. I mean, I think it would have been my, you know, first instinct also to be like, Well, I'm someone who cares about you.
Speaker 0: Yeah.
Speaker 1: You know, what would it be like to just, what would it be like to just pretend to believe it for a few minutes? Like, yeah, you know, how could that feel? Um, gosh, I once asked, I have a patient who does not have this disorder, but we were talking about other things. And I asked her, like, did anybody, was anybody just delighted by you growing up? Did any, did you ever feel like anybody just found your company delightful? And I just imagine that for these people, that question would be a preposterous one. You know, I mean, I just imagine never having a parent, a boyfriend, a girlfriend, you know, like anybody to just think, Wow, I just, just like being around you. Yeah, for what you offer me.
Speaker 0: Yeah. Yeah, that no, that's a really good question. Because I remember, I remember asking that early on. I was like, Is there anyone like your husband, your sorry, let me redo that. I remember asking that question early on, like, what, why did your wife love you? Like, how did you guys fall in love? What did you like about her? Just trying to get a sense of like, how he was able to create any connection. And he said, Well, we fell in love early. And I think it was mostly because the way I looked back then I was a lot skinnier. And I was a lot, you know, just more attractive. And now I'm not anymore. So it was as he explained it as like, this person who's still in my life, still married to me, loves me because of something that wasn't a part of me. That was something that was like, transient and went away. So it's like the core parts of the me hood, it was not something that was lovable. But the stuff that was just like, Oh, I was just I happened to be young and hot back then. Right? It's like, Oh, so heartbreaking.
Speaker 1: Yeah, I mean, I imagine to like too much. So maybe like parental overemphasis, emphasization, emphasizing of external traits would not be helpful here.
Speaker 0: Mm hmm.
Speaker 1: Yeah, so what Okay, so you know, if you're interacting these people, maybe don't try to push something too hard that they you know, they're not going to buy no matter what you say, it's just going to trigger them to fear closeness.
Speaker 0: Yeah, if you have a loved one with this disorder, first of all, you might not even know, because they might be the kind of people who just ghost a lot. And you don't know why and they just kind of pop up and they kind of keep you at arm's length. Mm hmm. And again, this is not just the one guy you're dating. You know, like, you're like, what's going on? But it's it's this person is doing this with literally everyone in their in his or her life. And just know that it is, it's not a you problem, this this person, even if you're reassuring them over and over and over again, and it feels like you're just throwing it down the trash chute, like it's just like this. This bottomless pit. Yeah, that that's because they just can't see themselves as lovable. And maybe not keep going with the reassurance thinking that one day it will stick. I think someone needs actually like deep therapy to get there. But maybe just like hold your ground. Maybe don't push too hard in the trying to pursue them or reassure like don't just keep leaning in relentlessly. Maybe step back, still be loving, but like step back a little bit. For example, like my supervisor recommended that if that person wanted to come back into therapy, do the opposite that I normally would and just pretend nothing happened. Right? Just like, okay. And, you know, just kind of like, oh, okay, are you would you like to come back to therapy? And if they come back, just don't address. You normally I'd be like, what happened? What like, what pulled you away from me? What what what did? What did I do that to hurt your feelings? I try to like, like, like, process the rupture between us. But instead, just like, oh, you're back. Like, what's new?
Speaker 1: Yeah, because they just don't they just can't they're not ready to process that.
Speaker 0: Yeah, it's a lot. I mean, ideally, you want to get there. And if they can, that would be great progress. But in the meantime, you might have to like, you know, really I mean, emotionally inhibit yourself until until you slowly warm up.
Speaker 1: I'm having some feelings of hopelessness about this. The end of this episode, you know?
Speaker 0: Yeah.
Speaker 1: Because at least at least with narcissism and anti social, there's this sense of like, they're just kind of bad people. So I don't care as much. Maybe that's not the right clinical thing to say here. But there's a sense of that. With AVPD, I don't feel that way. But there's also this added sense of like, I don't know how I can help you. Like, is this helpable?
Speaker 0: You know? Yeah.
Speaker 1: And that's tough. And I mean, with BPD, you have eggshells there too. But that feels more flexible to me. And maybe because DBT is so strong.
Speaker 0: Yeah.
Speaker 1: And because I've known a lot of people with BPD, and you don't have to treat them with this degree of sensitivity.
Speaker 0: I mean, I don't know.
Speaker 1: I mean, it feels a little bit different or something. Like, I feel like I've been like, part of DBT is irreverence being matter of fact, saying the thing and they can react. But it just I don't I don't know the flight risk feels a bit different, at least in the story with your patient.
Speaker 0: Yeah, I think that is why clinical science is this important. Because if you have a treatment, it is way it just feels more relieving for yourself and the loved one and everyone involved. Because it's like, oh, there is a path forward.
Speaker 1: Yeah.
Speaker 0: To be honest, like with people who have full blown borderline personality disorder, or nervous, you know, it takes a long time. I mean, real DBT is at least six months, most likely a year, at least like it is slow going. This these, when you're treating someone with personality disorder, you're trying to upend all they feel about themselves and the world, right? They got like, you're trying to change their entire concept of reality. And we just and when you don't have as many available empirically supported treatments, like for narcissism, or psychopathy, or AVPD, you there is a sense of hopelessness and the sense of like, just know that this is what they're like, and don't blame yourself. Like, yeah. But that is why there's got to be more treatments. And there actually is one that was tested that's supposed to be that's designed for this population. It's called radically open DBT. It's actually developed by Thomas Lynch, who Yeah, who he was like, our, you know, he was at Duke, he was Zach's our advisors old boss. But I don't think that has as much empirical basis as like, you know, traditional DBT,
Speaker 1: It's designed for OCPD.
Speaker 0: It's they're all similar. Yeah. But it's, oh, yeah, it's for OCPD. But I think it's, it's marketed as like, you could try it with anyone who has inhibited, like internalizing, who are just like, emotionally inhibited.
Speaker 1: So, yeah.
Speaker 0: Yeah, I mean, the hopelessness is real. And I think that part of what is like a tip for loved one is like, how do you cope with hopelessness, right? Because assuming that that person can change overnight, or assuming that it's something that you can do differently to change the course is probably setting yourself for more failure, right? It's more about protecting yourself.
Speaker 1: I'm thinking too, of like, how hard this would be on a partner to a be told that they don't mean it when they say they love you. Like, if I was being told by Jason, you don't mean that? I'd be like, well, don't tell me how I feel, first of all, but what do you mean? I'm trying to share vulnerability with you. And it's being spat back out at me in that. So I would imagine that would be hurtful. But you also probably feel like you're in the position of changing this person's whole view of themselves and being the love that's going to transform them. And that is a huge burden. And it's an unlikely consequence. You know, I mean, you're probably not, it's probably not going to work.
Speaker 0: Yeah. Oh, my heart went out to my patient's spouse. And I felt that too. I have, I thought about this page, I had other patients, but I thought about this patient most days, because I was like, Okay, I'm gonna, I'm gonna do this today. And it's good. And it's going to be good. It's finally going to help. And because you're like, that person's like, I want to be cared for. And then you're like, here it is, like, I'm giving you the thing that you're desperate to have. And it doesn't work. So there's a feeling of you getting rejected. It's hard. It's really hard. So I've loved ones with people. I mean, if someone is like the major ghoster in your life, at some point, you got to forgive yourself and not assume that your love is not good enough.
Speaker 1: Right. Yeah. And for people who have this disorder, I mean, any, I guess tips would be, try, try to push through the discomfort a little bit, try one more session with a therapist, yeah, try maybe, what would it be like to believe in love for 60 seconds at a time, or just maybe just sort of experiment with letting these things land on you a little bit longer.
Speaker 0: Yeah, learning awareness is really helpful. And definitely look for a cognitive behavioral therapist, because that's what the research shows that that's helpful. But maybe seeing if any of these concepts do land with your experience, because once you have at least awareness that this is the, your identity, and what's driving your avoidance, because a lot of people avoid social scenarios for a lot of reasons, right? Like at this point, oh my god, I mean, we're, we're at home most of the time, like you could avoid it because you just don't like to put on pants or because you don't like the sound of people chewing. You just don't like people, but if you're doing it, because you have this belief that you're broken, inferior, unlovable, and you must avoid all people because of that are all intimacy. I mean, even just knowing that there's a name for this might be helpful in terms of like looking for a therapist.
Speaker 1: Yeah, I mean, it's just it strikes me so sad. I mean, this, this model is created by genes and early environment experience, or early environmental experience that says people that your universe, your small little universe is supposed to nurture you isn't something's going on, something has formed a model that spits out any information that says I'm lovable, I'm good. And it only accepts in information that says I am inferior. But you're actually a perfectly wonderful person who is lovable and who other people might experience is great. It's just this model is, is stuck. Um, and what would it really mean to be unlovable? What kinds of people besides psychopaths, you know, and sometimes they're still, I mean, man, the amount of fan mail and Ted Bundy was getting. Like, what does it even mean to be unlovable? What's the shape of that? Like, what qualities would that be? I don't know.
Speaker 0: This makes me think that we should do an episode on identity and how, like, how it's made and how people change it. Yeah. Yeah. So, uh, yeah. I think, I think for those, I think, I think there's like, for, for people of personality in any, anyone, but people of personality disorders, changing the way you see yourself and the world and how people love you is super painful. But if it's the same thing with any therapy, you got to talk about what they'll get in return. Like what, if they work on that, if they work on actually seeing themselves as a lovable person, what will that get them? And then really hammering home those benefits, right? Like, just, you know, oh, you smile at someone, they smile back. Okay. What did that give you? How does that improve your life to kind of counteract the comfort of just hiding?
Speaker 1: Yeah. Yeah. Okay. Well.
Speaker 0: You sound bummed.
Speaker 1: I.
Speaker 0: Am bummed. I'm bummed. We're gonna do more research on this stuff. This is why we're talking about it.
Speaker 1: I know we do need more research.
Speaker 0: Let people in. That's the secret to all these things. Go see, go find a therapist. That's another one. All right.
Speaker 1: Well, happy holidays, guys. I mean, if you want to cheer me up, you know, you could always go rate, review and subscribe. I won't believe you anyway. I'm just kidding. It's a little ABPD joke.
Speaker 0: Yeah, I will post, I will post a little, some of the research that we were referring to. If you or a loved one has this disorder or even traits of it, it's really helpful just to read about it and know that it's not like, you know, just know what it is.
Speaker 1: Yeah, absolutely. And I hope any of you with this disorder or with loved ones with this disorder can find some comfort and safety and love this holiday season, at least for my sake, so that I don't just succumb to depression thinking about this. Oh, okay. We are going to be taking off the next couple of weeks for Christmas and New Year's, but we'll be back with you in January. We'll see you then.
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