1. The programme at a glance
Indication. The programme is for adults with avoidant personality, seen as outpatients, with distress or impairment, and a desire for relationships or activities that avoidance prevents.
Reference model. Cognitive behavioural therapy for personality disorders (Beck et al., 2015), centred on the avoidance cycle and the belief of inadequacy (section 4). It integrates graded exposure and behavioural experiments from treatments for social anxiety (sections 21 and 22), and work on safety behaviours and self-focused attention (section 4). For shame and self-criticism, it borrows from schema therapy (Young et al., 2003), which works on the deep beliefs formed in childhood, and from compassion-focused approaches (section 33).
Format. Treatment lasting about a year, some forty sessions; this manual describes sixteen key sessions, organised in five phases. The additional sessions are used mainly to repeat exposures and experiments (sessions 7 and 8, then 11 to 13); their number is decided with the patient and revised at the session 10 review, as the optimal duration has not been established (section 11). Sessions last 50 minutes, once a week. Each one ends with a task to do before the next, and three booster sessions, at one, three and six months after the last session, follow the end of the programme (session 16).
Targeted mechanism. Make visible the cycle linking the belief of inadequacy, anticipation of judgement, avoidance and the absence of any contrary experience; reduce avoidance and safety behaviours; test predictions of rejection; tolerate emotions rather than flee them; assert oneself; approach intimacy; get through real rejection; and build a chosen life with self-criticism eased.
| Phase |
Session |
Focus |
Session deliverable |
| I. Alliance |
1 |
Making it possible to come |
Reason for coming stated, avoidance of therapy anticipated |
|
2 |
Goals for a chosen life |
Goals written, framework set |
|
3 |
Assess |
Mood, alcohol, risk and isolation assessed |
| II. Understand |
4 |
The avoidance cycle |
Cycle drawn with a real situation |
|
5 |
What avoidance protects and costs |
Balance written |
|
6 |
Safety behaviours and self-focused attention |
Behaviours identified, experiment in session |
| III. Change |
7 |
Exposure |
Hierarchy built, first step taken |
|
8 |
Putting the prediction to the test |
One experiment done and reviewed |
|
9 |
No longer fleeing emotions |
Emotional avoidance identified, one emotion welcomed |
|
10 |
Mid-point review |
Measures repeated, plan revised |
| IV. Relationships |
11 |
Asserting oneself |
A request or refusal expressed |
|
12 |
Intimacy |
A gradual self-disclosure made |
|
13 |
Real rejection |
A rejection got through without a global conclusion |
| V. Consolidate |
14 |
The belief of inadequacy |
Belief revisited with history and evidence |
|
15 |
Self-criticism and a chosen life |
Kind voice practised, plans under way |
|
16 |
Review, relapse, next steps |
Plan written, measures repeated |
The last column states what must exist at the end of the session. A "step" is a situation in the exposure hierarchy, ranked from easiest to hardest (section 21); the "balance" takes stock of what avoidance brings and what it costs (section 19).
What distinguishes this programme from the other manuals on this site. Three things. Exposure holds a central place in it, larger than in any other manual in the series devoted to personality disorders. The patient shows great apparent compliance: they say yes to everything and do little. And a quiet, permanent shame colours their whole life.
2. Before you begin
The four preliminary decisions
1. Is this avoidant personality, social anxiety, or both? The overlap is large, and the distinction mainly changes the duration and the place of work on the belief. Sections 7 and 11.
2. Is there depression, alcohol use or suicide risk? Section 9.
3. Is there another disorder to treat first or in parallel? For example severe depression, an addiction, unrecognised autism spectrum disorder. Sections 7 and 8.
4. Does the patient want relationships? This is what distinguishes avoidance from schizoid detachment, in which withdrawal is not accompanied by this desire (section 7), and it gives the treatment its direction.
What this programme does not treat
Severe depression, which is treated first.
Patients whose withdrawal stems from an absence of desire for relationships, who fall under Schizoid personality: a therapist's manual.
Autism spectrum disorders, which require a different understanding of social difficulties, even though some elements of the programme can help.
Massive, long-lasting social withdrawal in young adults, which often requires work with the family and a more intensive setting; section 36 explains how to adapt the programme if it is offered anyway.
How to use it
Read sections 3 to 14 first, then section 32 on exposure before session 7. Read section 31 before the first session: avoidance of therapy sometimes begins with making the appointment. The sessions described are key sessions; the exposure and experiment sessions (7 and 8, then 11 to 13) in particular often take several. Section 39 sets out what must not be dropped. The folder given to the patient contains seven worksheets: 1 "What matters to me" (session 2), 2 "My circle" (sessions 4 and 5), 3 "My protections" (sessions 6 and 9), 4 "My ladder", with the experiment sheet (sessions 7 and 8, then 11 and 12), 5 "Speaking up, showing myself" (sessions 11 to 13), 6 "For those close to you" (section 35), 7 "My plan for what comes next" (sessions 14 to 16).
3. The clinical picture
What defines the disorder
The disorder is defined by a lasting, pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation, present since early adulthood and across a range of contexts.
The forms it takes
Avoiding occupational activities that involve significant contact with others, for fear of criticism or rejection: turning down a promotion, a team role, a presentation.
Getting involved with others only when certain of being liked.
Being reserved in intimate relationships for fear of being ridiculed or humiliated.
Being preoccupied with the fear of being criticised or rejected in social situations.
Being inhibited in new situations, through a sense of not measuring up.
Seeing oneself as socially inept, unappealing or inferior to others.
Being reluctant to take risks or engage in new activities, for fear of embarrassment.
What patients describe
A life at a distance. The desire for relationships, and the fear they arouse. The feeling of being invisible, or on the contrary watched and judged. The certainty of being boring, awkward, uninteresting, unattractive. Evenings ruminated over for days. Invitations turned down, then regretted. An old, quiet sense of shame that never leaves them. And often the conviction that they have "always been like this".
What you see in the consultation
A patient who is polite, discreet, who says little about themselves, who looks for what they ought to answer, apologises, minimises both difficulties and successes, readily says yes, and blushes or falls silent when attention turns to them. Sometimes a patient who arrives very early, or not at all.
The invisible cost
Avoidant personality produces few conflicts and few crises. Its cost is measured in what did not happen: studies not pursued, jobs turned down, relationships never begun, children not had, friendships allowed to fade. That cost is often neither seen nor spoken of.
Epidemiology
Avoidant personality is among the most common personality disorders in the general population and in clinical settings. It often develops as a continuation of shyness and inhibition present from childhood, but most shy children do not develop this disorder. It is associated with lasting occupational and social impairment, and with low quality of life.
4. The avoidance cycle
The model guiding this programme is cognitive and behavioural. It is presented to the patient without jargon.
The central piece
A belief of inadequacy: I'm uninteresting, I'm inferior, there's something wrong with me, if people really knew me, they would reject me. It comes with a belief about others — people judge, they'll see my flaws — and a rule: so as not to be rejected, don't show yourself.
It often forms where an inhibited temperament meets a history of criticism, teasing, rejection, humiliation at school or in the family, or an environment where people did not show themselves. This origin is offered to the patient as a hypothesis; you do not impose it on them (session 14, section 28).
The links
1. The situation. An invitation, a meeting, a phone call, an appointment, a compliment, a request to make.
2. Anticipation. Predictions of judgement and rejection: I won't know what to say, they'll see I'm boring, I'll blush.
3. The emotion. Anxiety, shame, sometimes sadness.
4. Avoidance, in several forms:
avoiding the situation — not going, declining, cancelling;
avoidance within the situation, through safety behaviours, that is, behaviours the patient adopts to prevent what they fear or to go unnoticed — keeping quiet, staying in the background, not making eye contact, rehearsing what to say, drinking, leaving early;
emotional and cognitive avoidance — not thinking about what one wants, not feeling, numbing oneself, distraction.
5. Immediate relief. Anxiety falls. Avoidance is reinforced: this relief makes it more likely the next time.
6. No contrary experience. The patient never discovers that the situation could have gone well, or that an awkward moment would have had no consequences. Safety behaviours, when they do go, lead them to believe it is thanks to those behaviours that the worst was avoided.
7. The consequences. Isolation, unpractised skills, missed opportunities, and sometimes genuinely distant behaviour that pushes others away.
8. The confirmation. I have no friends, so I must be uninteresting.
Self-focused attention
In social situations, the patient's attention turns to their sensations, their gestures and the image they think they are giving. They build an impression of themselves seen from outside, far more negative than what others perceive, and take it as information. This attention also prevents them from noticing others' signs of interest or goodwill. This mechanism, described by Clark and Wells (1995) in their cognitive model of social anxiety (section 11), largely applies here.
Rumination
Before the situation, the patient anticipates. Afterwards, they go through a post-mortem that searches for mistakes and signs of rejection, and turns an ordinary moment into proof of failure. This post-mortem is worked on in section 33.
What the treatment does
It makes the cycle visible, reduces avoidance and safety behaviours through chosen exposure, tests predictions, shifts attention outwards, teaches tolerance of emotions, develops assertiveness and intimacy skills, and revisits the belief of inadequacy in the light of accumulated experience.
What the model explains to the patient
That avoidance really does protect them, in the moment. That in the long run it prevents them from discovering that things could turn out differently. That what they believe about themselves has never been tested, because it never could be. And that we are going to test it together, at their pace.
5. Shyness, introversion and the disorder
Why this section exists
Because shyness and introversion are common traits, sometimes valuable ones, and treatment must not become a push towards extraversion. And because some cultures value reserve, modesty and restraint.
What needs to be distinguished
Introversion: a preference for solitude, small groups, quiet. It involves neither fear nor distress, and does not prevent desired relationships.
Shyness: discomfort in new situations or with strangers, which fades with familiarity and does not prevent a chosen life.
Social anxiety: a marked fear of judgement in social or performance situations, with avoidance and impairment.
Avoidant personality: pervasive inhibition that extends to most relationships, including intimate ones, and a lastingly negative self-image.
Cultural norms
In many contexts, reserve, modesty, restraint towards elders or superiors, or difficulty talking about oneself are expected. Acculturation, language, and recent migration can also produce social inhibition without a disorder. The diagnosis is based on distress and impairment in the patient's context, not on a departure from a norm of social ease.
What you are aiming for
A chosen life, not a different personality. An introverted, reserved patient who has two close friends, a job that matches their abilities and a relationship they wanted has reached the goal.
The weight of the label
The word "avoidant" can be heard as a reproach or as confirmation of a deep flaw. You talk instead about fear of judgement, a way of protecting oneself that costs a lot, and a very harsh self-image. If the patient asks, you answer honestly, saying that this disorder responds to treatment better than many others.