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 provided 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