Alpf Medical Research Personality Disorders

The schizotypal is perhaps one of the easiest personality disorders to identify but one of the most difficult to treat with psychotherapy. The thought disorder and accompanying paranoid ideation work to distort communication between therapist and client and inhibit the formation of a trusting therapeutic alliance. Moreover, because schizotypals are inherently isolative and nonrelational, the therapist may sometimes be experienced as an intrusive presence. Because the alliance is the very foundation of therapy, medication is often needed before lasting progress can be made, especially with subjects who express the disorder severely.

Therapeutic Traps

The expectations of the therapist and their influence on therapy are particularly important and may require careful monitoring. Most schizotypals initially see the therapist as attacking or humiliating (Benjamin, 1996). As anxiety increases, they may retreat further behind a curtain of disordered communication as a means of shielding themselves and confusing the intruder. Occasional retreats are universal. Therapists who become vexed when greeted with silence and emotional distancing only create an atmosphere that justifies such a reaction.

Instead, the need for distance must be respected, without conveying feelings of disapproval or inducing guilt, to which many subjects are especially sensitive. Not pushing too hard or too fast can prevent severe anxiety and paranoid reactions. Extraordinary patience may be required because schizotypals repeatedly misperceive aspects of the therapeutic relationship and then act on these misperceptions. Subjects who believe they have privileged access to information beyond the five senses sometimes apply their extrasensory powers to therapy and the therapist, believing that they can read the therapist's mind or arrive at conclusions about what the therapist secretly desires on the basis of tangential or irrelevant cues.

Accordingly, communication should be simple, straightforward, shorn of psychological jargon, and require a minimum of inference. Schizotypals find it difficult enough to bring order to their own thoughts, much less penetrate ambiguities and double messages carelessly introduced by others. The concrete is to be preferred over the poetic because the latter is naturally rich in connotations, which play havoc with schizotypal cognition. Special attention to the countertransference is in order, for unconscious feelings emitted by the therapist bring an unknown complexity to communication and are especially likely to be misconstrued by subjects.

Strategies and Techniques

What can be done in therapy often depends on the extent to which the thought disorder intrinsic to the syndrome can be controlled. Otherwise, every aspect of therapy becomes more complicated. Further, the appropriate goals and strategies for any particular subject depend on whether his or her symptoms most resemble an exaggerated schizoid pattern, an exaggerated avoidant pattern, or a mixture of the two. Strategies and techniques appropriate for the dominant underlying personality disorder can be used to supplement the primary goals of treating the schizotypal pattern (refer to the appropriate chapter).

Establishing a more normal pattern of interpersonal relationships is a primary goal of therapy. Social isolation intensifies cognitive deficits and allows social skills to atrophy. Contact with a therapist can prevent further deterioration. Because patterns of disordered family communication typify the early developmental environment of these subjects, therapy offers the chance for a novel, corrective interpersonal relationship through steady support and authenticity.

Accordingly, as emphasized by Benjamin (1996), the basic skills of humanistic therapy, including accurate empathy, mirroring, and unconditional positive regard, become particularly important. Benjamin states that the therapeutic alliance may represent a chance to experience a "nonexploitive protectiveness," one that eventually permits the schizotypal to give up management of the universe by magical means (p. 360). After an alliance has been established, subjects can be encouraged to voice distortions of reality as they occur, and these can be discussed in the context of the therapeutic relationship.

Benjamin (1996) further stresses that many schizotypals are likely to believe that harm may come to the therapist through their association. As such ideas are voiced, they can be tested realistically and tactfully refuted. In general, interpersonal therapy should enhance subjects' sense of self-worth and encourage the realization of positive attributes, an important step in defeating detachment, rebuilding motivation, and providing confidence necessary to take the first steps toward constructive social encounters outside therapy. Because schizotypals have difficulty sorting the relevant and irrelevant in interpersonal relationships, therapists may find that much of their time is spent helping the schizotypal test interpersonal reality and gain perspective on which behaviors might be appropriate in whatever situations are current in the subject's life. Repeated discussions of essentially similar situations may be necessary, as many schizotypals fail to realize that these are but variations on a theme. Basic social skills training is often helpful. Modeling behaviors provides an example that even concrete subjects can imitate. The ability to appraise interpersonal realities appropriately is an important step in decreasing social anxiety and accompanying paranoid symptoms while creating a capacity for appropriate affect and a sense of reward.

From a cognitive perspective, psychotherapy must adapt to the schizotypal's limited attentional resources and tendency to intrude tangential factors. Because many schizo-typals are either overly concrete or overly abstract, learning may be generalized to other settings and situations only with great difficulty. Simplicity and structure help prevent the lessons of therapy from being obscured by the discombobulating effects of thought disorder. Furthermore, cognitive techniques allow the content of thought to be identified and eventually modified. This suggests that the combination of medication and cognitive therapy should be particularly effective.

Writing in Beck et al. (1990), Ottaviani indicates that the first step is to identity characteristic automatic thoughts, such as, "I am a nonbeing," as well as patterns of emotional reasoning and personalization, reviewed previously. Moreover, she suggests that assumptions underlying social interaction present an especially profitable avenue for change, as schizotypals usually believe that others dislike them. Subjects must be taught to act as naive scientists and test their thoughts against the evidence. Feelings do not make facts; instead, each cognition is a hypothesis and should be disregarded if found inconsistent with the objective evidence. Even bizarre thoughts can be dealt with in this way. The thought, "I am leaving my body," for example, can be countered with prepared countercognitions: "There I go again. Even though I'm thinking this thought, it doesn't mean that it's true" (p. 141).

Because an effective grasp of objective reality is the Catch-22 of the cognitive approach, Ottaviani further suggests that schizotypals also be taught methods for gathering contrary evidence. Subjects can list evidence inconsistent with their predictions, for example. Going beyond content, cognitive style interventions can also be made. Rambling can be countered by requests for summary statements, and global statements can be countered by asking for elaboration. Finally, where subjects are not too paranoid or bizarre, group settings can be used to practice social functioning and provide feedback about distorted cognitions.

Because classical psychodynamic therapy is inherently unstructured, its use is probably not advised. As noted by Stone (1985), the purpose of psychodynamic therapy should be to internalize the therapeutic alliance. Because the early home environment of most schizotypals is likely to feature fragmented and chaotic communications, the ego boundaries of the schizotypal subject are only poorly developed. The interpretation of conflict not only disregards their desire for distance but also plays into their fear of engulfment. Accordingly, silence should be accepted as a legitimate part of the personality (Gabbard, 1994). Once this acceptance is felt, the subject may then begin to reveal hidden aspects of the self that can be adaptively integrated. Analytic procedures such as free association, the neutral attitude of the therapist, and the focus on dreams may foster an increase in autistic reveries and social withdrawal.

Probably the most useful analytic suggestion comes from Rado (1959), who suggests that identifying and capitalizing on some source of pleasure, however small, is a superordinate therapeutic goal. Motivation develops from the capacity for pleasure, and ultimately, only this can balance the painful emotions, attach the schizotypal to the real world, and prevent the dissolution of the self and cognitive disintegration that results from autistic withdrawal.

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