Management of avoidance behaviors using direct and indirect psychological methods.

This article was acceptedfOr publication April 5, 1996 M any persons with brain damage refuse or avoid participating in a therapeutic program. This avoidance is a major obstacle to rehabilitation (Zencius, Lane, & Wesolowski, 1991) and may be due to cognitive impairments (e.g., decreased awareness of deficits, limited insight and judgment) (Alderman 1991). To avoid participation in therapy, these persons may exhibit undesirable or maladaptive behavior patterns that are incompatible with therapy participation, such as physical and verbal aggression, fake anxiety, motoric disturbances, or frequent use of the bathroom. Exhibition of psychogenic manifestations of anxiety such as "blank staring" is one way these persons escape or avoid participation. Traditional behavior modification techniques of reinforcement and time-out programs have been found to be ineffective for treating avoidance behavior (Alderman, 1991). Several case studies have demonstrated the effectiveness of indirect confrontation, such as inexact interpretation of the cause of the symptoms, as an initial step in therapeutic management of avoidance behaviors for malingering and conversion reaction (Rabinowitz, Mark, Modai, & Margalit, 1990; Shen, Bowman, & Markand, 1990). Direct confrontation can be a powerful tool, but during the initial intervention phase of psychosocial management in avoidance behaviors and conversion disorders, it can be counterproductive (Behr, 1992; Krull & Schifferdecker, 1990; Lazare, 1981; Lowman & Richardson, 1987). Thus, it raises the issue of when and how to confront the client. Fras (1978) suggested that direct confrontation be avoided until a client-therapist relationship has been established and that confrontation be performed gently and nonpunitively. Furthermore, an empathic attitude in a supportive environment is important to building and maintaining rapport with the dient after the direct or indirect confrontation (Shen et al., 1990). This case report illustrates the use of confrontation techniques to treat an adult client who exhibited avoidance behavior-elective blank staring-to avoid participation in therapy. The techniques used were based on the rationales proposed in the previously discussed literature.