‘Cluster A’ comprises paranoid personality disorder (PPD), schizoid personality disorder (SPD), and schizotypal personality disorder (StPD). These disorders affect 2%, slightly less than 1%, and 4% of the Western population, respectively, and can be highly disabling. Their incidence is higher in men than in women and the conditions are characterized by odd, eccentric, or ‘cold’ behavior (particularly SDP and StPD). It is thought that a biological relationship may exist between the disorders and the schizophrenias, although of the three, StPD is more demonstrably linked to schizophrenia phenomenologically and genetically (McGlashan, 1983). SPD and StPD are sometimes grouped as part of a continuum, given the similarity of certain symptoms. No distinctive set of psychoanalytic, cognitive-behavioral therapy (CBT) or group theories is applicable to these conditions. More research is needed before specific psychological theories can be established. Conceptualization of Cluster A disorders tends to utilize theories developed from the study of psychosis.
The main characteristic of PPD is distrust and suspiciousness. The motives of others are construed as hostile and exploitative. The PPD patient's thoughts and feeling are preoccupied by conflicts and threats felt to emanate from outside. They experience doubts about the loyalty of others and anticipate betrayal. Given their preoccupation with threats, they are highly vigilant. Negative stereotyping can occur and this may lead to a search for security through contact with people who share the patient's paranoid beliefs. Individuals can express PPD through hostility, sarcasm, stubbornness, or a cynical world view. A beleaguered, self-righteous attitude conceals deep sensitivity to obstacles or setbacks, an unwillingness to forgive, inflation of subjective judgment, and difficulty in accepting another's viewpoint. These defenses reflect feelings of inferiority based on low self-esteem. Humiliation, shame, and depressive feelings are underlying affective characteristics of PPD. Encounters with PPD can leave others offended and disoriented or even provoked into conflict. History-taking may indicate that in childhood the patient withdrew from relationships and became preoccupied with ruminative, conflict-based fantasies. PPD can be differentiated from psychotic illness by an absence of delusions or hallucinations (Sperry, 1995). It is advisable to differentiate symptoms of PPD from those produced by substance abuse; they can appear similar but have different origins. Medication—usually neuroleptics or SSRI antidepressants—may be given, often in combination with psychotherapy. PPD patients struggle with any treatment regimen due to their distrust.
SPD is characterized by emotional detachment from social and personal relationships. Expressions of feeling towards others are limited because contact is painful and felt to lack meaning. Compelling experiences seem to pass the SPD individual by. At the same time they can feel isolated if left alone for too long. Close contact with others leads to feeling overwhelmed and a fear of loss of identity (sense of self). Hostility is rare; passive resistance and withdrawal predominate. Poor social skills and limited emotional range compound the ‘mechanical’ characteristics of SPD behavior. When under threat SPD individuals detach themselves still further. Confrontational therapy techniques are inadvisable as they heighten already severe anxieties. The fantasy life of SPD individuals can be intense: the difficulty for the psychotherapist lies in accessing it but if this is achieved SPD patients may do well. SPD can be differentiated from PPD by a reduced suspiciousness of others, although paranoid ideation is sometimes present. SPD is distinguishable from StPD by its less odd, eccentric, or obviously disturbed presentation. Similarities of presentation of SPD with autistic or Asperger's syndrome can sometimes make diagnosis difficult. Psychotic illness or severe depression may occur within SPD but severe symptoms can be associated with an accompanying personality disorder (such as avoidant or paranoid). Despite their detachment, many SPD individuals become concerned about the unfulfilling lives they lead. Many do not marry or form sexual relationships and if they do, they tend to settle for nondemanding partners. Enough contact to offset loneliness may be found in the workplace or through limited socializing. There is no generally accepted treatment for SPD, although group therapy can help with socialization. Psychotherapy (which may be a combination of group and individual), perhaps with some medication, is sometimes recommended. Pharmacological treatments alone seem to have little impact on the low affectivity and deep anxieties of these patients, as their problems lie primarily with relationships. Substance abuse in SPD (and in StPD) tends to be related to attachment to fantasy experiences as part of a general avoidance of human contact.
StPD is characterized by a ‘pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior’ (DSM-IV-TR, 1994; ICD-10, 1992). ‘Schizotypal personality’ derives from the term schizotype employed by Rado in 1953 to bring together schizophrenic and genotype into one category. ‘Schizotypal’ refers to a disordered personality in which there are constitutional defects similar to those underlying schizophrenia. Brief psychotic episodes due to stress may arise in StPD but these are usually transient. Some StPD individuals may go on to develop schizophrenia but they are a small minority. The principal characteristics of StPD are distortions in cognition and perception, including a disturbed view of the body, and the presence of odd, magical, or eccentric beliefs or ideas. StPD (and SDP) individuals have difficulty in experiencing pleasure (anhedonia). They may show ideas of reference and superstitions and suffer chronic social anxiety. Close relationships are felt to be threatening and social isolation is not uncommon. StPD individuals feel themselves to be at odds with, not part of, the world. Withdrawal and avoidance are used to counter feelings of confusion and conflict. Strong feelings evoke intense anxiety, and this can threaten their hold on reality. The need to avoid strong feelings leads to a tendency to overfocus on tangential issues (hence the characteristic of eccentricity). Their illusions and preoccupations defend against fragmented ego functioning and a precarious sense of identity. Social contacts, support from family and friends and engagement in therapeutic relationships are necessary to counter the tendency to remain withdrawn. Despite the genetic link with schizophrenia, StPD patients who enter psychotherapy can do better than SPD patients due to their greater affective availability. Progress may be slow and erratic and results rarely approximate to a normal life, but gradual personality integration can lead to a marked improvement in daily living. Treatment, especially in severe cases, may involve low dosages of the kind of medications used in schizophrenia. SSRIs can improve obsessive, compulsive, and depressive symptoms in StPD.
Psychoanalytic theory underpins psychodynamic approaches. Paranoia, in Freudian theory, has been defined traditionally as a defense against homosexuality (Freud, 1911/1958). Many psychoanalysts today understand this to reflect an object relations crisis in which the subject feels unable to surrender or yield to the experience of dependence upon the primary object (originally the mother/caregiver) for fear of unmanageable conflict and disintegration. Melanie Klein sought a similar foundation for the origins of paranoia, but through a slightly different route. Having located the paranoid phase within Abraham's first anal stage, she subsequently conceived of it as the earliest object relationship of the oral stage, from which evolved her concept of the paranoid-schizoid position. This concept is useful to understanding Cluster A disorders. The initial object is partial (the earliest representation being the breast, followed by the mother) and is subject to splitting into ‘good’ and ‘bad’ aspects—idealized and denigrated respectively. The ego attempts to rid itself of ‘bad’ object experiences using projective mechanisms. Introjection of the ‘bad’ part-object threatens the infant with a fear of destruction. Splitting, idealization, and disavowal contribute to a defensive, omnipotent attempt to ward off the ‘bad’ object, and are today accepted by the majority of psychoanalysts and psychotherapists as pivotal to understanding paranoid conditions such as PPD. Kernberg (1975), Rosenfeld (1975), Stone (1993), and Gabbard (2000) among others have noted how the PPD patient violently splits the object leading to separated ‘good’ and ‘bad’ aspects, reflecting developmental failure of mentalization in infancy (Target and Fonagy, 1996a,b). Object constancy (the internalization of a reliably available, caring other) is not established. The PPD patient expels aggressive impulses by projection: projective identification locates the impulses in others as a means of controlling fears of annihilating the object and of being annihilated in return. Beneath this defensive structure lie infantile feelings of helplessness, worthlessness, inadequacy, and depression (Rosenfeld, 1975; Meissner, 1995). Environmental failure to contain infantile feelings, above all aggression and hatred, plays a fundamental paranoiagenic role (cf. Winnicott, 1962; Balint, 1968; Kohut and Wolf, 1978).
A key assumption in cognitive-behavioral approaches to PPD is that the beliefs in PPD exist on a continuum between normal threat beliefs and persecutory delusions. Cognitive therapists focus on reducing distress and preoccupation with disturbing beliefs. Models of persecutory beliefs provide a basis for developing clinical formulations for people with PPD and for persecutory delusions in paranoid psychotic disorders. There are two main types of cognitive-behavioral conceptualizations of persecutory delusions. The first considers that the belief that others are persecutors may arise through processes of social learning (initially involving conditioning in threatening, humiliating, or submissive situations; cf. Carson, 1999). This evolves over the life course as an exaggerated response to threatening situations by a process of increasing vigilance and avoidance akin to a trauma or anxiety reaction (e.g., Pretzer, 1988; Beck et al., 1990; Fowler, 2000; Freeman et al., 2002). Depression and low self-esteem associated with paranoia are regarded as comorbid or secondary. The second conceptualization suggests that paranoid belief represents adaptation to social threat, and to the consequences of low self-esteem or depression (Colby, 1981; Turkat, 1985; Bentall et al., 2001). The primary concern is a need to avoid the devastating consequences of further social threat or of social isolation on the self-view of the subject. Persecutory beliefs are held to have arisen due to a tendency to externalize blame and project it on others, leading to paranoia. Chadwick et al. (1996) have described two types of paranoia arising from differing underlying processes linked to the above conceptualizations.
Psychodynamic approaches emphasize the extent to which schizoid individuals have detached themselves from human relating. Schizoid patients complain of being unable to maintain close relationships. They rapidly identify with others, becoming transiently dependent, and then withdraw. They are demanding, controlling, and often devaluing of others and tend to have grandiose ideas about themselves that conceal feelings of hopelessness and helplessness. Their sexual identity is usually unstable. Psychoanalytic theory considers the schizoid to be someone who craves love but who cannot love for fear that love (not only hate) will destroy the object (Fairbairn, 1954; Guntrip, 1968). He is enclosed in a claustro-agoraphobic object relational dilemma (Rey, 1994). This dynamic can be described as a fantasy of being trapped inside an object (other person), or else of being threatened by psychic disintegration when outside it, as a result of belief in its total loss. The anxiety derives from the proximity or distance the individual feels from the object. Too much closeness yields claustrophobic anxiety due to the intensity of affects aroused by fears of merging and engulfment. Too much distance creates agoraphobic fears of loss and collapse. The experience of time and space may become confused due to poor secondary process functioning. The schizoid individual tends to oscillate between extremes that are the product of massively divergent views of the object created by persistent, intense splitting and fragmentation of the object, ego, and internal objects. Expelled ‘bad’ parts of the self are introjected and then persecute the ego. ‘Good’ parts of the self are also projected into others leading to ego depletion and fears of loss of the object and sense of self. Problems of identity failure due to the retreat from object relationships lie at the crux of schizoid pathology (Winnicott, 1962, 1965).
Cognitive-behavioral approaches acknowledge that SPD is the least understood or researched of Cluster A conditions. Schizoid problems may exist on a continuum of behaviors between normality and negative symptoms. From the perspective of personality theorists schizoid disorders are seen to relate to extreme introversion (Jackson, 1998), and there may also be continuities with autistic spectrum disorders (Wolff, 1998). Problems in relationships, socializing, and emotional functioning may occur because of disorders in understanding and experiencing emotions, social rules, and interpersonal behavior. In a manner akin to autistic spectrum disorders, cognitive deficits in processing other peoples’ theory of mind may be crucial to the disorder (Millon, 1981). An alternative CBT conceptualization draws from psychoanalytic theory and implies that the disorder may arise from disturbed maternal relationships and compounded by failed social learning.
Psychodynamic approaches stress early fragmentation of the ego and damage to the sense of self of a type associated with schizophrenic states. Psychological functioning reveals primitive, part-object relationships (cf. Rey, 1994), impoverished mental representations, developmental deficits in terms of the capacity to mentalize and there is a potential for psychotic thinking under stress. The StPD patient's failure to internalize adequate representations of the object gives rise to a precarious sense of self. Development remains fixated at the paranoid-schizoid level (Klein, 1946) but because trauma is held to have occurred at the oral stage many psychotherapists see StPD anxieties as very primitive, requiring containment and interpretation at points when the ego is neither overwhelmed by anxiety nor paralyzed by defenses. Balint described two internal solutions to failure of the relationship between mother and baby. The ‘basic fault’ in the infant's personality can later be expressed as either the ‘ocnophilic’ or the ‘philobatic’ tendency. The former is a response to a chronic ‘emptiness inside’ and seeks to fill it by demanding more and more from others. The latter involves giving up on others and retreating into a world of fantasy (Balint, 1968). SDP and StPD patients fit the latter profile. Bowlby's ‘avoidantly attached’ category also characterizes these individuals who are too afraid of aversive contact to seek it (Bowlby, 1988).
Cognitive-behavioral approaches see ideas of reference, paranoid and suspicious thinking, odd beliefs, and magical ideation in StPD as part of a continuum between normality and the positive symptoms of psychosis. CBT conceptualizations of psychosis (Kingdon and Turkington, 1994; Fowler, 2000; Garety et al., 2000) are applicable to the disorder. Source monitoring problems are important (i.e., confusion about the origins of thoughts) and these states may link with everyday experiences such as ‘déjà vu’. Typically, the StPD patient may have little awareness of the internal origins of his or her cognitive confusion and may have succumbed to extensive irrational thinking. Development of bizarre convictions of apparently external origin, e.g., preoccupation with spirits, telepathy, hypnosis, spirits, etc., are not uncommon in StPD and are influenced and maintained, CBT theory argues, by internal emotional and reasoning biases.
There is little research into Cluster A disorders compared with other personality disorders (notably borderlines) and more is needed if these conditions are to become better understood. Psychodynamic research notes the stability of diagnosis and treatment outcomes, e.g., Stone (1983, 1985, 1993), McGlashan (1986), Gunderson (1993), Sandell et al. (1997). Psychoanalytic authors tend to study intrapsychic object relationships, defenses, psychotic anxieties, and transference–countertransference phenomena related to these conditions (e.g., Rosenfeld, 1964, 1975; Segal, 1978; Meissner, 1986; Lucas, 1992; Rey, 1994; Grotstein, 1995; Sohn, 1995; Target and Fonagy, 1996a,b; Caper, 1998; Gabbard, 2000; Jackson, 2000; Robbins, 2002). Attention to ‘psychotic anxieties’ is of special interest to psychoanalysts: psychotic elements may occur in severe neuroses, psychosomatic disorders, sexual perversions, and personality disorders alongside neurotic constellations. Such patients are not psychotic per se, but are vulnerable to compromised ego functioning that creates confusion between internal and external realities. Research into the role of countertransference factors has confirmed the centrality of the therapist's responsiveness (particularly to psychotic anxieties) for successful treatment as well as the hazards of inattention to countertransference phenomena (Hinshelwood, 1994; Lieberz and Porsch, 1997).
Cognitive research into PPD supports a continuum model of persecutory beliefs (Peters et al., 1999) and outcome studies show the benefits of CBT with persecutory beliefs through studies of schizophrenia, delusional disorder, and psychosis (Garety and Freeman, 1999; Bentall et al., 2001; Pilling et al., 2002; Turkington et al., Chapter 14, this volume). Cuesta et al. (1999) found that negative symptoms were associated with premorbid SPD behavior. Tsuang et al. (2002) and Faraone et al. (2001) indicate that negative schizotypy (schizotaxia) is more common in relatives of people with schizophrenia than schizotypal features and is associated with neuropsychological deficit (this supports a continuum model between schizoid behavior and negative symptoms). Theory of mind deficits in schizophrenia (Pickup and Frith, 2001; Roncone et al., 2002) are reflected in schizoid children and adults who were diagnosed as schizoid as children (Wolff and Barlow, 1979; Chick et al., 1980). StPD research has focused on the transition to psychosis in high-risk schizotypal groups (Peters et al., 1999, McGorry et al., 2002a,b). CBT concepts and research data that are employed in the study of psychosis are applicable to the study of schizotypal states. However, all theories remain speculative.
Group and therapeutic community (TC) research traditionally addresses these fields at a descriptive level linked to case studies and qualitative data. No randomized controlled trials have been undertaken with group therapy for personality disorders. The use of validated research instruments is a relatively recent development. Roberts (1991) has described how schizoid people function in group analytic psychotherapy and makes suggestions for adjunct therapeutic measures and preparatory individual work. He concludes pessimistically that ‘the sad truth is that we have no sure way of enabling release from this confinement’. Henderson Hospital research demonstrated that severe personality disorders are likely to be diagnosable with numerous single disorders in more than one cluster (Dolan et al., 1995). The Henderson and units like it that offer residential treatment have yielded a reduction in personality disorder symptoms and interpersonal problems (Dolan et al., 1997; Chiesa and Fonagy, 2000). Canadian and Norwegian day unit TCs confirm similar improvements on the basis of greater involvement with the patient (Piper et al., 1996; Wilberg et al., 1999). A Cassel Hospital study, however, showed increased improvement for those who have a shorter inpatient program of 6 months, followed by outpatient group therapy and nursing support, compared with a longer inpatient program of 1 year. Both groups improved significantly more than matched treatment-as-usual controls (Chiesa and Fonagy, 2000). A Finnish TC program yielded long-term follow-up and predictive factors for successful engagement (Isohanni and Nieminen, 1992). See also Vaglum et al. (1990). A review of TCs demonstrated positive findings indicating that there is accumulating evidence, albeit at a low level of research, of the effectiveness and suitability of the TC model to the treatment of personality disorder, particularly severe personality disorder (Lees et al., 1999).
Psychodynamic and cognitive-behavioral practice principles will be addressed first, followed by group and TC concepts and practices.
Psychodynamic approaches pay special attention to transference–countertransference phenomena in order to grasp what is taking place in the therapeutic relationship. Without careful attention to the therapeutic alliance and interpretation of the transference—particularly the negative transference—treatment can founder, above all with PPD where levels of suspicion are high. In practice, this means that the therapist must try to understand how he or she is being experienced by the patient, not least in object relations terms (‘Who am I currently representing for the patient, and in what way?’) and to how the patient is making the therapist feel [e.g. ‘I am now experiencing strong feelings (these may be boredom, sexual, aggressive feelings, etc.): to what extent do these feelings originate in me or is the patient inducing me to feel these?’). The effects of splitting of the patient's ego and of the object (cf. the paranoid-schizoid position, Klein, 1946) underlie these transference/countertransference issues and can make treatment confusing and erratic. At one moment the therapist may be experienced positively, even as an idealized figure; this can change dramatically into the therapist being seen as a persecuting critic or tyrant. This can take place without the therapist saying anything controversial and signifies a radical disjuncture in the patient's affective experience of others. A nondefensive, nonconfrontational approach, and willingness on the part of the therapist to tolerate being a sufficiently ‘bad’ (i.e., inadequate) as well as good object is essential to facilitate basic trust and reduce splitting and projection. The more a patient can express true feelings in the transference, the more therapeutic the treatment is likely to be. Avoiding malignant regression is important. Regression is a defensive reversion, under stress, to earlier forms of thinking and object-relating and is often inevitable in therapy. Benign regression signifies a healthy satisfying of certain infantile needs by working these through collaboratively in the therapy. Malignant regression denotes a situation is which the patient tries but fails to have these needs met and the situation yields a vicious cycle of demanding, addiction-like states. The analyst's technique, countertransference responses and capacity for maintaining boundaries are important in avoiding malignant regression (Balint, 1968). To achieve the trust of a Cluster A patient the therapist must tolerate difficult, even extreme countertransference feelings. These feelings are commonplace because the patient will try to rid him or herself of unacceptable feelings by projecting them on to the therapist. This activity needs to be attended to for its communications value and for its potential to derail an understanding of the patient's emotional state if the therapist reacts in an overemotional way (Heimann, 1950; Carpy, 1989; Gabbard and Wilkinson, 1994). Negative therapeutic reactions (stubborn resistances to improvement usually following some improvement; cf. Freud, 1923; Riviere, 1936; Steiner, 1994) are to be expected and the separation anxieties, narcissistic rages, and envious impulses associated with these require interpretation. For SPD patients transference interpretation of claustro-agoraphobic anxieties is necessary (Rey, 1994). Actings-out by patients and crises over money, timings, holidays, etc. can arise and these may need to be responded to by reality-based, supportive interventions, together with interpretation of the anxieties being defended against.
An SPD patient in her 40s found that the separation anxiety evoked by gaps in the therapy (between sessions, breaks, etc.) made her want to quit. She could not ‘hear’ interpretations of her emotional distress, so focused was she on the concrete action of quitting. The therapist was able to say:
I understand your wish to stop your therapy and, of course, I have no power to stop you: it is a difficult undertaking for anyone and I think that recently you have been finding it especially painful (supportive intervention). You feel frustrated and hurt by the comings and goings to and from our sessions and are left having to cope with a great deal on your own. I think this makes you feel resentful and you feel like sacking me. It must feel very hard to talk about these feelings—perhaps even to reach them—maybe because you are afraid that I might not be able to stand you if you complain (interpretation of underlying anxieties).
By working through the crisis on these lines the patient gained insight into her fantasy of the destructiveness of her feelings and was able to begin to use thinking and speech rather than action to deal with her fear.
Awareness of deficit as well as conflict models is useful in understanding the quality of patients’ attachments as these can be primitive and confused. Therapeutic goals require realistic assessment and regular monitoring: progress may be slow and erratic with setbacks and perhaps limited eventual gains. Interpretation and explication together may be required to support movement from disorganized thinking towards integration of severe anxieties, especially in StPD where fragmentation of the ego may prevail. Nonetheless, StPD patients may reveal areas of reasonable ego strength; this, combined with less rigid defenses than SPD patients, may enable them to respond more readily to analytic interpretations and tolerate depressive affects. Family, psychiatric, and community support alongside therapy can improve outcome for all Cluster A patients.
Cognitive approaches tend be technically similar for all Cluster A disorders in that they target the pathological belief or system (‘schema’) and this helps particularly in the amelioration of maladaptive habits and in limit setting. Associated problems of depression and self-image are tackled as secondary phenomena. Establishing initial trust in the therapeutic relationship requires a flexible approach that is sensitive to changes in the patient's mental state. A neutral standpoint is maintained in relation to the patient's perspective of their problems alongside validation of the affective experience. The therapist teases out particular life circumstances and events that provide a context for the formation and maintenance of the patient's beliefs. One important difference between a psychodynamic and CBT perspective is that paranoid responses (these are common in Cluster A disorders) are not necessarily regarded as transference issues but instead as reactions to perceived threat. In CBT the patient is invited to test out their beliefs and to review evidence and alternative hypotheses. A new, more realistic model of events is constructed with the patient. The therapist and patient collaborate to examine and assess evidence for and against certain beliefs using behavioral experiments. Negative self-evaluations may be isolated and reviewed according to a more realistic appraisal of the person's circumstances. A typical intervention, in this case with a paranoid patient, is one that would be characteristic of work with Cluster A or psychotic patients (Kingdon and Turkington, 2002):
Mary is 62 and had suffered a prolonged paranoid illness that centered around a fear that her husband was being unfaithful. The first two CBT sessions were spent with Mary gathering information about her perception of her condition. The third session included her husband to gain his perspective. A full history was taken and a formulation arrived at that took into account Mary's long-standing negative view of herself, her vulnerability, and the severity of her conviction in her beliefs. An action plan was drawn up to consider her experiences as beliefs; to make links between her perceptions, beliefs, and affects; to test the beliefs as hypotheses; to draw up alternative hypotheses and to review evidence for both. Given Mary's high level of conviction in her beliefs it was important during the first main intervention (below) to validate their affective component and to link current feelings to previous experiences.
Therapist: So what seems to be happening now?
Mary: Well, George's daughter obviously wants the house to herself. That's why she said that. She can get all the money then, leaving me with nothing.
Therapist: How did you feel when you heard that?
Mary: Sick. Really bad. Worried. And angry.
Therapist: I can understand that. It must have been made even worse given your experiences with your mum—is that right?
Mary: Yes, that was a frightening time. Not knowing where we were going to end up that night.
Mary: George keeps stealing money from my purse. I don't know why he's doing it. He only needs to ask and I'd give it to him. I don't understand why he needs to steal.
Therapist: Any ideas as to what's going on here?
Mary: It must be because he's spending it on some other woman.
Therapist: What does George say about this?
Mary: Oh, he denies it, of course.
Therapist: Right. So money seems to be disappearing from your purse, and you believe that George is taking it?
Mary: Yes.
Therapist: And your explanation for that is that he must be spending it on another woman, otherwise he'd tell you, right?
Mary: Yes
Therapist: Does this situation remind you of any of your early experiences?
Mary: Oh yes. We were always running short of money when I was a child. And my first husband was always having affairs. We never had any money then either.
Therapist: Do you remember any feelings of insecurity around those times?
Mary: Of course!
Therapist: So is it possible that your memories of those experiences have stayed with you, and that as a result you may pay particular attention to things that are happening now that look the same?
Mary: Maybe. I hadn't really thought of it like that.
A link is being made here between Mary's current belief and her long-standing, ‘schematic’ beliefs in order to provide a rationale for the beliefs and relief from feelings of stigma around them. Subsequently, certain hypotheses were generated around the missing money, including that Mary may have spent it but forgotten about it. Mary was then set homework to monitor any incidents of forgetting, especially concerning money, and this proved to be fruitful. An incident of a forgotten bill she had already paid opened up a new, more questioning attitude in her towards her behavior in relation to money. As she discovered during her sessions that there were plausible, alternative explanations to a number of different situations, so her affective investment in her convictions waned and her psychotic symptoms gradually receded. Making narrative sense of symptoms and contextualizing their emergence, as in the above example, is often a crucial initial component in CBT, as a shared rationale is usually missing. The CBT therapist works collaboratively to develop a less distressing understanding of the patient's difficulties, and this can involve normalizing or destigmatizing the nature of disturbing experiences. Kingdon and Turkington cite a normalizing rationale during the interview of Sarah, a psychotic patient, which would also be applicable to a StPD patient. Sarah was asked during the initial meeting how her psychotic symptoms had arisen and she described how, at the time, she was suffering a serious physical injury, was sleep-deprived and that her husband was in serious dispute with neighbors. A distress-reducing, normalizing rationale was sought to help explain Sarah's symptoms as understandable in the context of her physical and mental stress at the time (Kingdon and Turkington, 2002, pp. 101–2). This explanation reduced Sarah's anxiety levels and allowed her to reflect upon the hypervigilance associated with her symptoms and how this might lead to misinterpretation of environmental cues. Once a more settled state was achieved the scene was set for further, systematic examination of beliefs and evidence.
Group approaches are based upon the conscious and unconscious network of relationships within groups, sometimes referred to as the ‘matrix’ (Blackwell, 1998). The emphasis lies on social functioning rather than individual unconscious drives (‘the whole is more elementary than the parts’). The ‘matrix’—or the way the group functions as a social unit—is a powerful agency. It is an object of attachment and a source of safety and containment, and these harbor therapeutic potential. Group analytic theory was developed by Foulkes, a psychoanalyst, who paved the way for understanding group relations processes (Foulkes, 1964, 1986). He identified processes in groups such as ‘resonance’, ‘condenser phenomenon’, and ‘mirroring’ through which unconscious activity can be described: (1) resonance involves shared experience of supportive identifications between group members; (2) condenser phenomena describe articulation of unconscious feelings through shared forms of symbolization; and (3) mirroring is where group members can observe and integrate split-off parts of themselves by seeing them in others and coming to understand them through engagement with the group. Nonverbal therapeutic techniques such as acceptance of silence without striving to explore or interpret (particularly for schizoid members), tolerance of oddness (for the schizotypal) and use of sympathetic eye contact can be therapeutically effective in addition to verbal interventions. Foulkes’ ideas have been applied to work in TCs (Rawlinson, 1999) where the activities of daily living offer a benefit to Cluster A patients as they can be engaged in therapeutic relationship building without needing to talk. They observe what goes on before starting to benefit from meaningful verbal contact. The psychoanalyst Wilfred Bion (1961) conceived of basic assumptions operating in groups, expressed through the activities of pairing, fight/flight, or dependency. These assumptions seemed to him to be innate or instinctual and underlie, and sometimes override, the conscious communication system (Hinshelwood, 2002). The treatment objective is to transcend basic assumptions and help group members establish a capacity for sustained relationships founded on concern and respect. Cluster A patients tend to not normally seek group psychotherapy and will leave if they find it aversive. Substantial effort at engagement is required, and members of the group usually support and encourage this. For extremes of pathology, such as Cluster A, the creation of groups with more than one individual with a Cluster A presentation can provide a more understanding therapeutic environment.
TC approaches embody two main precepts: the community as the agent of change and the TC culture of self-help. Typically, TCs are residential facilities and the resident is expected to adhere to certain behavioral norms. The resident may progress through a hierarchy of increasingly more important roles, with greater privileges and responsibilities. Individual and group therapy, group sessions with peers, community-based learning, confrontation, games, and role-playing may all be utilized as part of an extensive therapeutic experience. Identifying, expressing, and managing feelings are important goals, as is heightened awareness of the impact of attitudes and behaviors on oneself and the social environment. TC members often become role models who reflect the values and teachings of the community. TC treatment varies but can be broadly divided into three major stages: (1) induction during the first month or so in order to assimilate the individual into policies and procedures; (2) systematic involvement at multiple levels of engagement—individual, group and social using the methods described above (a typical day might start at 7 a.m. and end at 11 p.m. and comprise morning and evening community groups/meetings, groups, seminars, work tasks, individual therapy, and recreation); and (3) a phased transition into the outside world in which the values and practices of TC are carried into normal living.
Cluster A individuals are the least likely of the personality disorder groups to undertake psychotherapy of any kind due to their reduced capacity to engage in relationships. However, it does not follow that psychotherapy is automatically contraindicated: many patients do benefit from therapy. All forms of therapy face significant challenges with Cluster A patients, although their strategies for dealing with these differ. PPD patients threaten the therapeutic relationship through their suspiciousness and distorted conviction that hostility and danger are omnipresent. Alertness to signs of mounting suspiciousness is therefore essential: this needs to be responded to by transference interpretation (psychodynamic therapists), empathic discussion, and review of evidence for beliefs (CBT) and open acknowledgement within the matrix (group therapists). Directly confronting PPD beliefs by argument can have the effect of reinforcing the belief as PPD patients use projective identification extensively to externalize hostile impulses for fear of destroying the therapeutic relationship. The following is an extract from a psychoanalytic psychotherapy session with a 40-year-old patient with PPD symptoms. She suffered an internal, superego ‘voice’ that advised her against relationships. This exchange took place following a session in which the patient had felt understood and closer to the therapist. A negative therapeutic reaction had ensued:
Patient: You don't understand. My mother never understood me. When my grandmother was dying, she was very old, I tried to give her the kiss of life. I was breathing into her. I was trying to get her heart going. My mother thought I was hurting her. I wasn't. I wanted to keep her alive, not die. She didn't understand, she just didn't understand. You don't understand (she cried, paused, and then resumed her complaint that I didn't understand her for several more minutes, before suddenly stopping and shouting, in alarm). You're trying to kill me. (Pause)
Therapist: ‘I think you are afraid of what you could do to me if you make demands on me. When you complain about me, as you are doing now, a voice in your head warns you that I will retaliate, even want to kill you. I think that the voice is trying to stop you from telling me more of what you're really feeling.
In this example the therapist responds to both psychotic and nonpsychotic areas of mental functioning and attempts to interpret their relationship to each other, in the transference, in order to reduce the split between these different levels of anxiety. SPD patients are often unable to describe their difficulties in the way the above PPD patient does, and may remain withdrawn for long periods. This can be unrewarding, challenging, and confusing for the therapist. As disengagement from the emotional aspect of relationships is the hallmark of SPD, the task is to expand their atrophied capacity for human contact. This is not easy: for example, some SPD patients cry in sessions without realizing the fact that they are in pain. Or they may appear to regard their social isolation or interpersonal behavior as unproblematic and ignore the therapist's interventions. Long silences can be bewildering and the therapist might be tempted to make sense of the silence with intellectual interventions. These are likely to make the patient more, not less, anxious, especially if the intervention remains at a reconstructive level. Tolerating and addressing the cold, mechanical, deadening defenses of SPD is the challenge for the psychodynamic, cognitive, or group therapist. StPD, in contrast, often produces chaotic and eccentric thinking that may be mixed with paranoid and manic ideation. The patient may not be aware of the oddness of their beliefs and behavior and feel threatened if confronted. Ongoing assessment of the StPD patient's ego strength is therefore required. Containing the patient's multifarious anxieties and interpreting their fixed ideas (that sometimes resemble delusions) is necessary, as in this example:
A female StDP in her 50s presented for psychoanalytic therapy with symptoms of StPD and severe hysteria. She suffered intense, sometimes unmanageable anxiety and thought disorder; she exhibited eccentric behavior and was paranoid; her ego was fragmented and her sense of self fragile. It required a great deal of containing activity on the part of the therapist before the patient was able to begin to be able to talk about her feelings, as she was consumed by a delusional conviction that the therapist could not bear her. Containment and interpretation of terror of rejection and associated paranoid anxieties was the main therapeutic task. When she eventually did talk of her feelings, she was impeded by retching, inside and outside the sessions. This continued for some weeks: she carried a utensil/container with her and sometimes could not leave her bed for fear of dying or committing suicide. The therapist's countertransference experience was one of anxiety that she might not survive as well as frustration and resentment at her inability to speak. These countertransference responses enabled the therapist to interpret likely feelings the patient was holding at bay and to speculate as to why. Eventually the patient began to speak, little by little, of her lifelong tendency to be compliant, her frustrations and longings and an internal hatred that paralyzed her thinking.
The above is a somewhat severe but not altogether unusual StPD presentation and requires of the psychodynamic therapist patience, sensitivity, and a capacity to sustain various axes of apprehension that encompass conflict, deficit, and developmental perspectives. The cognitive therapist is likely to approach the situation differently and would focus on a more pragmatic course of assessing the patient's beliefs and ideas and their relationship to external reality. StPD patients who do manage to trust their therapist can develop a capacity to tolerate more depressive affect and anxiety than they had previously imagined. However, setting realistic goals for StPD is advisable, given the severity of the condition.
Group therapy faces its most severe obstacles in treating PPD patients who are likely to be hostile and aversive to group situations. They believe others reject them and as a result are rarely referred (Haigh, 1998). SPD patients can become responsive to group or community treatments given their long-standing failure to socialize and spirals of increasing withdrawal and isolation. Their isolation can undermine reality testing and group treatment can help to reverse this regressive trend. Individual and group treatment combined may be particularly effective for many of these patients. The excessive social anxiety in StPD that, without therapy, may not abate over time renders improved socialization difficult. However, the accessibility of these anxieties, which may at times be psychotic, can help make these patients more amenable to contact at deeper levels in group, analytic, and cognitive therapy.
There are serious difficulties in treating Cluster A patients whatever the therapeutic setting or modality, as these individuals have to a great extent fallen out of the orbit of normal human relations. They display defenses sometimes seen in psychosis and will not respond to a therapist who does not take seriously their loss of faith in people. This lost capacity to depend on others leaves its imprint on their internal world: failed internalization of trusting relationships generates chronic mistrust and anxiety. Because these patients tend not to present voluntarily for treatment, there is a need for more detailed research and documented clinical experience if their conditions are to be better understood. Once in treatment, a capacity in the therapist for flexibility will improve treatment prospects. A multimodal approach can be more valuable than a single therapy alone in managing multiple anxieties. For example, a period of asylum may be helpful for some patients; a combination of minimal medication with group and individual therapy has also been shown to benefit many patients (cf. Jackson and Williams, 1994). Many psychotherapists find it important to obtain psychiatric back-up during therapy to act as a support for both patient and therapist. However, it needs to be underscored that whatever the therapeutic context, insufficient research or outcome evidence is available to offer definitive conclusions regarding therapy for Cluster A patients.
Despite the difficulties and setbacks involved in treating Cluster A conditions, there can be significant rewards not least when basic trust and new forms of relating develop, often after decades of isolation and illness. Despite their cold, hostile, or bizarre behavior, Cluster A patients suffer painful, confusing feelings, and significant problems of self-esteem based on their fragmented personality structures and primitive self-representations. Therapeutic gains in these areas, although often limited, can make a considerable difference to the quality of their lives.