For the schizoid individual, attempts to communicate and connect, as well as having a self and a will of one’s own, lead to being possessed, used, and sadistically punished or faced with profound indifference. Rather than being subjected to these treatments, the person with schizoid disorder prefers to stay separate and away from others. In their lives, these individuals aim to feel useful by serving the needs of those around them. These individuals, like the genie in a bottle, feel called when needed and then forgotten. For this reason, schizoid individuals constantly believe that connecting with others will make one become a puppet, servant, or slave. Correct diagnosis of these patients is important in therapy. Because schizoid individuals have a desire to keep their distance in their inner world, this may seem like a narcissistic defense by the clinician, their inability to establish a relationship may be considered autistic, and their adjustment may be evaluated as a borderline patient. In therapy, if the therapist does not understand the schizoid patient’s sitting and distanced approach, this situation may cause the schizoid client to experience self-expression and as being swallowed, occupation and control in the form of relationship. This situation, in contrast to the start of therapy, causes difficulties in therapy and inability to progress, and even causes the patient to break away from therapy (droup-out). Interpreting schizoid dilemmas immediately after the therapeutic alliance has been formed will help therapy begin and continue steadily. Late and inadequate interpretations may complicate the treatment process of the patient. The therapist’s involvement in the master-slave object relationship that emerges in schizoid client therapy is another issue that causes difficulties in therapy. The situation in which the schizoid client is a slave may continue throughout the session. In this case, the therapist may interpret the patient’s adjustment as healing. The lack of a relationship of trust between the therapist and the schizoid client during therapy is another issue that hinders the progress of therapy and the healthy continuation of the process. If the schizoid client cannot trust their therapist and cannot create a safe space in therapy, it will be difficult for them to open themselves in therapy and establish a healthy relationship by experiencing a secure attachment experience. In therapy with a schizoid patient, it is important for the therapist to create space for the schizoid patient for the therapy process and recovery. Emotionally, intellectually and behaviorally, it may take time for the schizoid client to express himself clearly and fluently in therapy. If the therapist does not create a space in therapy for the schizoid client in these situations, the patient sends himself into exile (breaking the relationship) and prevents the realization of therapy. All these are difficulties experienced in the therapy of the schizoid patient, which hinders the progress of the therapy process.
Keywords: Therapy, Difficulties in Treatment, Schizoid Personality Disorder
Difficulties In The Treatment Of Schizoid Personality Disorder
In the eyes of a schizoid individual, attemts of both communicating and having personal agency leads to being posessed, used, sadistically punished and deeply ignored. Rather than being a subject of these treatments, one with Schizoid disorder chooses to stay away from others. These individuals aim to feel useful in their daily lives by satisfying others’ needs. They feel like they are summoned when needed, and forgotten afterwards like a genie in a lamp. Hence, Schizoid individuals believe that constant communication with others would make one a puppet, servant or a slave. It is significant to diagnose these patients accurately. this is because Schizoid individuals have the wish to keep the distance between themselves and others in their inner worlds; this situation might be interpreted as a narcissistic defense by the clinician, the inability to establish a relationship might resemble autistic attributes and the orientation might resemble a borderline patient’s. If the therapist fails to make sense of the client ‘s distant seating and approach; the client may experience the relationship style as repressing, invading and controlling in his / her self expression. Instead of starting the therapy, this situation leads the client to have a hard time in progressing in the therapy, and even drop out. Interpreting Schizoid dilemmas right after forming the therapeutic alliance will help the therapy to start and progress consistently. Late and inadequate interpretations may complicate the patient’s treatment process. The involvment of the therapist to the master-slave-object relationship formed by the Schizoid client is another issue which leads to complications in therapy. This state of client as slave may continue during the whole session. In this state, the therapist may interpret the patient’s orientation as progression. The absence of a trust relationship between the therapist and Schizoid client in the course of therapy is another issue that hinders a healthy treatment process. It would be difficult for the Schizoid client to open up in therapy and experience a securely attached, healthy relationship if he/she does not trust the therapist and build a safe haven.
It is important that the therapist creates some free space for the Schizoid patient for the sake of the treatment process and recovery. It can take time for the Schizoid client to express himself/herself emotionally, intellectually and behaviorally, in a clear and fluent manner.In this case, the patient exiles himself/herself and spoil the therapy if the therapist does not give some free space to him/her. All the aforementioned are challenges in Schizoid patients’ therapy, which hinder the progress of the treatment process.
Personality; It is defined as the characteristics that show continuity in the form of perception, establishing relationships, thinking and perception about the environment and oneself. In other words, it is the sum of the internal and external behavior for the adaptation of the person to life.
Early childhood experiences, social and cultural factors play an important role in the development of personality. Childhood experiences pave the way for disordered behavior. Rewarding action, inhibiting creativity, encouraging incompatibility play an important role in the formation of personality disorder (Yüksel, 2006, p.351).
General Personality Disorder; It is defined as follows in DSM-V;
An ongoing pattern of internal experience and behavior that deviates markedly from the expectations of the culture in which one lives. This pattern manifests itself in two (or more) of the following areas:
Cognition (ways of perceiving and interpreting oneself, other people, and events).
Affect (range, intensity, variability, and relevance of emotional responses).
This ongoing, inflexible pattern encompasses a wide variety of personal and social situations.
This persistent pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
This pattern is persistent and long-lasting, with its onset extending at least into adolescence or early adulthood.
This ongoing pattern cannot be better explained as a manifestation of another mental disorder or as a result of another mental disorder.
This ongoing pattern cannot be attributed to the physiological effects of a substance (eg, a substance of abuse, a drug) or another health condition (eg, head injury)( DSM-V(2014) fifth edition).
Divides DSM-V Personality Disorders into Three Clusters:
Skeptical (Paronoid) Personality Disorder
Schizoid Personality Disorder
Schizotypal Personality Disorder. (In these personality disorders, individuals are seen as strange and eccentric.)
Antisocial Personality Disorder
Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder (Persons are seen as dramatic and labile).
Avoidant Personality Disorder
Dependent Personality Disorder
Obsessive-Compulsive (Obsessive-Compulsive) Personality Disorder
Other personality disorders (Personality Change Due to Another Health Condition) Here the cases are fearful, inhibited and anxious( DSM-V(2014) fifth edition).
Historical Process in Defining Schizoid Personality Disorder
The fundamental question is, are we going to define Schizoid Personality disorder separately from other personality disorders? Is this disorder an anxiety disorder, social phobia, avoidant personality, accommodating borderline, or contact avoidant narcissist?
When we look at the historical process, descriptive psychiatry (DSM-V) and dynamic psychiatry (classical psychoanalysis object relations) defined schizoid personality disorder. Bluer and Kfestchmer (1925) examined this structure in the historical process. The concept of schizoid was defined by Kfestchmer (1925) as ‘weird, cold and emotionless’ in terms of its meaning. Another prominent name in the historical process has been the contemporary object relations theorist Melanie Klein. Especially those who deal with the early period spiritual structure; While Melanie Klein describes this structure; emphasized the splitting mechanism. He hypothesized that the structure that separates the mother in the mind of the 0-3 year old baby as a nurturing breast and a non-nurturing breast (good breast and bad breast) combines good and bad (integrated on one person) after the age of 3 years. However, we see that this splitting mechanism is used as a defense in the schizoid personality structure (Klein, 2012, p.80).
Fairbain was among the important names in the definition of Schizoid pathology. Fairbain talks about three personality structures: neurotic, psychotic, and schizoid. He focused on the concept of distance in the relationship and the need for self-protection. In the first years of life, schizoid patients acquire a belief that they cannot love their mothers as they are, due to their mothers’ excessive or no care (Masterson, 2005, p.21).
Guntrip, on the other hand, emphasized the 9 characteristic features of the schizoid patient, the schizoid dilemma and ways of coping with them, the schizoid consensus, and finally the importance of fantasy as a regressive defense (Masterson, 2005, p.25).
Definition of Schizoid Personality Disorder
Schizoid personality disorder is defined as introverted, quiet people who distance themselves in social relationships, and isolated within the group. It was evaluated as weakness in social relationships in DSM-III and DSM-IV, and it was differentiated from avoidant personality disorder in DSM-IV. Currently, DSM-V has been evaluated as follows;
He neither wants nor enjoys close relationships, including being a member of the family.
He almost always prefers to act alone.
He has little interest in sexual intimacy with another, even if he does.
Even if he does, he takes pleasure in very few activities.
They have no close friends or confidants other than their first-degree relatives.
He doesn’t care about anyone else’s praise or criticism.
He is emotionally cold, detached or has a monotonous affect.'(DSM-V) (Köroğlu,2017,p.210).
Schizoid Personality Disorder
Schizoid Personality Disorder has been a widely discussed topic in both the dynamic and descriptive literature. According to the psychoanalytic literature, it has been concluded that individuals with schizoid personality disorder use defense mechanisms such as identity disorganization, division, and projective identification as a result of experiencing serious traumas in the early period. There are many childhood disorders that show symptoms similar to those of this disorder. However, their differential diagnosis is important. These are the situations that should be taken into account (Göker, 2017.p.24).
The diagnosis of schizoid personality disorder is defined as people who avoid social relationships for life and prefer solitude. These people do not like to establish relationships even with their own family members. They may have difficulty in establishing close friendships or even not be able to make them at all. They may spend long periods of time in solitary activities, such as watching television. They have difficulty in reacting emotionally, they have difficulty in responding with gestures and facial expressions when speaking. They are considered cold and strange by other people. Severe stress events can cause them to experience brief psychotic episodes. Unless there is an accompanying condition such as depression, anxiety and substance use, it may not be seen frequently in clinics because they do not consult a psychiatrist much. There are studies stating that it is seen twice as often in men. Relatives of those with schizophrenia or schizotypal personality disorder may be more likely to have schizoid personality disorder (Guntrip, 2013, p.17).
Guntrip defined it with 9 distinctive character traits;
1) Introversion (Emotionally detached from the outside world),
2) Withdrawal (Separation from the outside world),
3) Narcissism (directing all your libidinal energy towards yourself),
4) Self-Sufficient (not needing anyone, doing your own work),
5) Feeling of superiority (not needing other people, being different from others),
6) Loss of Emotion (difficulty in feeling the other person’s emotion),
7) Loneliness (Isolation from human relations, being alone even in a crowd),
8) Loss of Self (Loss of identity and individuality),
9) Regression (Fantasy of being safe in the womb)
(Guntrip, 2013, p.25).
In addition to these character traits;
1. Pure Schizoid Disorder Cluster (Individuals with marked isolation in relationships and high investment in objects rather than relationships),
2. Covert Schizoid Disorder Cluster (Social-looking but unable to relate deeply),
3. False Narcissistic Disorder Cluster (need to no one, distance and security seeking in a relationship, a sense of superiority and a sense of being different),
4. Four clusters have been mentioned, namely the False Borderline Disorder Cluster (Separation sensitivity and adaptive borderline structure that appears to be an attachment problem) (Guntrip, 2013, p.2).
When the outside world seems unanswered, insecure, or dangerous, the appropriate response is to turn inward. At worst, the schizoid patient lives with experiences of being manipulated, coerced, or sadistically punished. These patients often say that they are unable to play an important role in a family; when they have any role, they experience serving as being relegated to the background until another service is required. These patients feel that they are treated and used as if they are objects without special feelings. As Fairbairn says, object relations for all people are undeniably important, but these object relations become internal because external relations are very dangerous. In this way, introversion is the hallmark of Schizoid Personality Disorder.
For Guntrip, withdrawal means another side of introversion, a separation from the outside world. In many of our patients, we can see this behavior as avoiding contact with the outside world. They are clearly withdrawn. Ralph Klein has pointed out that there are many schizoids who are socially sociable and seem in touch with the world and do not conform to withdrawal. However, when their subjective experiences are explored, they describe being separated and emotionally withdrawn. This is the altered form of withdrawal and features of what Klein called the latent schizoid. This important distinction has led to an understanding and extension of the criteria for Schizoid Personality Disorder to the DSM.
According to Guntrip, “narcissism is rooted in the predominantly inner life of the schizoid. The narcissism of the schizoid is not associated with the desire to have a valuable object or with envy. The function of narcissism in the schizoid case is not to gain superiority, but to create security and distance. The narcissism of the schizoid reflects the failure to find external healthy narcissistic feedings. Unlike borderline and narcissistic personalities who rely on and focus on the other for emotion regulation, the schizoid personality turns inward and learns to manage on its own.
The ability to self-sufficiency to regulate emotion through internal relationships is a developed feature of the schizoid personality. When he turns to the outside world and finds few or no answers, the child is exposed to anxiety and danger so he turns inward and learns to manage it himself. Relying on the other reveals fear of manipulation, possession, oppression, or experience of sadism.
According to Guntrip, a sense of superiority naturally goes with self-sufficiency. It doesn’t need the other. For the schizoid personality, this sense of superiority is not like grandiosity in the narcissistic personality. This is a way to create a safe distance with others. Not needing others is the result of others not being reliable and responsive.
loss of affect
The schizoid patient has little ability to put oneself in another’s shoes because of the need to explore himself intensely as a protective defense mechanism against the dangers of the outside world. In my experience working with schizoid patients, these patients are not feeling but emotions are very strong and overwhelming; and they have very few words to describe them. Verbal telling to one another falls short of explaining the intensity of these patients’ emotional experiences.
Schizoid individuals generally come to therapy aware of their loneliness. However, their hopes of establishing a relationship did not die. It may not match up with the experiences of schizoid people in relationship coldness and indifference.
If the feeling of danger and anxiety becomes overwhelming, the only solution is to emotionally detach from the situation. Many schizoid patients have a history of sexual, physical, or emotional abuse for which they need a solution. Their experience turns into being the person watching the other, and the self cannot be connected. The observing ego is detached from the experiencing ego. Patients describe this experience as being outside of life and watching from afar.
Guntrip described the regression as follows: “The schizoid person at the bottom, feeling overwhelmed by the outside world, is in an inward and backward flow, this flow towards the reliability of the womb. Inward regression refers to a reliance on inner fantasy and self-sufficiency. Backward regression indicates the desire to reach the uterus, which is the safest place again.
Schizoid Personality and Inner World
We can also express the dilemma of the schizoid patient as follows. The schizoid person fears real feelings and relationships; because the need for the object of love can be sustained at the enthusiastic level, the infantile and absolute dependency level. Objects that excite him internally but leave him are experienced as ‘devouring things’. The destructiveness of hate does not prevent us from loving, but the destructiveness of your love is terrifying. Being pushed out of the relationship with the fear of losing one’s self with excessive identification and oscillation by escaping from this situation is a typical schizoid pattern (Masterson, 2013, p.17).
Identification of the schizoid person in the relationship may mean the loss of the sense of self and brings the feeling of being swallowed in the relationship. Breaking this relationship turns into a war for freedom, which brings about loss or becomes empty. The only real solution is the dissolution of identification, maturation of the personality, distinguishing between self and other, that is, spiritual rebirth and a true self development (Guntrip, 2010, p. 25).
Developmental History of Schizoid Personality Disorder
Knowing the developmental history guides therapists in distinguishing between normal development and pathology. Psychodynamic psychiatry, developmental theory, and descriptive psychiatry must be closely intertwined. Otherwise, restricting the diagnosis of the patient with behavioral patterns and symptoms will be insufficient to understand the pathology. From this point of view, we see that the developmental story of Schizoid Personality Disorder is evaluated as a developmental pause in the separation-individuation process in Mahler’s developmental theory. In the developmental processes, attention was drawn to the mental structure of the child, the mental and emotional separation of the mother and the child. It was seen that the importance of segregation and individualization was emphasized. The inability to distinguish between inner reality and outer reality may lead to the formation of a psychotic structure in general. What Mahler particularly emphasized in this process was the emotional availability of the mother. Another striking point in the developmental histories of the patients is that the mother meets the needs of the child in her mind while meeting the needs of the child. It has been seen that the person’s intimate relationship experience is occupation or neglect. It is the feeling of being used by other people who are thought to live in the inner world of the person who has this disorder, that is, people contact him when needed. For example, it can be thought of as an object that has to wait in the corner, like a cleaning cloth, is used when needed and then thrown aside (Masterson, 2013, p.40).
Having an idea about the relationship of the primary caregiver in schizoid personality disorder may make it easier for us to make sense of the developmental story. In this context, it was seen that the first caregiver was inconsistent in his relationship with the child and was indifferent to the child regarding attachment experiences. When the relationship of the first caregiver with the child is observed, it is seen that the child’s feeling towards the caregiver is invasive, intrusive and does not allow separation, which looks great in terms of quantity. It has been observed that there are babies who do not allow cuddling after separation from the first caregiver, hang from the caregiver’s arms even if they are hugged, have little or no intimacy, do not get angry with the caregiver, receive them without emotion, and focus on their toys and the environment (Palombo, 2010, p.72).
According to Allan Schore, when the caregiver neglects or occupies the child (mistreatment), the child reacts in two ways; dissociation and overstimulation. At one stage (overstimulation), the sympathetic system gives an alarm response; Fight, flight, fear, horror, overstimulation and stress hormones are activated. The child reacts to this situation by shouting or crying (Schore, 2012, p.25).
In the secondary stage (dissolution), the child is detached from the stimulation in the outer world and withdraws to his inner world, becoming invisible in order not to be the focus of attention. The child feels helplessness and hopelessness. She also prefers to run away to cope with trauma situations. Shows numbness, avoidance, consent to everything, and limited affect. As a result of trauma, there is a serious decrease in the emotion regulation capacity of the child (Schore, 2012, p.26).
In the schizoid patient, the guilt felt by the caregiver to the child is related to unacceptable behaviors, while the shame felt to the child is related to the self. Shame creates a sense of I am bad while guilt creates the feeling that I did something bad. We see this situation experienced by the child as an effort to make amends for the sin that he cannot remember in adult behaviors (Schore, 2012, p.25).
In essence, for Cozolino, a good enough mother means being strong enough to build one’s inner self-experience, to create a world in which one is safe. The capacity to be alone is one of the main gains of early attachment. It is thought that the capacity of being alone in adulthood of the child who grows up with a competent caregiver will be increased. This indicates the availability of the caregiver when needed. However, on the other hand, it has been stated that the caregiver can be neglectful, indifferent, anxious, indifferent, inconsistent (integrated/ambivalent), and especially being under heavy stress can be very effective in the attachment style. The fear and chaos in the mother’s inner world can be observed in the child’s behavior. The transmission of trauma to the child is both powerful and insidious (Cozolino, 2014, p.65).
Insecure, avoidant attachment babies cannot stop their anger when they are separated from their mothers and reunited, and they cannot experience emotion regulation with the mother. Long-term depressed (chronic) mothers respond inadequately and randomly to the baby. The frightening eyes of the mother give the message of an aggressive object and the child realizes a fearful, anxious and avoidant attachment (Schore,2012,p.35).
According to Winnicott, the child is not initially separated from the mother and the child experiences scattered experiences in time and space. These experiences form the core of the self. Integration and development of the self in relation to the mother; becomes possible in the environment that the mother provides. The child’s integrated self-perception takes place in the inclusive environment created by the mother. This situation enables the child to gradually perceive the integrity of the self (Winnicott, 2013, p.30).
Every child experiences attachment, but how this attachment occurs is important. The emotions that the baby experiences and cannot regulate; The first caregiver of fear, anxiety and sadness should be the one who alleviates and balances these feelings. The baby looks for a safe harbor to get rid of all these feelings and calm down. Repeated experiences create connections in the baby’s mind, which are coded as new connection schemes (Stern,2017, p.110).
The Spiritual World of Schizoid Personality Disorder
The mental world of schizoid personality disorder means understanding the true nature of the illness. While establishing a relationship, the schizoid patient asks: ‘Is there any possibility of reconciliation?’. For the schizoid patient, communicating is doubtful. This actually reveals the schizoid patient’s need for attachment.
There is a deep belief that the schizoid patient cannot have a relationship without danger or risk. The schizoid patient needs self-isolation as a result of suffering and intolerable anxiety.
The type of relationship experienced by the schizoid patient; being accessible (noticing) when he fulfills the expected task completely and getting approval in the relationship. When the schizoid patient relates in this way, he feels himself and manipulated.
If the schizoid individual does not receive the acceptance and approval he expects from the relationship, he feels a deep emptiness and suffers from loneliness. This is a terrifying experience for the schizoid patient.
The psychic structure of the schizoid patient consists of a divided object relations unit. We can describe it as an aggressive and libidinal unit, and it also acts as two opposite emotions in itself. In other words, when the schizoid patient is in the libidinal unit, he enters into a master-slave relationship, and while this is a dilemma, his way of relating is attuned to gain approval and acceptance. In the aggressive unit, on the other hand, in the relationship, the sadistic object experiences the self-dilemma in exile. In other words, he feels occupation from the person with whom he has a relationship, and by taking a distance against this occupation, he goes to the sheltered area, that is, he goes into exile, or he completely breaks away from the relationship. In the libidinal unit, this is seen as a desire for acceptance, approval and in return for love and connection. In the other unit (aggressive), approval and disapproval create a feeling of disconnection and emptiness (Masterson, 2013, p.50).
According to Masterson; When schizoid patients switch to the aggressive unit, he exiles himself and becomes disconnected. He is described as experiencing the person with whom he has a relationship as a sadistic object, and exiles himself by getting away from the relationship. When the schizoid patient passes into the libidinal unit, he/she fulfills his/her duty completely and adapts. This is the emotion that the schizoid patient experiences in the master-slave unit. (Masterson, 2013, p.55).
While the schizoid patient experiences the first caregiver as the appropriating object, that is, the occupant, he breaks the relationship and connection and goes to fantasy in order to get rid of the occupation. Only in this way does he live the relationship he dreams of in fantasy. As she experiences the relationship with her primary caregiver as neglect, she adjusts to gain approval and acceptance. This is the only way to stay in touch with this other (Masterson, 2013, p.55).
Building the Therapeutic Alliance in the Therapy of Schizoid Personality Disorder
In order for the therapeutic alliance (trust in therapy and the therapist) to be formed in schizoid patients, the therapist’s neutrality towards situations and events (the therapist’s neutrality), the therapy’s framework (predetermination of the rules that the therapist and the patient should follow), and the therapist’s stance, the transformation of the transference into action into the therapeutic alliance (the patient’s feelings the therapist’s activating his emotions and taking action towards behavior with these emotions), in addition to these, the interpretation of schizoid consensus (collaboration with the therapist) and schizoid dilemma (sadistic object in the aggressive unit, the sense of self in exile, master-slave feeling in the libidinal unit) are important points that facilitate the progress of the treatment.
The therapist’s sitting position is at a 90-degree angle rather than facing each other, making it easier for the schizoid patient to establish a relationship without experiencing the experience of being swallowed in the relationship. In this way, the therapist is not experienced as the first object, the first caregiver, the occupant.
The therapist’s acting as a teacher during the therapy process may cause the schizoid patient to adapt, and the repetitive pattern that is thought to be experienced with the first caregiver in order to gain approval and acceptance may also be revived in the therapy room. What the schizoid patient actually seeks is equal relationship and safe distance.
The schizoid patient’s sense of being occupied (as if the therapist can read what he or she is going through) may cause the patient to not speak at all. The fact that the patient does not talk at all or speaks little can lead the therapist and the patient to fantasy (dream, disorganized thought..). The therapist should interpret and address this situation, which is expected to occur in the therapy session of the schizoid patient. This interpretation made by the therapist was found to be important for the treatment process.
The schizoid patient comes to therapy with internal object representations, and in the aggressive unit the sadistic object may experience the therapist as the master in the libidinal unit. In such cases, the therapist needs to interpret the process.
What Does the Schizoid Consensus Mean?
The schizoid patient believes in the safety of the therapeutic relationship and sets out to resolve the dilemma. In this way, he tries to convey his feelings, thoughts and experiences. It also means collaborating in therapy. The fears and defenses of the schizoid patient when starting the treatment decrease with the increase of trust in the therapist during the therapy process and establishing an alliance with the therapist, and this is called schizoid consensus. The formation of schizoid consensus occurs with the increase of trust in the therapist and therapy. For the continuity of this consensus, the therapist must maintain a safe distance with the patient (Masterson, 2013, p.114).
What Does Fantasy Mean in the Schizoid Patient?
Since the schizoid patient cannot experience real attachment in the relationship with the first caregiver (first object), he cannot feel complete and whole in his relationships. In such cases, the patient goes into fantasy and creates a world he imagines but is not harmed (occupied) or aligned with, fear of being engulfed. Here he dreams of the relationship. This is a situation that prevents him from experiencing the real relationship (Masterson, 2013, p.116).
Treatment of Schizoid Personality Disorder
Short Term Treatment:
Short-term treatment of personality disorders is among the controversial issues. However, some patients and conditions have been found suitable for short-term treatment. However, this treatment is carried out under the pressure of long-term treatment discourses (Masterson, 2013, p.123).
Long Term Treatment
Step 1. Establishing Consensus
The therapist should interpret the client’s dilemmas as quickly and quickly as possible. It ensures that the therapist and the patient reach a consensus and maintain the therapeutic stance. It is also necessary to interpret the internal and external processes in the therapy room (Masterson, 2013, p.129).
Step 2 Classification
The therapist’s making and maintaining consistent comments helps build a relationship of trust and make sense of the schizoid cycle. Mirroring interpretation used in narcissistic patients also increases insight in schizoid patients. However, this interpretation may also be considered out of place by the schizoid patient in the inner world. At this point, it has been seen that using a general mirrored interpretation is more helpful (Masterson, 2013, p.131).
Clarification comments and the evaluation of the cycle that the patient is in prevent the patient from getting away from the relationship. At this point, it becomes easier to reach a schizoid consensus.
Step 3 Convergence Consensus
The ability of the schizoid patient to manage the bondage anxiety he feels without intimacy means that he accepts vulnerability. It is aimed that the patient becomes able to manage the risks, disappointments and hurts in the relationship. The therapist simply interprets the situation without reading the patient’s mind or imposing the agenda in his mind. The most important factor here is that the patient feels that the therapist is always emotionally available in the therapy room. Here, the therapist’s posture is safe and stable (Masterson, 2013, p.134).
Intensive and Long-Term Treatment:
In intensive and long-term treatment, the essential condition is a strong therapeutic alliance, while the key word for schizoid is the need for security. From the point of view of Masterson, we can think of intensive and long-term work as the separation of this sick part and the self. In other words, in order for Masterson’s true self to emerge, abandonment depression, that is, when leaving the sick shell, the patient mourns this part of himself that he feels and falls into depression, and this is seen as a difficult and painful process of reaching the real self. In schizoid patients, along with depression, anger is also seen intensely at this stage. In fact, the treatment of personality disorders should be long-term and intensive with whatever technical and theoretical framework is used. In order to pass this process, it is important for schizoid patients to have a strong therapeutic alliance, that is, to create a sense of trust (Masterson, 2013, p.161).
Finally, there are three phases of the treatment process. These are the testing phase, the therapeutic alliance building, and the hard work phase. In addition to these, an important point for the treatment process is the review of the diagnosis and the re-evaluation of the therapy.
Difficulties that May Occur in the Treatment of Schizoid Personality Disorder
The main problem of the schizoid patient is security, and he starts therapy by not feeling safe in the therapy room as he feels outside. She wants to trust the therapist, but her early experiences and inner pattern expose her to feelings of being engulfed, occupied, controlled or vice versa, experiencing the relationship from within a capsule, being ignored. For this reason, the therapist’s being at a safe distance is very important for the schizoid patient (Masterson, 2013, p.90).
In the treatment of the schizoid patient, the therapist’s posture, too long eye contact, and the patient’s anxiety about being read create. However, the therapist’s mind reading, imposing the agenda in his head, can be experienced as occupation by the schizoid patient.
In the treatment of the schizoid patient, the sitting style and the design of the therapy room may be as important as the therapist’s posture. Here, instead of sitting face to face with the patient (turning slightly on the side), it can be considered as one of the factors that make the patient feel safe. In addition, sitting opposite each other may cause anger feelings of the schizoid patient. Schizo patients may sit on the edge of the chair until they reach the stage of trusting the therapist, or they may sit close to the door and feel like they will escape immediately.
When working with schizoid patients, the frequency of sessions can be reduced until therapeutic cooperation and a sense of trust are established. In the initial phase, intense and long sessions can be challenging for the schizoid patient. In order to experience the patient as a safe place to stay connected, session frequencies can be planned intermittently at the beginning. For example, it was thought that the frequency of sessions could be planned as once a week or once every two weeks (Masterson, 2013,190).
When schizoid patients move into the aggressive unit, their anxiety increases and the first caregiver’s experience, internal object representations, come alive in therapy and experiences the therapist as a sadistic object and exiles himself. In other words, it can break the emotional connection with the patient. The therapist’s early interpretation and confrontation can complicate the therapy process. The patient experiences the therapist as cruel and feels misunderstood.
While the schizoid patient is in the libidinal unit, he or she can bring the master-slave relationship to the therapy session by fully adapting to the therapist. This attunement can be considered as a false healing by the therapist. It may help the patient to realize this situation if the therapist brings up this relationship with the patient in the session. In other words, the patient may be attuned to each interpretation of the therapist, and the therapist may not object.
While the therapist is giving psychoeducation, the schizoid patient experiences this as a teacher-student relationship and may respond by adapting here. Here again the master can enter the slave cycle. The therapist’s interpretation of this can help overcome this difficulty (Masterson, 2013, 211).
The need for security and distance of the schizoid patient can be evaluated as a narcissistic defense. This is more due to the schizoid patient’s experience of himself as strange, different, unlike the others, or even as a freak, rather than a sense of superiority. He can experience himself as if he is not of this world, as if he is an alien. While the basic emotion here is related to experiencing feelings of inability to relate, when the therapist is evaluated as a grandiose defense and is given feedback, the patient feels not understood and continues to move away from the harvest therapy process, which makes therapy and treatment difficult (Masterson, 2013, 200).
While working with the schizoid patient, it is important for the therapy process that the therapist informs the patient about the break times (such as holidays, etc.) in advance. Interruptions to the sessions without informing may undermine the confidence of the schizoid patient. This situation may be experienced as a feeling of neglect in the schizoid patient. Some schizoid patients may even quit therapy because of anger (we can think of it as punishing the therapist). In such cases, it is important for the patient to inform the patient beforehand. In sudden situations, revealing the patient’s emotion and interpreting it is important for the therapy process (Masterson, 2013, 210).
Another difficulty that can be experienced when working with schizoid patients is that the schizoid patient speaks very little or not at all. This situation may create anxiety for the therapist and patient during the therapy process and may complicate the therapy process. In these situations, the therapist can interpret his or her own emotion and the patient’s emotion. Sometimes talking through symbols can also relax the schizoid patient. Self-talk can be challenging for these patients until trust is established. At this point, the fact that the therapist’s toolbox is wide and using different techniques can ease the process (Masterson, 2013, 220).
The thing that schizoid patients do most in their relationships is that they go to fantasy when they can’t relate and they can’t experience the real relationship. When working with the schizoid patient, sometimes the patient goes to fantasy, sometimes the therapist goes to fantasy. It is a familiar cycle for the patient to fantasize, and the therapist must interpret it when he notices it. We can interpret the therapist’s going to fantasy as a transference action (the therapist’s behavior by entering the patient’s cycle with the emotion he receives from the patient) or the patient’s inability to experience the authentic relationship. The fact that the therapist does not realize this situation is another situation that creates difficulties for the therapy process (Cassıdy, 2009, p.90).
When working with schizoid patients, as in all other patients, differential diagnosis is of great importance. Schizoid patients Asberger syndrome can be confused with autism. The point to be noted here is that while individuals with autism have almost no relationship experience, schizoid patients desire relationship very much. However, the relationship may bring with it fears of being swallowed and being visible in the early period for the schizoid patient. The schizoid patient wants to fully trust the other person in the relationship. We can say that wrong or incomplete diagnosis is one of the most important factors that complicate the therapy process (Schane, 2012, p.197).
Ways to Overcome the Difficulties in the Treatment of the Schizoid Patient
The only source of security for the schizoid patient in the first phase of treatment is the schizoid patient’s confidence that the therapist will be stagnant and not intrusive or intrusive. We can say that trust and being at a safe distance are the keystones for the schizoid patient (Masterson, 2013, 17).
The therapeutic framework helps the schizoid individual understand that the therapist stands at a safe distance, as well as clarifying the patient’s responsibilities. What we mean by the therapeutic framework is that the therapy rules such as the fixed therapy day and time, session fee and duration are determined by the therapist from the beginning with the patient. (Masterson, 2013, 150).
Therapeutic Neutrality, that is, the therapist’s ability to remain constant according to the situation and the moment helps the patient to experience a secure relationship without feeling occupied (Masterson, 2013, 102).
Transforming the countertransference action (activating the therapist’s feelings towards the patient and, consequently, the therapist taking action according to the patient’s cycle) into alliance; It can be considered as the repetition of the trauma that the patient thought to have experienced in the early period in therapy. The therapist needs to realize this, interpret it, and give the client a corrective experience here and now (Masterson, 2013, 92).
Reviewing the differential diagnosis is one of the most important elements to overcome the difficulties experienced in therapy.
Discussion and Conclusion
When we look at the diagnosis process of Masterson’s theory of schizoid personality disorder, it is remarkable that it was the last personality disorder to be evaluated.
The patients with schizoid patients have a cold clinical appearance, far from being emotional, and have difficulties in relationships. The main need of the schizoid patient is trust. If we evaluate it in terms of attachment theorists, it is that the schizoid individual could not have a secure attachment experience as a result of the traumatic experiences with the caregiver in the early period.
Schizoid patients are patients who need intensive and long-term work, but due to misdiagnosis and difficulties in the relationship of schizoid patients, their application to therapy is delayed.
Schizoid personality disorder is not a psychotic disorder. In other words, his ability to evaluate reality is not impaired, only the anxiety and disconnection he experiences in establishing a relationship makes it difficult to establish a relationship. However, traumas experienced by the caregiver as a result of neglect and occupation in the early period bring this disease closer to psychosis and may apply to the clinic with a brief psychotic attack.
In order to overcome the difficulties experienced in the therapy of schizoid patients, the framework of the therapy and the therapist’s posture are of great importance. For example, it is necessary to realize the difficulties experienced by the patient in the relationship and interpret them. The therapist pretending to read the patient’s mind creates feelings of fear and panic. The therapist’s attempt to impose the agenda in his mind makes the patient feel occupied. The therapist’s prolonged eye contact with the patient complicates the therapy.
The main agenda of schizoid patients is the fear of reliving the trauma (with the caregiver) experienced in the early period. When we look at the developmental history of the schizoid patient, it was observed that she had an anxious and avoidant attachment to her primary caregiver in the early period.