Therapy

The prognosis for the schizoid personality is not promising. Because schizoids have no desire for interpersonal relationships and little emotional capacity, they develop only a limited transference relationship, fail to see anything in therapy that will benefit them, and are indifferent to the praise or criticism of the therapist. For example, we can imagine Leonard, the librarian, and the therapist sitting in their respective chairs, not knowing what to say to each other. After Leonard managed to force out a few sentences, the hour would be over. On the other hand, not all schizoids are prototypal cases. Some exhibit only mild characteristics of the disorder and may maintain good vocational and social adjustment with persistence and patience. Without intrinsic motivators, the presence of external structure becomes immensely important.

Therapeutic Traps

Probably the single most important trap in therapy with the schizoid subject is expecting too much. Neither Leonard, Doris, nor Hillary will ever become a social butterfly. Given their inability to infer the emotional states of others, they are likely to experience the therapeutic relationship as curious or perplexing. With few recorded autobiographical memories and only a limited ability to see connections between the actions of others and their own internal world, schizoids cannot be regarded as psychologically minded and are unlikely to respond to forms of insight therapy. Accordingly, the sophistication of any discussion with the subject must be keyed to the subject's level of understanding. This cannot be judged from their overall intellectual level, for schizoids may be intellectually bright yet socially unaware or naive.

Another trap is that the therapist may feel frustrated and defeated and simply give up. Such a reaction is normal and only recaptures the frustration of many individuals who may have had dreams for the subject in the past, including parents, siblings, and teachers. Not everyone can be "reached," even with perfect empathy. Beginning therapists should be aware of this fact when working with patients who have schizoid traits. Even those who make substantial progress are at constant risk for resuming an isolative lifestyle of passive detachment, especially those who must return to settings that offer the opportunity for a solitary existence. Booster sessions to prevent such regressions are especially wise following termination.

Therapeutic Strategies

When subjects possess predominantly schizoid traits, therapy has three overarching goals. First, something should be found that the subject somewhat associates with pleasure. Second, contact with the interpersonal world should be increased, where social anxiety permits. Third, the individual should be involved vocationally or educationally, if possible.

From an interpersonal perspective, the therapist should determine who is now actively involved in the daily life of the subject. Because most schizoids rarely date or marry, couples therapy is usually not relevant. Nevertheless, if some significant other exists, he or she should probably be brought into the therapeutic process. After all, the schizoid is unlikely to portray the relationship accurately and may not understand the extent to which his or her own indifference and lack of emotional support and understanding have already put the relationship in jeopardy. We know Hillary's appraisal that she and her boyfriend had "nothing to say to each other," but it would be interesting to hear his side of the story. Because the companion is likely to possess more adaptive traits than the schizoid, this relationship may be important to preserve.

If the subject resides with the family, attitudes toward relationships can be explored in therapy with the eventual goal of conferencing with family members. Mutual indifference is probably not uncommon: Neither may be hostile, but the schizoid passively ignores the family, and the family actively ignores the schizoid. Parents may feel exhausted, defeated, or disappointed. These feelings can be explored, and their expectations can be replaced with more modest goals that allow the subject to be praised on a daily basis. Otherwise, to the extent that the subject feels anything at all, it is likely to be rejection, a vague global sense of having fallen short of expectations without really knowing why, as Leonard feels when he says of his boss, "I guess he thought I'd do better by now."

Because individuals with schizoid traits value their time alone, they can be indulged with absolute solitude following a period of participation with family members, who keep a diary of their interactions and note anything the subject seems to find enjoyable or rewarding. Subjects can examine their interactions and attitudes toward family life in individual therapy: Is the family experienced as controlling, punishing, intrusive, supportive, or none of the above? If the subject says that no feelings come to mind, an adjective rating scale can be completed on the family and examined for salient themes, which then become the point of departure for discussion. Moreover, in the overall strategic plan, a supportive family provides the background structure through which the individual may be introduced into other contexts, such as job or school.

Two other interpersonal assessments should be made. First, even subjects with a predominance of schizoid traits sometimes experience a degree of social anxiety, perhaps related to interpersonal failures or a sense of awkwardness. Because social anxiety can be defeated through known techniques, its presence indicates some preservation of affect, possibly a good prognostic sign. Here, schizoid traits may cloak aspects of an avoidant personality, which can be coaxed toward greater sociability. In addition, some assessment should be made of the extent to which schizoid traits might serve as an extreme form of defense, a numbing of self against a hostile world. Reports of an abusive childhood environment offer support for, but do not confirm, such a hypothesis.

Second, an effort should be made to explore the content of the subject's fantasies. Fantasy is usually regarded as maladaptive for withdrawn subjects, yet fantasies compensate for unfulfilled needs or perceived flaws in the self and, as such, provide rich material for therapy. Any fantasy at all indicates that the schizoid has some need or desire, which can be used by the therapist as a portal to the subject's private world. A superhero fantasy, for example, obviously indicates a perception that the self is weak and powerless. Any intervention that increases competency should also produce a more competent self-image, possibly leading to increased social desire, more rewarding and realistic social encounters, and so on. Accordingly, schizoids who report no fantasies might be encouraged to develop some, as this at least provides some information about what they find to be reinforcing. Eventually, the functional role that isolation plays in the individual's life can be examined in therapy and connected to the fantasy material.

Working from a cognitive perspective, Ottaviani in Beck et al. (1990) suggest setting up a hierarchy of social interaction goals that the patient may want to accomplish. A daily diary can be used to keep track of automatic thoughts, especially those immediately preceding and following any social encounter. The act of identifying thoughts and emotions can be therapeutic in itself, for schizoids tend to be broadly impoverished as to mental content. Further, schizoids can be asked to identify and discuss the mental states of others. With practice, the ability to respond accurately and empathetically should increase the reinforcement value of social situations. Role playing and in vivo exposure can then be used to practice social skills. Audio and video feedback should be constructive in helping subject and therapist identify problem areas; audio feedback can be used to provide an emotional range to the voice, and videotaping can be used to give subjects perspective on how others perceive them and help them become more animated while remaining socially appropriate.

Because schizoids often appraise their experiences globally, Ottaviani states, they may miss aspects of experience that are genuinely rewarding. Questions that draw attention to positive specifics help the individual learn what he or she prefers and why. These activities can then be repeated to make life more rewarding. Finally, cognitive and interpersonal approaches can be combined in group therapy, where schizoids can be encouraged to develop more constructive social skills and attitudes. In the beginning, most will approach with an attitude of disinterest and decline to participate extensively. Some feel socially anxious; others find the group process curious or confusing. Nevertheless, within an accepting group, many individuals can eventually be drawn toward gradual disclosure and participation while obtaining genuine feedback about how they are viewed by others. This feedback can provide insight into the severity of schizoid traits or whether a true avoidant personality has been cloaked by said traits. Either way, the distinguishing feature of a pure schizoid, disinterest and apathy toward interpersonal relationships, can be measured against the individual's reaction to positive feedback from others. As such, the prognosis can be amended to more accurately reflect the therapeutic outcome.

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