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Ideally the therapist fosters safe, metered expression of emotional topics. When the therapist believes the patient needs to stop avoidance maneuvers, additional techniques to focus attention are used. By learning to control emotion without avoiding communication of feelings, the patient can explore topics that have been difficult to process. The patient learns to bring reactions to stress, trauma, and loss to a point of completion and ultimately mastery. Equally important, many patients have limited closeness and constancy in relationships because they present a personality trait of overly controlled emotional expression to others. In therapy, fostered by the therapist’s interventions to counteract excessive avoidance, they learn to safely express a richer tapestry of feelings.
In this chapter, the focus will be on observing excessive avoidance, formulating what might be going on in the patient’s conscious and unconscious mental processes, and safely challenging the patient’s excessive defenses.
The therapist may observe signs of avoidance without understanding the unwanted subject. The goal of counteracting avoidance is twofold: to discover and advance work on these underlying meanings, as well as to help the patient learn new ways of maintaining well-modulated states of mind.
Observation
The therapist observes both the verbal and non-verbal flow of messages from the patient, as well as the therapist’s own reactions. The following is an example of a therapist observing avoidance and reacting to it. The patient and therapist were focusing attention on the memory of a recent upsetting argument between the patient and his adolescent son. The patient felt angry then, but right now in therapy the patient was being unclear about who was angry and why. Probably both father and son were angry but instead of labeling the emotions the patient told the therapist peripheral details in an intellectualizing manner that was part of his long-standing defensive style.
The therapist told the patient that he observed him start out by clearly describing his feelings about the episode, but right in the present moment he seemed to avoid elaborating on his feelings. The patient continued with details, but began slowing down, having many pauses, taking back some ideas he just put forward, and going around and about while juggling ideas of who, he or his son, might have been to blame. Then the patient said he was sorry he became angry at his son and seemed to want to get off the topic altogether, as if that concluded discussion. The therapist said, “I am not sure if I am following you on what happened. Am I correct in thinking your son had done something wrong, you were admonishing him, and he disagreed with you, upon which you felt angry at him?”
The patient replied forcefully, “No, of course I was not too irritated with him!” This remark was an avoidance of (1) emotions regarding the argument with his son, and (2) how he felt currently talking about it with the therapist. What the therapist felt intuitively, observing his own reactions, was that the patient was feeling shame in the present moment for expressing too much anger in the memory of the argument with his son. And the patient was incipiently angry with the therapist for exposing him to potential embarrassment if he told the story completely. The therapist knew that avoidance was taking place, and could formulate some, but not all, of the underlying reasons.
The therapist chose to challenge the patient with a somewhat paradoxical reflection of what the patient had last said. The therapist said, “Oh, so of course you were not very irritated with him, I guess maybe he was the one who was angrier at you?” The patient stayed on the topic and added more information. Patient and therapist clarified together that both father and son were angry.
That work led the patient to say he regretted how he had spoken angrily. He experienced and then told the therapist about emotions related to his embarrassment in the present moment with the therapist. He felt he had lapsed in control of his anger in the argument with his son, and been overly harsh in his criticism.
This conversational passage stayed within the frame of a therapeutic alliance, without transference feelings of any intensity, and the patient and the therapist were moving forward in understanding the memory and what it now meant. The therapist was now observing, after a too-avoidant passage, an adaptive level of control over the emergent sense of shame.
This example illustrates a therapist observing avoidant maneuvers and their consequences. Although the patient did not exhibit failure of emotional regulation, he did exhibit avoidance as well as shame around the argument with his son. During the conversation with the therapist, the patient advanced to an adaptive use of his capacities to control the topic being communicated.
A general review of such avoidant maneuvers aimed at emotional control that might be observed in following a patient’s present-moment communication in words is depicted in Table 10.1. The table has categories of observable outcomes. In this and in all tables that follow, categories of process are listed vertically and observable outcomes are indicated horizontally. These outcomes are also loosely categorized as excessive avoidance, adaptive control, and failing to stifle unwanted feelings (failures of regulation).
| Maneuver | Outcomes | ||
|---|---|---|---|
| Adaptive control | Too-avoidant | Failure of regulation | |
| Altering Topics of Attention | Expresses a potentially stressful topic to a degree that both self and therapist can tolerate the evoked emotion. | Does not present stressful topic(s) and instead selects obscuring or misleading alternative topic(s). | Suddenly plunges too far into expressing emotionally overwhelming topic. |
| Altering Concepts | Communicates key facts and emotions; contemplates implications and possible solutions to problems; alert to remarks of therapist. | Conceptual reluctance; misleads others who are potentially helpful; gives misinformation; provides generalized discussion when specifics are indicated. Avoids expressing a concept that might prove useful in solving problems; switches facts back and forth; ignores remarks of therapist. | Fragments of sensations and ideas are disjointedly presented. |
| Altering the Importance to Self in a Chain of Concepts | As the patient speaks, the importance of the topic to self becomes clearer. | Saves face at the expense of rational recognitions. | Disruptive or chaotic shifts in appraisals. |
| Altering Threshold for Disengagement | Opens and closes a topic as helps contemplation. | Alters attention to terminate a tense state prematurely. | Unable to control the focus of attention or follow therapist’s efforts to do so. |
The first type of maneuver in the table is topic selection. In the previous example, the patient exhibited an avoidant moment when he attempted to change the topic of attention in therapy away from the memory. The second type of maneuver involves altering the expressed concepts of a specific topic. This maneuver was observed when the patient stayed on the topic of attention, but altered the concepts about his anger: he said he was angry, and then attempted to take it back. The outcome of this alteration of concepts seemed to the therapist to be overly avoidant.
Although at first the patient was disavowing anger, he soon moved into what seemed to the therapist as an adaptive level of control of emotion. The patient also reported that during the argument with his son he had experienced a relative failure of emotional regulation, expressing too much anger.
Maneuvers to control emotion may also affect the tone and manner in which a patient expresses ideas and emotions. Perhaps the most frequent observation of this kind concerns discord between verbal and non-verbal messages. In the above example, the patient may have said that he was not angry with his son, not now and not then, and not angry with the therapist in the present moment, but his non-verbal messages were discordant because he was glaring at the therapist, clenching and unclenching his fist, and raising his voice. The therapist might wonder if there was a danger of the patient becoming flooded with rage, but was observing avoidance behaviors that might function to prevent that from happening.
Later in the resumption of a working state, the patient displayed adaptive control: he expressed anger, remorse, shame, and acceptance emotions in harmony between verbal and non-verbal messages.
Table 10.1 concerned observations of verbal contents of what the patient says. The form of the communication is also important as an aspect of kinds of emotional regulation. Several such ways of regulating forms of communication are described in relation to observable consequences in Table 10.2.
| Maneuver | Outcomes | ||
|---|---|---|---|
| Adaptive control | Too-avoidant | Failure of regulation | |
| Altering Mode of Representation | Coherent mix of talk, facial expression, imagery metaphor, and gesture. | Disruptive image metaphors; flat verbiage; discordant messages across words, voice, face, and body. | Too intense expression of somatic emotion without talk about the meaning or context. |
| Altering Time Frame | Coherent framing of time as to past, present, future, or imaginary perspectives. | Disruptive or confusing shifts in temporal perspective. | Chaotic time jumps. |
| Altering Focus on Reality vs. Fantasy | Balance between rational planning and fantasy; restorative humor. | Disruptive or confusing shifts between analytic reasoning and fantasy; avoidant humor. | Inability to follow a thread of reasoning. |
| Altering Level of Action Planning | Appropriate choices of when to speak and when to listen. | Avoidant disruption of turn-taking in a dialog; restless bodily jittering to avoid thinking and feeling. | Impulsively excessive actions or “word salad.” |
| Altering Arousal Level | Appropriate moments of lulls and activations. | Excessive speed or slowing to avoid useful attention focusing. | Excessive agitation. |
Another category concerns how controlling maneuvers may alter the relative activation of self and other schemas. For example, a patient avoiding the mourning process for his brother who had committed suicide a decade earlier, seemed about to express guilt that he had been callous in dealing with the brother’s urgent requests for his attention. At that moment of incipient emotion, he switched his attitude and told the therapist he had been too weak to help his brother’s distress. This maneuver avoided the incipient feelings of guilt by switching to potential feelings of shame at his weakness. But before shame could be expressed, he switched away from the “I was just too weak” concept. His authentic emotions remained suppressed as a consequence of these flip-flops in apparent self-appraisals.
Several communicative maneuvers to control views of self and other, and their observable consequences in therapy communications, are summarized in Table 10.3. The case just discussed also exemplifies an avoidant alteration of role-relationship models, and that will be discussed further, below, under the formulation heading.
| Maneuvers Outcomes | Outcomes | ||
|---|---|---|---|
| Adaptive control | Too-avoidant | Failure of regulation | |
| Altering Self-Schemas | Coherent self-presentation. | Jarring shifts in apparent personality. | Chaotic fragments and depersonalization states. |
| Altering Schema of Other Person | Increases understanding of the intentions, motives, and predictable patterns of other (empathy); ability to “read” another during an interaction; holds a stable view of who the other is. | Provokes the other to conform to an internal misperception; short circuits to an inappropriate all-good or all-bad view of other; changes the object of a feeling, wish, or source of threat from the most pertinent one to a less pertinent one. | Chaotic or extreme irrational views about what to expect from others. |
| Altering Role-Relationship Models | Useful trials of a new scenario for a situation. | Preservation of a rigid view of the situation, rather than acting flexibly as the situation unfolds; switches working models between dichotomies such as all-good or all-bad views of the relationship; changes the source of an activity, wish, or feeling from self to other, or other to self. | Inability to use alliance to stabilize discourse. |
| Altering Values | Follows values, rules, and commitments. | Irrationally attributes blame outwardly to protect self-esteem. | Enraged reactions, as if therapist is rule-breaking. |
| Altering Executive Agency Schema | Acts responsibly to care for others and to care for self as a situation demands. | Extremes of selfish or self-sacrificing acts. | Inability to responsibly care for self. |
Formulation
A patient may express their thoughts enough for the therapist to infer how the patient may be controlling emotional arousal in the patient’s own mind. Sometimes these intra-psychic inferences are useful to share observations and formulations with the patient. Using reflective self-awareness, the patient can alter attention, intending to engage what may come up next, and thus modify an unconscious avoidance maneuver.
That is, some patients who have good reflective self-awareness can benefit from the therapist clarifying maneuvers that are not entirely conscious, but that could be counteracted by conscious intentions to do so.
For example, in Table 10.1 on the control of topics of attention, the outcome of avoidance (does not present stressful topics and instead selects obscuring or misleading alternative topics) could be shared with the patient. In the last example, the therapist could say to the patient avoiding the topic of his brother’s suicide, “It seems to me that you start to touch upon, but really stay away from presenting information on your brother’s suicide.”
The therapist could also share with the patient their guess of what may be taking place in the patient’s mind. In some patients, that may work better. Sharing guesses or inferences of the patient’s mental operations can help them to counteract avoidance by bringing attention to the subject, as well as to enhance their capacity for self-reflective awareness in general. The therapist could say:
“I am guessing that you avoid thinking about your brother’s suicide, which functions as a kind of denial of a topic that requires attention but that you have avoided because you do not want to experience the associated painful emotions.”
Table 10.1 summarized some categories of observing control of the contents of verbal communications during therapy dialogues. The same categories can be used to formulate the processes that may be going on in the patient’s mind. That inference about often preconscious mental processes leading to conscious mental experiences is summarized in Table 10.4, a companion to Table 10.1 in terms of the processes involved.
