Martin Kantor's Distancing:
Avoidant Personality Disorder is one of the most disappointing psychiatric
works I have ever read. It is self-indulgent, poorly written and logically
incoherent. I often felt as if I were reading a collection of unrelated rough
drafts.
Avoidant Personality Disorder is a
formal DSM-IV psychiatric diagnosis that is rarely used by clinicians and
almost unknown to the lay public. Kantor argues that AvPD is a serious and
pervasive disorder that "creates as much interpersonal difficulty as
schizoid remoteness, depressive withdrawal, and borderline ambivalence, and causes
as much social distress as ignorance and poverty" (i).
Treating this disorder is
difficult; most of its victims "think they are happy" and many
psychiatrists don't think the disorder exists. Kantor blames professional
indifference to AvPD on
the scientific literature and its
tendency to diminish the status of AvPD or threaten its very existence as a
syndrome by obsessively questioning whether or not AvPD is a discrete,
identifiable personality disorder with inclusive and exclusive syndromal
boundaries. ... There is a "mighty struggle" between "believers
who identify a discrete syndrome and nonbelievers who do not" (4,
emphasis in original).
For the believers, Kantor describes
four types of avoidants. The first type include the shy, socially inhibited or
phobic. The second type avoid intimacy by drifting among numerous shallow
relationships. The third type start serious relationships but then sabotage
them without warning. The fourth type have close, regressive relationships
with one or a few people in order to avoid contact with everyone else.
These divisions seem logical, but
only the first type corresponds to the DSM-IV's definition of Avoidant
Personality Disorder. Kantor argues that the standard definition of AvPD is
inadequate, and should be broadened to include all persistent patterns of
socially maladaptive behavior. This is an interesting idea, but there is a
troubling overlap between the last three types of avoidance and neurotic,
borderline, or narcissistic disorders. Furthermore, Kantor often classifies
clinically depressed individuals as "type I avoidants." Since all
mental illness involve some form of social difficulty, this new definition of AvPD
seems hopelessly vague. We have seen that Kantor is not troubled by questions
of "whether or not AvPD is a discrete, identifiable personality disorder
with inclusive and exclusive syndromal boundaries," but the reader may
wonder why one would write a book on a diagnosis that the author cannot define.
The bulk of Distancing is a
confusing, almost stream-of-consciousness collection of personal experiences
and clinical examples that the author finds annoying or offensive. The
examples are generally quite dull, and often incredibly banal. "Avoidants"
include sales clerks who give slow service and gym rats who miss the
opportunity to pick up dates because they are too busy exercising. "Sociocultural
manifestations" (75) include "musical avoidances like…the moonlit
remote works of Gabriel Fauré," those of
the people from New Jersey who will not
go to New York because it is dangerous, unfriendly, and too full of people too
close to one another; the tote bag carrier who haughtily proclaims to the
world, "I like refined things, not the crude things you like"; and
the owner of the bumper sticker that reads, "The worst day fishing is
better than the best day working." Many of these avoidants are bigots…
(75-76)
Kantor lists his cases without any theoretical or clinical
context; their only common thread is the personal offense he takes at them.
"Bigotry is in fact the ultimate in avoidance," (76) he remarks,
adding to the reader's sense that Distancing is simply an attempt to medicalize
everything the author--justly or unjustly--feels is wrong with other people.
In my experience, most avoidants could overcome
their relationship anxiety and meet people if only they could muster the
strength and courage to overcome the main thing holding them back…themselves.
(43)
As a rule, there is no theoretical
argument behind any of Kantor's pronouncements, making his combination of moral
judgment and amateurish misuse of psychoanalytic theory especially obnoxious.
Avoidants who stutter can be attempting to remain
silent in the guise of trying to talk. Or they can be attempting to spit
hatefully at others, both figuratively and literally. The avoidant intent can
sometimes be inferred from the effect of the behavior on others: the rather
unfortunate temptation to make fun of stutters… (102)
Here, as elsewhere, avoidant seems to function as a clinical
synonym for "bad." It is hard to imagine how it would be helpful for
a clinician to assume that a shy client who stutters is a hostile person whose
malicious intent can be proved by the fact that people make fun of him.
Once Kantor has branded a
patient "avoidant," he seems willing to interpret almost any mental
or physical symptom as further confirmation of the patient's avoidant
personality.
The complaints of symptoms of chronic
fatigue in avoidants (Epstein-Barr avoidance) such as, "I am tired all the
time" can be code for "Don't bother me, I prefer to stay
asleep." The attack (so often heard) on the treating professional takes
the form of, "You say this is psychological but it's really
physical." In true chronic fatigue, this attack is a legitimate
questioning of the diagnosis. In chronic fatigue in avoidance this attack is
an in-character sign that the patient wants to hurt another person, as is his
or her style, simply because this other person tries to get close, and offer
help. (103)
In brief, Kantor invents a new
Avoidant Personality Disorder that directly contradicts the established
definition of AvPD. He then demonstrates his new AvPD's use as a garbage can
diagnosis for difficult patients and other people whom he finds obnoxious.
Mixing arrogance with self-pity, he complains that resistance to this made-up
diagnosis is an "in-character sign that the patient wants to hurt another
person, as is his or her style, simply because this other person tries to get
close, and offer help."
It amazes me that this book would
be published by anyone, let alone in a second edition. It is an embarrassment
to the author and the field of psychiatry. While the cognitive-behavioral
therapy tips in the last few chapters may be of interest to some clinicians, I
would generally discourage anyone from wasting their time with Distancing.
© 2005 David A. Flory
David Flory is a writer and musician with a long-term
interest in clinical psychology. He has a B.S. in math
from the University of Texas, and he lives
in Texas."
Martin Kantor, MD submitted the following response to David
Flory's review. Published May 20, 2005:
Flory's review of my
book Distancing: Avoidant Personality Disorder is in my opinion not a
review but a prolonged rant--to paraphrase the reviewer himself, a
self-indulgent, poorly written tract full of subtle and overt conceptual
errors, logically incoherent, and replete with misunderstanding about
personology and other clinical matters. Flory and I do not necessarily agree on
the intent of the DSM-IV which he often refers to in the review. I asked
myself if this review were a tirade by someone who has just had a very personal
ox gored and will say or do anything to kill the messenger because he doesn't
like the message. I also asked myself if this was one of those reviews that was
the product of a knee-jerk emotional response that, after the fact, looked for
a relevant stimulus, in this case, without actually finding one.
The following are only
some of the flaws I perceive in the review:
Flory says that I "argue … that the
standard definition of AvPD is inadequate, and should be broadened to include
all persistent patterns of socially maladaptive behavior." I do not make
this argument. Rather, I suggest that avoidants primarily suffer from social or
relationship anxiety leading to distancing, one form, and only one form, of
socially-maladaptive behavior. Flory notes that "since all mental illness
involve (sic) some form of social difficulty, this new definition of AvPD seems
hopelessly vague." Of course, as I clearly state throughout, only some
mental illness involves distancing,
that is, interpersonal withdrawal based on a fear of closeness and commitment,
and this is what I am talking about. I am not discussing the much broader
concept of "social difficulty."
The reviewer notes that
there is a troubling overlap between my four types of avoidance and other
disorders. He feels that Type I avoidants are really depressed, and that my
last three types of avoidance overlap with neurotic, borderline, or
narcissistic disorders. First, I am troubled by the reviewer's making a
sequence out of "neurotic, borderline, and narcissistic" since he is
mixing concepts that are on different levels of abstraction. Neurotic, as
distinguished from psychotic, is a more general term than borderline and
narcissistic, both of which terms refer to a specific diagnostic category. As a
result, Flory is in effect lumping apples with oranges. Second, Flory fails to
mention that according to the DSM-IV "there appears to be a great
deal of overlap between Avoidant Personality Disorder and [a number of other
disorders]" (p. 663). It appears that Flory wants me to take the fall for
a simple fact, that in personology no personality disorder is pure and that
there is always overlap between personality disorders--a situation that I am
not in any position to change or do anything about much as I, and all
personologists, I think, might wish to have a more accurate set of calipers.
Flory says that I invent a new Avoidant
Personality Disorder that directly contradicts the established definition of
AvPD. No, what I did was expand on
the DSM-IV definition of AvPD. I
believe that expanding and contradicting are two very different things.
Flory seems particularly concerned that I don't
follow the DSM-IV exactly. It has
been my experience that many people, laypersons in particular, fail to
recognize that the DSM-IV is not
about painting a full picture of a syndrome but is about highlighting points
that enable one syndrome to be distinguished from another, that is, that enable
a differential diagnosis to be made. Many observers have called for a more
dynamically- oriented DSM-IV, for
example Theodore Millon (when making the diagnosis of Antisocial Personality
Disorder) and Lorna Smith Benjamin, who suggests that hostility be included as
part of the DSM-IV diagnostic profile of AvPD. Here I am both not alone
and in very good company.
I made a statement that
surmising from my clinical experience some people who suffer from AvPDwho complain of emotionally-based chronic fatigue
resist admitting that their chronic fatigue is emotional as part of their need
to distance themselves interpersonally from the diagnosing clinician. That is,
I suggested that theirs is an avoidant removal and uncooperativeness taking
place in the transference. There is absolutely nothing in this completely
dispassionate (and scientifically accurate) formulation that would or should
lead Flory to suggest, as he does, that in advancing this theory I am
"mixing arrogance with self-pity." I will let the reader judge for
him or herself.
The complaints of
symptoms of chronic fatigue in avoidants (Epstein-Barr avoidance) such as,
"I am tired all the time" can be code for, "Don't bother me, I
prefer to stay asleep." The attack (so often heard) on the treating
professional takes the form of, "You say this is psychological but it's
really physical." In true chronic fatigue, this attack is a legitimate
questioning of the diagnosis. In chronic fatigue in avoidants this attack is an
in-character sign that the patient wants to hurt another person, as is his or
her style, simply because this other person tries to get close, and offer
help" (p. 103).
Flory says, "Kantor
demonstrates his new AvPD's use as a garbage can diagnosis for difficult
patients and other people whom he finds obnoxious." I am not sure where he
gets the idea that I find these patients obnoxious, since he doesn't know me
and I never used the term myself. I have stated repeatedly that I view these
individuals as suffering from a fear of closeness and commitment, one that
makes them, as the title of my book clearly states, distancers. It is one thing
to say that people are suffering from relationship anxiety, and quite another
to suggest that they are obnoxious. Since the idea of obnoxiousness didn't come
from me perhaps it was projected onto me.
Flory says, "It is
hard to imagine how it would be helpful for a clinician to assume that a shy
client who stutters is a hostile person whose malicious intent can be proved by
the fact that people make fun of him."
What I said was that avoidants who stutter (that is, not all stutterers, only avoidants
who stutter) can be (italics added
here) attempting to spit hatefully at others, both figuratively and literally.
The avoidant intent can sometimes (again, italics added) be
inferred from the effect of the behavior on others: the rather unfortunate
temptation to make fun of stutterers (not stutters, as Flory misquotes me as
having said). Note the use of the word "can." That means possibly,
and it also means possibly not. I did not say "can be proved" but
rather said "can sometimes be inferred." And it is true. Sometimes
when we feel hostile to someone it is because they have been hostile to us.
Many stutterers I have spoken to have come up with this formulation on their
own. Whether or not Flory likes it, that is the way things happen in the
treatment room. (I might add that it is my distinct impression that, speaking
generally, observers who don't themselves evaluate and treat patients have
little to no understanding about how patients actually think and what is really
going on in their conscious and unconscious minds.)
Flory says that "Kantor lists his cases
without any theoretical or clinical context; their only common thread is the
personal offense he takes at them." This is just another one of many of
Flory's rude personal attacks on my intellect and character, coming from
someone who has no way of knowing what is in my mind and if I do or do not take
personal offense with these individuals. To make this statement Flory has to
conveniently overlook what I clearly stated in page x of my Preface:
"Collectively, all [avoidants] primarily suffer from social or
relationship anxiety leading to distancing. Individually, each is distinguished
by the specific way they distance." Clear enough? In think so, and I don't
think that I have to say it more than once.
Yes, I did say that bigotry is the ultimate in
avoidance, but how is this an attempt to medicalize everything that I feel is
wrong with other people? It is rather an attempt to understand bigotry in the
present context, and expand my list of avoidant personality traits. And just a
little question: anyway, is bigotry ever right? Is it ever nonavoidant, that
is, an attempt to get close and be loving?
Flory says that "As a rule, there is no
theoretical argument behind any of Kantor's pronouncements." Let's try
this, as just one of numerous examples of the theoretical basis I give to many
of my "pronouncements."
Defense and Symptom
Avoidant symptoms such as shyness, withdrawal, and ambivalence are
clinical manifestations of the avoidant's internal attempt to defend him- or
herself from social/relationship anxiety. More exactly, they are the clinical
manifestations of defense mechanisms brought into play to manage this
social/relationship anxiety. For example, an avoidant guilty about her sexual
wishes projected them, and the
self-blame for having them, onto others, to develop a symptomatic preoccupation
with being sexually harassed, which in her case meant, "See, I don't want
to do it with you, and to prove it I chastise you severely for wanting, and
trying to force me into, it." (p 156). Perhaps the reader can also use
this representative example to decide for him or herself whether or not my book
is "poorly written" and "logically incoherent."
Flory says that the reader may wonder why one
would write a book on a diagnosis that the author cannot define. I have simply
recognized that different observers don't agree on the exact parameters of
AvPD. I defined it as I thought it should be defined. Flory criticized my
definition, and now Flory is criticizing me for not being able to offer a
definition. Anyone who is interested in the difficulty of defining AvPD
definitively should pick up a book on Social Phobia, Generalized Type, and read
a discussion of how that disorder overlaps with Avoidant Personality
Disorder.
The reviewer calls my book "a confusing,
almost stream-of-consciousness collection of personal experiences and clinical
examples that the author finds annoying or offensive." (Flory undoubtedly
meant to say, "collection of personal experiences and clinical examples [of
people] that the author finds annoying or offensive.) I already dealt with
finding people annoying or offensive above. About the confusing stream-of-consciousness
part, it might help to look again at my table of contents and see how cleanly I
have organized the book and its chapters. I don't think I could come up with a
tight mental status profile, a thorough summary of the literature, a formal differential
diagnosis and a presentation of the different schools of psychotherapy while in
the throes of stream-of-consciousness.
As for my clinical examples seeming
"banal," I am not writing about rare, exotic, and unclassifiable
syndromes but about ordinary people doing ordinary things--that is, I am
writing about the ordinary avoidances of everyday life. Psychopathology ranging
from door-checking rituals to wrist-slashing is almost always remarkably banal
and the psychopathology of everyday life, my field, is by definition very much
so. I am attempting to speak to the clinician trying to help the everyday
sufferer as well as trying to help the everyday sufferers themselves. That is
why the book has been issued in a revised edition. Many people have found that
they relate to it, and the objections that Flory raises in his review don't
even enter their minds.
About my amateurish misuse of psychoanalytic
theory, I would like an example that does not rely on the reviewer's way of
proving his point via the mechanism of arbitrary inference: "It is so
because I say it is so." Of course, calling someone an amateur does or
should require revealing one's own credentials so that the reader can be
certain that it is not a case of the pot calling the kettle black.
(Along these lines, what exactly are Flory's
credentials for writing this review?)
Also, about my making moral judgments: I don't.
I simply look for behaviors that I identify as relatively or absolutely
avoidant (in the sense of being the product of interpersonal withdrawal due to
relationship anxiety) and list those. This doesn't paint a rosy picture of the
avoidant, but so be it. It is in the nature of the beast that personology
studies tend to paint less than rosy pictures of their subjects, some of whom themselves
tend to be very immoral people. (Immorality is a regular feature of those Type
II avoidants who lead innocents on then drop them leaving them confused,
depressed, and sometimes suicidal.)
In conclusion, again paraphrasing Flory, this
review is an embarrassment to its author and the field of book reviewing. It
shows both subtle and overt misunderstanding of the field of personology, and
is a paradigm of the triumph of emotion over logic as it veers from a
dispassionate discussion of the issues at hand to a very personal attack on me
that appears to be attempting to damage my professional reputation by calling
me things like "arrogant" and "self-pitying." This in
effect constitutes defamation of my character in a way that is completely out
of place and could have only been justified by putting words in my mouth. As
such, it does a disservice not only to me, but
to the many therapists and patients who might benefit from learning about
interpersonal relationship anxiety in order to correct the problem
definitively. What is particularly scary is that the tone and attitude of the
review seem to be modeled on the subject of the book under review. So, my
advice to readers is: before you make a decision whether or not to read or buy
based on a particular review, think about what the reviewer is really saying,
and in addition to checking out his or her motivation, check out his or her
credentials.
© 2005 Martin Kantor
David Flory has provited
the following reply to Martin Kantor.
Published May 20, 2005.
I will respond to Kantor's
concerns as best I can, although I am afraid my response will not be
satisfactory. With the exception of the
embarrassing grammatical errors and misspelling to which Kantor drew my attention,
I stand by my review as written.
I am following standard
psychoanalytic definitions in my use of the terms "neurotic, borderline,
and narcissistic." These are
distinct terms in the classic psychoanalytic literature (i.e. Otto Kernberg's Borderline
Conditions and Pathological Narcissism).
I do not see how "expanding" an
established definition is different from changing or contradicting it.
Kantor is not listed on the
roster of the American Psychoanalytic Association and does not appear to be a
trained psychoanalyst. He does not
describe behavior in the context of a transference relationship. None of Kantor's examples take shape as real
people with real personalities and motivations; they are simply behavioral
types.
In the case of
"Epstein-Barr avoidance," Kantor's claim that a patient "wants
to hurt another person, as is his or her style, simply because this other
person tries to get close, and offer help" tells the reader something
about Kantor's reaction to this patient, but says nothing about the patient. Who is this patient? Why should the reader believe that this
patient is avoidant? What does
"avoidance" really mean in this context?
Kantor has stated that his work is only concerned with
"interpersonal withdrawal based on fear of closeness and
commitment." I am sorry if I
misunderstood his intention, but much of Distancing condemns the public
behavior of strangers whose motivation Kantor is in no position to
analyze. Kantor never explains why
sales clerks who are reluctant to search the stockroom, people who carry
expensive tote bags and individuals who prefer not to pick up dates at the gym
are expressing "fear of closeness and commitment," as opposed to
fatigue, bad manners, or simply a normal personality that rubs the author the
wrong way.
© 2005 David A. Flory