How Do You Treat Schizoid Personality Disorder with Therapy?

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It is tempting to think that there is one basic treatment for schizoid personality disorder, but the reality is a bit more confusing. Not everyone with the same diagnosis needs exactly the same type of psychotherapy. I think of schizoid personality disorder as the “hidden self disorder” because the majority of people who have it look perfectly normal. However, inside they have all the usual issues that are associated with schizoid personality disorder, including:

• Contact Anxiety: My clients with SPD have a deep-seated mistrust of other people going back to early childhood. They experience contact with most people as anxiety-provoking.
• False self: They bury their real feelings deep inside and present a constructed mask of normality to the world at large.
• Distancing defenses: My schizoid clients practiced social distancing before Covid became a problem. Physical distance from other people and control over their personal space makes them feel safer.
• Independence: Unlike my clients with borderline or narcissistic disorders, my schizoid clients prefer not to depend on other people because they do not trust anyone else to really care about them.
• Dissociation: Because they were abused as children and could not physically escape, they learned to dissociate from their bodies when stressed.
• Splitting: Like all people with personality disorders, they see themselves and other people in a split, unintegrated, and highly unrealistic way as either all-good or all-bad.
• Fantasy life: They fulfill some of their social needs by developing a very rich and elaborate fantasy life in which they get to control everything—the plot, the players, and what everyone says.
• Existential despair: This is a type of schizoid depression in which life seems inherently meaningless, something to be endured, not enjoyed.

Note: I am using the terms schizoid and SPD as shorthand ways of referring to people who qualify for a diagnosis of schizoid personality disorder.

Many individuals with SPD adapt to their situation and never seek therapy. The ones that do come for therapy do so because they find their schizoid issues too limiting. They want more for themselves. Below are some typical examples of schizoid clients, their issues, and how I might intervene to help them.

Contact Anxiety, Dissociation, Lack of Meaning

Susan

My client Susan, a very intelligent young woman in her late 20’s, came for therapy for a problem that she described like this:

Whenever I am with someone I like, suddenly I feel incredibly cut off emotionally. It is as if an invisible plastic shield comes down and separates me from them. I can still see and hear the person, but everything now feels emotionally meaningless.

Dan

Dan, a high-functioning man in his 40s, has just shown up at my office for his first session. When I ask where he would like to sit, he gives me a funny little smile. I ask what he is thinking, and he answers very honestly:

If you really mean I have a choice, I want to sit as far away from you as possible. Actually, outside your office and down the hallway would be my preference.

As you can see from these two brief examples, Susan and Dan both have schizoid contact anxiety. However, Dan can talk about his issue without dissociating and actually has some ability to tolerate physical intimacy. Susan’s dissociation is not under her conscious control and happens automatically. You can also see, I hope, that Susan and Dan will need different treatments and Susan’s problems are likely to require longer and slower therapy.

What are some basic Interventions for contact anxiety?

Susan

I worked with Susan by asking her to monitor her moment-by-moment comfort with me—its ebb and flow during each session. The goal was for her to sense her own growing discomfort before the shield automatically came down. I encouraged her to view her discomfort as a signal that she needed to take more space from me or the topic we were discussing. Eventually, Susan was able to say: “I want more space now.” Or “What you are saying is making me uncomfortable, please stop.”

Dan

Dan was far ahead of Susan. He could speak about his symptoms, instead of automatically enacting them. He wanted to use his therapy to talk about “choices” and how his controlling and overprotective mother had never allowed him to make any for himself.

My interventions focused on giving him lots of in-session choices: “What do you want to talk about today?” “Would you have preferred me to phrase my comment more neutrally?” Dan’s out-of-session homework involved him telling other people what he really preferred, instead of just going along with their choices.

Body Dissociation

Mario

Mario, who had been sexually abused as a child, periodically got into what he called “work mode.” In work mode he ignored his body and kept working for as many hours as possible—sometimes 20 hours straight. He said that in work mode, he felt like a robot without feelings. His body was just a vehicle to hold his mind and all he thought about in that state was work. Nothing else existed. He described this as:

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It is a little like being on meth. I can keep working forever. I don’t care what happens to my body. I’ve been like this since I was little. The first time I was raped by my uncle, I left my body behind. Now, I wish I didn’t have a body. It just is something else for people to hurt. Most of the time I just ignore it.

Jane

Jane complained that she sometimes felt so detached from her body that she did not recognize her own face in the mirror, but that no one else seemed to notice anything strange about her. She related this dream:

I am in the subway station. I am a perfectly groomed head with makeup and a nice hairdo, but I don’t have a body. I, the head, bounce down the subway stairs and get on a train. No one seems to notice anything strange about me.

What are some interventions for dissociation?

Mario

I asked Mario a lot of questions about work mode before I tried to get him to make any changes. It was entirely possible that Mario’s current ability to function depended on him going into a dissociated state. I paid particular attention to the following things:

• How did Mario react to my questions about work mode?
• Did Mario have any conscious control over going into work mode?
• Did he have a theory about why he went into “work mode” and what would happen if he did not?

Mario gradually became interested in exploring why he went into work mode. He discovered that being in work mode protected him from experiencing the painful and traumatic feelings that were the result of his abuse as a child. As Mario got comfortable with me, he began to experiment with not going into work mode and allowing himself to see what he was actually feeling underneath. This led to him beginning to process his sexual abuse for the first time.

Jane

As with Mario, I asked Jane a lot of questions over the course of some sessions before I made any direct interventions. I found out that I was the first person Jane had told about her feelings of being detached from her body. Jane tended to be a very private person and rarely confided in anyone.

She had occasionally dissociated as a child, but everything got much worse since a date sexually assaulted her in college. I asked Jane if she felt ready to experiment with reattaching to her body. I framed it as “taking back your body” because her body had not felt like her own property after the attack.

Jane said she did, so I proposed a simple exercise: when she passed a mirror and noticed that she was disassociated, she should stop, look at her face and touch or point to each part and reclaim it by saying: “This my forehead, these are my eyes,” and so on.

I started with her head because that was less likely to disturb her than if I had started with her body. The general rule is to go with what is easiest first, then see how the person reacts before doing anything more challenging. Jane’s dream had shown me that she still “owned” her head.

Summary

As the above examples show, clients with the same diagnosis of schizoid personality disorder may need different treatments. Each client will have his or her own history, level of functioning, strengths, needs, and sensitivities. Although they may have many general issues in common, there is no one-size-fits-all treatment. The best psychotherapy for clients with schizoid personality disorder is the one that makes them comfortable and is adapted to their individual needs.

A version of this post appears on Quora.