Moderating Severe Personality Disorders: A Personalized Psychotherapy Approach

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Moderating Severe Personality Disorders A Personalized Psychotherapy Approach Theodore Millon

Seth Grossman

John Wiley & Sons, Inc.

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Moderating Severe Personality Disorders

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Other Books in the Series Resolving Difficult Clinical Syndromes: A Personalized Psychotherapy Approach Theodore Millon and Seth Grossman Overcoming Resistant Personality Disorders: A Personalized Psychotherapy Approach Theodore Millon and Seth Grossman

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Moderating Severe Personality Disorders A Personalized Psychotherapy Approach Theodore Millon

Seth Grossman

John Wiley & Sons, Inc.

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∞ This book is printed on acid-free paper. 

C 2007 by John Wiley & Sons, Inc. All rights reserved. Copyright 

Published by John Wiley & Sons, Inc., Hoboken, New Jersey. Published simultaneously in Canada. Wiley Bicentennial Logo: Richard J. Pacifico No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400, fax (978) 646-8600, or on the web at www.copyright.com. Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, (201) 748-6011, fax (201) 748-6008, or online at http://www.wiley.com/go/permissions. Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts in preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives or written sales materials. The advice and strategies contained herein may not be suitable for your situation. You should consult with a professional where appropriate. Neither the publisher nor author shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold with the understanding that the publisher is not engaged in rendering professional services. If legal, accounting, medical, psychological or any other expert assistance is required, the services of a competent professional person should be sought. Designations used by companies to distinguish their products are often claimed as trademarks. In all instances where John Wiley & Sons, Inc. is aware of a claim, the product names appear in initial capital or all capital letters. Readers, however, should contact the appropriate companies for more complete information regarding trademarks and registration. For general information on our other products and services please contact our Customer Care Department within the United States at (800) 762-2974, outside the United States at (317) 572-3993 or fax (317) 572-4002. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. For more information about Wiley products, visit our web site at www.wiley.com. Library of Congress Cataloging-in-Publication Data: Millon, Theodore. Moderating severe personality disorders : a personalized psychotherapy approach / Theodore Millon, Seth Grossman. p. ; cm. Includes bibliographical references. ISBN 978-0-471-71772-0 (pbk. : alk. paper) 1. Personality disorders–Treatment. 2. Psychotherapy. I. Grossman, Seth. II. Title. [DNLM: 1. Personality Disorders–therapy. 2. Psychotherapy–methods. WM 190 M656m 2007] RC554.M5424 2007 616.85 8106–dc22 2006037557 Printed in the United States of America. 10

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To all our patients of the past 50 years

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CONTENTS

Preface

ix

Part One CHAPTER 1

Personalized Psychotherapy: A Recapitulation

3

Part Two CHAPTER 2 CHAPTER 3 CHAPTER 4 CHAPTER 5 CHAPTER 6

Personalized Therapy for the Retiring/Schizoid Personality Patterns

51

Personalized Therapy for the Shy/Avoidant Personality Patterns

85

Personalized Therapy for the Pessimistic/Depressive Personality Patterns

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Personalized Therapy for the Aggrieved/Masochistic Personality Patterns

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Personalized Therapy for the Eccentric/Schizotypal Personality Patterns

195 vii

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viii CONTENTS CHAPTER 7 CHAPTER 8

Personalized Therapy for the Capricious/Borderline Personality Patterns

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Personalized Therapy for the Suspicious/Paranoid Personality Patterns

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References

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Index

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PREFACE

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ould it not be a great step forward in our field if diagnosis or psychological assessment, following a series of interviews, tests, or laboratory procedures, actually pointed clearly to what a clinician should do in therapy? Would it not be good if evaluations could spell out which specific features of a patient’s psychological makeup are fundamentally problematic—biological, cognitive, interpersonal—and therefore deserved primary therapeutic attention? Is it not time for clinicians to recognize that diagnosis can lead directly to the course of therapy? This diagnosis-to-therapy goal can be achieved by employing treatment-oriented assessment tools (e.g., the Millon Clinical Multiaxial Inventory III Facet Scales, the Millon-Grossman Personality Disorder Checklist). “Personalized psychotherapy” is not a vague concept or a platitudinous buzzword in our treatment approach, but an explicit commitment to focus first and foremost on the unique composite of a patient’s psychological makeup. That focus should be followed by a precise formulation and specification of therapeutic rationales and techniques to remedy those personal attributes that are assessed as problematic. Therapists should take cognizance of the person from the start, for the psychic parts and environmental contexts take on different meanings and call for different responses depending on the specific person to whom they are anchored. To focus on one social structure or one psychological realm of expression, without understanding its undergirding or reference base, is to engage in potentially misguided, if not random, therapeutic techniques. Fledgling therapists should learn further that the symptoms and disorders we diagnose represent but one or another segment of a complex of organically interwoven psychological elements. The significance of each clinical feature can best be grasped by reviewing a

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x PREFACE

patient’s unique psychological experiences and his or her overall psychic pattern or configurational dynamics, of which any one component is but a single part. Therapies that conceptualize clinical disorders from a single perspective, be it psychodynamic, cognitive, behavioral, or physiological, may be useful, and even necessary, but are not sufficient in themselves to undertake a therapy of the patient, disordered or not. The revolution we propose asserts that clinical disorders are not exclusively behavioral or cognitive or unconscious, that is, confined to a particular expressive form. The overall pattern of a person’s traits and psychic expressions are systemic and multioperational. No part of the system exists in complete isolation from the others. Every part is directly or indirectly tied to every other, such that there is an emergent synergism that accounts for a disorder’s clinical tenacity. Personality is real; it is a composite of intertwined elements whose totality must be reckoned with in all therapeutic enterprises. The key to treating our patients, therefore, lies in therapy that is designed to be as organismically complex as the person himself or herself; this form of therapy should generate more than the sum of its parts. Difficult as this may appear, we hope to demonstrate its ease and utility. If our wish takes root, this book will serve as a revolutionary call, a renaissance that brings therapy back to the natural reality of patients’ lives. It is our hope that the book will lead all of us back to reality by exploring both the unique intricacy and the wide diversity of the patients we treat. Despite frequent brilliance, most single-focus schools of therapy (e.g., behavioral, psychoanalytic) have become inbred. Of more concern, they persist in narrowing the clinicians’ attention to just one or another facet of their patients’ psychological makeup, thereby wandering ever farther from human reality. They cease to represent the full richness of their patients’ lives, considering as significant only one of several psychic spheres: the unconscious, biochemical processes, cognitive schemas, or some other. In effect, what has been taught to most fledgling therapists is an artificial reality, one that may have been formulated in its early stages as an original perspective and insightful methodology, but has drifted increasingly from its moorings over time, no longer anchored to the complex clinical reality from which it was abstracted. How does our therapeutic approach differ from others? In essence, we come to the treatment task not with a favored theory or technique, but with the patient’s unique constellation of personality attributes given center stage. Only after a thorough evaluation of the nature and prominence of these personal attributes do we think through which combination and sequence of treatment orientations and methodologies we should employ. It should be noted that a parallel personalized approach to physical treatment has currently achieved recognition in what is called genomic medicine. Here medical scientists have begun to tinker with a particular patient’s DNA so as to decipher and remedy existing, missing, or broken genes, thereby enabling the physician to tailor treatment in a highly personalized manner, that is, specific to the underlying or core genetic defects of that particular patient. Anomalies that are etched into a patient’s

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Preface xi

unique DNA are screened and assessed to determine their source, the vulnerabilities they portend, and the probability of the patient’s succumbing to specific manifest diseases. As detailed in the first chapter of the first book of this Personalized Psychotherapy series, we have formulated eight personality components or domains comprising what we might term a psychic DNA, a framework that conceptually parallels the four chemical elements composing biologic DNA. Deficiencies, excesses, defects, or dysfunctions in these psychic domains (e.g., mood/temperament, intrapsychic mechanisms) effectively result in a spectrum of 15 manifestly different variants of personality styles and pathology (e.g., avoidant style, borderline disorder). It is the unique constellation of vulnerabilities as expressed in and traceable to one or several of these eight potentially problematic psychic domains that become the object and focus of personalized psychotherapy (in the same manner as the vulnerabilities in biologic DNA result in a variety of different genomically based diseases). In the first book of the personalized series, we attempt to show that all the clinical syndromes that constitute Axis I can be understood more clearly and treated more effectively when conceived as an outgrowth of a patient’s overall personality style. To say that depression is experienced and expressed differently from one patient to the next is a truism; so general a statement, however, will not suffice for a book such as this. Our task requires much more. The first book focuses on resolving difficult clinical syndromes of Axis I of the Diagnostic and Statistical Manual of Mental Disorders; it provides extensive information and illustrations on how patients with different personality vulnerabilities react to and cope with life’s stressors. With this body of knowledge in hand, therapists should be guided to undertake more precise and effective treatment plans. For example, a dependent person will often respond to a divorce situation with feelings of helplessness and hopelessness, whereas a narcissist faced with similar circumstances may respond in a disdainful and cavalier way. Even when both a dependent and a narcissist exhibit depressive symptoms in common, the precipitant of these symptoms will likely have been quite different; furthermore, treatment—its goals and methods—should likewise differ. In effect, similar symptoms do not call for the same treatment if the pattern of patient vulnerabilities and coping styles differ. In the case of dependents, the emotional turmoil may arise from their feelings of lower self-esteem and their inability to function autonomously; in narcissists, depression may be the outcropping of failed cognitive denials as well as a consequent collapse of their habitual interpersonal arrogance. Whether we work with a clinical syndrome’s “part functions” as expressed in behavior (social isolation), or cognitions (a delusional belief ), or affect (depression), or a biological defect (appetite loss) or we address contextual systems that focus on the larger environment, the family, or the group, or the socioeconomic and political conditions of life, the crossover point, the place that links the varieties of clinical expression to the individual’s social context, is the person. The person is the intersecting medium that brings functions and systems together. Persons, however, are more than just crossover

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xii PREFACE

mediums. As we elaborate in the first book of the series, they are the only organically integrated system in the psychological domain, inherently created from birth as natural entities. Moreover, it is the person who lies at the heart of the therapeutic experience, the substantive being who gives meaning and coherence to symptoms and traits—be they behaviors, affects, or mechanisms—as well as that being, that singular entity, who gives life and expression to family interactions and social processes. Looking at a patient’s totality can present a bewildering if not chaotic array of therapeutic possibilities, potentially driving even the most motivated young clinician to back off into a more manageable and simpler worldview, be it cognitive or pharmacologic. But as we contend here, complexity need not be experienced as overwhelming; nor does it mean chaos, if we can create a logic and order to the treatment plan. We try to provide logic and order by illustrating that the systematic integration of an Axis I syndrome into its foundation in an Axis II disorder is not only feasible, but is one that is conducive to both briefer and more effective therapy. We should note, however, that a therapeutic method, no matter how logical and rational it may be, can never achieve the precision of the physical sciences. In our field we must be ever alert to the many subtle variations and sequences, as well as the constantly evolving forces, that compose the natural course of human life. We are pleased to report that an excellent 240-minute videotape entitled “DSM-IV Personality Disorders: The Subtypes” has been produced and is distributed by Insight Media (800-233-9910, www.Insight-Media.com), psychology’s premier publisher of videos and CD-Roms. It is available for purchase by instructors and clinicians who wish to view over 60 case vignettes that illustrate all DSM-IV personality prototypes and subtypes, as interviewed by psychologists and discussed by the senior author of this book. THEODORE MILLON SETH D. GROSSMAN Coral Gables, Florida

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ONE

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CHAPTER

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Personalized Psychotherapy: A Recapitulation

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his chapter is written for readers not fully acquainted with Chapter 1 of the first book, Resolving Difficult Clinical Syndromes, of this Personalized Psychotherapy series (Millon & Grossman, 2007). It provides a brief synopsis of the essential themes and rationale of this new approach to psychotherapy. Are not all psychotherapies personalized? Do not all therapists concern themselves with the person who is the patient they are treating? What justifies our appropriating the name “personalized” to the treatment approach we espouse? Are we not usurping a universal, laying claim to a title that is commonplace, routinely shared and employed by most (all?) therapists? We think not. In fact, we believe most therapists only incidentally or secondarily attend to the specific personal qualities of their patients. The majority come to their treatment task with a distinct if implicit bias, a preferred theory or technique they favor, one usually encouraged, sanctioned, and promoted in their early training, be it cognitive, group, family, eclectic, pharmacologic, or what have you. How does our therapeutic approach differ? In essence, we come to the treatment task not with a favored theory or technique, but giving center stage to the patient’s unique constellation of personality attributes. Only after a thorough evaluation of the nature and prominence of these personal attributes do we think through which combination and sequence of treatment orientations and methodologies we should employ. “Personalized” is therefore not a vague concept or a platitudinous buzzword in our approach, but an explicit commitment to focus first and foremost on the unique composite of a patient’s psychological makeup, followed by a precise formulation

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4 PERSONALIZED PSYCHOTHERAPY: A RECAPITULATION

and specification of therapeutic rationales and techniques suitable to remedying those personal attributes that are assessed as problematic. We have drawn on two concepts from our earlier writings, namely, personalityguided therapy (Millon, 1999) and synergistic therapy (Millon, 2002), integrating them into what we have now labeled “personalized psychotherapy.” Both prior concepts remain core facets of our current treatment formulations in that, first, they are guided by the patient’s overall personality makeup and, second, they are methodologically synergistic in that they utilize a combinational approach that employs reciprocally interacting and mutually reinforcing treatment modalities that produce a greater total result than the sum of their individual effects. The preface recorded a parallel “personalized” approach to physical treatment recognition in what is called genomic medicine. Here medical scientists have begun to investigate a particular patient’s DNA so as to decipher and remedy existing, missing or broken genes, thereby enabling the physician to tailor treatment in a highly personalized manner, that is, specific to the underlying or core genetic defects of that particular patient. Anomalies that are etched into a patient’s unique DNA are screened and assessed to determine their source, the vulnerabilities they portend, and the probability of the patient’s succumbing to specific manifest diseases. Personalized psychological assessment is therapy-guiding; it undergirds and orients personalized psychotherapy. Together, they should be conceived as corresponding to genomic medicine in that they seek to identify the unique constellation of underlying vulnerabilities that characterize a particular mental patient and the consequent likelihood of his or her succumbing to specific mental clinical syndromes. In personalized assessment, we seek to employ customized instruments, such as the Grossman Facet Scales of the Millon Clinical Multiaxial Inventory (MCMI-III), to identify the patient’s vulnerable psychic domains (e.g., cognitive style, interpersonal conduct). These assessment data furnish a foundation and a guide for implementing the distinctive individualized goals we seek to achieve in personalized psychotherapy. As will be detailed in later sections, we have formulated eight personality components or domains constituting what we term a psychic DNA, a framework that conceptually parallels the four chemical elements composing biologic DNA. Deficiencies, excesses, defects, or dysfunctions in these psychic domains (e.g., mood/temperament, intrapsychic mechanisms) effectively result in a spectrum of 15 manifestly different variants of personality pathology (e.g., Avoidant Disorder, Borderline Disorder). It is the unique constellation of vulnerabilities as expressed in and traceable to one or several of these eight potentially problematic psychic domains that becomes the object and focus of personalized psychotherapy (in the same manner as the vulnerabilities in biologic DNA result in a variety of different genomically based diseases). Psychotherapy has been dominated until recently by what might be termed domainor modality-oriented therapy. That is, therapists identified themselves with a singlerealm focus or a theoretical school (behavioral, intrapsychic) and attempted to practice within whatever prescriptions for therapy it made. Rapid changes in the therapeutic milieu, all interrelated through economic pressures, conceptual shifts, and diagnostic

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Personalized Psychotherapy: A Recapitulation

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innovations, have taken place in the past few decades. For better or worse, these changes show no sign of decelerating and have become a context to which therapists, far from reversing, must now themselves adapt. The simplest way to practice psychotherapy is to approach all patients as possessing essentially the same disorder, and then utilize one standard modality of therapy for their treatment. Many therapists still employ these simplistic models. Yet everything we have learned in the past 2 or 3 decades tells us that this approach is only minimally effective and deprives patients of other, more sensitive and effective approaches to treatment. In the past 2 decades, we have come to recognize that patients differ substantially in the clinical syndromes and personality disorders they present. It is clear that not all treatment modalities are equally effective for all patients, be it pharmacologic, cognitive, intrapsychic, or another mode. The task set before us is to maximize our effectiveness, beginning with efforts to abbreviate treatment, to recognize significant cultural considerations, to combine treatment, and to outline an integrative model for selective therapeutics. When the selection is based on each patient’s personal trait configuration, integration becomes what we have termed personalized psychotherapy, to be discussed in the next section. Present knowledge about combinational and integrative therapeutics has only begun to be developed. In this section we hope to help overcome the resistance that many psychotherapists possess to the idea of utilizing treatment combinations of modalities that they have not been trained to exercise. Most therapists have worked long and hard to become experts in a particular technique or two. Though they are committed to what they know and do best, they are likely to approach their patients’ problems with techniques consonant with their prior training. Unfortunately, most modern therapists have become expert in only a few of the increasingly diverse approaches to treatment and are not open to exploring interactive combinations that may be suitable for the complex configuration of symptoms most patients bring to treatment. In line with this theme, Frances, Clarkin, and Perry (1984, p. 195) have written: The proponents of the various developing schools of psychotherapy tended to maintain the pristine and competitive purity of their technical innovations, rather than attempt to determine how these could best be combined with one another. There have always been a few synthesizers and bridgebuilders (often derided from all sides as “eclectic”) but, for the most part, clinicians who were trained in one form of therapy tended to regard other types with disdain and suspicion.

The inclination of proponents of one or another modality of therapy to remain separate was only in part an expression of treatment rivalries. During the early phases of a treatment’s development, innovators, quite appropriately, sought to establish a measure of effectiveness without having their investigations confounded by the intrusion of other modalities. No less important was that each treatment domain was but a single dimension in the complex of elements that patients bring to us. As we move away from a simple medical model to one that recognizes the psychological complexity of patients’ symptoms and causes, it appears wise to mirror the patients’ complexities by developing therapies that are comparably complex.

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6 PERSONALIZED PSYCHOTHERAPY: A RECAPITULATION

As will be elaborated throughout the text, certain combinational approaches have an additive effect; others may prove to possess a synergistic effect (Klerman, 1984). The term additive describes a situation in which the combined benefits of two or more treatments are at least equal to the sum of their individual benefits. The term synergistic describes a situation in which the combined benefits of several treatment modalities exceed the sum of their individual components; that is, their effects are potentiated. This entire book series is intended to show that several modalities— pharmacotherapy, cognitive therapy, family therapy, intrapsychic therapy—may be combined and integrated to achieve additive, if not synergistic, effects. It is our view that psychopathology itself contains structural implications that legislate the form of any therapy one would propose to remedy its constituents. Thus, the philosophy we present derives from several implications and proposes a new integrative model for therapeutic action, an approach that we have called personalized psychotherapy. This model, which is guided by the psychic makeup of a patient’s personality—and not a preferred theory or modality or technique—gives promise, we believe, of a new level of efficacy and may, in fact, contribute to making therapy briefer. Far from being merely a theoretical rationale or a justification for adhering to one or another treatment modality, it should optimize psychotherapy by tailoring treatment interventions to fit the patient’s specific form of pathology. It is not a ploy to be adopted or dismissed as congruent or incongruent with established therapeutic preferences or modality styles. Despite its name, we believe that what we have termed a personalized approach will be effective not only with Axis II personality disorders, but also with Axis I clinical syndromes. Integration should be more than the coexistence of two or three previously discordant orientations or techniques. We cannot simply piece together the odds and ends of several theoretical schemas, each internally consistent and oriented to different data domains. Such a hodgepodge will lead only to illusory syntheses that cannot long hold together (Messer, 1986, 1992). Efforts such as these, meritorious as they may be in some regards, represent the work of peacemakers, not innovators and not integrationists. Integration is eclectic, of course, but more. As we will argue further, it is our belief that integration should be a synthesized system to mirror the problematic configuration of traits (personality) and symptoms (clinical syndromes) of a specific patient-at-hand. In the next section, we discuss integration from this view. Many in the past have sought to coalesce differing theoretical orientations and treatment modalities with interconnecting bridges. By contrast, those of us in the personalized therapeutic persuasion bypass the synthesis of theory. Rather, primary attention should be given to the natural synthesis or inherent integration that may be found within patients themselves. As Arkowitz (1997) has noted, efforts to create a theoretical synthesis are usually not fully integrative in that most theorists do not draw on component approaches equally. Most are oriented to one particular theory or modality, and then seek to assimilate other strategies and notions to that core approach. Moreover, assimilated theories and techniques are invariably changed by the core model into which they have been imported. In other words, the assimilated orientation or methodology is

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frequently transformed from its original intent. As Messer (1992, p. 151) wrote, “When incorporating elements of other therapies into one’s own, a procedure takes its meaning not only from its point of origin, but even more so from the structure of the therapy into which it is imported.” Messer illustrates this point by describing a two-chair gestalt procedure that is brought into a primary social-learning model; in this assimilation, the two-chair procedure will likely be utilized differently and achieve different goals than would occur in the hands of a gestalt therapist using the same technique. Furthermore, by seeking to impose a theoretical synthesis, therapists may lose the context and thematic logic that each of the standard theoretical approaches has built up over its history. In essence, intrinsically coherent theories are usually disassembled in the effort to interweave their diverse bits and pieces. Such an integrative model composed of alternative models (behavioral, psychoanalytic) may be pluralistic, but it reflects separate modalities with varying conceptual networks and their unconnected studies and findings. As such, integrative models do not reflect that which is inherent in nature, but invent a schema for interweaving that which is, in fact, essentially discrete. As will be discussed in the following section, intrinsic unity cannot be invented, but can be discovered in nature by focusing on the intrinsic unity of the person, that is, the full scope of a patient’s psychic being. Integration based on the natural order and unity of the person avoids the rather arbitrary efforts at synthesizing disparate and sometimes disjunctive theoretical schemas. Efforts at synthesizing therapeutic models have been most successful in desegregating the field rather than truly integrating it. As Arkowitz (1997, pp. 256–257) explains: Integrative perspectives have been catalytic in the search for new ways of thinking about and doing psychotherapy that go beyond the confines of single-school approaches. Practitioners and researchers are examining what other theories and therapies have to offer. . . . Several promising starts have been made in clinical proposals for integrative therapies, but it is clear that much more work needs to be done.

As noted, it is the belief of the authors that integration cannot stem from an intellectual synthesis of different theories, but from the inherent integration that is discovered in each patient’s personal style of functioning, a topic to which we now turn. Unlike eclecticism, integration insists on the primacy of an overarching gestalt that gives coherence, provides an interactive framework, and creates an organic order among otherwise discrete units or elements. Whereas the theoretical syntheses previously discussed attempt to provide an intellectual bridge across several theories or modalities, personalized integrationists assert that a natural synthesis already exists within the patient. As we better understand the configuration of traits that characterize each patient’s psyche, we can better devise a treatment plan that will mirror these traits and, we believe, will provide an optimal therapeutic course and outcome. As noted previously, integration is an important concept in considering not only the psychotherapy of the individual case but also the place of psychotherapy in clinical science. For the treatment of a particular patient to be integrated, the elements of a

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8 PERSONALIZED PSYCHOTHERAPY: A RECAPITULATION

clinical science—theory, taxonomy, assessment, and therapy—should be integrated as well (Millon, 1996b). One of the arguments advanced earlier against empirically based eclecticism is that it further insulates psychotherapy from a broad-based clinical science. In contrast to eclecticism, where techniques are justified empirically, personalized psychotherapeutic integration should take its shape and character from an integrative theory of human nature. Such a grand theory should be inviting because it attempts to explain all of the natural variations of human behavior, normal or otherwise; moreover, personalized psychotherapy will grow naturally out of such a personalized theory. Theory of this nature will not be disengaged from therapeutic technique; rather, it will inform and guide it. Murray (1983) has suggested that the field must develop a new, higher order theory to help us better understand the interconnections among cognitive, affective, self, and interpersonal psychic systems. It is the belief of personalized therapeutic theorists, such as ourselves, who claim that interlinked configurations of pathology deduced from such a theory can serve to guide psychotherapy. Although differential treatment gives special weight to the specific problem areas of the patient, most theorists and therapists pay little attention to the particular domains composing different diagnostic categories. We argue for considering the configuration of personality traits that characterize each specific patient. Differential treatment recognizes that current diagnostic information, such as listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV ), provides only a surface coverage of the complex elements that are associated with a patient’s inner and outer worlds. As noted previously, whether we work with “part functions” that focus on behaviors, cognitions, unconscious processes, or biological defects, or whether we address contextual systems that focus on the larger environment, the family, the group, or the socioeconomic and political conditions of life, the crossover point, the place that links parts to contexts, is the person. The individual is the intersecting medium that brings them together. Persons, however, are more than crossover mediums. They are the only organically integrated system in the psychological domain, inherently created from birth as natural entities, rather than experience-derived gestalts constructed via cognitive attribution. Moreover, it is persons who lie at the heart of the psychotherapeutic experience, the substantive beings that give meaning and coherence to symptoms and traits—be they behaviors, affects, or mechanisms—as well as those beings, those singular entities, that give life and expression to family interactions and social processes. The cohesion (or lack thereof ) of intrinsically interwoven psychic structures and functions is what distinguishes most complex disorders of psychopathology; likewise, the orchestration of diverse, yet synthesized modalities of intervention is what differentiates synergistic from other variants of psychotherapy. These two parallel constructs, emerging from different traditions and conceived in different venues, reflect shared philosophical perspectives, one oriented toward the understanding of mental disorders, the other toward effecting their remediation.

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It is not that one-modality or school-oriented psychotherapies are inapplicable to more focal or simple syndrome pathologies, but rather that synergistically planned therapies are required for the intricate relationships that interconnect personality and clinical syndromes (whereas depression may successfully be treated either cognitively or pharmacologically); it is the very interwoven nature of the components that compose such complex disorders that makes a multifaceted and synthesized approach a necessity. In the following pages we present a few ideas in sequence. First, personalized therapies require a foundation in a coordinating theory of nature, that is, they must be more than a schema of eclectic techniques, a hodgepodge of diverse alternatives assembled de novo with each case. Second, although the diagnostic criteria that make up DSM syndromes are a decent first step, these criteria must become comprehensive and comparable, that is, be systematically revised so as to be genuinely useful for treatment planning. Third, a logical rationale can be formulated as to how one can and should integrate diverse modality-focused therapies when treating complex psychopathologies. Before turning to these themes, we would like to comment briefly on some philosophical issues. They bear on a rationale for developing a wide-ranging theory of nature to serve as a basis for treatment techniques, that is, universal principles that transcend the merely empirical (e.g., electroconvulsive therapy for depressives). It is our conviction that the theoretical foundations of our personologic science must be advanced further if we are to succeed in constructing a personalized approach to psychotherapy. Obviously, a tremendous amount of knowledge, both about the nature of the patient’s disorders and about diverse modes of intervention, is required to perform personalized therapy. To maximize synergism among numerous modalities requires that the therapist be a little like a jazz soloist. Not only should the professional be fully versed in the various musical keys, that is, in techniques of psychotherapy that span all trait domains, but he or she should also be prepared to respond to subtle fluctuations in the patient’s thoughts, actions, and emotions, any of which could take the composition in a wide variety of directions, and integrate these with the overall plan of therapy as it evolves. After the instruments have been packed away and the band goes home, a retrospective account of the entire process should reveal a level of thematic continuity and logical order commensurate with that which would have existed had all relevant constraints been known in advance. The integrative processes of personalized therapy should be dictated by the nature of personality itself. The actual logic and foundation of this therapy, however, must be grounded on some other basis. Psychopathology is by definition a patterning of intraindividual variables, but the nature of these variables must be supplied by a set of fundamental principles or on some basis beyond the personologic construct. In our view, for example, the structure and functions of personality and psychopathology are grounded in evolutionary theory, a discipline that informs but exists apart from our clinical subject. In and of itself, pathologic personality is a structural-functional concept that refers to the intraorganismic patterning of variables; it does not in itself say what these variables are or how they relate, nor can it.

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10 PERSONALIZED PSYCHOTHERAPY: A RECAPITULATION

We believe that several elements characterize all mature clinical sciences: (a) They embody conceptual theories based on universal principles of nature from which their propositional deductions can be derived; (b) these theories provide the basis for coherent taxonomies that specify and characterize the central features of their subject domain (in our case, that of personality and psychopathology, the substantive realm within which scientific psychotherapeutic techniques are applied); (c) these taxonomies are associated with a variety of empirically oriented assessment instruments that can identify and quantify the concepts that constitute their theories (in psychopathology, methods that uncover developmental history and furnish cross-sectional assessments); and (d) in addition to natural theory, clinical taxonomy, and empirically anchored assessment tools, mature clinical sciences possess change-oriented intervention techniques that are therapeutically optimal in modifying the pathological elements of their domain. Most current therapeutic schools share a common failure to coordinate these four components of a mature science. What differentiates them has less to do with their scientific grounding than with the fact that they attend to different levels of data in the natural world. It is to the credit of those of an eclectic persuasion that they have recognized, albeit in a fuzzy way, the arbitrary if not illogical character of single-focus positions, as well as the need to bridge schisms among these approaches that have evolved less by philosophical considerations or pragmatic goals than by the accidents of history (Millon, 2004). There are numerous other knotty issues with which the nature of psychic pathology and personalized therapy must contend (e.g., differing worldviews concerning the essential nature of psychological experience). There is no problem, as we see it, in encouraging active dialectics among these contenders. However, there are two important barriers that stand in the way of personalized psychotherapy as a treatment philosophy. The first is the DSM. The idea of diagnostic prototypes was a genuine innovation when the DSM-III was published in 1980. The development of diagnostic criteria work groups was intended to provide broad representation of various points of view, while preventing any single perspective from foreclosing on the others. Even some 25 years later, however, the DSM has yet to officially endorse an underlying set of principles that would interrelate and differentiate the categories in terms of their deeper principles. Instead, progress proceeds mainly by way of committee consensus, cloaked by the illusion of empirical research. The second barrier is the human habit system. The admonition that different therapeutic approaches should be pursued with different patients and different problems has become almost self-evident. But given no logical basis from which to design effective therapeutic sequences and composites, even the most self-consciously antidogmatic clinician must implicitly lean toward one orientation or another. What specifically are the procedures that distinguish personalized therapy from other models of an eclectic nature? The integrative model labeled 2 decades ago by the senior author as “personologic psychotherapy” (Millon, 1988) insisted on the primacy of an overarching gestalt that gave coherence, provided an interactive framework, and created an organic order among otherwise discrete polarities and attributes. It was eclectic, but more. It was derived

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from a substantive theory whose overall utility and orientation derives from that old chestnut, “The whole is greater than the sum of its parts.” The problems our patients bring to us are often an inextricably linked nexus of interpersonal behaviors, cognitive styles, regulatory processes, and so on. They flow through a tangle of feedback loops and serially unfolding concatenations that emerge at different times in dynamic and changing configurations. Each component of these configurations has its role and significance altered by virtue of its place in these continually evolving constellations. In parallel form, personalized therapy should be conceived as an integrated configuration of strategies and tactics in which each intervention technique is selected not only for its efficacy in resolving particular pathological attributes, but also for its contribution to the overall constellation of treatment procedures of which it is but one integral part. Although the admonition that we should not employ the same therapeutic approach with all patients is self-evident, it appears that therapeutic approaches accord more with where training occurred than with the nature of the patients’ pathologies. To paraphrase Millon (1969/1985), there continues to be a disinclination among clinical practitioners to submit their cherished techniques to detailed study or to revise them in line with critical empirical findings. Despite the fact that most of our therapeutic research leaves much to be desired in the way of proper controls, sampling, and evaluative criteria, one overriding fact comes through repeatedly: Therapeutic techniques must be suited to the patient’s problem. Simple and obvious though this statement is, it is repeatedly neglected by therapists who persist in utilizing and argue heatedly in favor of a particular approach to all variants of psychopathology. No school of therapy is exempt from this notorious attitude. Why should we formulate a personalized therapeutic approach to psychopathology? The answer may be best grasped if we think of the psychic elements of a person as analogous to the sections of an orchestra, and the trait domains of a patient as a clustering of discordant instruments that exhibit imbalances, deficiencies, or conflicts within these sections. To extend this analogy, therapists may be seen as conductors whose task is to bring forth a harmonious balance among all the sections, as well as their specifically discordant instruments, muting some here, accentuating others there, all to the end of fulfilling the conductor’s knowledge of how the composition can best be made consonant. The task is not that of altering one instrument, but of altering all, in concert. What is sought in music, then, is a balanced score, one composed of harmonic counterpoints, rhythmic patterns, and melodic combinations. What is needed in therapy is a likewise balanced program, a coordinated strategy of counterpoised techniques designed to optimize sequential and combinatorial treatment effects. If clinical syndromes were anchored exclusively to one particular trait domain (as phobias are thought to be primarily behavioral in nature), modality-bound psychotherapy would always be appropriate and desirable. Psychopathology, however, is not exclusively behavioral, cognitive, biologic, or intrapsychic, that is, confined to a particular clinical data level. Instead, it is multioperational and systemic. No part of the system exists in complete isolation. Instead, every part is directly or indirectly tied to every other, such that a synergism lends the whole a tenacity that makes the full system of

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12 PERSONALIZED PSYCHOTHERAPY: A RECAPITULATION

pathology “real”—a complex that needs to be fully reckoned with in a comprehensive therapeutic endeavor. Therapies should mirror the configuration of as many trait and clinical domains as the syndromes and disorders they seek to remedy. If the scope of the therapy is insufficient relative to the scope of the pathology, the treatment system will have considerable difficulty fulfilling its meliorative and adaptive goals. Both unstructured intrapsychic therapy and highly structured behavioral techniques, to note the extremes, share this deficiency. Psychopathology is neither exclusively behavioral, exclusively cognitive, nor exclusively interpersonal, but is instead a genuine integration of each of its subsidiary domains. Far from overturning established paradigms, such a broad perspective simply allows a given phenomenon to be treated from several angles, so to speak. Even agnostic therapists, with no strong allegiance to any one point of view, may avail themselves of a kaleidoscope of modalities. By turning the kaleidoscope, by shifting paradigmatic sets, the same phenomenon can be viewed from any of a variety of internally consistent perspectives. Eclecticism becomes a first step toward synthesizing modalities that correspond to the natural configuration of each patient’s traits and disorders. The open-minded therapist is left, however, with several different modality combinations, each with some currency for understanding the patient’s pathology, but no real means of bringing these diverse conceptions together in a coherent model of what, exactly, to do. The therapist’s plight is understandable, but not acceptable. For example, modality techniques considered fundamental in one perspective may not be so regarded in another. The interpersonal model of Lorna Benjamin and the neurobiological model of Robert Cloninger are both structurally strong approaches to understanding personality and psychopathology. Yet their fundamental constructs are different. Rather than inherit the modality tactics of a particular perspective, then, a theory of psychotherapy as a total system should seek some set of principles that can be addressed to the patient’s whole psyche, thereby capitalizing on the naturally organic system of the person. The alternative is an uncomfortable eclecticism of unassimilated partial views. Perhaps believing that nothing more is possible, most psychotherapists have accepted this state of affairs as an inevitable reality. Fortunately, modality-bound psychotherapies are increasingly becoming part of the past. In growing numbers, clinicians are identifying themselves, not as psychodynamic or behavioral, but as eclectic or integrative. As noted earlier, eclecticism is an insufficient guide to personalized therapy. As a movement, and not a construct, it cannot prescribe the particular form of those modalities that will remedy the pathologies of persons and their syndromes. Eclecticism is too open with regard to content and too imprecise to achieve focused goals. The intrinsically configurational nature of psychopathology, its multioperationalism, and the interwoven character of clinical domains simply are not as integrated in eclecticism as they need be in treating psychopathology. The following text, figures, and tables will provide the reader with a brief synopsis of a personality-based evolutionary model; other sources should be pursued for a more

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extensive elaboration of these ideas (Millon & Bloom, in press; Millon & Davis, 1996; Millon & Grossman, 2006). Three figures, 1.1, 1.2, and 1.3, present circumplex representations of the overall theoretically derived personality spectra of normal and abnormal patterns and their associated clinical domains. Figure 1.1, the Personality Spectra Circulargram, portrays the 15 prototypal variants derived from the theory. Legend I of Figure 1.1 relates to the prototype’s primary evolutionary foundation (e.g., the retiring/schizoid reflects a detached pattern that stems from deficiencies in the pain-pleasure polarity). Figure 1.2 represents the four functional domains for each of the 15 personality prototype patterns. Legend II of Figure 1.2, for example, relates to the prototype’s characteristic LEGEND

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FIGURE 1.1 Personality spectra circulargram I: Normal and abnormal personality patterns. Evolutionary foundations of the normal and abnormal extremes of each personality prototype of the 15 spectra. I: Evolutionary Orientation; II: Normal Prototype; III: Abnormal Prototype; IV: Adaptation Style; V: MCMI-III-E Scale number/letter.

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14 PERSONALIZED PSYCHOTHERAPY: A RECAPITULATION

i loit

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FIGURE 1.2 Personality circulargram IIA: Functional personologic domains. I: Expressive Behavior; II: Interpersonal Conduct; III: Cognitive Style/Content; IV: Intrapsychic Mechanisms; V: MCMI-III Scale.

interpersonal conduct (e.g., the retiring/schizoid’s conduct is noted as unengaged). Figure 1.3 portrays the four structural domains for all of the 15 personality prototypes. Legend IV of Figure 1.3, to illustrate, concerns the prototypal fundamental mood/affect (e.g., the retiring/schizoid’s typical mood is recorded as apathetic). Scores on these functional and structural domains, as calculated by MCMI-III analyses and/or obtained on the Millon-Grossman Personality Domain Checklist (MG-PDC), to be described shortly, serve as the basis for identifying, selecting, and coordinating the major foci and techniques of therapeutic action. Thus, high ratings on the pessimistic/melancholic interpersonal and mood/affect domains may identify the more problematic realms of a patient’s psychological makeup. It also suggests the use of a combination of two therapeutic techniques: interpersonal methods (e.g.,

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Personalized Psychotherapy: A Recapitulation

inviolable suspiciousparanoid

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FIGURE 1.3 Personality circulargram IIB: Structural personologic domains. I: Self-Image; II: Intrapsychic Content; III: Intrapsychic Structure; IV: Mood-Affect; V: MCMI-III Scale.

Benjamin’s 2005 approach) and pharmacologic medications (e.g., daily regimen of Prozac). Several words may usefully be said regarding the newly devised MG-PDC instrument (Millon & Grossman, 2006). Clinicians and personologists employ numerous sources to obtain assessment data on both persons in general and their patients. These range from incidental to well-structured observations, casual to highly systematic interviews, and cursory to formal analyses of biographic history; also employed are a variety of laboratory tests, self-report inventories, and performance-based or projective techniques. All of these have proven to be useful grounds for diagnostic study. How do we put these diverse data sources together to systematize and quantify the information we have gathered? It is toward the end of organizing and maximizing the clinical utility of our personality findings that the MG-PDC has been developed.

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16 PERSONALIZED PSYCHOTHERAPY: A RECAPITULATION

On their own, observations and projective techniques are viewed as excessively subjective. Laboratory procedures (e.g., brain imaging) are not yet sufficiently developed, and biographical data are often too unreliable to depend on. And despite their popularity with many a distinguished psychometrician, the utility of self-report inventories is far from universally accepted. Whether assessment tools are based on empirical investigations, epidemiologic research, mathematical analyses or theoretical deductions, they often fail to characterize persons in the language and concepts traditionally employed by clinical personologists. Although many instruments have proven of value in numerous research studies, such as demonstrating reasonable intercorrelations or a correspondence with established diagnostic systems (e.g., the DSM), many an astute clinician has questioned whether these tools yield anything beyond the reliability of surface impressions. Some (Westen & Weinberger, 2004) doubt whether self-report instruments, for example, successfully tap into or unravel the diverse, complex, and hidden relationships among difficultto-fathom processes. Other critics have contended that patient-generated responses may contain no clinically relevant information beyond the judgments of nonscientists employing the vocabulary of a layperson’s lexicon. Data obtained from patient-based self-judgments may be contrasted with the sophisticated clinical appraisals of mental health professionals. We must ask whether clinical language, concepts, and instruments encoded in the evolving professional language of the past 100 years or so generate information incremental to the naive descriptions of an ordinary person’s everyday lexicon. We know that clinical languages differ from laypersons’ languages because they serve different and more sophisticated purposes (Livesley, Jackson, & Schroeder, 1989). Indeed, clinical concepts reflect the experienced contributions of numerous historical schools of thought (Millon, 2004). Each of these clinical schools (e.g., psychodynamic, cognitive, interpersonal) have identified a multitude of diverse and complex psychic processes that operate in our mental life. Surely the concepts of these historical professional lexicons are not reducible to the superficial factors drawn from the everyday vocabulary of nonscientists. It is to represent and integrate the insights and concepts of the several major schools of thought that has led us to formulate a domain-based clinician-rated assessment (Millon, 1969/1985, 1981, 1984, 1986, 1990, 1996b; Tringone, 1990, 1997), and now to develop, following numerous empirical and theoretical refinements, the MG-PDC. In contrast with the five-factor method, popular among research-oriented psychologists, the Personality Domain Checklist (PDC) is based on the contributions of five of the major clinical traditions; the behavioral, the interpersonal, the self, the cognitive, and the biological. Three optional domains are listed additionally in the instrument to reflect the psychoanalytic tradition; the use of these intrapsychic domains has diminished in recent decades and they are therefore included as elective, that is, not required components of the instrument. Several criteria were used to select and develop the clinical domains listed in the checklist: (a) that they be broad-based and varied in the features they embody, that is, not

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limited just to biological temperaments or cognitive processes, but instead encompass a full range of personality characteristics that are based on frequently used clinical terms and concepts; (b) that they correspond to the major therapeutic modalities employed by contemporary mental health professionals to treat their patients (e.g., cognitive techniques for altering dysfunctional beliefs, group procedures for modifying interpersonal conduct) and, hence, are readily employed by practicing therapeutic clinicians; (c) that they be coordinated with and reflect the official personality disorder prototypes established by the International Classification of Diseases (ICD) and DSM and, thereby, be understood by insurance and other management professionals; (d) that a distinctive psychological trait can be identified and operationalized in each of the clinical trait domains for each personality prototype, assuring thereby both scope and comparability among personological criteria; (e) that they lend themselves to the appraisal of domain characteristics for both normal and abnormal personalities and, hence, further promote advances in the field of normality, one of growing interest in the psychological literature; and (f ) that they can serve as an educational clinical tool to sensitize mental heath workers in training (psychologists, psychiatrists, clinical social workers, etc.) to the many distinctions, subtleties, and domain interactions that are worth considering in appraising personality attributes. The integrative perspective encouraged in the MG-PDC views personalities as a multidetermined and multireferential construct. One, albeit problematic, means by some clinical researchers of dealing with the conceptual alternatives that characterizes personality study today is to oversimplify the task. They choose to assess the patient in accord with a single conceptual orientation, eliminating thereby the integration of divergent perspectives by an act of regressive dogmatism. A truly effective assessment, however, one that is logically consonant with the modern integrative character of personality, both as a construct and as a reality, requires that the individual be assessed systematically across multiple characterological domains, thereby ensuring that the assessment is comprehensive, useful to a broad range of clinicians, and more likely valid. In assessing with the MG-PDC, clinicians should refrain, therefore, from regarding each domain as an independent entity, and thereby falling into a naive, single-minded approach. Each of the domains is a legitimate but highly contextualized part of a unified or integrated whole, a necessary composite that ensures that the full integrity of the person is represented. As noted previously, the domains of the instrument can be organized in a manner similar to distinctions drawn in the biological realm; that is, they may be divided and characterized as structural and functional attributes. The functional domains of the instrument represent dynamic processes that transpire between the individual and his or her psychosocial environment. These transactions take place through what we have termed the person’s modes of regulatory action, that is, his or her demeanor, social relations, and thought processes, each of which serve to manage, adjust, transform, coordinate, and control the give-and-take of inner and outer life. Several functional domains relevant to each personality are included among the major components of the MG-PDC.

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18 PERSONALIZED PSYCHOTHERAPY: A RECAPITULATION

In contrast to the functional characteristics, structural domains represent templates of deeply embedded affect dispositions and imprinted memories, attitudes, needs, and conflicts that guide experience and orient ongoing life events. These domains may be conceived as quasi-permanent substrates for identity and temperament. These residues of the past and relatively enduring affects effectively constrain and even close off innovative learnings and limit new possibilities to already established habits and dispositions. Their persistent and preemptive character perpetuates the maladaptive behavior and vicious circles of a patient’s extant personality pathology. Of course, individuals differ with respect to the domains they enact most frequently. People vary not only in the degree to which they approximate each personality prototype but also in the extent to which each domain dominates their behavior. In conceptualizing personality as a system, we must recognize that different parts of the system will be dominant in different individuals, even when those individuals are patients who share the same prototypal diagnosis. It is the goal of the MG-PDC to differentiate, operationalize, and measure quantitatively those domain features that are primary in contributing to the person’s functioning. Thus identified, the instrument should help orient the clinical therapist to modify the person’s problematic features (e.g., interpersonal conduct, cognitive beliefs), and thereby enable the patient to acquire a greater variety of adaptive behaviors in his or her life circumstances. The reader may wish to review the trait options that constitute the choices for each of the domains. While reading and thinking about the several domain descriptions, and to help guide your choices, feel comfortable in moving freely, back and forth, as you proceed. For example, while working on reviewing the trait options for the Expressive Behavior domain, do not hesitate to look at the trait descriptions for any of the other domains (e.g., Interpersonal Conduct) if by doing so you may be aided in understanding the characteristics of the Expressive Behavior group of choices. For each of the domains in Tables 1.1 through 1.8, beginning with Expressive Behavior, you will see 15 descriptive trait choices. Locate the descriptive choice that appears to you to best fit in characterizing the patient you are thinking about. You would fill in that choice in the 1 box column. Because most people can be characterized by more than one expressive behavior trait, locate a second-best-fit descriptive characteristic, one not as applicable to this person as the first-best-fit you selected, but notable nonetheless. Fill in the 2 box, the second-best-fit column. Should there be other listed descriptive trait features that are applicable to this person, but less so than the one selected as second best, fill in the 3 box in the thirdbest-fit column. You may fill in up to three boxes in the third-best-fit column. (Note that only one trait description may be marked in each of the first- and second-best-fit columns.) Consider the following points as you proceed. The 15 descriptive traits for each domain were written to characterize patients. Further, each trait is illustrated with several clinical characteristics and examples. Note that the person you are rating need

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not display precisely the characteristics that are listed; they need only be the best fit of the listed group of features. It is important to note also that for rated persons of a nonclinical character, that is, normal personalities who display only minor or mild aspects of the trait characteristic, you should, nevertheless, fully mark the bestfit columns (even though the descriptor is characterized with a more serious clinical description than suits the person). In short, do not leave any of the best-fit columns blank. Fill them in, in rank best-fit order, even when the features of the trait are only marginally present. After completing ratings for the Expressive Behavior domain, you would proceed to fill in your choices for the next seven domains, one at a time, using the same first, second, and third ratings you followed previously. Because readers of this text are not actually completing the following MG-PDC judgment forms, it will be useful for them to know which personality prototype corresponds to the letters that precede each of the descriptors. For example, in the Expressive Behavior domain, note that the letter A precedes the first descriptor, “Impassive.” The letter A signifies that this descriptor characterizes the Retiring/Schizoid Prototype. Each of the following letters on all eight domains corresponds to the following associated prototypes: A. Retiring/Schizoid B. Eccentric/Schizotypal C. Shy/Avoidant D. Needy/Dependent E. Exuberant/Hypomanic F. Sociable/Histrionic G. Confident/Narcissistic H. Suspicious/Paranoid I. Nonconforming/Antisocial J. Assertive/Sadistic K. Pessimistic/Melancholic (Depressive) L. Aggrieved/Masochistic M. Skeptical/Negativistic N. Capricious/Borderline O. Conscientious/Compulsive On the basis of your knowledge of the person you have evaluated, using the domain categories listed in Tables 1.1 through 1.8, summarize your judgments by making an overall 1st, 2nd, and 3rd best fit personality spectrum diagnosis on Table 1.9.

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20 PERSONALIZED PSYCHOTHERAPY: A RECAPITULATION Table 1.1 MG-PDC I. Expressive Behavior DOMAIN These attributes relate to observables at the behavioral level of emotion and are usually recorded by noting how the patient acts. Through inference, observations of overt behavior enable us to deduce what the patient unknowingly reveals about his or her emotions or, often conversely, what he or she wants others to think about him or her. The range and character of expressive actions are wide and diverse and they convey distinctive and worthwhile clinical information, from communicating a sense of personal incompetence to exhibiting emotional defensiveness to demonstrating disciplined self-control, and so on. 1st Best Fit

2nd Best Fit

3rd Best Fit

1

2

3

A. Impassive: Is colorless, sluggish, displaying deficits in activation and emotional expressiveness; appears to be in a persistent state of low energy and lack of vitality (e.g., phlegmatic and lacking in spontaneity).

1

2

3

B. Peculiar: Is perceived by others as eccentric, disposed to behave in an unobtrusively aloof, curious, or bizarre manner; exhibits socially gauche habits and aberrant mannerisms (e.g., manifestly odd or eccentric).

1

2

3

C. Fretful: Fearfully scans environment for social derogation; overreacts to innocuous events and judges them to signify personal derision and mockery (e.g., anxiously anticipates ridicule/humiliation).

1

2

3

D. Incompetent: Ill-equipped to assume mature and independent roles; is passive and lacking functional competencies, avoiding self-assertion and withdrawing from adult responsibilities (e.g., has difficulty doing things on his or her own).

1

2

3

E. Impetuous: Is forcefully energetic and driven, emotionally excitable and overzealous; often worked up, unrestrained, rash, and hotheaded (e.g., is restless and socially intrusive).

1

2

3

F. Dramatic: Is histrionically overreactive and stimulus-seeking, resulting in unreflected and theatrical responsiveness; describes penchant for sensational situations and short-sighted hedonism (e.g., overly emotional and artificially affected).

1

2

3

G. Haughty: Manifests an air of being above conventional rules of shared social living, viewing them as naive or inapplicable to self; reveals an egocentric indifference to the needs of others (e.g., acts arrogantly selfassured and confident).

Characteristic Behavior

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Personalized Psychotherapy: A Recapitulation

Table 1.1

21

(Continued )

1st Best Fit

2nd Best Fit

3rd Best Fit

1

2

3

H. Defensive: Is vigilantly guarded, hyperalert to ward off anticipated deception and malice; is tenaciously resistant to sources of external influence (e.g., disposed to be wary, envious, and jealous).

1

2

3

I. Impulsive: Since adolescence, acts thoughtlessly and irresponsibly in social matters; is shortsighted, heedless, incautious, and imprudent, failing to plan ahead or consider legal consequences (e.g., Conduct Disorder evident before age 15).

1

2

3

J. Precipitate: Is stormy and unpredictably abrupt, reckless, thickskinned, and unflinching, seemingly undeterred by pain; is attracted to challenge, as well as undaunted by punishment (e.g., attracted to risk, danger, and harm).

1

2

3

K. Disconsolate: Appearance and posture convey an irrelievably forlorn, heavy-hearted, if not grief-stricken quality; markedly dispirited and discouraged (e.g., somberly seeks others to be protective).

1

2

3

L. Abstinent: Presents self as nonindulgent, frugal, and chaste, refraining from exhibiting signs of pleasure or attractiveness; acts in an unpresuming and self-effacing manner, placing self in an inferior light (e.g., undermines own good fortune).

1

2

3

M. Resentful: Exhibits inefficiency, erratic, contrary, and irksome behaviors; reveals gratification in undermining the pleasures and expectations of others (e.g., uncooperative, contrary, and stubborn).

1

2

3

N. Spasmodic: Displays a desultory energy level with sudden, unexpected self-punitive outbursts; endogenous shifts in emotional state places behavioral equilibrium in constant jeopardy (e.g., does impulsive, self-damaging acts).

1

2

3

O. Disciplined: Maintains a regulated, emotionally restrained, and highly organized life; often insists that others adhere to personally established rules and methods (e.g., meticulous and perfectionistic).

Characteristic Behavior

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8:23

22 PERSONALIZED PSYCHOTHERAPY: A RECAPITULATION Table 1.2 MG-PDC II. Interpersonal Conduct DOMAIN A patient’s style of relating to others may be captured in a number of ways, such as how his or her actions affect others, intended or otherwise; the attitudes that underlie, prompt, and give shape to these actions; the methods by which he or she engages others to meet his or her needs; and his or her way of coping with social tensions and conflicts. Extrapolating from these observations, the clinican may construct an image of how the patient functions in relation to others. 1st Best Fit

2nd Best Fit

3rd Best Fit

1

2

3

A. Unengaged: Is indifferent to the actions or feelings of others, possessing minimal “human” interests; ends up with few close relationships and a limited role in work and family settings (e.g., has few desires or interests).

1

2

3

B. Secretive: Strives for privacy, with limited personal attachments and obligations; drifts into increasingly remote and clandestine social activities (e.g., is enigmatic and withdrawn).

1

2

3

C. Aversive: Reports extensive history of social anxiety and isolation; seeks social acceptance, but maintains careful distance to avoid anticipated humiliation and derogation (e.g., is socially pan-anxious and fearfully guarded).

1

2

3

D. Submissive: Subordinates needs to a stronger and nurturing person, without whom will feel alone and anxiously helpless; is compliant, conciliatory, and self-sacrificing (e.g., generally docile, deferential, and placating).

1

2

3

E. High-Spirited: Is unremittingly full of life and socially buoyant; attempts to engage others in an animated, vivacious, and lively manner; often seen by others, however, as intrusive and needlessly insistent (e.g., is persistently overbearing).

1

2

3

F. Attention-Seeking: Is self-dramatizing, and actively solicits praise in a showy manner to gain desired attention and approval; manipulates others and is emotionally demanding (e.g., seductively flirtatious and exhibitionistic).

1

2

3

G. Exploitive: Acts entitled, self-centered, vain, and unempathic; expects special favors without assuming reciprocal responsibilities; shamelessly takes others for granted and uses them to enhance self and indulge desires (e.g., egocentric and socially inconsiderate).

Characteristic Conduct

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Personalized Psychotherapy: A Recapitulation

Table 1.2

23

(Continued )

1st Best Fit

2nd Best Fit

3rd Best Fit

1

2

3

H. Provocative: Displays a quarrelsome, fractious, and distrustful attitude; bears serious grudges and precipitates exasperation by a testing of loyalties and a searching preoccupation with hidden motives (e.g., unjustly questions fidelity of spouse/friend).

1

2

3

I. Irresponsible: Is socially untrustworthy and unreliable, intentionally or carelessly failing to meet personal obligations of a marital, parental, employment, or financial nature; actively violates established civil codes through duplicitous or illegal behaviors (e.g., shows active disregard for rights of others).

1

2

3

J. Abrasive: Reveals satisfaction in competing with, dominating, and humiliating others; regularly expresses verbally abusive and derisive social commentary, as well as exhibiting harsh, if not physically brutal behavior (e.g., intimidates, coerces, and demeans others).

1

2

3

K. Defenseless: Feels and acts vulnerable and guilt-ridden; fears emotional abandonment and seeks public assurances of affection and devotion (e.g., needs supportive relationships to bolster hopeless outlook).

1

2

3

L. Deferential: Relates to others in a self-sacrificing, servile, and obsequious manner, allowing, if not encouraging others to exploit or take advantage; is self-abasing, accepting undeserved blame and unjust criticism (e.g., courts others to be exploitive and mistreating).

1

2

3

M. Contrary: Assumes conflicting roles in social relationships, shifting from dependent acquiescence to assertive independence; is obstructive toward others, behaving either negatively or erratically (e.g., sulky and argumentative in response to requests).

1

2

3

N. Paradoxical: Needing extreme attention and affection, but acts unpredictably and manipulatively and is volatile, frequently eliciting rejection rather than support; reacts to fears of separation and isolation in angry, mercurial, and often self-damaging ways (e.g., is emotionally needy, but interpersonally erratic).

1

2

3

O. Respectful: Exhibits unusual adherence to social conventions and proprieties; prefers polite, formal, and “correct” personal relationships (e.g., interpersonally proper and dutiful).

Characteristic Conduct

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8:23

Table 1.3 MG-PDC III. Cognitive Style/Content DOMAIN How the patient focuses and allocates attention, encodes and processes information, organizes thoughts, makes attributions, and communicates reactions and ideas to others represents key cognitive functions of clinical value. These characteristics are among the most useful indices of the patient’s distinctive way of thinking. By synthesizing his or her beliefs and attitudes, it may be possible to identify indications of problematic cognitive functions and assumptions.

24

1st Best Fit

2nd Best Fit

3rd Best Fit

1

2

3

A. Impoverished: Seems deficient in human spheres of knowledge and evidences vague thought processes about everyday matters that are below intellectual level; social communications are easily derailed or conveyed via a circuitous logic (e.g., lacks awareness of human relations).

1

2

3

B. Autistic: Intrudes social communications with personal irrelevancies; there is notable circumstantial speech, ideas of reference, and metaphorical asides; is ruminative, appears self-absorbed and lost in occasional magical thinking; there is a marked blurring of fantasy and reality (e.g., exhibits peculiar ideas and superstitious beliefs).

1

2

3

C. Distracted: Is bothered by disruptive and often distressing inner thoughts; the upsurge from within of irrelevant and digressive ideation upsets thought continuity and interferes with social communications (e.g., withdraws into reveries to fulfill needs).

1

2

3

D. Naive: Is easily persuaded, unsuspicious, and gullible; reveals a Pollyanna attitude toward interpersonal difficulties, watering down objective problems and smoothing over troubling events (e.g., childlike thinking and reasoning).

1

2

3

E. Scattered: Thoughts are momentary and scrambled in an untidy disarray with minimal focus to them, resulting in a chaotic hodgepodge of miscellaneous and haphazard beliefs expressed randomly with no logic or purpose (e.g., intense and transient emotions disorganize thoughts).

1

2

3

F. Flighty: Avoids introspective thought and is overly attentive to trivial and fleeting external events; integrates experiences poorly, resulting in shallow learning and thoughtless judgments (e.g., faddish and responsive to superficialities).

1

2

3

G. Expansive: Has an undisciplined imagination and exhibits a preoccupation with illusory fantasies of success, beauty, or love; is minimally constrained by objective reality; takes liberties with facts and seeks to redeem boastful beliefs (e.g., indulges fantasies of repute/power).

Characteristic Cognitive Style

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Personalized Psychotherapy: A Recapitulation

Table 1.3

25

(Continued )

1st Best Fit

2nd Best Fit

3rd Best Fit

1

2

3

H. Mistrustful: Is suspicious of the motives of others, construing innocuous events as signifying conspiratorial intent; magnifies tangential or minor social difficulties into proofs of duplicity, malice, and treachery (e.g., wary and distrustful).

1

2

3

I. Deviant: Construes ordinary events and personal relationships in accord with socially unorthodox beliefs and morals; is disdainful of traditional ideals and conventional rules (e.g., shows contempt for social ethics and morals).

1

2

3

J. Dogmatic: Is strongly opinionated, as well as unbending and obstinate in holding to his or her preconceptions; exhibits a broad social intolerance and prejudice (e.g., closed-minded and bigoted).

1

2

3

K. Fatalistic: Sees things in their blackest form and invariably expects the worst; gives the gloomiest interpretation of current events, believing that things will never improve (e.g., conceives life events in persistent pessimistic terms).

1

2

3

L. Diffident: Is hesitant to voice his or her views; often expresses attitudes contrary to inner beliefs; experiences contrasting and conflicting thoughts toward self and others (e.g., demeans own convictions and opinions).

1

2

3

M. Cynical: Skeptical and untrusting, approaching current events with disbelief and future possibilities with trepidation; has a misanthropic view of life, expressing disdain and caustic comments toward those who experience good fortune (e.g., envious or disdainful of those more fortunate).

1

2

3

N. Vacillating: Experiences rapidly changing, fluctuating, and antithetical perceptions or thoughts concerning passing events; contradictory reactions are evoked in others by virtue of his or her behaviors, creating, in turn, conflicting and confusing social feedback (e.g., erratic and contrite over own beliefs and attitudes).

1

2

3

O. Constricted: Constructs world in terms of rules, regulations, time schedules, and social hierarchies; is unimaginative, indecisive, and notably upset by unfamiliar or novel ideas and customs (e.g., preoccupied with lists, details, rules, etc.).

Characteristic Cognitive Style

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8:23

26 PERSONALIZED PSYCHOTHERAPY: A RECAPITULATION Table 1.4 MG-PDC IV. Self-Image DOMAIN As the inner world of symbols is mastered through development, one major configuration emerges to impose a measure of sameness on an otherwise fluid environment: the perception of self-asobject, a distinct, ever-present identity. Self-image is significant in that it serves as a guidepost and lends continuity to changing experience. Most patients have an implicit sense of who they are but differ greatly in the clarity, accuracy, and complexity of their introspection of the psychic elements that make up this image. 1st Best Fit

2nd Best Fit

3rd Best Fit

1

2

3

A. Complacent: Reveals minimal introspection and awareness of self; seems impervious to the emotional and personal implications of his or her role in everyday social life (e.g., minimal interest in own personal life).

1

2

3

B. Estranged: Possesses permeable ego boundaries, exhibiting acute social perplexities and illusions as well as experiences of depersonalization, derealization, and dissociation; sees self as “different,” with repetitive thoughts of life’s confusions and meaninglessness (e.g., self-perceptions are haphazard and fragmented).

1

2

3

C. Alienated: Sees self as a socially isolated person, one rejected by others; devalues self-achievements and reports feelings of aloneness and undesirability (e.g., feels injured and unwanted by others).

1

2

3

D. Inept: Views self as weak, fragile, and inadequate; exhibits lack of self-confidence by belittling own aptitudes and competencies (e.g., sees self as childlike and/or fragile).

1

2

3

E. Energetic: Sees self as full of vim and vigor, a dynamic force, invariably hardy and robust, a tireless and enterprising person whose ever-present energy galvanizes others (e.g., proud to be active and animated).

1

2

3

F. Gregarious: Views self as socially stimulating and charming; enjoys the image of attracting acquaintances and pursuing a busy and pleasureoriented social life (e.g., perceived as appealing and attractive, but shallow).

1

2

3

G. Admirable: Confidently exhibits self, acts in a self-assured manner, and publicly displays achievements, despite being seen by others as egotistic, inconsiderate, and arrogant (e.g., has a sense of high selfworth).

Characteristic Self-Image

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Personalized Psychotherapy: A Recapitulation

Table 1.4

27

(Continued )

1st Best Fit

2nd Best Fit

3rd Best Fit

1

2

3

H. Inviolable: Is highly insular, experiencing intense fears of losing identity, status, or powers of self-determination; nevertheless, has persistent ideas of self-reference, asserting as personally derogatory and scurrilous entirely innocuous actions and events (e.g., sees ordinary life events as invariably referring to self).

1

2

3

I. Autonomous: Values the sense of being free, unencumbered, and unconfined by persons, places, obligations, or routines; sees self as unfettered by the restrictions of social customs and the restraints of personal loyalties (e.g., values being independent of social responsibilities).

1

2

3

J. Combative: Values aspects of self that present tough, domineering, and power-oriented image; is proud to characterize self as unsympathetic and unsentimental (e.g., proud to be stern and feared by others).

1

2

3

K. Worthless: Sees self as valueless, of no account, a person who should be overlooked, owing to having no praiseworthy traits or achievements (e.g., sees self as insignificant or inconsequential).

1

2

3

L. Undeserving: Focuses on and amplifies the very worst features of self; judges self as worthy of being shamed, humbled, and debased; has failed to live up to the expectations of others and, hence, should be reproached and demeaned (e.g., sees self as deserving to suffer).

1

2

3

M. Discontented: Sees self as unjustly misunderstood and unappreciated; recognizes that he or she is characteristically resentful, disgruntled, and disillusioned with life (e.g., sees self as unfairly treated).

1

2

3

N. Uncertain: Experiences the marked confusions of a nebulous or wavering sense of identity and self-worth; seeks to redeem erratic actions and changing self-presentations with expressions of contrition and selfpunitive behaviors (e.g., has persistent identity disturbances).

1

2

3

O. Reliable: Sees self as industrious, meticulous, and efficient; fearful of error or misjudgment and, hence, overvalues aspects of self that exhibit discipline, perfection, prudence, and loyalty (e.g., sees self as reliable and conscientious).

Characteristic Self-Image

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28 PERSONALIZED PSYCHOTHERAPY: A RECAPITULATION Table 1.5 MG-PDC V. Mood/Affect DOMAIN Few observables are more clinically relevant than the predominant character of an individual’s affect and the intensity and frequency with which he or she expresses it. The meaning of extreme emotions is easy to decode. This is not so with the more subtle moods and feelings that insidiously and repetitively pervade the patient’s ongoing relationships and experiences. The expressive features of mood/affect may be revealed, albeit indirectly, in activity level, speech quality, and physical appearance. 1st Best Fit

2nd Best Fit

3rd Best Fit

1

2

3

A. Apathetic: Is emotionally impassive, exhibiting an intrinsic unfeeling, cold, and stark quality; reports weak affectionate or erotic needs, rarely displaying warm or intense feelings, and apparently unable also to experience either sadness or anger (e.g., unable to experience pleasure in depth).

1

2

3

B. Distraught or Insentient: Reports being either apprehensive and ill at ease, particularly in social encounters; anxiously watchful, distrustful of others, and wary of their motives; or manifests drab, sluggish, joyless, and spiritless appearance; reveals marked deficiencies in emotional expression and in face-to-face encounters (e.g., highly agitated and/or affectively flat).

1

2

3

C. Anguished: Vacillates between desire for affection, fear of rebuff, and numbness of feeling; describes constant and confusing undercurrents of tension, sadness, and anger (e.g., unusually fearful of new social experiences).

1

2

3

D. Pacific: Quietly and passively avoids social tension and interpersonal conflicts; is typically pleasant, warm, tender, and noncompetitive (e.g., characteristically timid and uncompetitive).

1

2

3

E. Mercurial: Volatile and quicksilverish, at times unduly ebullient, charged up, and irrepressible; at other times, flighty and erratic emotionally, blowing hot and cold (e.g., has marked penchant for momentary excitements).

1

2

3

F. Fickle: Displays short-lived and superficial emotions; is dramatically overreactive and exhibits tendencies to be easily enthused and as easily bored (e.g., impetuously pursues pleasure-oriented social life).

Characteristic Mood

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Table 1.5

8:23

(Continued )

1st Best Fit

2nd Best Fit

3rd Best Fit

1

2

3

G. Insouciant: Manifests a general air of nonchalance and indifference; appears coolly unimpressionable or calmly optimistic, except when selfcentered confidence is shaken, at which time either rage, shame, or emptiness is briefly displayed (e.g., generally appears imperturbable and composed).

1

2

3

H. Irascible: Displays a sullen, churlish, and humorless demeanor; attempts to appear unemotional and objective, but is edgy, touchy, surly, quick to react angrily (e.g., ready to take personal offense).

1

2

3

I. Callous: Exhibits a coarse incivility, as well as a ruthless indifference to the welfare of others; is unempathic, as expressed in wideranging deficits in social charitableness, human compassion, or personal remorse (e.g., experiences minimal guilt or contrition for socially repugnant actions).

1

2

3

J. Hostile: Has an overtly rough and pugnacious temper, which flares periodically into contentious argument and physical belligerence; is fractious, willing to do harm, even persecute others to get own way (e.g., easily embroiled in brawls).

1

2

3

K. Woeful: Is typically mournful, tearful, joyless, and morose; characteristically worrisome and brooding; low spirits rarely remit (e.g., frequently feels dejected or guilty).

1

2

3

L. Dysphoric: Intentionally displays a plaintive and gloomy appearance, occasionally to induce guilt and discomfort in others (e.g., drawn to relationships in which he or she will suffer).

1

2

3

M. Irritable: Is often petulant, reporting being easily annoyed or frustrated by others; typically obstinate and resentful, followed in turn by sulky and grumpy withdrawal (e.g., impatient and easily provoked into oppositional behavior).

1

2

3

N. Labile: Fails to accord unstable moods with external reality; has marked shifts from normality to depression to excitement, or has extended periods of dejection and apathy, interspersed with brief spells of anger, anxiety, or euphoria (e.g., mood changes erratically from sadness to bitterness to torpor).

1

2

3

O. Solemn: Is unrelaxed, tense, joyless, and grim; restrains overtly warm or covertly antagonistic feelings, keeping most emotions under tight control (e.g., affect is constricted and confined).

Characteristic Mood

29

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8:23

Table 1.6 MG-PDC VI. Intrapsychic Mechanisms DOMAIN Although mechanisms of self-protection, need gratification, and conflict resolution are consciously recognized at times, they represent data derived primarily at the intrapsychic level. Because the ego or defense mechanisms are internal regulatory processes, they are more difficult to discern and describe than processes that are anchored closer to the observable world. As such, they are not directly amenable to assessment by self-reflective appraisal in their pure form but only as derivatives that are potentially many levels removed from their core conflicts and their dynamic resolution. Despite the methodological problems they present, the task of identifying which mechanisms are most characteristic of a patient and the extent to which they are employed is extremely useful in a comprehensive clinical assessment.

30

1st Best Fit

2nd Best Fit

3rd Best Fit

1

2

3

A. Intellectualization: Describes interpersonal and affective experiences in a matter-of-fact, abstract, impersonal, or mechanical manner; pays primary attention to formal and objective aspects of social and emotional events.

1

2

3

B. Undoing: Bizarre mannerisms and idiosyncratic thoughts appear to reflect a retraction or reversal of previous acts or ideas that have stirred feelings of anxiety, conflict, or guilt; ritualistic or “magical” behaviors serve to repent for or nullify assumed misdeeds or “evil” thoughts.

1

2

3

C. Fantasy: Depends excessively on imagination to achieve need gratification and conflict resolution; withdraws into reveries as a means of safely discharging affectionate, as well as aggressive impulses.

1

2

3

D. Introjection: Is firmly devoted to another to strengthen the belief that an inseparable bond exists between them; jettisons any independent views in favor of those of another to preclude conflicts and threats to the relationship.

1

2

3

E. Magnification: Engages in hyperbole, overstating and overemphasizing ordinary matters so as to elevate their importance, especially features that enhance not only his or her own virtues but those of others who are valued.

1

2

3

F. Dissociation: Regularly alters self presentations to create a succession of socially attractive but changing fac¸ades; engages in self-distracting activities to avoid reflecting on/integrating unpleasant thoughts/emotions.

1

2

3

G. Rationalization: Is self-deceptive and facile in devising plausible reasons to justify self-centered and socially inconsiderate behaviors; offers alibis to place self in the best possible light, despite evident shortcomings or failures.

Characteristic Mechanism

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Personalized Psychotherapy: A Recapitulation

Table 1.6

31

(Continued )

1st Best Fit

2nd Best Fit

3rd Best Fit

1

2

3

H. Projection: Actively disowns undesirable personal traits and motives and attributes them to others; remains blind to own unattractive behaviors and characteristics, yet is overalert to and hypercritical of the defects of others.

1

2

3

I. Acting Out: Inner tensions that might accrue by postponing the expression of offensive thoughts and malevolent actions are rarely constrained; socially repugnant impulses are not refashioned in sublimated forms, but are discharged directly in precipitous ways, usually without guilt.

1

2

3

J. Isolation: Can be cold-blooded and remarkably detached from an awareness of the impact of his or her destructive acts; views objects of violation impersonally, often as symbols of devalued groups devoid of human sensibilities.

1

2

3

K. Asceticism: Engages in acts of self-denial, self-tormenting, and selfpunishment, believing that one should exhibit penance and not be rewarded with life’s bounties; not only is there a repudiation of pleasures but there are harsh self-judgments and minor self-destructive acts.

1

2

3

L. Exaggeration: Repetitively recalls past injustices and seeks out future disappointments as a means of raising distress to troubled homeostatic levels; misconstrues, if not sabotages, personal good fortunes to enhance or maintain preferred suffering and pain.

1

2

3

M. Displacement: Discharges anger and other troublesome emotions either indirectly or by shifting them from their true objective to settings or persons of lesser peril; expresses resentments by substitute or passive means, such as acting inept or perplexed, or behaving in a forgetful or indolent manner.

1

2

3

N. Regression: Retreats under stress to developmentally earlier levels of anxiety tolerance, impulse control, and social adaptation; is unable or disinclined to cope with responsible tasks and adult issues, as evident in immature, if not increasingly childlike behaviors.

1

2

3

O. Reaction Formation: Repeatedly presents positive thoughts and socially commendable behaviors that are diametrically opposite to his or her deeper, contrary, and forbidden feelings; displays reasonableness and maturity when faced with circumstances that normally evoke anger or dismay in most persons.

Characteristic Mechanism

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32 PERSONALIZED PSYCHOTHERAPY: A RECAPITULATION Table 1.7 MG-PDC VII. Intrapsychic Content DOMAIN Significant experiences from the past leave an inner imprint, a structural residue composed of memories, attitudes, and affects that serve as a substrate of dispositions for perceiving and reacting to life’s events. Analogous to the various organ systems in the body, both the character and the substance of these internalized representations of significant figures and relationships from the past can be differentiated and analyzed for clinical purposes. Variations in the nature and content of this inner world, or what are often called object relations, can be identified with one or another personality and lead us to employ the following descriptive terms to represent them. 1st Best Fit

2nd Best Fit

3rd Best Fit

1

2

3

A. Meager: Inner representations are few in number and minimally articulated, largely devoid of the manifold percepts and memories, or the dynamic interplay among drives and conflicts that typify even welladjusted persons.

1

2

3

B. Chaotic: Inner representations consist of a jumble of miscellaneous memories and percepts, random drives and impulses, and uncoordinated channels of regulation that are only fitfully competent for binding tensions, accommodating needs, and mediating conflicts.

1

2

3

C. Vexatious: Inner representations are composed of readily reactivated, intense, and anxiety-ridden memories, limited avenues of gratification, and few mechanisms to channel needs, bind impulses, resolve conflicts, or deflect external stressors.

1

2

3

D. Immature: Inner representations are composed of unsophisticated ideas and incomplete memories, rudimentary drives and childlike impulses, as well as minimal competencies to manage and resolve stressors.

1

2

3

E. Piecemeal: Inner representations are disorganized and dissipated, a jumble of diluted and muddled recollections that are recalled by fits and starts, serving only as momentary guideposts for dealing with everyday tensions and conflicts.

1

2

3

F. Shallow: Inner representations are composed largely of superficial yet emotionally intense affects, memories, and conflicts, as well as facile drives and insubstantial mechanisms.

1

2

3

G. Contrived: Inner representations are composed far more than usual of illusory ideas and memories, synthetic drives and conflicts, and pretentious, if not simulated, percepts and attitudes, all of which are readily refashioned as the need arises.

Characteristic Content

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Table 1.7

8:23

(Continued )

1st Best Fit

2nd Best Fit

3rd Best Fit

1

2

3

H. Unalterable: Inner representations are arranged in an unusual configuration of rigidly held attitudes, unyielding percepts, and implacable drives which are aligned in a semidelusional hierarchy of tenacious memories, immutable cognitions, and irrevocable beliefs.

1

2

3

I. Debased: Inner representations are a mix of revengeful attitudes and impulses oriented to subvert established cultural ideals and mores, as well as to debase personal sentiments and conventional societal attainments.

1

2

3

J. Pernicious: Inner representations are distinguished by the presence of aggressive energies and malicious attitudes, as well as by a contrasting paucity of sentimental memories, tender affects, internal conflicts, shame, or guilt feelings.

1

2

3

K. Forsaken: Inner representations have been depleted or devitalized, either drained of their richness and joyful elements or withdrawn from memory, leaving the person to feel abandoned, bereft, discarded.

1

2

3

L. Discredited: Inner representations are composed of disparaged past memories and discredited achievements, of positive feelings and erotic drives transposed onto their least attractive opposites, of internal conflicts intentionally aggravated, of mechanisms of anxiety reduction subverted by processes that intensify discomforts.

1

2

3

M. Fluctuating: Inner representations compose a complex of opposing inclinations and incompatible memories that are driven by impulses designed to nullify his or her own achievements and/or the pleasures and expectations of others.

1

2

3

N. Incompatible: Rudimentary and expediently devised, but repetitively aborted, inner representations have led to perplexing memories, enigmatic attitudes, contradictory needs, antithetical emotions, erratic impulses, and opposing strategies for conflict reduction.

1

2

3

O. Concealed: Only those inner affects, attitudes, and actions that are socially approved are allowed conscious awareness or behavioral expression, resulting in gratification being highly regulated, forbidden impulses sequestered and tightly bound, personal and social conflicts defensively denied, kept from awareness, all maintained under stringent control.

Characteristic Content

33

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34 PERSONALIZED PSYCHOTHERAPY: A RECAPITULATION Table 1.8 MG-PDC VIII. Intrapsychic Structure DOMAIN The overall architecture that serves as a framework for an individual’s psychic interior may display weakness in its structural cohesion, exhibit deficient coordination among its components, and possess few mechanisms to maintain balance and harmony, regulate internal conflicts, or mediate external pressures. The concept of intrapsychic structure refers to the organizational strength, interior congruity, and functional efficacy of the personality system, a concept almost exclusively derived from inferences at the intrapsychic level of analysis. Psychoanalytic usage tends to be limited to quantitative degrees of integrative pathology, not to qualitative variations in either integrative structure or configuration. Stylistic variants of this structural attribute, such as the following, may be employed to characterize each of the personality prototypes. 1st Best Fit

2nd Best Fit

3rd Best Fit

1

2

3

A. Undifferentiated: Given an inner barrenness, a feeble drive to fulfill needs, and minimal pressures to defend against or resolve internal conflicts, or to cope with external demands, internal structures may best be characterized by their limited coordination and deficient organization.

1

2

3

B. Fragmented: Coping and defensive operations are haphazardly organized in a fragile assemblage, leading to spasmodic and desultory actions in which primitive thoughts and affects are directly discharged, with few reality-based sublimations, leading to significant further structural disintegrations.

1

2

3

C. Fragile: Tortuous emotions depend almost exclusively on a single modality for their resolution and discharge, that of avoidance, escape, and fantasy; hence, when faced with unanticipated stress, there are few resources available to deploy and few positions to revert to, short of a regressive decompensation.

1

2

3

D. Inchoate: Owing to entrusting others with the responsibility to fulfill needs and to cope with adult tasks, there is both a deficit and a lack of diversity in internal structures and controls, leaving a miscellany of relatively undeveloped and immature adaptive abilities and elementary systems for independent functioning.

1

2

3

E. Fleeting: Structures are highly transient, existing in momentary forms that are cluttered and disarranged, making effective coping efforts temporary at best. Affect and action are unconstrained owing to the paucity of established controls and purposeful goals.

Characteristic Structure

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Table 1.8

8:23

(Continued )

1st Best Fit

2nd Best Fit

3rd Best Fit

1

2

3

F. Disjointed: A loosely knit structural conglomerate exists in which processes of internal regulation and control are scattered and unintegrated, with few methods for restraining impulses, coordinating defenses, and resolving conflicts, leading to broad and sweeping mechanisms to maintain psychic cohesion and stability and, when employed, only further disarrange thoughts, feelings, and actions.

1

2

3

G. Spurious: Coping and defensive strategies tend to be flimsy and transparent, appear more substantial and dynamically orchestrated than they are, regulating impulses only marginally, channeling needs with minimal restraint, and creating an egocentric inner world in which conflicts are dismissed, failures are quickly redeemed, and self-pride is effortlessly reasserted.

1

2

3

H. Inelastic: A markedly constricted and inflexible pattern of coping and defensive methods exists, as well as rigidly fixed channels of conflict mediation and need gratification, creates an overstrung and taut frame that is so uncompromising in its accommodation to changing circumstances that unanticipated stressors are likely to precipitate either explosive outbursts or inner shatterings.

1

2

3

I. Unruly: Inner defensive operations are noted by their paucity, as are efforts to curb irresponsible drives and attitudes, leading to easily transgressed social controls, low thresholds for impulse discharge, few subliminatory channels, unfettered self-expression, and a marked intolerance of delay or frustration.

1

2

3

J. Eruptive: Despite a generally cohesive structure of routinely modulating controls and expressive channels, surging, powerful, and explosive energies of an aggressive and sexual nature produce precipitous outbursts that periodically overwhelm and overrun otherwise reasonable restraints.

1

2

3

K. Depleted: The scaffold for structures is markedly weakened, with coping methods enervated and defensive strategies impoverished and devoid of vigor and focus, resulting in a diminished if not exhausted capacity to initiate action and regulate affect.

1

2

3

L. Inverted: Structures have a dual quality, one more or less conventional, the other its obverse—resulting in a repetitive undoing of affect and intention, of a transposing of channels of need gratification with those leading to their frustration, and of actions that produce antithetical, if not self-sabotaging consequences.

Characteristic Structure

(continued )

35

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36 PERSONALIZED PSYCHOTHERAPY: A RECAPITULATION Table 1.8

(Continued )

1st Best Fit

2nd Best Fit

3rd Best Fit

1

2

3

M. Divergent: There is a clear division in the pattern of internal elements such that coping and defensive maneuvers are often directed toward incompatible goals, leaving major conflicts unresolved and psychic cohesion impossible, as fulfillment of one drive or need inevitably nullifies or reverses another.

1

2

3

N. Split: Inner cohesion constitutes a sharply segmented and conflictful configuration with a marked lack of consistency among elements; levels of consciousness occasionally blur; a rapid shift occurs across boundaries separating unrelated memories/affects, results in schisms upsetting limited extant psychic order.

1

2

3

O. Compartmentalized: Psychic structures are rigidly organized in a tightly consolidated system that is clearly partitioned into numerous distinct and segregated constellations of drive, memory, and cognition, with few open channels to permit any interplay among these components.

Table 1.9

Characteristic Structure

Spectra that Best Characterize the Person

1st-best fit

2nd-best fit

3rd-best fit

Normal to Abnormal Personality Spectrum

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

Retiring—Schizoid Eccentric—Schizotypal Shy—Avoidant Needy—Dependent Exuberant—Hypomanic Sociable—Histrionic Confident—Narcissistic Suspicious—Paranoid Nonconforming—Antisocial Assertive—Sadistic Pessimistic—Melancholic Aggrieved—Masochistic Skeptical—Negativistic Capricious—Borderline Conscientious—Compulsive

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37

Empirical and theoretical developments of the past decade have led to an expansion in the number of personality disorder types and subtypes in the recent and forthcoming literature. Likewise, there has been a growing interest in refining the disorders into a continuum or spectrum from normal to abnormal personalities. Toward the end of contributing further to these advances, we would like you to select, as best you can, three of the personality spectra listed in Table 1.9 that you believe may best characterize the person you have just evaluated. As before, select the 1st best fit, the 2nd best fit, and the 3rd best fit. If you wish, you may go back to review your eight “first best” choices and double encircle the three that you judge most important for therapeutic intervention. As earlier, we would like you to further evaluate the person you have just rated using the preceding eight domain characteristics. In Table 1.10 please assess his or her current overall level of social and occupational functioning. Make your judgment using the 7-point continuum, which ranges from Excellent to Markedly Impaired. Focus your rating on the individual’s present mental state and social competencies, overlooking where possible physical impairments or socioeconomic considerations. Circle the number on the chart that closely approximates your best judgment. We will return to many of the numerous guiding principles and issues touched on in this extensive chapter as we proceed to the following chapters of this and the third book in the personalized psychotherapy series. Many themes characterizing our rationale for personalized psychotherapy have been presented and argued in the preceding pages. It is hoped that these themes and justifications will become more clearly evident to the reader as we move forward to the next chapters and books.

Potentiated Pairings and Catalytic Sequences What procedures contributed to making personalized therapy individualized and synergized rather than eclectic? To restate from earlier paragraphs, there is a separateness among eclectically designed techniques, just a wise selectivity of what works best. In personalized therapy there are psychologically designed composites and progressions among diverse techniques. In an attempt to formulate them in current writings (Millon, 1988), terms such as “catalytic sequences” and “potentiated pairings” are employed to represent the nature and intent of theory-based polarity- and domain-oriented treatment plans. In essence, they comprise therapeutic arrangements and timing series that will resolve each patient’s distinctive polarity imbalances and effect targeted clinical domain changes that would otherwise not occur by the use of several essentially uncoordinated techniques. The first of the personalized procedures we recommended some years ago (Millon, 1988, 1990) was termed “potentiated pairings”; these are treatment methods that are combined simultaneously to overcome problematic characteristics that might be refractory to each technique if administered separately. These composites pull and push for change on many different fronts, so that the therapy becomes as multioperational and as tenacious as the disorder itself. A recent and popular illustration of treatment

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38 PERSONALIZED PSYCHOTHERAPY: A RECAPITULATION Table 1.10

Overall Level of Social and Occupational Functioning

Judgment

Rating Number

Description

Excellent

1

Clearly manifests an effective, if not superior level of functioning in relating to family and social peers, even to helping others in resolving their difficulties, as well as demonstrating high occupational performance and success.

Very Good

2

Exhibits considerable social and occupational skills on a reasonably consistent basis, evidencing few if any major areas of interpersonal stress or occupational difficulty.

Good

3

Displays a higher than average level of social and occupational competence in ordinary matters of everyday life. He or she does experience intermittent difficulties in interpersonal relationships and in efforts to achieve work satisfaction.

Fair

4

Functions about average for a typical patient seen in outpatient clinical work. Although able to meet everyday family, social, and occupational responsibilities adequately, there remain problematic or extended periods of occupational stress and/or interpersonal conflict.

Poor

5

Able to be maintained on an outpatient basis, but often precipitates severe conflicts with others that upset his or her equanimity in either or both interpersonal relationships and occupational settings.

Very Poor

6

There is an inability to function competently in most social and occupational settings. Difficulties are precipitated by the patient, destabilizing job performance and upsetting relationships with significant others. Inpatient hospitalization may be necessary to manage periodic severe psychic disruptions.

Markedly Impaired

7

A chronic and marked disintegration is present across most psychic functions. The loss of physical and behavioral controls necessitate extended stays in residential or hospital settings, requiring both sustained care and selfprotection.

Source: c 2006. DICANDRIEN, Inc. All rights reserved.

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Potentiated Pairings and Catalytic Sequences

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pairings is found in what has been referred to as cognitive-behavior therapy, one of the first of the combinatorial therapies (Craighead, Craighead, Kazdin, & Mahoney, 1994; Rasmussen, 2005). In the second personalized procedure, termed “catalytic sequences,” one might seek first to alter a patient’s humiliating and painful stuttering by behavior modification procedures which, if achieved, may facilitate the use of cognitive or self-actualizing methods to produce changes in self-confidence, which may, in its turn, foster the utility of interpersonal techniques in effecting improvements in relationships with others. Catalytic sequences are timing series that should optimize the impact of changes that would be less effective if the sequential combination were otherwise arranged. A more recent example has begun to show up in numerous clinical reports this past decade (Slater, 1998). It relates to the fact that patients with depressive personalities or long-term dysthymic disorders have their clinical symptoms markedly reduced by virtue of pharmacologic medications (e.g., selective serotonin reuptake inhibitors [SSRIs]). Although these patients are greatly comforted by the reduction of their clinical symptoms, “depressiveness” has over time become a core part of their overall psychological makeup. Because their depressiveness is no longer a part of their everyday experience, many may now feel empty and confused, not knowing who they are, not knowing to what they may aspire, or how to relate to the world. It is here where a catalytic sequence of psychotherapies may come into play constructively. Patients may no longer be depressed, but they may require therapy for their new self-image and its valuation. No less important to their subsequent treatment will be opportunities to alter their formerly habitual interpersonal styles and attitudes, substituting in their stead social behaviors and cognitions that are more consonant with their current state. Former cognitive assumptions and expectations will no longer be infused with depressogenic elements calling for substantial psychic reformulations. As the great neurological surgeon and psychologist Kurt Goldstein (1940) stated, patients whose brains have been altered to remedy a major neurological disorder do not simply lose the function that the extirpated area subserved. Rather, patients restructure and reorganize their brain capacities so that they can maintain an integrated sense of self. In a similar way, when one or another major domain of patients’ habitual psychological makeup is removed or diminished (e.g., depression), the patients must reorganize themselves, not only to compensate for the loss, but also to formulate a new self. Similarly, the neurologist Oliver Sacks in his 1973 book Awakenings describes what happens to patients who had been immobile for decades with encephalitis lethargica who suddenly “unfroze” when given the drug L-Dopa. Although these patients were restored to life, they had to learn to function in a world that had long passed them by. For them, their immobile state had an element of familiarity in which they had learned to cope, miserable though it was, for 10, 20, or 30 years. With the elimination of their adaptive lifestyle, they now had to deal with the new world in which they

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40 PERSONALIZED PSYCHOTHERAPY: A RECAPITULATION

found themselves, a task that rarely can be managed without considerable guidance and encouragement. Catalytic sequences represent the steps that should be employed in succession to facilitate these relearning and reintegrative processes. There are no discrete boundaries between potentiated pairings and catalytic sequences, just as there is no line between their respective pathological analogues, that is, adaptive inflexibility and vicious circles (Millon, 1969/1985). Nor should therapists be concerned about when to use one rather than another. Instead, they are intrinsically interdependent phenomena whose application is intended to foster increased flexibility and, hopefully, a virtuous rather than a vicious circle. Potentiated pairings and catalytic sequences represent the logic of combinatorial therapies. The idea of a potentiated sequence or a catalytic pairing recognizes that these logical composites may build on each other in proportion to what the tenacity of the patient’s interwoven disorder domains require. One question concerns the limits to which the content of personalized therapy can be specified in advance, that is, the extent to which specific potentiated pairings and catalytic sequences can be identified for each of the typical complex syndromes and personality disorders that exist. Many of the chapters of this and later texts of this series contain charts that present the salience of each of the clinical domains for that syndrome or disorder. To the extent that each patient’s presentations are prototypal, the potentiated pairings and catalytic sequences that may be used should derive from the more or less typical modality tactics that are optimal for their problematic domains, for example, pharmacology for mood/affect. That, however, probably represents the limits to which theory or “therapies that work” can guide clinical practice, that is, without knowing anything about the history and characteristics of the specific individual case. Patient individuality is so rich and special that it cannot fit into any ideal taxonomic schema; personalized therapy, properly practiced, is full of specificities that cannot readily be resolved by classification generalities. Potentiated pairings, catalytic sequences, and whatever other higher order composites therapists may evolve are best conducted at an idiographic person level rather than at a nomothetic taxonomic level. Accordingly, their precise content is specified as much by the logic of the individual case as by the logic of the syndrome or disorder. At an idiographic level, each of us must ultimately be artful and open-minded therapists, using simultaneous or alternately focused methods. The synergism and enhancement produced by such catalytic and potentiating processes are what constitute genuinely innovative personalized treatment strategies. Personalized therapists will be more efficacious if they think about the likely utility of treatment choices in probabilistic terms; that is, they should make concurrent and sequential modality arrangements, knowing that the effectiveness of each component is only partial, and that the probability of success will be less than perfect. To generate a high-probability estimate, therapists must gather all available assessment information and, as do mathematicians, calculate which combination of modalities will have the

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highest overall probability of being effective. Note that no combinational approach can automatically be judged “best.” With each new patient, a therapist should recognize that he or she is dealing with a person whose composite of dispositions and vulnerabilities has never before existed in this exact form. Moreover, it is important that the personalized therapist never think in treatment absolutes, or in black-and-white results; all treatment modalities have reasonable probabilities of success. There will be many cases in which the pattern of a patient’s characteristics does not lend itself to an intelligent estimate of treatment success probabilities. Under such circumstances, therapists should not feel that they must create a long-term or overall plan. Available options in the early stages of treatment may not provide a good, no less an excellent, course of action. Such indeterminate states favor selecting a rather tentative or conservative course—until such time as greater clarity emerges. It should be evident from the foregoing comments that a personalized therapist will be challenged to make a series of difficult judgments, one more demanding and possibly with less assurance as to outcome than if the therapist routinely selected a specific modality for all or most of his or her cases. The latter course will be easier for the therapist, but not necessarily best for the patient. The remainder of this and other books of this series will seek to make the probabilistic task less indeterminate and less onerous. We provide a rationale for which modalities and which combinations are likely to be most effective, given the pattern of the patient’s clinical syndromes and personality disorders. Turning to the specific domains in which clinical problems exhibit themselves, we can address dysfunctions in the realm of interpersonal conduct by employing any number of family or group therapeutic methods, as well as a series of recently evolved and explicitly formulated interpersonal techniques. Methods of classical analysis or its more contemporary schools may be especially suited to the realm of object representations, as would the methods of Beck and Ellis be well chosen to modify difficulties of cognitive beliefs and self-esteem. Tactics and strategies keep in balance the two conceptual ingredients of therapy; the first refers to what goes on with a particular focused intervention, and the second refers to the overall plan or design that characterizes the entire course of therapy. Both are required. Tactical specificity without strategic goals implies doing without knowing why in the big picture, and goals without specificity implies knowing where to go, but having no way to get there. Obviously, one uses short-term modality tactics to accomplish higher level strategies or goals over the long term. Psychotherapies seem to vary in the amounts of tactical specificity and strategic goals they prefer. This is not often merely an accident of history, but can be tied back to assumptions latent in the therapies themselves. Historically, a progression seems to be toward both greater specificity and clearer goals. More modern approaches to psychotherapy, such as the cognitive-behavioral, put into place highly detailed elements (e.g., agreed upon goals, termination criteria, and ongoing assessments) in

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42 PERSONALIZED PSYCHOTHERAPY: A RECAPITULATION

which therapy itself becomes a self-regulating system. Ongoing assessments ensure the existence of a feedback process that is open to inspection and negotiation by both therapist and patient. The mode is one of action rather than talk. Talk is viewed as incapable of realizing possibilities in and of itself, but is merely a prerequisite for action, used to reframe unfortunate circumstances so that obstacles to action are removed or minimized. Action is more transactive than talk, and therapy is forward-looking and concentrates on realizing present possibilities as a means of creating or opening up new possibilities. Persons are often changed more through exposure and action than by focusing and unraveling the problems of the past. Insight may be a useful, even necessary but limited goal in itself. It must be remembered that the primary function of any system is homeostasis. In an early book (Millon, 1981), personality was likened to an immune system for the psyche, such that stability, constancy, and internal equilibrium become the goals of a personality. Obviously, these run directly in opposition to the explicit goal of therapy, which is change. Usually, the dialogue between patient and therapist is not so directly confrontational that it is experienced as particularly threatening. When the patient does feel threatened, the personality system functions for the patient as a form of passive resistance, albeit one that may be experienced as a positive force (or trait) by the therapist. In fact, the structural grounding of a patient’s self-image and object representations are so preemptive and confirmation-seeking that the true meaning of the therapist’s comments may never reach the level of conscious processing. Alternatively, even if a patient’s equilibrium is initially up-ended by a particular interpretation, his or her defensive mechanisms may kick in to ensure that a therapist’s comments are somehow distorted, misunderstood, interpreted in a less threatening manner, or even ignored. The first is a passive form of resistance, the second an active form. No wonder, then, that effective therapy is often considered anxiety provoking, for it is in situations where the patient really has no effective response, where the functioning of the psychic immune system is temporarily suppressed, that the scope of his or her response repertoire is most likely to be broadened. Personality goes with what it knows, and it is with the unknown where learning is most possible. If the psychic makeup of a person is regarded as a system, then the question becomes: How can the characteristics that define systems be co-opted to facilitate rather than retard change? A coordinated schema of strategic goals and tactical modalities for treatment that seeks to accomplish these ends are what we expect to achieve in personalized psychotherapy. Through various coordinated approaches that mirror the system-based composition of the patient’s complex clinical syndrome and personality disorder, an effort is made to select domain-focused tactics that will fulfill the strategic goals of treatment. If interventions are unfocused, rambling, and diffuse, the patient will merely lean forward a little, passively resisting change by using his or her own weight, that is, habitual characteristics already intrinsic to the system. Although creating rapport

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Potentiated Pairings and Catalytic Sequences

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is always important, nothing happens unless the system is eventually shaken up in some way. Therapists should not always be toiling to expose their patient’s defenses, but sooner or later, something must happen that cannot be readily fielded by habitual processes, something that often will be experienced as uncomfortable or even threatening. In fact, personalized therapy appears in many ways to be like a “punctuated equilibrium” (Eldridge & Gould, 1972) rather than a slow and continuous process. This evolutionary insight argues for periods of rapid growth during which the psychic system reconfigures itself into a new gestalt, alternating with periods of relative constancy. The purpose of keeping to a domain or tactical focus, or knowing clearly what you are doing and why you are doing it, is to keep the whole of the therapeutic enterprise from becoming diffused. The person-focused systems model runs counter to the deterministic universe-as-machine model of the late nineteenth century, which features slow but incremental gains. In the prepunctuated evolutionary model as applied to therapy, moderate interventions become an input that is processed gradually and homeostatically, producing minor, if not zero change. In these earlier procedures, conservation laws play a prominent role; mild interventions produce small increments of change, with the hope that therapeutic goals will be reached, given enough time and effort. In contrast, in a focused, “punctuated” personalized model, therapeutic advances may clearly be spelled out to have genuine transformational potential, a potential optimized through procedures such as those we have termed potentiated pairings and catalytic sequences. Tactical specificity is required in part because the psychic level in which therapy is practiced is fairly explicit. Most often, the in-session dialogue between patient and therapist is dominated by a discussion of specific domain behaviors, specific domain feelings, and specific domain cognitions, not by an abstract discussion of personality disorders or clinical syndromes. When the latter are discussed, they are often perceived by the patient as an ego-alien or intrusive characterization. A statement such as “You have a negativistic personality that should be changed” conceives the patient as a vessel to be filled or altered by some noxious substance. Under these conditions, the professional is expected to empty the vessel and refill it with something more desirable; the patient has relinquished control and responsibility and simply waits passively for the therapist to perform some mystical ritual, one of the worst assumptive sets in which to carry out psychotherapy. For the therapist, operationalizing clinical syndromes and personality disorders as domain clusters of expressive behaviors or cognitive styles can be especially beneficial in selecting tactical modalities. The avoidant’s social withdrawal can be seen as having enough pride in oneself to leave a humiliating situation. The dependent’s clinging to a significant other can be seen as having the strength to devote oneself to another’s care. Of course, these reframes will not be sufficient in and of themselves to produce change. They do, however, seek a bond with the patient by way of making positive attributions

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44 PERSONALIZED PSYCHOTHERAPY: A RECAPITULATION

and thereby raising self-esteem, while simultaneously working to disconfirm or make the patient reexamine other beliefs that lower esteem and function to keep the person closed off from trying on new roles and behaviors. Understanding traits as domain clusters of behaviors and/or cognitions is just as beneficial for the therapist as for the patient when it comes to overturning the medical model of syndromal and personality pathology and replacing it with a personalized model. One of the problems of complex syndromes and personality disorders is that their range of attributions and perceptions is too narrow to characterize the richness that in fact exists in their social environment. As a result, they end up perpetuating old problems by interpreting even innocuous behaviors and events as noxious. Modern therapists have a similar problem, in that the range of paradigms they have to bring to their syndromal and disordered patients is too narrow to describe the rich set of possibilities that exist for every individual. The belief that mental difficulties are medical diseases, monolithically fixed and beyond remediation, should itself be viewed as a form of iatrogenic pathology. As has been noted previously, there are strategic goals of therapy, that is, those that endure across numerous sessions and against which progress is measured, and there are specific domain modality tactics by which these goals are pursued. Ideally, strategies and tactics should be integrated, with the tactics chosen to accomplish strategic goals, and the strategies chosen on the basis of what tactics might actually achieve, given other constraints, such as the number of therapy sessions and the nature of the problem. To illustrate, intrapsychic therapies are highly strategic but tactically impoverished; pure behavioral therapies are highly tactical but strategically narrow and inflexible. There are, in fact, many different ways that strategies might be operationalized. Just as diagnostic criteria are neither necessary nor sufficient for membership in a given class, it is likely that no technique is an inevitable consequence of a given clinical strategy. Subtle variations in technique and the ingenuity of individual therapists to invent techniques ad hoc assure that there exists an almost infinite number of ways to operationalize or put into action a given clinical strategy. Individuals should be viewed as system units that exist within larger ecological milieus, such as dyads, families, communities, and, ultimately, cultures. Like the personality system, these higher level systems contain homeostatic processes that tend to sustain and reinforce their own unique patterning of internal variables. The fact that the ecology of complex clinical syndromes and personality disorders is itself organizational and systemic argues for another principle of therapy: Pull as much of the surrounding interpersonal and social context into the therapeutic process as possible, or risk being defeated by them. Where ecological factors are operative, therapeutic gains may be minimized and the risk of relapse increased. In the best-case scenario, family members can be brought into therapy as a group or as needed; if no latent pathologies exist, the family will cooperate in discussing characteristics of the status quo that perpetuate pathology and explore alternatives that might promote change. In the worst-case scenario, family members will refuse to come into therapy under some

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Procedural Caveats and Considerations

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thin rationale, probably because nonparticipation is one way to passively undermine a change they in fact fear. If family members are not motivated to assist in the therapeutic process, it is likely that the individual is in therapy either because he or she must be, as in cases of court referral, or because family members do not want the burden of guilt that would accrue from actively refusing assistance.

Procedural Caveats and Considerations All personalized therapies must consider several factors following the implementation of the general plan. First, progress must be evaluated on a fairly regular basis; second, problems of resistance and risk should be analyzed and counteracted; and third, efforts should be made to anticipate and prevent relapsing. In personalized therapies, where things hopefully will change rapidly, treatment review should be a continuous process, every few sessions or so. The purpose of evaluating the plan is to ensure that progress is directed to achieving its strategic goals. Part of the evaluation process is intended to give the therapist a rough sense of how long treatment will be. Should progress be delayed or fail to reach a reasonable level, then it is clear that some rethinking of goals and strategies is called for. Evaluating the progress of therapy is difficult when treatment is unstructured or when the time commitment is limited. Personalized therapy may begin with a series of explicit goals and modalities; however, these may change over time, especially if treatment is open-ended (Bergin & Lambert, 1978). Originally planned strategies and modalities are periodically found lacking. Therapies start with a limited set of impressions and with only a rough notion of the more complex elements of the patient’s makeup. As treatment proceeds and knowledge of the patient grows and becomes more thoroughly understood, this new information may strengthen the original plan and strategy; on the other hand, as the assessment process continues, so may the conception of the patient’s psychic difficulties be altered. A fine-tuning process may be called for. The overall configuration of syndromes and disorders may require a significant shift toward the use of different domain-oriented modalities. Hence, both strategies and tactics may have to be modified to accord with this new information. There are numerous issues that arise with patients as therapy progresses. Some patients are highly resistant to the probing and psychic dislodging they experience in treatment. Others feel they have become free from their original constraints, employing treatment as a rationale to engage in increasingly risky activities. Therapeutic resistance derives from the patient’s defensive armor, usually indicating a reluctance to voice his or her feelings and thoughts to the therapist. Most resistances manifest themselves in a number of well-known ways: silence, lateness, becoming helpless, missed appointments, having significant memory lapses, or simply paying later and later each month. On the other hand, risky behaviors are likely to show themselves in a tendency

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46 PERSONALIZED PSYCHOTHERAPY: A RECAPITULATION

to act out, to be open with regard to expressing resentments, proving the therapist is wrong, exhibiting parasuicidal behaviors, and engaging in irrational behaviors. As Messer (1996) has noted, however, resistances are not the enemy of therapy but an informative expression of the way patients feel, act, and think in everyday life. There are several choices when resistances or risks present themselves. We can insist on continuing with the original plan; we can interpret the meaning of the resistance and point out the consequences of risky behaviors; or we can alter aspects of the overall treatment strategy. Whatever the choice will be, it should be formulated as a positive and active decision. Otherwise, the whole structure of the treatment plan may be seriously compromised. Despite substantial progress over the treatment course, patients should leave therapy in a better state than when they entered. A worst-case scenario is when certain fundamental aspects of the patient’s psychic makeup have remained unresolved at the point of treatment termination. Whether it is the patient’s decision that he or she has had enough therapy, or the therapist believes that there will be diminishing returns for continuing further, it may be advisable at some point to terminate treatment. It is the task of the good personalized therapist to help the patient anticipate potential setbacks, to avoid stressful situations in which the patient may be highly vulnerable, and to assist him or her to develop problem-solving skills, as well as to strengthen his or her more constructive potentials. It is not uncommon to have patients develop new psychic symptoms during the treatment process. More typically, many patients experience a reassertion of pathological thoughts and feelings following termination. We strongly encourage therapists to stretch the time between sessions as therapy progresses. This enables the therapist to determine which aspects of the treatment strategy have been resolved adequately and which remain vulnerable and potentially problematic. It is our general belief that adequate therapy should continue over these periodic sessions to ensure that substantial relapses will not occur. The reemergence of certain symptoms does not mean that the patient has deteriorated, but that the more complex elements of the patient’s psyche have come together with life circumstances in an especially troublesome way. Such symptoms serve as clues to both the therapist and the patient, enabling them to learn and anticipate what will continue to be troublesome in the future. The system we have termed personalized therapy has raised concerns by some as to whether any one therapist can be sufficiently skilled, not only in employing a wide variety of therapeutic approaches, but also to synthesize them and to plan their sequence. As the senior author was asked at a conference some years ago: “Can a highly competent behavioral therapist employ cognitive techniques with any measure of efficacy; and can he or she prove able, when necessary, to function as an insightful intrapsychic therapist? Can we find people who are strongly self-actualizing in their orientation who can, at other times, be cognitively confronting? Is there any wisdom

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in selecting different modalities in treating a patient if the therapist has not been trained diversely or is not particularly competent in more than one ore two therapeutic modalities?” It is our belief that the majority of therapists have the ability to break out of their single-minded or loosely eclectic frameworks, to overcome their prior limitations, and to acquire a solid working knowledge of diverse treatment modalities. Developing a measure of expertise with the widest possible range of modalities is highly likely to increase treatment efficacy and the therapist’s rate of success.

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Personalized Therapy for the Retiring/ Schizoid Personality Patterns Recapitulation of Personalized Idea

I

t is our contention that integrative therapists should take cognizance of the person from the start, for the parts and the contexts take on different meanings and call for different interventions in terms of the person to whom they are anchored. To focus on one social structure or one psychic form of expression without understanding its undergirding or reference base is, as we see it, to engage in potentially misguided, if not random, therapeutic techniques. Psychotherapy today seems preoccupied with horizontal refinements. However, a search for a natural integrative schema should be based on intrinsically cohesive constructs that interweave each patient’s closely related traits of structure and function. The goal—albeit a rather grandiose one—is to refashion the patchwork quilt of separate modalities into a well-tailored tapestry of uniquely integrated persons, hence permitting the development of combined techniques that mirror the diverse forms in which lives express themselves. What better sphere is there within the psychological sciences to undertake such syntheses than the subject matter of personology and psychopathology? Persons are the only integrated system in the psychological domain, evolved through the millennia as natural entities. The intrinsic cohesion of persons is not merely a rhetorical construction, but an authentic substantive unity. Personologic features may often be dissonant, and may be partitioned conceptually for pragmatic or scientific purposes; they are nonetheless segments of an inseparable biopsychosocial entity.

51

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A useful metaphor derived from the philosophies of Leibniz and Whitehead, termed “holography,” may be useful as a means of explaining the widely distributed impact of life experiences. As Abroms (1993, p. 85) has written: Holographically distributed patterns are those in which each part (e.g., . . . isolated body cell) contains information about what is stored in all other parts, thus permitting one to reconstruct . . . the entire genetic code of the organism from each of its pieces. Thus, a hologram is a representation of an object or an event in which every part contains sufficient information to characterize the whole. Each part represents the whole, and the whole implies each part.

In our judgment, the holographic metaphor applies with equal merit to the different conceptual realms of clinical functioning when seen idiographically in a specific patient. Each realm is a part of a single unified whole. That which may be primarily expressed cognitively, or interpersonally, or intrapsychically are mere facets of the patient’s total personal makeup. As therapists, we have separated these domains for scientific or clinical purposes. In reality, what happens cognitively is also registered in the intrapsychic realm; what happens behaviorally also registers in the realm of self-image, and so on. As a result, every change that transpires in one trait domain will have an effect on every other. The task is to identify those traits that are most central for each patient, that is, have a pernicious influence or pervasive impact on all other facets of the person’s psychic hologram. Much of what personality synergism seeks to accomplish is to identify the domains that are saliently problematic and to facilitate significant changes, both there and in all other covariant and troublesome domains.

The Retiring/Schizoid Personality The essential features of the retiring/schizoid personality are a defect in the ability to form social relationships and an underresponsiveness to all forms of stimulation. Such individuals also exhibit an intrinsic emotional blandness, an imperviousness to joy, anger, or sadness. Notably unmoved by emotional stimuli, the retiring/schizoid appears to possess a generalized inability to be aroused and activated, as well as a general lack of initiative and vitality (Smith, 2006). Their interpersonal passivity, then, is not by intention or for self-protective reasons, but due to a fundamental imperceptiveness to the moods and needs of others (Millon, 1969, 1981, 1996b). Retiring/schizoid personalities typically prefer limited interpersonal contact and only a peripheral role in social and family relationships. They tend to choose interests and vocations that will allow them to maintain their social detachment (McWilliams, 2006). Colorless and lacking in spontaneity, they are usually perceived as unresponsive, boring, or dull in relationships. Their speech tends to be characterized by emotional flatness, vagueness, and obscurities, and there is a seeming inability to grasp the emotional components of human interactions and communications (Collins, Blanchard, & Biondo, 2005). They seem indifferent to both praise and criticism. Consistent with their interpersonal style, schizoids possess little awareness of themselves and employ

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only minimal introspection. Lacking in insight and relatively untroubled by intense emotions or interpersonal conflicts, the retiring/schizoid possesses limited and uncomplicated intrapsychic defenses. Schizoid personalities’ pervasive imperviousness to emotions puts them among the personality styles least susceptible to genuine depression or other affective distress. Having failed to develop an appetite for social stimulation (including affection and attachment), these individuals are not vulnerable to dejection resulting from object loss. In addition, because retiring/schizoids derive only limited pleasure from themselves, they are not particularly susceptible to loss of self-esteem or self-deprecation. Emotional distress may develop, however, when faced with unusual social demands or responsibilities, or when stimulation levels become either excessive or drastically curtailed. In addition, their inner barrenness and interpersonal isolation may occasionally throw them into a fear of nonbeing or petrifaction (Raja, 2006). On rare occasions, schizoids may exhibit brief, frenzied episodes of maniclike excitement in an attempt to counter the anxieties of depersonalization. A fleeting and erratic course of frantic and rather bizarre conviviality may then temporarily replace the retiring/schizoid’s characteristic impassive, unsociable pattern. More frequently, however, the schizoid reacts to disequilibrium with increased isolation and dissociation (Camisa et al., 2005). Lacking an investment and interest in self, as well as external events, the retiring/schizoid fails to acquire a coherent and well-integrated inner identity. Disruption to the consistency of the schizoid’s lifestyle, as might result from unwanted social overstimulation or prolonged periods of social isolation, may consequently result in a kind of splitting or disintegration. During such periods of self-estrangement, retiring/ schizoids may experience irrational thinking and compounding of their typical emotional poverty. Behaviorally, this might be manifested in profound lethargy, lifeless facial expressions, and inaudible speech, simulating but not reflecting a depressive mood. Although empirical data on affective disorders in schizoid personalities are lacking, at least two of the factor-analysis-generated subtypes would seem to fit the experience of depression in these individuals. “Factor Pattern A,” generated in the 1961 study by Grinker et al., is described as a depressive who is not particularly anxious, clinging, or attention seeking, but rather isolated, withdrawn, and apathetic. A slowing in thought and speech, with some evidence of cognitive disturbance, is also seen. The absence of large amounts of gloomy affect, complaining, and attempts at restitution give this depressive subtype the appearance of an empty person. Although much of this description would fit the theoretical picture of depression in the schizoid, Grinker et al. specify other features of this depressive factor pattern that might be more characteristic of a compulsive premorbid personality. The “retarded depression” discussed by Overall and Hollister (1980) might also be consistent with the symptomatic presentation of depression in the retiring/schizoid. Such depression is characterized by retardation in speech, gross motor behavior, and social interaction. A diminishment in affective responsiveness may frequently accompany the “generalized behavioral inhibition” (p. 376) that is present in this form of depression.

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The restriction in the DSM-IV to the interpersonal and mood domains limits the range of possible useful criteria to a rather narrow band. Relevant though these domains are, the schizoid manifests a much wider scope of domain characteristics than has been included in the DSM-IV, for example, self-image, cognitive style, and intrapsychic structural features. Although derived from the authors’ theoretical schema, an empirically and numerically derived set of factors comprising the distinguishable and partially separable traits of the retiring/schizoid personality has been developed and will be recorded in subsequent research papers (J. G. Johnson, Cohen, Chen, Kasen, & Brook, 2006). Next, however, are a few words describing the evolutionary model and theory as it pertains to the schizoid personality prototype. Reviewing the polarity schema for retiring/schizoids (Figure 2.1), we can see that they possess a marked deficiency in the capacity to experience both psychic pleasure

SCHIZOID PROTOTYPE

Enhancement

Preservation

(Pleasure)

(Pain)

Accomodation

Modification

(Passive)

(Active)

Individuation

Nurturance

(Self)

(Other)

Weak on Polarity Dimension Average on Polarity Dimension Strong on Polarity Dimension

FIGURE 2.1 Status of the retiring/schizoid personality prototype in accord with the Millon polarity model.

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(enhancement) and pain (preservation). In other words, they are unmotivated to seek out joy and gratification, are unable to view life enthusiastically, and experience none of the distressing affects of life, such as sadness, anxiety, and anger. As a consequence of these deficiencies, retiring/schizoids have little motivation to seek out rewards or to distance themselves from potentially discomforting experiences; the result is a rather passive (accommodating) individual, one ill-disposed to modify his or her life circumstances or to participate actively in life’s events. Owing to these deficiencies and inclinations, there is little motivation to become involved in the affairs of others (nurturance). Hence, by default, if nothing else, these individuals tend to be self-involved (individuated). The deductive model presented in Figure 2.1 reflects the manner in which the theory formulates a personality disorder; it is essentially the same procedure by which Costa and Widiger (1993) articulate the components of these disorders using the quantitatively derived five factors as their model, as well as the manner in which Cloninger (1986) does likewise, employing his biologically anchored tripartite schema of harm avoidance, novelty seeking, and reward dependence. The key distinction between Millon’s model and those of a quantitative or neurobiological character is its grounding in a theory that transcends the particular forms of expression in which personality disorders manifest themselves (lexical, biochemistry). Instead, Millon’s model is anchored to the deeper elements of nature, as found in evolution’s principles that apply to all of the major disciplines of science.

Clinical Picture Perhaps it is not necessary to say, but there are many variations to be seen in individuals diagnosed with the same label. Desirous though it may be to find that everyone given the same designation displays the same pattern of behaviors, feelings, and thoughts, the reality is that there are numerous and variegated forms that might be comfortably subsumed under the same label. It would not be judicious to lead the naive reader into believing that there is a single pattern of features that typify each of our categorical classes. Hence, in this section, we describe some of the many varieties of each of the prototypal personality disorders, for we are convinced, for the most part, that each prototypal personality is largely an extension or more extreme variant of normal types that exhibit similar features. With the foregoing as a background, this section details the clinical characteristics of the core group of prototypal schizoids in a more explicit and systematic fashion. Reference should be made to the adjoining Table 2.1 in this and later chapters; these tables summarize and highlight the different domains that characterize the prototype of each personality disorder. Also, Figure 2.2 on page 57 presents these same clinical domains, but highlights their relative salience among retiring/schizoid personalities, for example, the unengaged interpersonal conduct and the apathetic mood/temperament

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56 PERSONALIZED THERAPY FOR THE RETIRING/SCHIZOID PERSONALITY PATTERNS Table 2.1

Clinical Domains of the Retiring/Schizoid Prototype

Behavioral Level: (F) Expressively Impassive (e.g., appears to be in an inert emotional state; lifeless, undemonstrative, lacking in energy and vitality; is unmoved, boring, unanimated, robotic, and phlegmatic, displaying deficits in activation, motoric expressiveness, and spontaneity). (F) Interpersonally Unengaged (e.g., seems indifferent and remote, rarely responsive to the actions or feelings of others; chooses solitary activities, possesses minimal human interests; fades into the background, is aloof or unobtrusive, neither desires nor enjoys close relationships, prefers a peripheral role in social, work, and family settings). Phenomenological Level: (F) Cognitively Impoverished (e.g., seems deficient across broad spheres of human knowledge and evidences vague and obscure thought processes, particularly about social matters; communication with others is often unfocused, loses its purpose or intention, or is conveyed via a loose or circuitous logic). (S) Complacent Self-Image (e.g., reveals minimal introspection and awareness of self; seems impervious to the emotional and personal implications of everyday social life, appearing indifferent to the praise or criticism of others). (S) Meager Objects (e.g., internalized representations are few in number and minimally articulated, largely devoid of the manifold percepts and memories of relationships with others, possessing little of the dynamic interplay among drives and conflicts that typify well-adjusted persons). Intrapsychic Level: (F) Intellectualization Mechanism (e.g., describes interpersonal and affective experiences in a matter-of-fact, abstract, impersonal, or mechanical manner; pays primary attention to formal and objective aspects of social and emotional events). (S) Undifferentiated Organization (e.g., given an inner barrenness, a feeble drive to fulfill needs, and minimal pressures either to defend against or resolve internal conflicts or cope with external demands, internal morphologic structures may best be characterized by their limited framework and sterile pattern). Biophysical Level: (S) Apathetic Mood (e.g., is emotionally unexcitable, exhibiting an intrinsic unfeeling, cold, and stark quality; reports weak affectionate or erotic needs, rarely displaying warm or intense feelings, and apparently unable to experience most affects—pleasure, sadness, or anger—in any depth). Note: F = Functional Domains; S = Structural Domains.

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SCHIZOID PROTOTYPE

Impassive Expressive Behavior

Complacent

Intellectualization

Self-Image

Unengaged

Apathetic

Interpersonal Conduct

Impoverished

Regulatory Mechanism

Mood/Temperament

Meager Object Representations

Undifferentiated Morphologic Organization

Cognitive Style

FIGURE 2.2 Salience of retiring/schizoid domains.

are the two most prominent or characteristic features that distinguish the schizoid prototype. Impassive Expressive Behavior Most characteristic of retiring/schizoids is their lack of demonstrativeness and their deficits in energy and vitality. They appear to the observer to be unanimated and robotic; many display marked deficits in activation and spontaneity. Speech among schizoids typically is slow and monotonous, characterized by an affectless vacancy and obscurities that signify either inattentiveness or a failure to grasp the emotional dimensions of human communication. Movements are lethargic and lacking in rhythmic or expressive gestures. They rarely perk up or respond alertly to the feelings of others; they are not intentionally unkind, however. They seem invariably preoccupied with tangential and picayune matters, rather passively detached from others and drifting along quietly and unobtrusively, as if in a world of their own. Individuals of this cast evidence underresponsiveness to all forms of stimulation. Events that normally provoke anger, elicit joy, or evoke sadness in others seem equally bland. There is a pervasive imperviousness to emotions, not only to those of joy and pleasure. Feelings of anger, depression, or anxiety rarely are expressed. This apathy and

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emotional deficit are cardinal signs of the retiring/schizoid syndrome. Their generalized inability to be activated and aroused may be exhibited in a wide-ranging lack of initiative and the failure to respond to most reinforcements that prompt others into action. Thus, they are not only unmoved by emotional stimuli but seem to possess a general deficiency in energy and vitality. When they do become involved, their activities tend to be mental, such as reading or television watching, or physical activities that call for minimal energy expenditures, such as drawing, watch repairing, or needlepoint. Unengaged Interpersonal Conduct For the most part, retiring/schizoids seem interpersonally indifferent and remote, failing to be responsive to the emotions and behaviors of others. They prefer solitary activities, exhibit few interests in the lives of others, and tend to fade into the social background, being either unobtrusive or seemingly aloof. They appear to prefer maintaining a peripheral role in most interpersonal settings, neither desiring nor enjoying any close relationships. The inability of schizoids to engage in the give-and-take of reciprocal relationships may readily be observed. They are rather vague and disengaged from group interactions, appearing preoccupied in their own world. It is difficult for them to mix with others even in pleasant social activities, let alone those demanding leadership. When they must relate to others, such as at school or work, their social communications are expressed not in a peculiar or irrational way but in a perfunctory, formal, and impersonal manner. For the same reasons they fail to develop intrapsychic mechanisms, retiring/schizoids also tend not to learn complex interpersonal coping maneuvers. Their drives are meager, and they lack the intense personal involvement sometimes conducive to painful emotional conflicts. This is not to say that they possess no drives or discords, but that those they do experience are of mild degree and of minor consequence. One of the distinctions of the schizoid personality, then, is the paucity (rather than the character or direction) of interpersonal coping. If any factor in their generally feeble hierarchy of motives can be identified, it is their preference for remaining socially detached. This is not a driving need of theirs, as it is with the avoidant personality, but merely a comfortable and preferred state. When social circumstances press them beyond comfort, they may simply retreat and draw into themselves. Should social discord or demands become intense or persistent, they may revert to more severe coping reactions and display various pathological disorders, such as schizophrenic syndromes. Impoverished Cognitive Style The thought processes of the retiring/schizoid tend, in general, to be rather deficient, not only in most spheres of human interest, but especially so with regard to social and personal life. Not uncommonly, schizoids’ communications with others seem unfocused, conveyed in a loose or circuitous way, and occasionally wandering off the track, losing purpose or intention. Schizoid personalities rarely are introspective as the satisfactions to be found in self-evaluation are minimal for those who are incapable

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of experiencing deep emotions. This diminished introspectiveness, with its attendant lowering of insight, derives from another feature of the retiring/schizoid pattern: They display a vagueness and impoverishment of thought, a tendency to skim the surface of events, and an inability to convey articulate and relevant ideas regarding interpersonal phenomena. This style of amorphous communication may be related to another trait, one referred to here as “defective perceptual scanning.” It is characterized by a tendency to miss or blur differences and to overlook, diffuse, and homogenize the varied elements of experience. Instead of differentiating events and sensing their discriminable and distinctive attributes, schizoids tend to mix them up, intrude extraneous or irrelevant features, and perceive them in a somewhat disorganized fashion. This inability to attend, select, and regulate their perceptions of the environment seems, once again, to be especially pronounced with social and emotional phenomena. Complacent Self-Image The retiring/schizoid appears emotionally impervious to the character of social transactions, revealing little awareness or interest in the personal lives of others, as well as in their own lives. They are not only indifferent to the meaning of what others convey to them, such as praise or criticism, but they exhibit little or no tendency to look into their personal feelings and attitudes. To the extent that they look inward, schizoid personalities characterize themselves as bland persons who are reflective and introversive. Most seem complacent and satisfied with their lives and are content to remain aloof from the social aspirations and competitiveness they see in others. Selfdescriptions, however, tend to be vague and superficial. This lack of clarity does not indicate elusiveness or protective denial on their part, but rather their deficient powers to reflect on social and emotional processes. Interpersonal attitudes are no less vague and inarticulate. When self-descriptions are adequately formulated, retiring/schizoids perceive themselves to be somewhat reserved and distant, lacking in much concern or care for others. Rather interestingly, they are able to recognize that others tend to be indifferent to them and their needs. Meager Object Representations The inner template of past experiences that are embedded in the mind of most schizoids appears to contain few and diffusely articulated memories. In contrast to those of other personalities, these imprinted memories seem to be devoid of specificity and clarity. They also possess little of the dynamic interplay among drives, impulses, and conflicts that are found among well-adjusted persons. Owing to the feeble manner in which they experience events and persons, there is relatively little that imprints strongly in their minds. Schizoids are low in arousal and in emotional reactivity, as well as relatively imperceptive and therefore inclined to blur distinctions; thus, their inner life remains largely homogeneous and undifferentiated. Lacking the natural variety of experiences

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that most people enjoy, they are unable to engage in dynamic interplay, nor are they able to change and evolve as a consequence of their intrapsychic interactions. Intellectualization Regulatory Mechanism Retiring/schizoids describe the interpersonal and affective character of their experiences and memories in a somewhat impersonal and mechanical manner. They tend to be abstract and matter-of-fact about their emotional and social lives; when they do formulate a characterization, they pay primary attention to the more objective and formal aspects of their experiences rather than to the personal and emotional significance of these events. Schizoids engage in few complicated unconscious processes. Relatively untroubled by intense emotions, insensitive to interpersonal relationships, and difficult to arouse and activate, they hardly feel the impact of events and have little reason to devise complicated intrapsychic defenses and strategies. They do harbor segments of the residuals of past memories and emotions, but, in general, their inner world lacks the intensities and intricacies found in all other pathological personalities. Undifferentiated Morphologic Organization As indicated, the inner world of the retiring/schizoid is largely desolate, devoid of the complex emotions, conflicts, and cognitions that are harbored even in most “normal” persons. Their inner world is barren. There are minimal drives to fulfill their needs; likewise, they experience minimal pressure to resolve their internal conflicts or to deal with external demands. More than for any other personality, excluding perhaps some schizotypals, the structural composition of their intrapsychic world is highly diffuse and dynamically inactive. Apathetic Mood/Temperament Perhaps the most striking and fundamental element of retiring/schizoids is their intrinsic deficiency in affective sensibility (Haznedar et al., 2004). Not only do they report few, if any, affectionate or erotic needs, but they appear unable to experience these major affective states—pleasure, sadness, or anger—to any degree. They are emotionally unexcitable, exhibit the weakest level of feelings, and seem to go through life in a cold and stark manner.

Self-Perpetuation Processes What does the future hold for the schizoid? This section explores personality features that are themselves pathogenic, that is, foster increments in the individual’s difficulties. Also touched on are some of the therapeutic steps that might help reverse these trends. The impassivity and lack of color of retiring/schizoids enable them to maintain a comfortable distance from others. But their preferred state of detachment is itself pathogenic, not only because it fails to elicit experiences that could promote a more

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Self-Perpetuation Processes

Table 2.2

61

Self-Perpetuating Processes: Retiring/Schizoid Personality

Impassive and Insecure Behavior Intensifies detachment Inarticulate and affectively unresponsive Boring and colorless Diminished Perceptual Awareness Flattens emotional events Projects undifferentiated cognitions Homogenizes variegated experiences Social Inactivity Limits emotional involvements Shrinks interpersonal milieu Excludes life-energizing events

vibrant and rewarding style of life but because it fosters conditions that are conducive to more serious forms of psychopathology. Among the more prominent factors that operate to this end are the following (see Table 2.2). Impassive and Insensitive Behavior The inarticulateness and affective unresponsiveness that characterize retiring/schizoids do little to make them attractive to others. Most persons are not inclined to relate to schizoids for any period, tending to overlook their presence in most settings and, when interacting socially, doing so in a perfunctory and unemotional way. Of course, the fact that others consider them boring and colorless suits the asocial predilections of retiring/schizoids quite well. However, this preference for remaining apart and alone only perpetuates and intensifies their tendencies toward detachment. Diminished Perceptual Awareness The schizoid personality not only is socially imperceptive but tends to flatten emotional events, that is, to blur and homogenize experiences that are intrinsically distinct and varied. In effect, these personalities project their murky and undifferentiated cognitions on discriminable and complex social events. As a consequence of this perceptual diffusiveness, they preclude the possibility of learning from experiences that could lead them to a more variegated and socially discriminating life. Social Inactivity Passively detached retiring/schizoids perpetuate their own pattern by limiting severely their social contacts and emotional involvements Only those activities required to perform their job or fulfill their family obligations are pursued with any diligence. By

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shrinking their interpersonal milieu, they preclude new experiences from coming to bear on them. This is their preference, of course, but it only fosters their isolated and withdrawn existence because it excludes events that might alter their style.

Interventional Goals The prognosis for this moderately severe personality is not promising. Many appear limited by a constitutional incapacity for affective expression and physical vigor. These liabilities may be inborn or acquired as a consequence of early experience. Regardless of their origin, however, the affectivity and interpersonal deficits found in these individuals are chronic and pervasive features of their personality makeup. Coupling these ingrained traits with the characteristic lack of insight and poor motivation for change, we can only conclude that the probability is small that they will either seek or succeed in a course of remedial therapy. However, if their deficits are mild and if the circumstances of their life are favorable, they stand a good chance of maintaining adequate vocational and social adjustments. Given their lack of intrinsic motivators, the role of contextual factors in mobilizing therapeutic progress is paramount. The styles that schizoids have developed to cope with the events of their everyday life are a result, in great measure, of deficits in their intrinsic capacities to experience painful and pleasurable emotions. The impact of early learning may have further weakened these dispositions over time, continuing to color all subsequent events and thereby perpetuating the initial maladaptive patterns (see Table 2.3).

Table 2.3 Therapeutic Strategies and Tactics for the Prototypal Retiring/Schizoid Personality Strategic Goals Balance Polarities Increase pleasure-enhancing Increase active-modifying Counter Perpetuations Overcome impassive behaviors Increase perceptual awareness Stimulate social activity Tactical Modalities Energize apathetic mood Develop interpersonal involvement Alter impoverished cognitions

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Interventional Goals

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Reestablishing Polarity Balances As noted in previous pages, the coping strategy that characterizes the retiring/schizoid’s mode of relating to his or her environment can best be described as passively detached. Not only do these individuals appear to lack the capacity to experience pleasure or pain, but they do not obtain gratification from either self or others. A major treatment goal of therapy with this disorder is the enhancement of pleasure, particularly to overcome the imbalance in the pain–pleasure polarity. Moreover, their passively detached nature places them near the extreme end on the active–passive polarity. This latter imbalance warrants therapeutic efforts directed toward strengthening the active end of the continuum. Countering Perpetuating Tendencies When schizoids do come to the attention of a therapist, initial efforts are best directed toward combating their withdrawal tendencies. A major therapeutic goal is to prevent the possibility that they will isolate themselves entirely from the support of a benign environment. The therapist should seek to ensure that they continue some level of social activity to prevent them from becoming lost in fantasy preoccupations and separated from reality contacts. However, efforts to encourage a great deal of social activity are best avoided as their tolerance in this area is limited. Further therapeutic strategies should be oriented toward enhancing their perceptual awareness and countering their underresponsiveness to the environment. Retiring/schizoids typically display an emotional inattentiveness to others that needs to be addressed. Increasing affectivity will in turn promote more variegated social experiences. Identifying Domain Dysfunctions Primary domain dysfunctions can be seen in both the interpersonal conduct and mood/temperament domains. Providing the patient with an opportunity for social interaction can foster improvements in the interpersonal domain and lessen social isolation. Targeting the mood/temperament domain will involve activating these patients’ characteristically dull mood and increasing their capacity to experience pleasurable affective states. Deficits in activation are also observed in their expressive behavior. Improvements in this area would consist of elevating their energy level and enhancing their expressive abilities. Their cognitive style is rather vague and lacks richness. Intervention necessitates bringing clarity to their thought processes, helping them attend to both internal and external processes without losing focus. Secondary dysfunctions can be seen across several other domains. Their self-image, object representations, regulatory mechanisms, and morphological organization all lack complexity and depth. By expanding their behavioral and social repertoire and simultaneously improving their ability to attend to different stimuli, a groundwork may be provided for improving these remaining domains.

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Selecting Therapeutic Modalities To accomplish these goals, a variety of therapeutic modalities can be employed to target the clinical domain dysfunctions. These techniques should then be combined and put in sequence to promote maximal growth (L¨offler-Stastka, Ponocny-Seliger, Fischer-Kern, & Leithner, 2005). Because each individual possesses a unique constellation of attributes, a thorough assessment of the saliences of the clinical domains should be conducted (Bender, 2005). The formulations provided here are not foolproof, of course, and the therapist needs to be aware of the potential stumbling blocks and resistances that may arise. Behavioral Techniques Techniques of behavioral modification appear to be of limited value other than to reinforce some social skills. Because schizoids commonly lack full awareness of customary ways of behaving in social spheres, social skills training and other, more directive and educative measures may be employed to build a more appropriate interpersonal behavioral repertoire. Beck and Freeman (1990a, 1990b; Beck, Freeman, & Davis, 2004) suggest setting up a hierarchy of social interaction goals that the patient may want to accomplish. Role-playing and in vivo exposure can then be utilized to practice these skills. Audio-playback devices can be of some benefit in allowing patients to monitor their monotone speech. Videotaping can similarly be used in helping patients identify more subtle nuances in their own behavior (Coen, 2005). A critical limitation of operant techniques is that so few external sources of reinforcement can be identified, as these patients appear to have a limited capacity to experience consequent events as either rewarding or punishing. Affection and recognition, which serve as potent reinforcers for most people, are not valued. An attempt should be made to carefully analyze the patient’s behavioral repertoire and past history of reinforcement to identify any operant reinforcers that might be activated at this time. Behavioral change can at times be brought about by encouraging environmental modifications (Young, 1990). Such changes may include occupational adjustments or a change in living situation. Interpersonal Techniques Interpersonal techniques may prove problematic because a key element in interpersonal treatment is the therapeutic relationship, a feature in the retiring/schizoid’s asocial world that possesses little value. Transference reactions are less likely to occur but, if present, may only recapitulate earlier maladaptive interpersonal patterns (Meyer, Pilkonis, & Beevers, 2004). The therapist’s empathic stance and continued acceptance of the patient may facilitate rapport building. This may prove more fruitful than an insight-oriented approach, the latter seeking with minimal success to analyze the patient’s mode of interacting in the session.

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By providing a supportive and trusting environment, the therapist can facilitate collaboration. The dyadic relationship can be used as a forum for practicing recently acquired interpersonal and social skills. Here the therapist can function as a mirror, enabling the patient to gain a closer look at the self, providing a measure of confirmation and elaboration of inchoate self-schemas. If patients display an interest in developing interpersonal relations and skills, group methods may prove useful in encouraging and facilitating the acquisitions of constructive social attitudes. In this setting, schizoids may begin to alter their self-image and increase their motivation and skills for a more effective interpersonal style. Group settings are also uniquely suited for triggering schemas of an interpersonal nature (Young, 1990). The patient is provided with the opportunity to test the accuracy of the schemas as feedback from the other group members is readily available. Leszcz (1989) suggests that the group provides an opportunity for retiring/schizoids to become involved in a nonrelating way, slowly building a feeling of trust. Here they do not have to abandon the protection of distancing from others, but can learn how people relate to one another. Clinicians should permit this detached position until the patient learns how to relate as well as how to tolerate any mildly disturbing affects. Most important, schizoids learn to recognize their different responses to the other group members and to observe and experience their bodily responses to these differences. Yalom (1985) contends that these self-awareness goals are preferable to cathartic methods. However, the therapist will have to be extremely cautious not to expect the same degree of participation from the retiring/schizoid group member. Being in a group setting may place interactional demands on the client that might initially cause a great deal of anxiety. It is not unlikely that schizoids do come in for therapy at the request of family members. A decision may be made to involve other members of the family system in the therapeutic process. In some cases, family and marital therapy are best directed to educating the family members with regard to their relative’s potential for change. Adjusting their expectations may in turn facilitate improvements when there is more tolerance and less intrusion in the retiring/schizoid’s privacy by family members. Moreover, family members can be instrumental in cultivating reform by assisting in environmental modifications and by allowing the patient to explore newly learned social skills and modes of interacting. An in-depth assessment of the family system may, however, reveal maladaptive patterns that over time have perpetuated the personality pattern. Potential capacities for self-remediation that may have existed within the patient may have been squelched, thereby reinforcing this schizoid’s image as a developmental failure. Cognitive Techniques Attempts to cognitively reorient the patient’s attitudes may be useful for developing self-insight and for motivating greater interpersonal sensitivity and activity. The retiring/schizoid’s cognitive style is markedly impoverished. Homework assignments, such as having patients keep a daily record of dysfunctional thoughts, can help identify automatic thoughts and assist in disambiguating their vague cognitions. Identified

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automatic thoughts typically center around negative cognitions about themselves, their preference for solitude, and the feeling that they are detached observers in life (Beck & Freeman, 1990a, 1990b). These records can also help patients identify their emotions and gradations in intensity and how their emotional states affect their interactions with others (Will, 1994). As Young and Lindeman (1992) note, it is through interpersonal experience that schemas are developed and maintained. In the case of schizoids it may have been the absence of interpersonal experience that has contributed to the observed poverty of cognitions and their characteristic low complexity of self and other object representations. Another drawback is that therapists frequently use affective techniques to trigger schemas. The tendency of these patients to intellectualize only serves to reduce the likelihood that arousal of emotions allows access to schemas. The automatic thoughts and schemas that revolve around beliefs that they are better off alone and that relationships have nothing to offer them can be explored. It is worthwhile for the therapist and the patient to examine both functional and dysfunctional aspects of isolation in the patient’s life. A more realistic goal formulation, one on which the therapist and the patient can agree, should be determined. For example, the retiring/schizoid is often unable to recognize and articulate subtleties of reinforcement. Cognitive methods developed in conjunction with the therapist can assist the patient in identifying gradations of enjoyment obtained from a variety of experiences. Self-Image Techniques A major difficulty among schizoids is their lack of a sense of self; as do others, most retiring/schizoids consider themselves to be bland and uninspiring. It is a major task of therapy to attempt to stimulate the limited affective capacities of these patients. Although nondirective Rogerian techniques are not likely to be fruitful initially, they can ultimately prove helpful; similarly, little can be expected of the more humanisticexistential methods until preliminary development of a more vibrant sense of self can be generated. Schizoids’ inability to generate thoughts and feelings spontaneously owes to their natural blandness and social indifference. What may prove helpful in the early phases of treatment, however, are experiential techniques, as well as certain gestalt procedures. The emotional insensitivity of retiring/schizoids may be counteracted by techniques that sensitize them to even the most subtle of their feelings, thereby gradually activating their capacity to become aware of how they feel. These techniques may be extremely helpful in fostering experiences that the patient hasn’t had in years. Similarly, the social indifference of schizoids may be overcome in part by procedures that engage them in role-reversal rehearsals, such as playing the role of one’s wife when she’s interacting with the patient. In this manner it may be possible to help an other orientation in what has likely been an other-indifferent orientation. Along these lines, patients may be gently urged to engage in activities where their active participation is minimal at first. Progressively, further involvements with others may be encouraged, such as participation in a computer group or on a travel tour. In productive substitution

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(Kantor, 1992) the task is to provide patients with self-gratifying replacements for what may be missing in their everyday life. New social relationships with peers, as in a therapy group, may also substitute for a lack of social skills and worth. Intrapsychic Techniques Little may be expected of psychoanalytic approaches as retiring/schizoids possess a relatively uncomplicated world of intrapsychic emotions and defenses. They are not very psychologically minded and frequently lack the desire to explore their inner world. In those few cases where analytically oriented psychotherapy may be indicated, the therapist will have to take a more active role than usual. Interventions should be directed to exploring the patient’s internal object relations (Hantman, 2004). The basis for intrapsychic therapy is not likely to be an interpretation of inner conflicts, but the learning that can take place by virtue of the therapeutic relationship. As Gabbard (1994) has indicated, the clinician’s task is to reduce the patient’s fixed internal representations and provide a corrective experience through the everyday transference analysis. The proclivity of schizoids to be silent and unrelated can prove stressful to the clinician. The therapist must guard against proclivities to speak and act out, thereby threatening the patient when he or she needs to withdraw and disconnect. Clinicians should adopt a permissive and accepting attitude with these patients, recognizing that silence is how they typically relate to others; moreover, it need not signify treatment resistance. By sensing the countertransference feelings evoked, the clinician may obtain useful information regarding the patient’s intrapsychic world. Being in therapy can provide a positive, more stable relational experience which can then be internalized (Gabbard, 1994). This new sense of relatedness may result in the patient’s feeling more at ease, revealing possible hidden aspects of the self (Borgogno, 2004). As a result, a greater awareness of the self may ensue. Dorr (1985) notes that enriching internal representations of self and others, increasing reality contacts, and enhancing the sense of self are primary therapeutic goals. Pharmacologic Techniques At the behavioral level, deficiencies are exhibited in the expressive act domain. When therapy is first initiated, schizoids’ low energy level and activation deficits may render the therapeutic process ineffectual. Psychopharmacologic treatment may be called for. Trial periods with a number of stimulants can be explored to see if they increase energy and affectivity. Notable in this regard may be the antidepressant bupropion (Wellbutrin), which appears somewhat effective in dealing with the retiring/schizoid’s apathy and anhedonia. Low doses of risperidone and olanzapine also appear useful in a trial run to see if various negative symptoms such as anhedonia and anergia can be modulated. Clozapine may also be explored, if given in low doses to avoid the possibility of agranulocytosis. Each of these should be used with caution, however, as they may activate feelings and drive states that the patient’s impoverished defensive structures and cognitive schemas are ill-equipped to handle.

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Making Synergistic Arrangements To prevent dropout, it is pertinent that the patient perceive therapy as having something valuable to offer. Therapeutic efforts with schizoids may require psychopharmacologic intervention at the outset to activate arousal systems and thereby counter their inability to experience affect or energy. This may in turn facilitate the use of other interventions that necessitate a certain amount of motivation and commitment. Such intervention can, however, be seen by the patient as a quick fix, resulting in premature termination. It may be necessary to enhance the therapeutic relationship before deciding on pharmacotherapy. The complaints that these patients do not get enjoyment out of activities and interpersonal relations can be addressed cognitively at first. Behavioral methods may be used more fruitfully after the patient’s experiential repertoire has been increased or when the patient has attained a deeper level of experiencing. Group therapy can be used concurrently with individual psychotherapy, but only after the patient’s desire as well as capability for social interaction has been adequately assessed. Family or marital approaches may be used conjointly and can complement individual therapy.

Illustrative Cases The cases presented here, as well as those in later chapters, represent actual patients treated or supervised by Millon in the past 40+ years, as well as those treated or supervised by Grossman in recent years. Graduate students, interns, and residents contributed to a significant degree to these formulations, as well as implementing their therapeutic goals. All cases have been substantially camouflaged; changes include age, sex, and vocation. The prototypes that make up the body of the personality disorder chapters in this text represent derivations that are based essentially on theoretical deduction. They are given their descriptive characterizations from the vast literature provided by earlier clinicians and theorists, as well as from the texts of the DSM-III, III-R, and IV. What is presented is, in great part, a series of ideal or pure textbook conceptions of each disorder (see Table 2.4). There are numerous variations of these prototypal personality disorders, divergences from the theoretically derived prototype that represent the results of empirical research and clinical experience. Although it is our belief that the deeper or underlying laws that give shape to each of the personality prototypes are best understood in terms of theory, it is wise to recognize that there are fruitful, nontheoretical sources where such information has been and can be gathered (Millon, 1987a). In this section on adult subtypes, as well as in subsequent parallel sections, we describe variations on the core prototypal personality pattern that research and clinical observation suggests be included in our thinking about each personality disorder. We know that there is no single schizoid (or avoidant, or depressive, or histrionic) type.

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Retiring/Schizoid Personality Disorder Subtypes

Affectless: Passionless, unresponsive, unaffectionate, chilly, uncaring, unstirred, spiritless, lackluster, unexcitable, unperturbed, cold; all emotions diminished. MCMI 1 (7) Remote: Distant and removed; inaccessible, solitary, isolated, homeless, disconnected, secluded, aimlessly drifting; peripherally occupied. MCMI 1-2A/S Languid: Marked inertia; deficient activation level; intrinsically phlegmatic, lethargic, weary, leaden, lackadaisical, exhausted, enfeebled. MCMI 1-2B Depersonalized: Disengaged from others and self; self is disembodied or distant object; body and mind sundered, cleaved, dissociated, disjoined, eliminated. MCMI 1-S

Rather, there are several variations, different forms in which the core or prototypal personality expresses itself. Some reflect the workings of constitutional dispositions that life experience subsequently reshapes and impacts in different ways, taking divergent turns and producing moderately different psychological characteristics. The course and character of life experiences are complexly interwoven; numerous influences have simultaneous or sequential effects, hence often producing a mixture of patterns of different personality prototypes in the same person. It is for these and other reasons that clinicians and students in our field must learn not only the pure prototypal personalities, but the alternatives and mixtures that are seen in clinical reality. What follows, therefore, are a number of these variations, or what we have termed “subtypes” (Millon, 1996a). They reflect mixtures, they reflect pure and mixed patterns of learning and experience, they reflect consistent inclinations of a specific type, and they reflect conflict resolutions in which overt patterns appear quite different from that which is covert or unconscious. The authors believe strongly that the reader should acquire increasing sophistication in the realm of personality subtypes as well as of personality prototypes. There are numerous patterns that may eventuate in the retiring/schizoid personality prototype. We briefly describe presenting pictures of several of these, as well as discuss the results of a clinical assessment, the synergistic treatment plan, and the course of treatment that was employed.

Case 2.1, Josef W., 26 A Retiring/Schizoid Personality: Languid Type (Schizoid with Depressive Traits) Presenting Picture Josef was referred for counseling through his employee assistance program. His employer was quite fond of him, offering frequent accolades, regular encouragement,

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70 PERSONALIZED THERAPY FOR THE RETIRING/SCHIZOID PERSONALITY PATTERNS and assistance in completion of routine tasks, but had become frustrated with his inability to motivate himself to accomplish even the simplest of tasks or communicate on any effectual level with his coworkers. Josef listlessly reflected on this situation in session, as follows: “I do okay, but my boss thought I’d do better by now.” Not one to enjoy the company of others, Josef lived alone, didn’t socialize with coworkers or others in his environment, and even failed to maintain contact with his family. This void did not bother him, he claimed. His therapist asked if he was lonely. Josef’s reply: “I like it quiet.” In essence, Josef was saying that because he maintained a fairly empty existence, there was nothing with which to be dissatisfied, much less anything at which to be distressed. The aspect that did not entirely fit this presentation, however, was that Josef did occasionally demonstrate affective investment. Generally, his responses were slow, and he evidenced obvious pauses before answering any query. However, these usually seemed to be devoid of introspection except when he was asked about love interests. Slight as it may have seemed in comparison with the affective response of other personalities, Josef’s thoughtful pause here reflected some investment, and even some painful content. However, he still appeared to be passionless regarding this or, for that matter, any other emotion-laden thought or event.

Initial Impressions In Josef, a languid schizoid, what we saw clinically was a mixed pattern that reflected a core retiring/schizoid makeup that had been interpenetrated with features of the depressive personality. As with other schizoids, Josef’s lethargic way of moving in the world may have been traceable either to life experiences or to inherent disabilities. Here we are likely to find that Josef had been subjected to marked stimulus impoverishment in the sensorimotor-autonomy stage, leading to the underdevelopment of relevant neural substrates. The source might have been a failure to receive psychic nourishment requisite to the stimulation of his inherent activation and pleasurable potentials, or perhaps a deficit that stemmed from an inborn deficiency. Particularly relevant here, though, is that we were unable to garner this specific information from Josef’s subjective report, as he was ill-disposed to such introspection. Most notable about Josef was the poverty and slowness of his activation level. He was characterized by a marked inertia, unable to rouse himself to meet his responsibilities, or to engage in even the simplest of pleasurable activities. Perhaps his nature was intrinsically phlegmatic, especially when the tempo of his behavior was uniformly slow. His interactions were typified by a quiet, colorless, and dependent way of relating to others. His introversive pattern covaried with a general lack of vitality, deficits in social initiative and stimulus-seeking behaviors, impoverished affect, and a cognitive vagueness regarding interpersonal matters. His most notable features included fatigability, low energy level, and weakness in motoric expressiveness and spontaneity.

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Of primary importance, at the outset of treatment, was to stimulate activity in this very passive, discouraged man, thereby undoing constitutional depressive proclivities and fostering greater interests in social skills. Of note, it was most important to direct attention to Josef’s passive coping construct of gravitating toward pseudo-relationships with others who expected very little to nothing from him, rather than more fulfilling attachments that required investment. Pleasure had become something nearly lost to Josef, just about extinct in his memory, and he needed to be able to feel engaged in life activities to make improvement. Ultimately, this was the primary thrust of his treatment; he needed to enhance receptivity and expressivity, capabilities that certainly existed within him. The obstacle, of course, was that Josef had shut down these intrinsic receptors by means of listlessness, compounded by a generally pessimistic, self-denigrating disposition. Domain Analysis With a simple “Okay,” Josef consented to psychological testing. Along with objective self-report and clinician checklist measures, Josef’s testing protocol also included several projective techniques, which attempted to identify other implicit features. Not entirely surprisingly, Josef’s limited responses to these latter techniques failed to adequately specify more latent, idiographic dimensions. Most useful in this assessment was the clinician-completed MG-PDC, which identified the following domains as focal points for treatment: Temperamentally Apathetic: Evidence of Josef’s more visceral existence was apparent only in intellectualized (but still sparse) descriptions; there was a dullness to his affective world that belied his current circumstances of having his job in jeopardy, with the few important figures in his life exasperated by the listless and languid manner in which he conducted his life. Cognitively Pessimistic: Less clear but evident from the domain analysis was Josef’s self-denigrating and morose attitudes and beliefs, which supported a generally dysthymic presentation and perpetuated apathy, impassivity, and complacency. Interpersonally Unengaged: There was a general unresponsiveness that permeated all of Josef’s meager interactions, and he seemed entirely unaffected by the responses and feelings of others, preferring instead to lead a solitary day-to-day existence without the interference of the complexities of interpersonal relatedness. Therapeutic Steps Psychopharmacologic treatment was employed at the outset in an effort to increase Josef’s energy and affectivity. Without this step, it appeared to his therapist, it may have been futile to try to initiate and facilitate investment in his “given-up”

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72 PERSONALIZED THERAPY FOR THE RETIRING/SCHIZOID PERSONALITY PATTERNS affective style and belief structure, much less his involvement in activities and exercises that may have helped foster more active social responsiveness. Cymbalta, an SSNRI (an antidepressant medication affecting both serotonin and norepinephrine systems), was used with caution, however, as such agents sometimes activate problematic expectations with some patients in terms of their continuation of treatment. Although the early success of these methods in addressing Josef’s apathy did justify an optimistic outlook, his initial receptivity caused a misleading perception that further progress would be rapid and effortless. Following early treatment success, it was imperative to monitor his tendency to reestablish his comfortable sense of ambivalence between pursuing social challenges and fearing vulnerability, a potential source of anxiety that may have gone unchecked with the concomitant rise in expressive and social desire and affective engagement. In other words, rekindling temperamental motivation may have ignited long-abandoned aspirations, but also fears of failure, humiliation, or rejection; an easy plateau, though a premature one, would be to find some new comfort zone of intellectualized engagement but, essentially, continued inertia in acting on it. Enabling him to forgo his long-standing expectations of disappointment, and thus thwart such a decompensation, required several sessions dedicated to bolstering previous gains following initial successes. He was then ready to more directly address tenacious belief systems perpetuating his ambivalence. Although he could not be pushed beyond his fairly low tolerable limits, careful and well-reasoned cognitive methods, specifically those developed by Beck (2004) and Meichenbaum (1977), served to foster the development of more precise, connected thinking styles, which aided in Josef’s ability to effectively associate with environmental tasks. Josef had overgeneralized that everything he could potentially aspire to—more satisfying familial relationships, achievement at work, or reciprocal socialization—was thwarted owing to his anticipation of failure or rejection. In place of strivings, he disengaged and became apathetic. In essence, a catch phrase for him may have been “No pain—no pain,” or, “It can’t hurt me if I don’t care about it.” All of these have a downtrodden, “given-up” sort of quality to the base schema. By challenging internalized beliefs and experientially replacing cognitive processes, Josef was able to replace many of his pessimistic expectations with more balanced, precise, and valid schemas. The next major task for Josef was to augment social interests and improve competence in relating to others. In addition to working toward the extinction of false beliefs about himself and the attitudes of others toward him, the therapist always was ready to capitalize on those spheres of life in which Josef possessed positive emotional inclinations and encouraged him, through interpersonal methods and behavior skill development techniques, to undertake activities consonant with these tendencies. As noted, attempts to cognitively reorient his problematic attitudes were useful in motivating interpersonal sensitivity and confidence. Likewise, behavioral modification procedures were valuable in strengthening his deficient social

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skills. A group assignment, concurrent with the last third of individual treatment, was also useful in encouraging and facilitating his acquisition of constructive social attitudes. In this benign setting, Josef began to alter his social image and develop both the motivation and the skills for a more engaged interpersonal style. Combining a short-term program such as this with individual treatment sessions aided in forestalling untoward recurrences of the discomfort he experienced. Focused treatment efforts for this introversive and passive man were best directed toward countering his tendencies to shut off the outside world by subduing his cognitive-affective receptors. Minimally introspective and consistently dampening affect and energy, Josef had to be prevented from increasing his isolation from others. To exercise interactional opportunity, energy was invested to enlarge his social context, as his tendency was to pursue with any diligence only those activities required by his job or by his family obligations. He had shrunk his interpersonal milieu, thereby succeeding in precluding exposure to new experience. Of course, this was his preference, but such behavior only fostered his isolated and withdrawn existence. To prevent such backsliding, the therapist ensured the continuation of all constructive social activities as well as potential new ones. Otherwise, Josef may have become increasingly lost in asocial and fantasy preoccupations. Excessive social pressure, however, was avoided because Josef’s tolerance and competencies in this area were rather limited.

Case 2.2, Doug G., 23 A Retiring/Schizoid Personality: Remote Type (Schizoid with Avoidant Traits) Presenting Picture Doug, a student at the local technical institute, had been engaged in several different Internet certificate programs over the past few years, and was about to engage in yet another, when his mother, confused as to why he would not apply for a traditional degree at a “real” college, insisted he seek therapy. A loner by nature, Doug preferred not to socialize in any traditional sense, having little to no desire to get to know much about the people in his immediate social context. The way Doug saw it, they were all antagonistic, but “at least at my school you just go to class and go home.” Routinely, he slept through much of his day and then spent his evenings, nights, and weekends at the school’s computer lab, “chatting” with others over the Internet while not in class. Notably, people that he chatted with often sought to meet Doug, but he always declined these invitations, stating that he didn’t really have any desire to learn more about them than what they shared over the computer in the chat rooms. He described a family life that was similar to that of his social surroundings; he was mostly oblivious of his younger brother and sister, two very

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74 PERSONALIZED THERAPY FOR THE RETIRING/SCHIZOID PERSONALITY PATTERNS outgoing teens, despite the fact that they seemed to hold him in the highest regard, and he had recently alienated himself entirely from his father, who had left the family several years earlier. Though his father had a history of being hostile toward Doug, he had recently made some small efforts to relate on a healthier and more intimate level, but Doug told him that he wasn’t needed in his life. The only apparent investment Doug had in his family was with his mother, but he declined to discuss this relationship substantively. Initial Impressions In the remote schizoid early difficulties result in defensive, isolative, withdrawing interaction patterns. Although we believe this to be an adaptive maneuver more typical of avoidants, it remains a possibility among retiring/schizoids as well. Doug was subjected to intense hostilities and rejection by his father very early in life, and thus protectively withdrew in a manner so extreme as to reduce his original potential to feel and relate to the external world. Defensive maneuvers of this intensity may have been so severe as to make a child incapable of subsequent feeling and relating. As a youngster, it is likely that Doug was quite capable of desiring relationships and feeling emotions intensely, but he learned that such desires and emotions result in extreme anguish and disillusionment. Hence, he did not lack the capacity to feel and to relate to others, as do other schizoids, but he protectively damped down these emotions and wishes to such an extent as to be unaware of them. Depending on the time and intensity of these overwhelming negative experiences, Doug began to exhibit signs that were more like the intrinsically deficient retiring/schizoid than the protectively avoidant pattern; we believe that he retained the wish for affective bonding but was deeply convinced that it would not be forthcoming. In essence, what we see when we examine a more moderately severe remote personality such as Doug is a commingling of both core schizoid and avoidant features. A marked deficit in social interest was notable in Doug, as were frequent behavioral eccentricities, occasional autistic thinking, and depersonalization anxieties. At best, he had acquired a peripheral but dependent role in social and family relationships. Both stemmed from low self-esteem and inadequacies in autonomy and social competence. Rather than venturing outward, he had increasingly removed himself from others and from sources of potential growth and gratification. Life was uneventful, with extended periods of solitude interspersed with occasional feelings of being disembodied, empty, and depersonalized. He had not adapted to functioning independently. He gave the impression of possessing a weakness of will or a deficient intellectual endowment, though these features were not truly present in him. Also notable, Doug’s career ambitions were not substantial; attendance at college was just something expected in his socioeconomic bracket, and he may have been partial to simply finding a subordinate, unskilled position, or even opted for public support and welfare.

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An overarching goal for Doug was the enhancement of a seriously weakened pleasure polarity, although efforts here, largely nondirective in nature, would have to be applied very judiciously and would become central only following earlier, more focused and short-term advances. Doug’s perpetuating tendencies, unlike many other retiring/schizoids, had him focused actively on remaining in the periphery of his environment (ironically, a passive role), a defensive stance typical of his guarded nature. In the early stages of therapy, it would be necessary to address anxietyproducing beliefs to reduce his vigilance in avoiding pain, which consistently led to inertia. As trust developed and a greater sense of self was established, the focus of treatment could shift to social realms to assure that venturing into social relationships (other polarity) would not always bring about pain and hostilities directed at him. With a safe measure of success in these more focused approaches, continued growth could be achieved with less directive approaches applied at a comfortable pace for Doug. Domain Analysis Doug was highly responsive to the questions of the MCMI-III, noting that he especially liked the computer application. The prospect of learning about himself through true/false statements seemed to have a minor but noticeable energizing effect. Highlights from the Grossman Facet Scales were as follows: Alienated Self-Image: Over time, Doug, who in a rare expressed reflection actually noted that he was more outgoing as a young child, began to carry around great feelings of ineptitude, social awkwardness, and inadequacy, but shut down these feelings, effectively covering them with a safe distance from more intimate interpersonal interactions. Interpersonally Unengaged: Doug spent most of his time with solitary pursuits, evidencing some need for interaction (e.g., heavy involvement in chat rooms) but only in remote transactions; he noted that he didn’t particularly enjoy close relationships, and that he had a minimal appetite for intimacy. Expressively Impassive: Often in a self-imposed state of inertia, Doug could be described as listless, undemonstrative, and lacking in active spontaneity. He showed some motoric slowing and phlegmatic physical expressiveness and was often tired, unmotivated, and disinterested in “human” activities. Therapeutic Steps Doug’s most important therapeutic tasks were the accretion of both his contextual interests and interpersonal competence. At this early stage, it was apparent that the therapist would need to tread cautiously, as Doug’s threshold for being pushed therapeutically was rather low. It was crucial to emphasize the fact that therapy was, in fact, a safe environment where he could securely explore more potent thoughts

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76 PERSONALIZED THERAPY FOR THE RETIRING/SCHIZOID PERSONALITY PATTERNS and feelings that he had successfully muted over time. Aspects of motivational interviewing were used to unearth ambivalence and identify self-generated motivations, as a directive but highly empathic, humanistic first paradigm. In this first session or two, it became safe for Doug to touch on his feelings of alienation, as well as fears associated with “coming out of this shell.” Most of this would have to wait, and Doug was encouraged to share “only what was comfortable at this point.” Having control of the direction and rate of work was highly facilitating at this early stage. As opposed to more traditional humanistic approaches, which likely would have been too open-ended and baffling for Doug, this directive approach helped him key in to certain areas he found problematic and do his own fine-tuning in terms of what he wished to accomplish. As a level of trust was established, cognitive methods (e.g., Beck, 2004; Meichenbaum, 1977), applied prudently and judiciously, were fruitful in bringing about more balanced thought patterns and less troublesome self-beliefs. These cognitive reorientation methods also facilitated self-confidence and stimulated emotional awareness, helping Doug further combat self-denigrating, pessimistic views regarding himself in a world of hostile others. Beyond cognitive routines of disputing automatic thoughts and reorienting to new schemas, the therapist worked to encourage Doug, through interpersonal methods and behavior skill development techniques, to actively employ his healthier affective propensities. Similarly, short-term behavioral modification techniques augmented his deficient social skills. In these brief, circumscribed exercises, it was possible for Doug to develop new rudimentary expressive behavior sets that were less impassive and more vital and animated. This included a series of more engaged interactions. As adjunct to this individual modality, a group milieu helped Doug learn to utilize many of these skills and develop new positive attitudes toward relational tasks within a benign setting. He was able to effect changes and improvements in his interpersonal style. As he gained confidence, it became appropriate to apply some existential and experiential techniques, albeit judiciously, to enhance his sensitivity and desire for more meaningful experiences and relationships, further combating his well-ingrained alienated self-image. Combining the short-term group experience with individual treatment sessions bolstered his immunity to his prior social discomfort. Though Doug was quite receptive to this regimen from early in treatment, it was necessary for the therapist to guard against the likely belief that the process would be easy and expeditious. As anticipated, Doug was loath to take any emotional risks, and perhaps preferred the safety of social alienation. It required several sessions, following this initial positive track, to undermine his tendency toward self-fulfilling prophecies of failure. Supportive techniques helped him through his pervasive belief that any improvement would be short-lived, impossible to maintain, and guaranteed to leave him once again in a state of social disapproval. Psychopharmacologic treatment was also considered during this intervention, but ultimately rejected. In many cases, it is advantageous to explore several agents targeted at a patient’s activity level and emotional responsiveness. With Doug, however, it was believed

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that the introduction of such agents would likely trigger emotions too quickly and intensely, and this would overwhelm him. Most important in Doug’s treatment course was targeting his propensity to withdraw. Ill inclined from the outset to explore psychological difficulties, and having particularly low energy and feeling, he was prevented, through these defined treatments, from fully isolating himself from others, a fate for which he seemed destined regardless of the character of those in his context. As Doug had a strong predilection for solitary activity and was disinclined to pursue any other activity unless it was absolutely necessary, he severely precluded any exposure to new experience or social contacts and further reinforced his isolated and withdrawn style. The therapist encouraged Doug’s continuation in these more social tasks and activities beyond the scope of therapy, and also recommended further social explorations, as Doug’s tendency still was to lean toward asocial and fantasy preoccupations. The byword here was encouragement as opposed to pressure; Doug would not have been receptive to any therapeutic pushing, as his competence in social realms remained quite restricted. These brief and focused treatment techniques aided him in developing more skills in this area.

Case 2.3, Patricia L., 36 A Retiring/Schizoid Personality: Affectless Type (Schizoid with Compulsive Traits) Presenting Picture Patricia was a bookkeeper in a small law firm, where she had worked dutifully for the past 13 years without incident. One day, she just “exploded,” evidencing a panic attack wherein she felt shortness of breath, palpitations, loss of control, and derealization. A forensic psychologist happened to be consulting at the law office that day and was able to guide her out of the attack; she then asked this psychologist for her card, to which she replied that she could not personally see her, but she could help her with a referral. During the interview, Patricia seemed outwardly content with her quiet, rather unobtrusive life and was comfortable with the fact that coworkers, family, and others in her surroundings didn’t bother her. Although this was her first panic attack, she admitted that it was not her first experience with acute anxiety spells, as she had felt such “swellings” numerous times while alone at home. She did not note anything lacking in her existence, but one could not help but notice that there was a disturbing lack of enthusiasm for, or even reaction to, anything, including activities and interests she claimed to enjoy. She stated that she was quiet even as a child and went through school with only a few friends who joined her for homework. When

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78 PERSONALIZED THERAPY FOR THE RETIRING/SCHIZOID PERSONALITY PATTERNS asked if there might be some other occupation for which she might hold some interest, she seemed lost at first, but then remarked that she might do well in historical research. She seemed to have thought about this possibility before, but her emotional involvement in speaking of this interest remained barren. Initial Impressions In what is termed the affectless schizoid subtype, we believe that the isolated, emotionally detached, and nonsocially communicative features are likely to be a consequence, at least in part, of constitutional deficiencies. Perhaps Patricia had marked neurologic deficits in those regions of her nervous system that subserved the capacity to relate with warmth and sensitivity to others, some lesion or structural aplasia, perhaps, in relevant systems (e.g., limbic). Here we were dealing with a person who was at the lower end of the normal distribution of affective sensibility; as noted, this diminished capacity was probably attributable largely to inborn limitations. Given her emotionally diminished qualities that coexisted with her sense of duty and industry, Patricia was likely to show up clinically as possessing features that interweave with those seen in compulsive personalities. In terms of clinical syndromes, her anxiety-spectrum disorder may also be seen as an outgrowth of this particular personality configuration. Patricia’s deficiencies were not motoric and behavioral, as they are with some other retiring/schizoid patterns, but were in the spheres of emotion and feeling. She seemed unable to activate her affect; she was affectively lame, not energetically lame. Whereas some schizoids are torpid and phlegmatic and look weary and depressed, Patricia was unexcitable, unperturbed and cold and looked restrained and dispassionate. What we saw in her was simply an inability to activate any intense emotions, be it social or antisocial in character. There was minimal warmth, but there was also minimal anger and hostility. Patricia’s constitutional tendency was to be virtually shut off in affect and simply live as an automaton; that is, she did what she perceived to be her role without straying in any remarkable way or traversing any rule by involving her meager emotional life or her independent decision making. She might have been ill at ease in working with more potent emotional material, as was evident in what likely were affectively charged introspections that had recently been evoked and expressed in her acute anxiety expressions; therefore, a very empathic approach was necessary from the outset. It would be necessary to undo this very passive, constricted mode of existence by working to undo her very rigid adherence to her affectless routine, and subsequently, work to increase pleasure and decrease her tendency to view herself as unable or unworthy of fulfillment via decisions that disrupt the ordinary (bolstering her self orientation). Patricia needed to cultivate relationships and increase social skills and behaviors, tasks that were very difficult at first, but that would eventuate in a strong other emphasis at a slightly later point in treatment.

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Domain Analysis Patricia was agreeable in her response to the domain analysis. Salient areas for intervention, as measured by the MCMI-III Grossman Facet Scales and the MG-PDC, were as follows: Cognitively Constricted: Patricia was rigid in her worldview, insistent that she remain closely tied to what she believed was her role; she viewed independent thought or functioning outside “established” rules and traditions to be an aberration of her purpose, and this basic schema was to be honored at all times. Meager/Concealed Objects (Intrapsychic Content): Figures from Patricia’s past were sparse and poorly defined, and those that carried any painful or deviant content were quashed; this domain shared qualities of both the retiring/schizoid and compulsive patterns, giving it a rather unique absence of resonance. Interpersonally Unengaged: Generally, Patricia was remote, almost as if there were an invisible wall between her and others even in what might appear to be closer interactions; her unobtrusiveness also played out in impassive expressions, complacency, and intellectualized responsiveness to any more loaded emotional content. Therapeutic Steps Patricia’s most tangible goals included development of self-confidence and sociability, as well as extinguishing her trepidation over independent decision making, but she would have resisted any action toward these goals at the outset. She would likely feel, at this early stage, that the therapist’s efforts to encourage responsibility and skill development essentially would equate to his rejection of her, and she would have become more withdrawn. It was necessary to be prepared for and counteract such a reaction, as failure to do so may have precipitated recurrences and squelched exploration. The alliance between the therapist and Patricia was most important, as she needed to learn how to tolerate conflicting emotions and anxieties. She needed special care when it came to trust issues. She would not have remained in therapy long enough for any substantial improvement without a clearly empathic and understanding atmosphere. It made sense to begin with a humanistic/existential approach, largely nondirective in nature, to validate the purpose, but not the execution, of her constricted beliefs before looking toward replacing schemas and initiating new behaviors. Patricia required such bolstering of her intents owing to her largely impoverished intrapsychic content. A thorough reworking of underlying subconscious structure was unnecessary and, quite possibly, may have initiated deeper ambivalences. But it was possible to facilitate generation of new, healthier representations via more focused dynamic methods, gradually integrated into the more humanistic approach laid out at the

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80 PERSONALIZED THERAPY FOR THE RETIRING/SCHIZOID PERSONALITY PATTERNS outset. In this manner, Patricia was able not only to loosen some constricted beliefs in a safe environment (owing to the cognitive elements of such an approach), but was also able to touch on and build less meager objects that she found more acceptable to her widening cognitive flexibility. As she gained new experience in this stage, she was able to undertake (and asked for) more focused skill-building interventions. Learning methods, such as facing and controlling less stable emotions, were then coordinated with cognitive strengthening (e.g., Beck) and interpersonal methods (e.g., Benjamin, Kiesler). Much of her interpersonal disengagement was prompted by pronounced uncertainties, previously guarded by her constricted worldview. Meeting these new challenges with the combined arsenal of both behavioral and interpersonal techniques aimed at accomplishing more resonant and secure interactions bolstered Patricia’s confidence; although she still was, by nature, a rule follower, she began to voice the new belief that “sometimes higher principles are involved and that sometimes takes a little bit of social risk.” The therapist also provided an additional resource for learning how to approach uncertainties with reasonable poise and prevision. She stayed with a course of interpersonal treatment, but it was sometimes inconsistent, with bolder progression sometimes alternating with patterns of apathy and schemes targeted at testing the therapist’s sincerity. Her withdrawal tendencies, as well as her tendency toward decompensation, had to be blocked. The supportive, humanistic environment was kept in place throughout treatment, in case Patricia began to shown signs of conspicuous discouragement, alienation, or consistent melancholy. Self-actualizing and cognitive modalities were used to address periods when she suffered from a sagging morale, to encourage her to continue in her social activities, to build confidence, and to combat her preoccupation with despondent feelings. She could not be pressed beyond her capabilities, however, because any failure on her part would reinforce her belief in herself as inadequate.

Case 2.4, Marla D., 36 A Retiring/Schizoid Personality: Depersonalized Type (Schizoid with Schizotypal Traits) Presenting Picture Marla presented for therapy at the insistence of her mother, with whom she had lived all of her adult life, as Marla’s phlegmatic life of inactivity and asociality had thoroughly irritated and frustrated her. Originally happy for the company Marla provided, especially after her husband died, her mother had since grown quite weary of taking care of her, wondering when she might “meet a husband” and “go on and live an adult life.” Marla worked in the back room of a small shop near her home, doing a rather dull, repetitive task. “I make boxes” was how she flatly described her work, and gradually

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she and her mother revealed that Marla was paid under the table to put together small boxes for a card and gift store. Her speech in session was largely limited to one-word answers and incomplete thoughts, and even when she began to answer a query more substantively, her thoughts inevitably got circumvented into something unrelated, and a more characteristic, fragmented answer would occur. Marla’s free time was usually taken up watching television or renting movies. She had acquaintances at work, but had no desire to spend time with them outside of that context. It was interesting to note, too, that she did not resonate with (or even comprehend) the stories in her television and movie watching, but fixated on the particular actors who were featured. Clinical Assessment On initial observation, one may have felt that Marla was enjoying the contemplation of some inner vision, some inner reality that drew her more and more into her isolated state. As with other retiring/schizoids, she was extremely inattentive and disengaged from the real world. But more than others, she had not only deteriorated into a state of obliviousness, appearing as if preoccupied inwardly but, in fact, she was preoccupied with nothing in particular. Though present in the world of others, she appeared to be staring into empty space, relating neither to the actions and feelings of others, nor to those that emanate from within herself. These features bring Marla into a close amalgamation with the schizotypal personality such that many of her characteristics blend and unite. As with many others who experience depersonalization, Marla was very much an outside observer, viewing herself as a distant object, disembodied and vacant, unconnected to her own feelings and thoughts. She had drifted into a state in which she ignored not only external phenomena but those that emanated from within herself. Disconnected from whatever was tangible and real in the world, including her own corporeal being, she was also not preoccupied with her own imagination and fantasies. Despite her inward turning, thoughts and feelings were little more than a diffuse vagueness, an unclear and fuzzy set of disconnected ideas. Not only were her internal processes undefined and diffuse, but her obscurity and inability to relate led others to sense increasingly that something might be missing within her. Not only did she seem a million miles away, unrelated and unfocused in human interactions, but her inner world appeared equally distant and obscure, if not largely absent. Therefore, the overarching goal for Marla was to achieve some improved level of connectedness to both her intrapersonal and interpersonal worlds. Both her self and other polarities were, at the outset of treatment, diffuse and without direction. It would become necessary to disrupt her perpetuating tendencies of isolating herself, deadening her awareness of not only her social context but of her own being, and assuming an extremely passive stance, but these measures would need to follow a very nonthreatening period of trust enhancement that would serve to validate her. As Marla became more engaged in her identity, it would become

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82 PERSONALIZED THERAPY FOR THE RETIRING/SCHIZOID PERSONALITY PATTERNS possible to help her reorganize and focus her beliefs and help her build expressive skills. It would be possible, also, to gradually augment her pleasure-orientation as her connectedness as a corporeal being improved. Domain Analysis Marla’s domain analysis, based mainly on the MG-PDC, identified these domains as relevant points for intervention: Complacent Self-Image: Reflecting little introspective awareness of herself, Marla was rather indifferent to the impact life events or actions of others might reasonably have on her; she seemed content in her aloofness, feeling that little existed to engage her in a more resonant affective life. Cognitively Autistic: Marla seemed to drift along her own path of understanding, disconnected from the thoughts and feelings of those around her, while following an idiosyncratic and circumstantial logic; her ability to connect with the logic or emotion of others was notably fragmented, occasionally vaguely within the proper context but usually lost in odd beliefs blurring the lines of fantasy and reality. Interpersonally Unengaged: Leading a life that could only be described as remote and indifferent, Marla seemed content to stay on the periphery of her social context, never engaging in closer contact with others and remaining in the background of any event. Therapeutic Course In the earliest phases of treatment, not surprisingly, Marla submitted to treatment goals relevant to enhanced self-esteem and social relationships, but subsequently resisted these aims. It was wise, especially in the first session or two, to be alert to her probable feeling that the therapist’s efforts to encourage her to assume responsibility and social skills were a sign of rejection, and this may have engendered disappointment and dejection. Rage was even a possibility, how Marla had set up her personal logic in terms of feelings of inadequacy was unknown. However, the therapist anticipated and prepared for this potential therapeutic static and counteracted it so that fundamental changes could be explored and rapid recurrences prevented. Special attention was given to Marla’s withdrawal tendencies and her persistent tendency toward circumstantial logic that also distanced her from others. She was not prone to sustain a therapeutic course without a heavy dose of repeated caring and empathy, expressed through a nondirective, person-centered paradigm, which was all she could tolerate at first. As a sound and secure therapeutic alliance was established, Marla explored and gradually made steps toward overcoming her complacent self-image, which she learned was anchored to her (until then unrecognized) contrary feelings and dependency anxieties. Clear signs of warmth and

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understanding were needed to ensure that Marla would not abandon treatment before substantial improvement had occurred. Early efforts at establishing empathy and unconditional regard for Marla paid the dividend of a greater level of trust, in which she felt safer unearthing her odd, autistic belief structure and process. More progressively, she could then not only feel “real” in expressing some of these idiosyncratic processes, but she could begin to reject and modify those she felt were no longer useful, occasionally implementing more connected and logical processes. Learning how to face and handle these disorganized thoughts along with less stable emotions was coordinated with the cognitive reframing and dysfunctional thought stopping methods of some of the cognitive theorists (e.g., Beck, et al., 2004; Young, 1990). These also fostered healthier and more complete attitudes regarding the nature of the world. This served as a good time, as well, to begin to introduce methods designed to address her interpersonal disengagement (e.g., Benjamin, Kiesler). Between those techniques aimed at fostering better and more intimate transactions and the therapist’s providing a model for the social learning of how feelings, conflicts, and uncertainties could be approached and resolved with reasonable equanimity and foresight, Marla, for the first time family members could recall, showed signs of interpersonal curiosity. Family methods were implemented here, as well, to experiment with Marla’s newly learned social skills and strategies in a more natural setting than that found in individual treatment. Though she stayed with a course of interpersonal treatment, it often followed an inconsistent pattern, with frequent periods of indifference mixed with testing the therapist’s sincerity. Both cognitive and interpersonal techniques forestalled her habitual coping style of withdrawal and her unwillingness to face the humiliation of confronting her mix of an uneventful lifestyle and the experience of growing resentments. Efforts were made to counter her fear of activating false hopes and disappointment in therapy.

Resistances and Risks The impoverished and globally undifferentiated phenomenology of the schizoid is itself a profound form of passive resistance. Once in therapy, the retiring/schizoid is not very likely to value the therapeutic relationship and may actually see the therapist as intrusive and hence shy away from therapy (Beck & Freeman, 1990a, 1990b). A continuous risk is the possibility that these patients will drop out of therapy and revert back to their prior isolated and detached lifestyle. Even if impressive progress is made in a particular session, generalization of insight or behavior may not occur if the patient simply goes home to a solitary existence. Booster sessions to prevent regressions such as these are especially wise following termination.

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Another danger is that the therapist may find interacting with such a patient unrewarding. Feelings such as frustration, helplessness, boredom, and impotence may be experienced. Therapists will need to be keenly aware that progress made with some schizoids will consist of their ability to derive greater satisfaction from solitary activities and not necessarily reduced social isolation. Even though strengthening social connectedness is a primary goal in therapy, group methods and other more interactive forms of therapy may be contraindicated. If the therapist is not careful in determining the patient’s social skill level and desire for social involvement, the premature push toward interacting with others may cause discomfort, which may, in turn, reinforce existing beliefs that one is better off alone.

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CHAPTER

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Personalized Therapy for the Shy/Avoidant Personality Patterns

T

he retiring/schizoid and shy/avoidant personality patterns may appear superficially rather similar, yet they differ in several key ways, including their susceptibility to anxiety and depression. Both personality patterns may appear withdrawn, emotionally flat, and lacking in communicative and social skills. The affective flatness of the avoidant, however, is typically a defensive maneuver against underlying emotional tension and disharmony. Similarly, the apparent detachment and interpersonal withdrawal of avoidants develop in response to a fear of intimacy and a hypersensitivity to rejection and ridicule. Strong desires for affection and acceptance exist in these individuals, but are denied or restrained out of apprehension and fearful mistrust of others. Not infrequently, shy/avoidants have had experiences of painful social derogation, which resulted in an acute sensitivity and alertness to signs of ridicule and humiliation (Dimic, Tosevski, & Jankovic, 2004; Zimmerman, Rothschild, & Chelminski, 2005). This hypersensitivity and vigilance often result in the misperceiving of innocuous social comments or events as critical rejection (Millon, 1981, 1996b; Shea et al., 2004). For the most part, shy/avoidants engage in self-imposed isolation and social withdrawal. They will, however, enter into relationships with a limited number of people (J. G. Johnson, Cohen, Chen, et al., 2006; King, Terrance, & Cramer, 2006; Warner et al., 2004) if provided with strong guarantees of uncritical acceptance. Avoidants may become quite dependent on the one or two people they do allow into their lives. However, they are likely to remain rather cautious in relationships, engaging in frequent, subtle testing of their partner’s sincerity.

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Although shy/avoidants may view people in general as critical, betraying, and humiliating, they are usually very dissatisfied with the peripheral social role they feel forced to play and experience painful feelings of loneliness and alienation. Avoidants tend to be excessively self-critical, blaming themselves for their social undesirability (Huprich, 2005). Consequently, they may become estranged from themselves as well as from others. They tend to resort to extreme defensive coping strategies to deal with the chronic feelings of interpersonal ambivalence and affective distress that they experience (J. G. Johnson, Cohen, Kasen, & Brook, 2006; Meyer, Ajchenbrenner, & Bowles, 2005). In addition to active avoidance and withdrawal from threatening social situations, they may attempt to block and interfere with their own troubling cognitions, resulting in a fragmentation of their thoughts and disjointed verbal communications, as well as the appearance of being emotionally confused or socially irrelevant (Battle et al., 2004; Farmer, Nash, & Dance, 2004; Haller & Miles, 2004). Shy/avoidant types are among the most vulnerable of the personality patterns to psychiatric symptom disorders. Perhaps most frequently, the avoidant will suffer from feelings of anxiety and ruminative worry. Also, like the schizoid, prolonged estrangement from self and others can result in varied forms of dissociative disorders. Shy/avoidants are also quite prone to feelings of deep sadness, emptiness, and loneliness. Frustrated yearnings for affection and approval, coupled with the self-deprecation they experience for their unlovability and ineffectuality, may result in a chronic melancholic tone. Depression may nonetheless be difficult to detect in avoidants, given their characteristic affective flattening and their typically slow speech and movement (Skodol, Pagano, et al., 2005; Stein, Ono, Tajima, & Muller, 2004). Furthermore, shy/avoidants will attempt to hide and contain their feelings of inner despair for fear that overt expressions of such weakness and suffering might render them even more vulnerable to social ridicule, humiliation, and rejection (Bienvenu & Brandes, 2005; Li-ying, Yunping, & Tao, 2004; Ralevski et al., 2005; Taylor, Laposa, & Alden, 2004; Tillfors, Furmark, Ekselius, & Fredrikson, 2004). Whereas major depressive episodes in these individuals may be similar to the symptomatic presentation of depressed schizoids (i.e., psychomotor retardation, extreme social withdrawal, and apathy), avoidants may also experience anxiety or obsessive ruminations with their depression (J. G. Johnson, Cohen, Kasen, & Brook, 2005; Skodol, Oldham, et al., 2005). The shy/avoidant’s susceptibility to depression can be readily explained from a cognitive-behavioral framework (Arntz, Dreessen, Schouten, & Weertman, 2004; Jovev & Jackson, 2004). First is the avoidant’s tendency to view things pessimistically; that is, contempt directed at the self, fear and suspicion of others, and a sense of future despair. Next is the limited opportunity the shy/avoidant has for experiencing reinforcing events. Characteristically, these individuals tend to be inflexible, confining themselves to a small range of potentially reinforcing experiences (Grilo, 2004). Although they possess the innate capacity to experience pleasure, their interpersonal anxiety may cause them to deny themselves the satisfaction they could derive from

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others, and to discount praise, compliments, and other social reinforcers (Grant et al., 2005). Similarly, the distorted view of self as ineffectual and unlovable precludes the possibility of pleasure coming from within. Although the shy/avoidant personality is a relatively new concept to psychiatric nosology (Millon, 1969), the characteristics of this pattern have frequently been cited in the literature on depression (Skodol et al., 2005). Arieti and Bemporad (1980), in their proposal of three premorbid types of depressive personality, describe a depressive personality structure that is characterized by constant feelings of depression lurking in the background and an inhibition of an early form of gratification (Grilo et al., 2005; Nagata et al., 2004). Other features of this form of chronic character structure are a chronic, mild sense of futility and hopelessness which results from a lack of involvement in everyday activities . . . emptiness because they do not develop deep relationships for fear of being exploited or rejected . . . harsh, critical attitude toward themselves and others. (Arieti & Bemporad, 1980, p. 1362)

We believe such depressive subtypes experience episodes of clinical depression when they are forced by some event to reevaluate their mode of existence and are confronted with the barrenness and meaninglessness of their lives. We can review the features of the avoidant personality prototype using the theoretical model of polarities by examining Figure 3.1. As discussed in Book 1 of this series, we may best conceive of the polarity model as a framework of ecological adaptations that represent styles of dealing with life circumstances based on constitutional dispositions and early learning. Personalities that are termed “disordered” represent different forms of maladaptation, modes of ecological functioning that are not only pathological, but also pathogenic. In some persons, such as the shy/avoidant type, we may find an inborn sensitivity to pain; a biologically based extreme fearfulness, even in relatively benign circumstances; and a tendency to feel anxiously disrupted when facing potential or actual physical or psychic stress. No less likely, in the history of otherwise normally endowed youngsters we may find a fearful reactivity when the child has been repeatedly exposed to threatening life circumstances, such as being reared by rejecting and hostile parents. As a result, there may be a deficiency in the capacity to experience the pleasures of life, the joys, the rewards, the means by which life is enhanced and extended (Hans, Auerbach, Styr, & Marcus, 2004). Conversely, we may see an overconcern and preoccupation with activities that center on the preservation of life, that is, avoiding the sadness and anxiety that are generated as emotional responses to psychic pain. Central here is a hyperalertness to the possibility that life will likely get worse rather than better. On the one hand, there is a focus on preserving oneself, and on the other, an inattention to experiences that can make life more gratifying and pleasurable. On the second pair of polarities, we see an excessive utilization of the active mode of adaptation (modifying one’s ecological niche). Interpretively, this signifies a necessary element in preserving life, a hypervigilant awareness and avoidance of events that may portend rejection, denigration, humiliation, and failure. At the third polarity level, the

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AVOIDANT PROTOTYPE

Enhancement

Preservation

(Pleasure)

(Pain)

Accomodation

Modification

(Passive)

(Active)

Individuation

Nurturance

(Self)

(Other)

Weak on Polarity Dimension Average on Polarity Dimension Strong on Polarity Dimension

FIGURE 3.1 Status of the shy/avoidant personality prototype in accord with the Millon polarity model.

role of self versus others is of minimal consequence: They are only background factors in orienting and motivating the life of the avoidant. In effect, the central features of the shy/avoidant personality are most clearly seen in a hyperalertness and reactivity to the possibility of psychic pain.

Clinical Picture This section outlines the major domains that provide useful information in diagnosing the prototypal variant of the shy/avoidant personality (see Figure 3.2). Shy/avoidant personalities are acutely sensitive to social deprecation and humiliation. They feel their loneliness and isolated existence deeply, experience being “out of

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Clinical Picture

89

AVOIDANT PROTOTYPE Fretful

Distracted

Expressive Behavior

Aversive

Interpersonal Conduct

Cognitive Style

Alienated Self-Image

Fragile Morphologic Organization

Fantasy

Regulatory Mechanism

Anguished

Mood/Temperament

Vexatious

Object Representations

FIGURE 3.2 Salience of prototypal shy/avoidant domains.

things” as painful, and have a strong, though often repressed desire to be accepted. Despite their longing to relate and to be active participants in social life, they fear placing their welfare in the hands of others. Their social detachment does not stem, therefore, from deficit drives and sensibilities, as in the schizoid personality, but from an active and self-protective restraint. Although experiencing a pervasive estrangement and loneliness, they dare not expose themselves to the defeat and humiliation they anticipate. Because their affective feelings cannot be expressed overtly, they cumulate and are often directed toward an inner world of fantasy and imagination. Their need for affect and closeness may pour forth in poetry, be sublimated in intellectual pursuits, or be expressed in sensitively detailed artistic activities. Unfortunately, isolation and protective withdrawal results in secondary consequences that further compound avoidants’ difficulties. Their obviously tense and fearful demeanor often elicits ridicule and deprecation from others. Expressions of self-doubt and anxious restraint leave them open to persons who gain satisfaction in taunting and belittling those who dare not retaliate. The additional humiliation they experience thereby not only confirms their mistrust of others but reactivates the wounds of the past. With this pr´ecis in mind, the domains of clinical data that help diagnose the shy/avoidant pattern are detailed next (see Table 3.1).

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90 PERSONALIZED THERAPY FOR THE SHY/AVOIDANT PERSONALITY PATTERNS Table 3.1

Clinical Domains of the Shy/Avoidant Personality Prototype

Behavioral Level: (F) Expressively Fretful (e.g., conveys personal unease and disquiet, a constant timorous, hesitant, and restive state; overreacts to innocuous events and anxiously judges them to signify ridicule, criticism, and disapproval). (F) Interpersonally Aversive (e.g., distances from activities that involve intimate personal relationships and reports extensive history of social pan-anxiety and distrust; seeks acceptance, but is unwilling to get involved unless certain to be liked, maintaining distance and privacy to avoid being shamed and humiliated). Phenomenological Level: (F) Cognitively Distracted (e.g., warily scans environment for potential threats and is preoccupied by intrusive and disruptive random thoughts and observations; an upwelling from within of irrelevant ideation upsets thought continuity and interferes with social communications and accurate appraisals). (S) Alienated Self-Image (e.g., sees self as socially inept, inadequate, and inferior, justifying thereby isolation and rejection by others; feels personally unappealing, devalues selfachievements, and reports persistent sense of aloneness and emptiness). (S) Vexatious Objects (e.g., internalized representations are composed of readily reactivated, intense, and conflict-ridden memories of problematic early relations; limited avenues for experiencing or recalling gratification and few mechanisms to channel needs, bind impulses, resolve conflicts, or deflect external stressors). Intrapsychic Level: (F) Fantasy Mechanism (e.g., depends excessively on imagination to achieve need gratification, confidence building, and conflict resolution; withdraws into reveries as a means of safely discharging frustrated affectionate as well as angry impulses). (F) Fragile Organization (e.g., a precarious complex of tortuous emotions depends almost exclusively on a single modality for its resolution and discharge, that of avoidance, escape, and fantasy; hence, when faced with personal risks, new opportunities, or unanticipated stress, few morphologic structures are available to deploy and few backup positions can be reverted to, short of regressive decompensation). Biophysical Level: (F) Anguished Mood (e.g., describes constant and confusing undercurrent of tension, sadness, and anger; vacillates between desire for affection, fear of rebuff, embarrassment, and numbness of feeling). Note: F = Functional Domains; S = Structural Domains.

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Fretful Expressive Behavior The pervasive sense of unease and disquiet is what is most observable about avoidants. They evince a constant timorous and restive state, overreacting to innocuous experiences, hesitant about relating to events that may prove personally problematic, and anxiously judging these events as signifying ridicule or rejection from others. The speech of shy/avoidants is generally slow and constrained. They exhibit frequent hesitations, aborted or fragmentary thought sequences, and occasional confused and irrelevant digressions. Physical behaviors tend to be highly controlled or underactive, although marked with periodic bursts of fidgety and rapid staccato movements. Overt expressions of emotion are typically kept in check, but this underresponsiveness belies deep tension and disharmony. They exert great restraint, not only in controlling anxiety, but in controlling feelings of confusion and in subduing the upsurge of anger. Aversive Interpersonal Conduct Avoidants distance themselves from situations that may involve them in close personal relationships; they are strongly disinclined to become intimate unless they are certain that they will be liked and fully accepted. There is a long history of maintaining distance from others and of preferring privacy to avoid being shamed and humiliated. They report an extensive history of rejection, leading them to acquire a general distrust of others and a social pan-anxiety. A shy and apprehensive quality characterizes shy/avoidants. They are not only awkward and uncomfortable in social situations but seem to shrink actively from the reciprocal give-and-take of interpersonal relations. They often impose a strain on others in face-to-face interactions. Their discomfort and mistrust often take the form of subtle testing operations, that is, guarded maneuvers by which they check whether others are sincere in their friendly overtures or are a deceptive threat to their security. Most observers who have only passing contact with avoidant personalities tend to see them as timid, withdrawn, or perhaps cold and strange—not unlike the image conveyed by the schizoid personality. Those who relate to them more closely, however, quickly learn of their sensitivities, their touchiness, evasiveness, and mistrustful qualities. Interpersonally, shy/avoidants are best characterized as actively detached personalities. They are guided by the need to put distance between themselves and others, that is, to minimize involvements that can reactivate or duplicate past humiliations. They seek privacy and avoid as many social obligations as possible without incurring further condemnation. Any event that entails a personal relationship with others, unless it assures uncritical acceptance, constitutes a potential threat to their fragile security. They may deny themselves even simple possessions to protect against the pain of loss or disappointment. Efforts to comply with the wishes of others, much less to assert themselves, may have proved fruitless or disillusioning. Appeasement may have resulted in a loss of what little personal integrity they may have felt they still possessed,

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leading only to feelings of greater humiliation and disparagement. They have learned that the only course that will succeed in reducing shame and humiliation is to back away, drawing within themselves and keeping a watchful eye against incursions into their solitude. In sum, these personalities avoid the anguish of social relationships by distancing themselves and remaining vigilant and alert to potential threat. This actively detached coping style contrasts markedly with the strategy of passively detached schizoids, who are perceptually insensitive to their surroundings. Avoidants are overly attentive and aware of variations and subtleties in their stimulus world. They have learned in the past that the most effective means of avoiding social rejection and deprecation is to be hyperalert to cues that forewarn their occurrence. By decreasing the number of their relationships and diminishing their importance, they can minimize the hazards they fear surround them. Distracted Cognitive Style It is characteristic of shy/avoidants to scan their environment for potential threats. Also problematic is their preoccupation with intrusive and disruptive inner thoughts that seem to flood their efforts at maintaining psychic control. This upwelling from within of seemingly random and irrelevant feelings and ideas will often upset the continuity of their thoughts and interfere with their social communications. The avoidant personality is hyperalert to the most subtle feelings and intentions of others. These individuals are “sensitizers,” acutely perceptive observers who scan and appraise every movement and expression of those with whom they come into contact. Although their hypervigilance serves to protect them against potential dangers, it floods them with excessive stimuli and distracts them from attending to many of the ordinary yet relevant features of their environment. This flooding of irrelevant environmental details interferes with thought processes, which are complicated further by inner emotional disharmonies that intrude and divert shy/avoidants’ attentions. Combined with extraneous perceptions, these intrusive feelings upset their cognitive processes and diminish their capacity to cope effectively with many of the ordinary tasks of life. This cognitive interference is especially pronounced in social settings, where avoidants’ perceptual vigilance and emotional turmoil are most acute. Alienated Self-Image For the most part, shy/avoidants see themselves as socially inept and inferior. Their self-evaluations judge them as personally unappealing and interpersonally inadequate, and they devalue whatever achievements they have attained. Most fundamentally, they find valid justifications for their being isolated, rejected, and empty. Avoidants describe themselves typically as ill at ease, anxious, and sad. Feelings of loneliness and of being unwanted and isolated are often expressed, as are fear and distrust of others. People

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are seen as critical, betraying, and humiliating. With so trouble-laden an outlook, the avoidant experiences social behavior that is characterized by interpersonal aversiveness. Disharmonious emotions and feelings of emptiness and depersonalization are especially noteworthy. Shy/avoidant personalities tend to be excessively introspective and self-conscious, often perceiving themselves as different from others, and they are unsure of their identity and self-worth. Their feeling of alienation from others thus is paralleled by a feeling of alienation from themselves. They voice futility with regard to the life they lead, have a deflated self-image, and frequently refer to themselves with an attitude of contempt and derision more severe than they hear from others. Vexatious Objects The internalized residue of the past that inheres within the mind of the avoidant is composed of intense, conflict-ridden memories of problematic early relationships. These can be readily reactivated with minimal promptings. Moreover, avoidants have limited recollections of a more rewarding nature to draw on or to dispose them to perceive the world optimistically. Owing to the pervasiveness of these troublesome memories, they have few opportunities to develop effective and satisfying means to bind their impulses, to resolve their conflicts, or to deflect external stressors. Shy/avoidants are trapped in the worst of both worlds, seeking to avoid both the distress that surrounds them and the emptiness and wounds that inhere within them. This latter feature is especially significant to an understanding of the avoidant for it signifies the fact that turning away from the external environment brings him or her little peace and comfort. Shy/avoidants find no solace and freedom within themselves. Having internalized the pernicious attitude of self-derogation and -deprecation to which they were exposed in earlier life, they not only experience little reward in their accomplishments and thoughts but find instead shame, devaluation, and humiliation. In fact, they may feel more pain being alone with their despised self than from the escapable torment of others. Immersing themselves in their own thoughts and feelings is the more difficult experience, as they cannot physically avoid themselves, cannot walk away, escape, or hide from their own being. Deprived of feelings of worth and selfrespect, these persons suffer constantly from painful thoughts about their pitiful state, their misery, and the futility of being themselves. Efforts that are even more vigilant than those applied to the external world must be expended to ward off the painful ideas and feelings that well up within them. These aversive signals are especially anguishing because they pervade every facet of avoidants’ makeup. It is their entire being that has become devalued, and nothing about them escapes the severe judgment of self-derision. Fantasy Mechanisms The shy/avoidant’s prime, if not sole, recourse is to break up, destroy, or repress these painful thoughts and the emotions they unleash. These personalities struggle to prevent self-preoccupations and seek to insert irrelevancies by blocking and making their

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normal thoughts and communications take on different and less significant meanings. In effect, and through various intrapsychic ploys, they attempt to interfere actively with their own cognitions. Similarly, the anxieties, desires, and impulses that surge within them must be restrained, denied, turned about, transformed, and distorted. Thus, they seek to muddle their emotions also, making their affective life even more discordant and disharmonious than it is typically. To avoidants it is better to experience diffuse disharmony than the sharp pain and anguish of being themselves. Despite their efforts at inner control, painful and threatening thoughts and feelings will periodically break through, disrupting more stable cognitive processes and upsetting whatever emotional equanimity they are able to muster. Apart from destroying their inner cognitions, shy/avoidants depend excessively on fantasy and imagination to achieve a measure of need gratification, to build what little confidence they may have in their self-worth, and to work out what few methods they can for resolving conflicts. Avoidants experience their feelings deeply and hence must use their daydreams and reveries as a means of dealing with their frustrated affectional needs and discharging their resentful and angry impulses. But fantasies also prove distressing in the long run because they point up the contrast between desire and objective reality. Repression of all feelings is often the only recourse, hence accounting for the shy/avoidant’s initial appearance of being flat, unemotional, and indifferent, an appearance that belies the inner turmoil and intense affect these persons truly experience. Fragile Organization The intrapsychic structure of the avoidant is composed of a precarious complex of tortuous emotions, each of which can be reactivated and can overthrow the fragile psychic controls of these patients. What holds the structure together is a reliance, excessive in its use, of avoidance, escape, and fantasy. When faced with personal risks or unanticipated stress, the shy/avoidant possesses few morphologic structures or dynamic mechanisms to deal with these difficulties. Similarly, there are few backup positions to which avoidants can revert, short of regressive decompensation. Protecting themselves from real and imagined psychic pain is a paramount goal in these personalities. Avoiding situations that may result in personal humiliation or social rejection is the guiding force behind their interpersonal relationships. Of equal threat is the shy/avoidant’s own aggressive and affectional impulses. These are especially distressing because these persons fear that their own behaviors may prompt others to reject and condemn them. Much intrapsychic energy is devoted to mechanisms that deny and bind these inner urges. Shy/avoidant personalities are beset by several notable conflicts. The struggle between affection and mistrust is central. They desire to be close, show affection, and be warm with others, but they cannot shake themselves of the belief that such actions will result in pain and disillusion. They have strong doubts concerning their competence and, hence, have grave concerns about venturing into the more competitive aspects of our society. This lack of confidence curtails their initiative and leads to the fear that

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their efforts at autonomy and independence will only fail and result in humiliation. Every route toward gratification seems blocked with conflicts. They are unable to act on their own because of marked self-doubt; on the other hand, they cannot depend on others because they mistrust them. Security and rewards can be obtained, then, neither from themselves nor from others; both provide only pain and discomfort. Anguished Mood Avoidants describe their emotional state as a constant and confusing undercurrent of tension, sadness, and anger. They feel anguish in every direction, vacillating between unrequited desires for affection and pervasive fears of rebuff and embarrassment. Not infrequently, the confusion and dysphoria they experience leads to a general state of numbness. As noted, shy/avoidant personalities have a deep mistrust of others and a markedly deflated image of their own self-worth. They have learned to believe through painful experiences that the world is unfriendly, cold, and humiliating and that they possess few of the social skills and personal attributes by which they can hope to experience the pleasures and comforts of life. They anticipate being slighted or demeaned wherever they turn. They have learned to be watchful and on guard against the ridicule and contempt they expect from others. They must be exquisitely alert and sensitive to signs that portend censure and derision. And, perhaps most painful of all, looking inward offers them no solace for they find there none of the attributes they admire in others. Their outlook is therefore negative: to avoid pain, to need nothing, to depend on no one, and to deny desire. Moreover, they must turn away from themselves also, away from an awareness of their unlovability and unattractiveness, and from their inner conflicts and disharmony. For them, life is a negative experience, both from without and from within. The hyperarousal of avoidants may reflect a biophysical sensory irritability or a more centrally involved somatic imbalance or dysfunction. Using a different conceptual language to refer to this biophysical speculation, it might be hypothesized that these individuals possess a constitutionally based fearful or anxious temperament, that is, a hypersensitivity to potential threat. The conjectures suggested here may be no more than different conceptual approaches to the same thesis; for example, a fearful temperamental disposition may simply be a behavioral term to represent a biophysical limbic system imbalance. A few speculations of an anatomical and biochemical nature may be in order. For example, shy/avoidant personalities may experience aversive stimuli more intensely and more frequently than others because they possess an especially dense or overabundantly branched neural substrate in the aversive center of the limbic system. As Millon (1996a) has described in slightly greater detail in a section on “hypothetical biogenic factors,” another plausible speculation for their avoidant tendencies is a possible functional dominance of the sympathetic nervous system. Thus, excess adrenaline owing to any one of a number of autonomic or pituitary-adrenal axis

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dysfunctions may give rise to the hypervigilant and irritable characteristics of this personality. Imbalances of this kind may lead also to the affective disharmony and cognitive interference found among these patients. Deficiencies or excesses in certain brain neurohormones may facilitate rapid synaptic transmission and result in a flooding and scattering of neural impulses. Such individuals will not only appear overalert and overactive but may experience the shy/avoidant’s characteristic cognitive interference and generalized emotional dysphoria.

Self-Perpetuation Processes The coping style employed by the avoidant personality is not a matter of choice. It is the principal, and perhaps only, means these individuals have found effective in warding off the painful humiliation experienced at the hands of others. Discomforting as social alienation may be, it is less distressing than the anguish of extending themselves to others, only to be rebuffed or ridiculed. Distance guarantees a measure of safety; trust only invites disillusion. The coping maneuvers of shy/avoidants prove self-defeating. There is a driven and frightened quality to their behaviors. Moreover, avoidants are adaptively inflexible because they cannot explore alternative actions without feeling trepidation and anxiety. In contrast to that of other personalities, the shy/avoidant coping style is essentially negative. Rather than venturing outward or drawing on what aptitudes they possess, they retreat defensively and become increasingly remote from others and removed from sources of potential growth. As a consequence of their protective withdrawal, avoidants are left alone with their inner turmoil, conflicts, and self-alienation. They have succeeded in minimizing their external dangers, but they have trapped themselves in a situation equally devastating. Several behaviors that foster and intensify the shy/avoidant’s difficulties are described next (see Table 3.2) Active Social Detachment Avoidant personalities assume that the experiences to which they were exposed in early life will continue forever. Defensively they narrow the range of activities in which they allow themselves to participate. By sharply circumscribing their life, they preclude the possibility of corrective experiences that might lead them to see that all is not lost and that there are kindly persons who will neither disparage nor humiliate them. A further consequence of detaching themselves from others is that they are left to be preoccupied with their own thoughts and impulses. Limited to the inner world of stimuli, they will reflect on and ruminate about the past, with all the discomforts it brings forth. Because their experiences have become restricted largely to thinking about past events, life becomes a series of duplications. As a consequence, shy/avoidants are left to relive the painful experiences of earlier times rather than be exposed to new and different events that might alter their outlook and feelings. Moreover, these

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Table 3.2

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Self-Perpetuating Processes: Shy/Avoidant Personality

Active Social Detachment Defensive narrowing precludes corrective experiences Preoccupations relive painful past Intensifies social estrangement Suspicious and Fearful Behavior Evokes reciprocal disaffection Weakness attracts humiliaters Rebuff reinforces aversiveness Emotional-Perceptual Hypersensitivity Sensitive to derogatory events Scanning elevates threats into fears Sensitivity deepens plight Cognitive Interference Intrusive fears fragment and derail thoughts Diminished ability to function Social communication becomes tangential and irrelevant

self-preoccupations serve only to further widen the breach between themselves and others. A vicious circle may take hold. The more they turn inward, the more they lose contact with the typical interests and thoughts of those around them. They become progressively more estranged from their environment, increasingly out of touch with reality and the checks against irrational thought provided by social contact and communication. Away from the controls and stabilizing influences of ordinary human interactions, they begin to lose their sense of balance and perspective, often feeling puzzled, peculiar, unreal, and “crazy.” Suspicious and Fearful Behaviors Detached and mistrustful behaviors not only establish distance from others but evoke reciprocal reactions of disaffiliation and rejection. An attitude that communicates weakness, self-effacement, and fear invariably attracts those who enjoy deprecating and ridiculing others. Thus, the hesitant posture, suspicious demeanor, and self-deprecating attitudes of the avoidant will tend to evoke interpersonal responses that lead to further experiences of humiliation, contempt, and derogation—in short, a repetition of the past. Any apparent sensitivity to rebuff or obviously fearful and unassertive style will tend to evoke ridicule from peers, an experience that will only reinforce and intensify this personality’s aversive inclinations.

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Emotional and Perceptual Hypersensitivity Shy/avoidant personalities are painfully alert to signs of deception, humiliation, and deprecation. As noted in a later case presentation, these patients detect the most minute traces of indifference or annoyance on the part of others and make the molehills of minor and passing slights into mountains of personal ridicule and condemnation. They are incredibly sensitive instruments for picking up and magnifying incidental actions and for interpreting them as indications of derision and rejection. This hypersensitivity functions well in the service of self-protection but fosters a deepening of the person’s plight. As a result of their extensive scanning of the environment, avoidants actually increase the likelihood that they will encounter precisely those stimuli they wish most to avoid. Their exquisite antennae pick up and transform what most people overlook. In effect, their hypersensitivity backfires by becoming an instrument that brings to their awareness, time and again, the very pain they wish to escape. Their defensive vigilance thus intensifies rather than diminishes their anguish. Intentional Cognitive Interference Shy/avoidants must counter the flood of threatening stimuli that they register as a consequence of their emotional and perceptual hypersensitivities. To assure a modicum of personal tranquility, they engage constantly in a series of cognitive reinterpretations and digressions. They may actively block, destroy, and fragment their own thoughts, seeking to disconnect relationships from what they see, what meanings they attribute to their perceptions, and what feelings they experience in response. Defensively, then, they intentionally destroy the clarity of their thoughts by interjecting irrelevant distractions, tangential ideas, and discordant emotions. This coping maneuver exacts its price. By upsetting the smooth and logical pattern of their cognitive processes, avoidants further diminish their ability to deal with events efficiently and rationally. No longer can they attend to the most salient features of their environment, nor can they focus their thoughts or respond rationally to events. Moreover, they cannot learn new ways to handle and resolve their difficulties because their thinking is cluttered and scattered. Social communications also take on a tangential and irrelevant quality, and they may begin to talk and act in an erratic and halting manner. In sum, in their attempt to diminish intrusively disturbing thoughts, they fall prey to a coping mechanism that further aggravates their original difficulties and ultimately intensifies their alienation from both themselves and others.

Interventional Goals The shy/avoidant personality disorder is among the most frequent disorders that therapists encounter. As is evident from the preceding discussions, the prognosis for the avoidant personality is often quite poor. Not only are these persons’ habits and attitudes pervasive and ingrained, as are all personality patterns, but many are trapped in environments that provide them with few of the supports and encouragements needed

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to reverse their lifestyle. A therapist with shy/avoidant clients will be challenged not only to keep them in therapy but also to get beyond these patients’ tendency to reveal only that which they believe will restrain the therapist from thinking ill of them. If the therapist manages to gain these clients’ trust, however, a strong alliance can be forged, and progress can be made—given enough time, patience, and conscientious use of interventions. Therapeutic intervention with avoidant patients has as its ultimate aim to reestablish balance within the pleasure–pain and active–passive polarities. The asymmetric focus within these domains leads to a clinical picture characterized by overly active avoidance of perceived threatening situations. An active search for psychic enhancement (pleasure) is notably absent. Therapeutic strategies need to be aimed at countering the patient’s tendencies that serve to perpetuate a pattern of social withdrawal, perceptual hypervigilance, and intentional cognitive interference. Clinical work targeting the most salient of the domain dysfunctions can help alter the alienated self-image, aversive interpersonal conduct, vexatious object representations, and anguished mood that characterize these patients’ psychic state (see Table 3.3). Reestablishing Polarity Balances Like the schizoid, the shy/avoidant patient has marked difficulty experiencing pleasure. Unlike the schizoid, however, who has a lowered capacity to experience emotional distress as well as pleasure, the avoidant is hyperresponsive to anxietyprovoking stimuli. Shy/avoidants’ primary aim of avoiding humiliating interpersonal experiences precludes being exposed to interactions in which the affection for which they yearn can occur. Active withdrawal from situations they fear may be hurtful ensures Table 3.3 Therapeutic Strategies and Tactics for the Prototypal Shy/Avoidant Personality Strategic Goals Balance Polarities Diminish anticipation of pain Increase pleasure/enhancing Counter Perpetuations Reverse social detachment Diminish suspicious/fearful behavior Moderate perceptual hypersensitivity Undo intentional cognitive interference Tactical Modalities Adjust alienated self-image Correct aversive interpersonal conduct Remove vexatious objects

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that avoidants will rarely express their wishes even in nonintimate relationships. This leads to frustration of goals in general, as well as to feelings of loneliness. Typically, in their determination to avoid rejection and pain, shy/avoidants preclude from their repertoire of behaviors interactions that might result in personal gratification. A major therapeutic goal thus is to increase these patients’ active focus on pleasurable stimuli and to decrease their active avoidance of potentially painful stimuli. Countering Perpetuating Tendencies The characteristic active social detachment that shy/avoidants employ as a defense against experiencing rebuff and criticism actually ensures that they experience no social interaction that serves to disconfirm their pessimistic expectations. An understanding of how their own actions solicit the very reactions from others that they so fear can help avoidants appreciate that they need to control their suspicious and fearful expectancies and behaviors in order for normal interaction to take place. Increased social contact can lead to nonthreatening encounters that can help reorganize their extreme schemas. Therapeutic intervention can provide patients with self-understanding, social skills, and the means to control or tolerate their symptoms of anxiety to help assure that their fledgling efforts to reach out for rewarding interaction will be successful. Unfortunately, the wood that feeds the fire of withdrawal and suspicious behaviors is the very emotional and perceptual hypersensitivity that shy/avoidants develop as a defense against potentially painful interactions (Hyman & Schneider, 2004). As their sensitivity escalates, all positives are seen as true positives. Their subjective identification of threat skyrockets so that avoidants spend much time and emotional energy avoiding and processing nonexistent personal assaults. An understanding of “normal” human behavior, and the ability to differentiate between real, incidental, and imagined threats, can allow more normal living to occur. Internal reference points according to which they can judge their own behavior need to be established so that they do not feel at the mercy of others’ often unpredictable and irrational responses. Once shy/avoidants’ hypersensitivities are reduced, they can begin to decrease their use of intentional cognitive interference as a defense against their (often misguided) painful conclusions about others’ reactions. More realistic thought processes allow them to deal more effectively with their environments, learn from their surroundings, and communicate more profitably. Positive social interaction may serve, in turn, to further distract them from the thoughts and impulses that preoccupy them. No longer limited to their inner world of impulses, they have material other than their past pain to ponder and can develop more normative and adaptive attitudes toward their lives, allowing them to communicate with others and to feel less “unusual.” Identifying Domain Dysfunctions The shy/avoidant’s predisposition and/or learning history leads to a clinical picture dominated by primary disturbances in self-image, interpersonal conduct, object representations, and mood/temperament. The self is perceived as socially inept and

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self-achievements are devalued. The emotional suffering that accrues from social isolation and perceived rejection are seen as justified natural consequences of personal inadequacy. Feelings of aloneness, and even depersonalization, are often reported. Increased social contact, assertiveness, improved social skills, and exploratory clientcentered therapy can all direct the avoidant toward an improved self-image. Aversive interpersonal conduct leads the shy/avoidant to maintain social distance in the hope that privacy will ensure protection against anticipated humiliation and derogation. Cognitive, interpersonal, and other exploratory therapies can help the avoidant rework aversive schemas. Behavior modification programs may prove invaluable in providing shy/avoidants with necessary social skills and incipient self-confidence. Together, these interventions help create more realistic and optimistic mental schemas about human relationships to replace the vexatious object representations that characterize their mental framework. Pharmacological intervention can also be considered to help ease anxiety that interferes with personal growth, effectively lowering the threshold at which avoidants may be cajoled into taking initiative with respect to their own lives. Shy/avoidants also need to learn to control their fretful expressive behavior in favor of a more relaxed and confident style that promotes rewarding relationships. Their distracted cognitive style interferes with fluid thinking and spontaneous communication. On an intrapsychic level, avoidants rely too heavily on fantasy as a regulatory mechanism to cope with environmental stress. Neither reveries nor isolation will promote adaptive resolution of problems, or help strengthen the fragile morphologic organization of their coping system.

Selecting Therapeutic Modalities It is important for the therapist working with a shy/avoidant client to keep in mind that the avoidant will be hesitant to share feelings of shame or inadequacy with the therapist for fear of rejection. The best way to counter such client apprehension is with freehanded empathy and support. Benjamin (1993) points out that many shy/avoidants find it particularly difficult to discuss maltreatment in their childhood family, as well as any negative feelings they have toward family members (Bender, 2005; Bender et al., 2006). This arises from the pressure many avoidants feel to be loyal to the family and its members, and from the accompanying transmitted belief that outsiders are dangerous and not to be trusted. Continued support and understanding are the therapist’s only recourse against even this resistance. A protective, sanctuarylike therapeutic environment is the only one that is likely to draw the shy/avoidant out of his or her shell. Behavioral Techniques At the behavioral level, avoidants manifest both aversive interpersonal conduct and fretful expressive behavior. Behavior modification may prove useful as a way to learn less fearful reactions to formerly threatening situations; in general, in vivo exposure

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is considered more effective than desensitization for symptoms of social anxiety. Behavioral management can be greatly facilitated by a variety of rather straightforward techniques, such as anxiety management, assertiveness and social skills training, and a variety of modeling opportunities, each directed at enhancing self-confidence and interpersonal skills. Before actually engaging in social interaction exercises, shy/avoidant patients can be assigned preliminary cognitive tasks such as self-monitoring of their withdrawal behavior to help clarify their inclination to avoid certain people or social situations. They can also be asked to keep a log of their self-deprecatory statements and physiological arousal. Anxiety-management training can be very helpful. If past avoidant behavior has resulted in a failure to acquire critical social skills, then behavioral rehearsal will often improve assertiveness and behavioral fluidity. Once these tasks have been accomplished, hierarchical grading of social tasks in regard to anxiety-provoking potential (talking to a mailman versus engaging in conversation with one’s boss) can help organize the sequence of homework assignments. It is very important not to rush the patient through these steps. Initial success is critical in shifting the balance to a more active stance with regard to procuring interpersonal pleasure and correcting aversive interpersonal conduct. Interpersonal Techniques The techniques just mentioned are especially useful as short-term adjunct interventions. More lasting change, however, requires additional techniques. Interpersonal therapy represents a prolonged effort toward healing through a “corrective emotional experience” with the therapist, ideally one that will generalize to contexts outside the therapy hour, as patients learn that they can succeed in the chances they take in treatment. Notably helpful in this regard is that most shy/avoidants are able to relate comfortably to a select few persons. Clinicians who can model themselves to reflect the character of such “outsiders” may be able to provide the empathy and warm support needed to encourage patients to share the intimacies of their life, as well as their personal feelings of shame, guilt, or inadequacy. As therapy begins to explore the patient’s long-term maladaptive patterns, eschewing statements or actions that expose the patient’s hypersensitivities, there is a reasonable likelihood that the patient will also become increasingly self-accepting (Herbert et al., 2005). The interpersonal approach outlined by Benjamin (1993) suggests a general sequence of strategic interventions we have found to be clinically effective. Once the patient’s trust is gained through supportive reassurance and protection, the therapist can move the patient toward more functional behaviors by refusing to support avoidance and by encouraging assertive behavior. Examination of the effects of his or her own behavior can help the avoidant sacrifice the safety of problematic patterns for the possibility of achieving enhancing experiences through more “risky” behavior, such as giving up a triangular relationship despite opening himself or herself up to the mercy of the whims of only one person with nowhere to turn for comfort. For example, a secret lover who provides comfort and is protective when a spouse is angry or withdrawn may be given up in favor of improving the relationship with the spouse.

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Family or couple therapy can be very helpful for a patient who is caught in a social environment that unwittingly supports shy/avoidant behaviors (Carson, 1982; Kiesler, 1982). If the therapist is careful not to allow “trashing” in the name of communication to occur during the sessions, these techniques can help speed the healing process for the patient (Benjamin, 1993). Group approaches allow for forced exposure to strangers in an atmosphere of acceptance and can help patients overcome painful social embarrassment in most therapeutic groups. Patients should not be forced into interacting, but rather should be allowed to observe from the sidelines until they feel ready to risk exposure. In groups that emphasize behavioral approaches, patients also have a unique opportunity to acquire and practice behavioral and social skills. Cognitive Techniques Avoidant patients can also profit from methods of cognitive reorientation designed to alter erroneous self-attitudes and distorted social expectancies. In an effort to change the dysfunctional schemas that underlie shy/avoidant behavior, cognitive therapy focuses largely on clarifying for the patient his or her pattern of automatic thoughts within the therapeutic relationship (Clark et al., 2006; Strauss et al., 2006). This helps patients discover thinking errors they commit in everyday life that contribute to their dysphoria and self-defeating behaviors. These persons are notoriously difficult to engage in exploratory treatment methods in light of their strategy of avoiding fears and shames, especially their hypersensitivity to criticism. Not only do they avoid unpleasant experiences, but they also do their best not to think about matters that they experience as unpleasant or threatening. A useful step in this regard is to increase their tolerance for what they perceive as emotionally upsetting relationships or events. These difficulties arise most clearly in close or intimate relationships. Efforts such as behavioral exposure should be utilized to help the patient learn to tolerate minor degrees of disapproval or rejection. An important goal is enabling the avoidant to recognize that difficulties in close relationships do not result in devastation and abandonment. Honest discussion of the patient’s feelings toward the therapist and his or her fears regarding the relationship are primary tools. As patients realize that the therapist (who serves as a mirror for other relationships) will not reject, abandon, or denigrate them despite exposure, they start to reformulate automatic thinking patterns and reestablish a measure of balance within their personality structure. In working toward this end, Beck and Freeman (1990a, 1990b) suggest that patients can rate their therapist’s feedback on a scale ranging from 0% to 100%, and thus monitor their own trust in the therapist as well as in the feedback provided. Beck and Freeman (1990a, 1990b) suggests that patients and therapists engage in experiments to evaluate the validity of their distorted cognitive schemas and automatic thoughts. For example, the therapist can ask the patient if there is anything that the patient cannot disclose. Frequently the patient will express hesitation that can then be examined, and his or her fears of rejection can be confronted. The patient’s fantasies about negative and rejecting therapist response can be discussed, and more realistic possibilities can be explored.

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Self-Image Techniques Considering therapy from the viewpoint of formal technique, a key approach is to assist the patient in arranging a more rewarding environment, one that facilitates opportunities that enhance feelings of self-worth. In the beginning, self-enhancing therapeutic approaches of this type may be all shy/avoidant patients can tolerate until they are capable of dealing comfortably with their more painful feelings. Early self-actualization is necessary, but not sufficient, to produce therapeutic change. The element of trust is central to maintaining a continuous increment in feelings of self-worth. Although the client-centered/humanistic approach of Rogers (1961) can be extremely fruitful, the growth of feelings of self-esteem and self-worth must be nourished through the therapist’s rapport-building techniques. There is some value in bringing experiential methods into play to assist patients in recognizing even the most subtle of feelings that certain circumstances elicit. In this way, it may be possible to demonstrate for patients which events and relationships elicit their painful and pleasurable feelings. As they rework these implicit reactions via cognitive methods, it may be possible subsequently for them to experience genuine therapeutic trust, a not insignificant element in their ultimate improvement. Intrapsychic Techniques Psychodynamic theories frame avoidant behavior as being driven by the shame of not measuring up to one’s ego ideal, of being weak, defective, even disgusting. Treatment emphasizes a strongly empathic understanding of patients’ experience of humiliation and embarrassment due to exposure both in front of the therapist and in their daily lives. Childhood memories are analyzed to clarify the roots of the disorder. Efforts are made to explore the underlying elements of the past that have led to feelings of rejection and shame. Therapy is facilitated as the patient learns to confront the source of these problematic feelings. Most patients, especially shy/avoidants, have difficulty communicating the deeper origins of their current discomforts (Schut et al., 2005). Useful in this regard may be the exploration of their fantasies as they emerge in free association and transference communications (Bradley, Heim, & Westen, 2005). Even the slightest experience of fear or shame might be utilized to explore how the patient is really thinking and feeling. In this way, patients may develop a more accurate awareness of the events that provoke their dysphoric affect. Confrontation of feared situations should be attempted, as should be detailed exploration of anxiety-provoking fantasies, particularly in the context of transference feelings toward the therapist. These deeper and searching procedures of intrapsychic therapies can also be useful in reconstructing unconscious mechanisms that pervade all aspects of the patient’s behavior and of the communication style that contributes to or intensifies his or her problems. Pharmacologic Techniques If social hypersensitivity is severe, and the fear of rejection and denigration puts the patient at risk for extreme behavioral withdrawal or the termination of treatment, possible benefits of psychopharmacological intervention should be evaluated. It should

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be noted also that avoidant patients often shy away from medications owing to their habitual aversion to new experiences. Despite occasionally troubling side effects, there is evidence that their social anxiety may be very responsive to medications (Scott, 2006; Seedat & Stein, 2004). For example, monoamine oxidase inhibitors (MAOIs) may be considered as a possible adjunct to behavioral methods, as well as other forms of psychological treatment. This medication has been found to be effective at times in controlling the symptoms of social phobia and may allow the patient to experience a measure of initial treatment success when joined with behavioral intervention techniques. Beta blockers may also prove helpful in controlling symptoms of autonomic excitation, such as sweating, trembling, and blushing, without any direct psychoactive effect (Marchesi, Cantoni, Fonto, Giannelli, & Maggini, 2005). Brief episodes of panic may also be controlled with benzodiazepine anxiolytics. Serotonin uptake-inhibitor antidepressant medications may be especially effective in this regard, particularly when social anxiety symptoms are paramount. A clustering of several pharmacologic agents should be explored where possible to deal with patterns of a highly generalized nature. In this regard, a number of investigators suggest the use of benzodiazepines such as alprazolam. As will be elaborated in later paragraphs, many avoidants regress into psychoticlike fears and withdrawal. In these circumstances it may prove fruitful to consider the use of an antipsychotic agent.

Making Synergistic Arrangements Any intervention plan that is chosen by the therapist is at risk for failure if the initial stages of the therapeutic interaction are not primarily supportive and aimed at fostering trust. With trust established, the therapist can help the patient to arrange for a rewarding environment and facilitate the discovery of opportunities that will enhance self-worth. With continued therapy, the therapist can gradually shift to a slightly more confrontational style within the framework of a cognitive, interpersonal, psychodynamic, or behavioral intervention. In the course of any long-term individual exploratory psychotherapy aimed at helping patients get at the root of their dysfunctional patterns, it is often advisable to make concomitant use of shorter-term behavioral techniques. More withdrawn patients can thus acquire the skills necessary for initial experiences of social success that instill hope and foster the motivation needed to tolerate the more painful aspects of therapy. Group therapy can be considered as a more benign and accepting social forum than shy/avoidants normally encounter, one ripe for learning new attitudes and skills when the therapist considers the patient ready. Favorable response to anxiolytic medication may also allow highly symptomatic patients to tolerate new situations and more proactive social behavior. Especially in the initial stages, selectively combined interventions allow for positive reward gained by interacting socially in previously unthinkable ways, and for the formation of new schemas about self and others without the failure-inducing disruption caused by overwhelming anxiety. After initial success with behavioral, interpersonal, or cognitive therapy, some patients may profit from family or couple therapy. These interventions are indicated

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for individuals who are embedded in social contexts that unwittingly help maintain the patient’s avoidant behavior, and whose treatment may be facilitated by the development of a more supportive environment. As is suggested by Beck and Freeman (1990a, 1990b), the therapist should work with the patient on a program designed to prevent relapse. Ongoing behavioral goals include establishing and improving friendships, behaving in appropriately assertive ways in different social contexts, and trying new experiences. These help maintain motivation and give patients a chance to monitor their own behavior. Patients can be taught to use anxiety as a signal to check for maladaptive automatic thoughts, to keep logs of avoidance-producing thinking and discrediting evidence against their own irrational beliefs, to plan strategies ahead of time for difficult situations, and to call the therapist for a booster session if all else fails.

Illustrative Cases Shy/avoidant patients often acquire subsidiary features as they begin to withdraw socially and experience critical and unsupportive responses from others. Research utilizing the MCMI-III (Millon, Millon, Davis, & Grossman, 2006) shows that profiles including the avoidant pattern are shared most often with schizoid, dependent, depressive, negativistic, schizotypal, and paranoid personalities. When they begin to exhibit some of these associated personality features, these patients will manifest moods and actions that differ from their original traits. Insidiously developing features combine with the avoidant pattern and express themselves in a number of the subtypes discussed next (see Table 3.4). Table 3.4

Shy/Avoidant Personality Disorder Subtypes

Hypersensitive: Intensely wary and suspicious; alternately panicky, terrified, edgy, and timorous, then thin-skinned, high-strung, petulant, and prickly. (Mixed Avoidant/ Paranoid Subtype) Self-Deserting: Blocks or fragments self-awareness; discards painful images and memories; casts away untenable thoughts and impulses; ultimately jettisons self (suicidal). (Mixed Avoidant/Depressive Subtype) Phobic: General apprehensiveness displaced with avoidable tangible precipitant; qualms and disquietude symbolized by repugnant and specific dreadful object or circumstances. (Mixed Avoidant/Dependent Subtype) Conflicted: Internal discord and dissension; fears independence and dependence; unsettled; unreconciled within self: hesitating, confused, tormented, paroxysmic, embittered, unresolvable angst. (Mixed avoidant/Negativistic Subtype)

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Case 3.1, Sharon B., 31 A Shy/Avoidant Personality: Conflicted Type (Avoidant with Negativistic Traits) Presenting Picture Sharon, a 3rd-year microbiology graduate student, came to therapy at the behest of her father, who called the office and said, “She’s so clammed up; she could really use some ‘chutzpah.’ ” Sharon had been able to narrowly escape teaching responsibilities in the early part of her program, thanks to a benevolent older professor who had taken a liking to her and allowed her to work in his laboratory. However, he passed away unexpectedly shortly before the new semester, and Sharon’s sanctuary disappeared unceremoniously with his passing. She was unnerved by her mentor’s death and extremely uneasy regarding her teaching assistantship. She imagined that she could possibly get by unnoticed, for the most part, by spending most of her class time writing on the chalkboard, relying on her excellent knowledge of the subject matter. She first said, “I’ll only talk when they have questions.” But then she added, “But I just know, they’ll always have questions!” In the past, when asked to give a presentation, Sharon would become thoroughly overwhelmed, fighting the urge to run out of the classroom into a nearby restroom and lock the door. Extremely fearful of rejection, she also had a great deal of difficulty relating to her peers in her program of study. Although she had several “friendly acquaintances,” she stopped short of considering them friends. “If they really got to know me, they just wouldn’t like me. I’m not likeable,” she remarked. Throughout the initial interview, Sharon repeatedly confronted this central theme of not allowing any possible vulnerability, for everyone seemed to her to be set in motion in her world only to judge her every move, thereby discovering all of her inadequacies and her lack of autonomy. Clinical Assessment More than is typical of the ordinary shy/avoidant, Sharon, a conflicted avoidant, ceaselessly faced an internal struggle between desiring solace and shelter from others and fears both of being independent and of being humiliated and rejected. Exquisitely pain-sensitive and retreating, as may be expected of a shy/avoidant, she also experienced a self–other conflict that perpetuated angst somewhat typical of the negativistic personality. Where her struggle differed, however, was that the basis of this conflict played out in fearfulness rather than underhanded hostility, although resentment did underlie much of her motivation. She would like to have been close and show affection, but she constantly anticipated the experience of intense pain and disillusionment. Complicating the concern about venturing into close relationships was her markedly deflated self-esteem. Thus, any effort to make a go at independence was constrained by the fear that it would fail and result in shame. Although she had no alternative but to depend on supporting persons and

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108 PERSONALIZED THERAPY FOR THE SHY/AVOIDANT PERSONALITY PATTERNS institutions, this behavior cloaked deep-seated resentment. Others, she felt, had either turned against her or disapproved of her efforts to achieve autonomy. This gave rise to her frequent petulance and negativism, and on occasion she would attack others for failing to recognize her need for affection and nurturance. The dependency security she sought was seriously jeopardized under these circumstances. To bind her conflictful feelings and anger, and thereby protect against humiliation and loss, she evidenced anxiety and withdrawal, along with a persistent and pervasive dysphoric mood that, not surprisingly, evoked humiliating reactions from others, thereby serving to reinforce her self-protective withdrawal. Disposed to anticipate disappointments, she often precipitated disillusionment through obstructive and negative behaviors. Unable to muster the wherewithal to overcome deficits, and unable to achieve the support desired from others, Sharon remained embittered and conflicted, disposed to turn against herself, expressing feelings of unworthiness and uselessness. Expecting to be slighted or demeaned, she had learned to be watchful and on guard against the ridicule and contempt she anticipated from others. Looking inward offered her no solace because she saw none of the attributes admired in others in herself. Sharon’s perpetuating tendencies included a hypervigilance that constantly searched for signs of rejection, as well as a fear of inadequacy (her conflict in the self–other polarity). These tendencies had her constantly anticipating disappointment and avoiding an “unmasking” of what she perceived to be her pathetic shortcomings. Within this framework, it was obvious that she expended most of her energy as a sentinel, remarkably active in thwarting any possible damage to her already depleted and faulty image. It would be necessary to establish as safe and empathic an environment in therapy as possible, bolstering her confidence to reduce this hypervigilance and enhance her affect positively. This would also give her a more favorable, controlled impression of her environment. As trust developed, it would be possible to question her defeatist beliefs and help her overcome hostilities, instead favoring healthier interactions. Domain Analysis Though fearful of exposing too much, as evidenced in her modifying indices painting a self-sheltering and conflictful positive/negative impression, Sharon acceded to psychological testing. Results of her domain analysis, as measured with the MG-PDC and the MCMI-III Grossman Facet Scales, were as follows: Alienated Self-Image: Sharon saw herself as depleted, inferior, and worthy only of ridicule and dejection, and actively anticipated being scorned; this self-reflection, paradoxically, sometimes prompted such reactions from others. Temperamentally Anguished: Underlying and obfuscating Sharon’s difficulties was a persistent dysphoric mood, further complicated by vacillating tension and numbness, with an active undercurrent of undisclosed but percolating anger.

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Interpersonally Contrary: Despite her desire for closer and more straightforward positive relationships, Sharon meted out unpredictable and confusing behaviors toward others, usually acquiescent but sometimes clandestinely and irritably aggressive, further provoking rebuke from others.

Therapeutic Steps A major early focus with Sharon was to thwart any decompensation from evolving into a full-blown anxiety or depressive disorder. At the same time, vigilance was necessary to detect rash acting-out behavior (such as suicide gestures). Because she entered treatment in a highly agitated state, the reduction of her anxieties and guilt was an early goal of short-term treatment. It was most important to stabilize her anguished, fluctuating mood, as this would preclude most setbacks and help Sharon become more responsive to progressively demanding goals. A pharmacological agent (in this case, paroxetine, which is helpful for such broadband social tension-dysphoric disturbances) was utilized. Immediate goal setting was handled judiciously in this early stage, as Sharon was highly fearful of failure and she tended to routinely feel overwhelmed, guilty, and melancholic. Most important was a diligent focus on the suitability of goals, as intangible aims would most likely trigger decompensatory responses. If she felt that she could not tolerate the demands of intervention, withdrawal from therapy could be anticipated, likely resulting in relapse. Though, ideally, Sharon might have been guided to avoid anxiety-inducing situations, this was not possible given that these were directly related to her teaching assistantship. However, supportive therapy was successfully employed in helping her with these pressures. Because of her confusion and alienated self image, Sharon had difficulty with trust issues, especially with the therapist. Needing reassurance but fearful of interpersonal risk, she required copious measures of warmth and attention in the therapeutic relationship. As she was engaged in this manner from the very outset of therapy, there was little need to test the therapist’s motives, though at times she did. Once she allied with the therapist, the collaborative effort focused first on reducing stress and widening her self-view, along with efforts directed at building her trust. This was accomplished by directing her attention to her more positive traits, thus enhancing her self-image. Combining this humanistic approach with the aforementioned pharmacotherapy created a therapy environment in which Sharon could gain self-confidence and more rapidly incorporate more directive measures to follow. Working with Sharon’s clearly ingrained patterns of interpersonal contrariness required a cocktail of progressively more challenging and pervasive measures aimed at several domains that had created a tenacious pattern of thinking, expecting, and responding. Defined behavior modification techniques were utilized to focus on socialization skills that could be augmented quickly. Cognitive techniques (Beck, Ellis) confronted her well-ingrained inimical and disadvantageous thoughts and

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110 PERSONALIZED THERAPY FOR THE SHY/AVOIDANT PERSONALITY PATTERNS expectations. Her relationship skills were bolstered by employing a number of interpersonal treatment techniques (e.g., Klerman, Benjamin), and a marked improvement was noted with her peers and students. Family techniques were essential as well, and fortunately, her father and other family members were generally helpful. With Sharon, the most significant setback was her initial wish to withdraw from treatment before she was asked to confront painful feelings. This was overcome with a nurturant and empathic attitude on the part of the therapist, which moderated her belief that she would automatically be rejected. Otherwise, this belief would have led her to pull back and stifle potentially gratifying experiences. The later cognitive reorientation approach short-circuited this tendency to preliminarily defeat her chances to experience more positively stimulating events.

Case 3.2, Malcolm S., 25 A Shy/Avoidant Personality: Hypersensitive Type (Avoidant with Paranoid Traits) Presenting Picture Perhaps what made Malcolm pursue counseling was the painful awareness of his inability to socialize at a party hosted by a professor. A first-semester computer science graduate student, Malcolm watched other new students in his program fraternize at this gathering while he suffered in silence. He wanted desperately to join his new cohorts, but, as he described it, “I was totally at a loss as to how to go about talking to anyone.” The best feeling in the world, he stated, was getting out of there. The following Monday, he came to the university counseling center, realizing he would have to be able to function in this group, but not before his first teaching experience that morning, which he described as “the most terrifying feeling I have ever encountered.” As an undergrad, he spent most of his time alone in the computer lab working on new programs, which was what he most enjoyed as “no one was looking over my shoulder or judging me.” In contrast to this, with his teaching assistantship duties, now the most acute source of consternation, he felt he constantly ran the risk of being made to look like a fool in front of a large audience. When asked about personal relationships he had previously enjoyed, Malcolm admitted that any interaction was a source of frustration and worry. From the moment he left home for undergraduate school, he lived alone, attended functions alone, and found it nearly impossible to make conversation with anyone. Initial Impressions In what has been termed the hypersensitive avoidant (Millon, 1996a), we see many of the general features characteristic of the basic avoidant personality core but in an

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accentuated and more rigid form. Malcolm’s behavior was characterized by a high-strung and prickly manner, a hyperalertness to signs of rejection and abuse, and an excessive weariness that led to a peevish and wary attitude toward his environment. As such, he displayed a fusion of basic active-pain shy/avoidant characteristics permeated with features more central to the paranoid personality, specifically the immutability and pervasive inflexibility of that personality structure. The expectancy that people would be rejecting and disparaging precipitated profound gloom at one time, and irrational negativism at another. Despite a longing to relate and be accepted, Malcolm consistently constrained his needs, protectively withdrew from threats to his fragile emotional balance, and maintained a safe distance from all emotional involvement. Retreating defensively, he become remote from others and from needed sources of support. He found it difficult to bind his exasperation toward those whom he felt had been unsupportive, critical, and disapproving, but regardless, he was able to whitewash his affect with a surface apathy to dead-down and mask his true feelings of apprehension and frustration. Malcolm had learned to be watchful, on guard against ridicule, and ever alert to signs of censure and derision. He detected the most minute traces of annoyance expressed by others and made the molehill of a minor and passing slight into a mountain of personal ridicule and condemnation. He had learned that good things don’t last, that affection would capriciously end, followed by disappointment and rejection. Trust building was of foremost importance for this highly suspicious and very sensitive man, due to his active evasion of his salient perceptions of perceived derogatory views of others (pain sensitivity). Also, it was most prudent to take measures to adjust discomforting pressures in his immediate context, wherever possible. After creating this safe haven within therapy, it would then be feasible to begin exploring his tendencies to overinterpret the behaviors of others, which would likely lead to a gradual discovery of a distorted self-view as constitutionally weak, irreversibly flawed, and pervasively inadequate. As this understanding evolved, it would be crucial to remain supportive and continuously express an empathic stance, while fortifying his self-image. As confidence grew and pleasure became tangible rather than an out-of-reach abstraction, it would be a natural progression to encourage a more sociable and extraverted character with practice and experience in social situations. Domain Analysis Malcolm’s MCMI-III Grossman Facet Scales and the MG-PDC revealed the following significant trends in his domain analysis: Cognitively Distracted/Suspicious: Beyond that of most shy/avoidants, Malcolm’s thought processes were a cacophony of random intrusions, quickly changing channels, and continuously overwhelming and anxiety-provoking stimuli; the only

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112 PERSONALIZED THERAPY FOR THE SHY/AVOIDANT PERSONALITY PATTERNS consistency among these thoughts was that others were mistrustful and conspiring to undermine and deprecate Malcolm. Unalterable Objects: Much of Malcolm’s negative self-perception stemmed from troublesome perceptions of others, ostensibly derived from malevolent early impressions of others as hostile, undercutting, and fearsome. He had grave difficulty believing that others might be anything but hostile toward them. Interpersonally Aversive: Malcolm moved himself far from sources of interpersonal anxiety whenever possible, but wished desperately to be able to interact with a modicum of comfort; he routinely, however, felt he would be derided, ridiculed, and at times, conspired against. Therapeutic Steps In this scenario, short-term techniques were employed to help Malcolm feel secure in therapy. It was imperative that measurable results would happen somewhat rapidly in order for Malcolm to build trust and feel as though improvement was possible. However, this needed to be delicately balanced in a manner that allowed him a modicum of comfort and a tentatively less demanding series of goals. Pharmacologic agents were considered to attempt to augment this process, but Malcolm did not feel comfortable with this suggestion. Efforts were also made to reduce the stressors in his home and school environments that aggravated his anxieties and dejection. Supportive therapy was employed to assuage anxiety from those sources that could not be avoided. Additionally, techniques of motivational interviewing were utilized effectively to engage him in the process of identifying and setting objectives in a more directive but still supportive humanistic milieu. This process was able to bring attention to unalterable representations ingrained in his representation. Simple awareness was the key at this point; he would be able to address beliefs more operationally at a later point in therapy, but for now, it was beneficial to bring awareness and allow these objects to remain as they were. Toward the goal of reducing the likelihood of retrogression, the therapist avoided setting goals too high or pressing changes too quickly. Initial efforts were primarily directed at building Malcolm’s trust in the therapeutic relationship and the process of therapy. Short-term procedures designed to orient his attentions to his positive traits and to enhance his confidence and self-esteem were highly productive and worthwhile. Further, they allowed for more expedient progress in the second, explicit goal-implementation stage of treatment. Circumscribed behavioral modification methods were explored to focus on social behavior that could be strengthened in a relatively short time period. His relations, first with significant others, then with social peers, were strengthened gradually by employing several interpersonal treatment techniques (e.g., Klerman, Benjamin). Such approaches had to be handled cautiously, however, as Malcolm frequently

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anticipated feeling that he was a failure and tended to become unduly guilt-ridden, depressed, and even suicidal. Because of an intense ambivalence between his desire for reassurance and nurturance and his fear of trusting an unknown person, Malcolm required a thoroughly warm and attentive attitude on the part of the therapist to combat this interpersonal aversiveness. Additionally, cognitive techniques, specifically those of Beck and Ellis, were introduced throughout as punctuation to this primarily interpersonal/behavioral stage to confront him with the obstructive and selfdefeating character of his distractible style and suspicious beliefs and expectations. Work with family members would have been ideal, but they were not available; treatment therefore required a progressively greater intensity as Malcolm could handle it, to reduce the possibility of setbacks. With a nurturant and empathic attitude, the therapist was able to overcome the patient’s fear of reexperiencing false hopes and disappointments. The warmth and understanding of the therapist moderated Malcolm’s expectation that others would be rejecting, leading him to pull back, thereby cutting off experiences that might have proved gratifying had they been completed. It was important to decrease his anticipation of loss, which may have prompted him into a self-fulfilling prophecy. Without focused attention, he may have defeated the chance to experience events that could promote change and growth. It was this pattern that a cognitive reorientation treatment approach successfully interrupted.

Case 3.3, Ariane A., 45 A Shy/Avoidant Personality: Phobic Type (Avoidant with Dependent Traits) Presenting Picture Ariane was constantly frustrated by the plethora of little things that got in the way of her achieving goals or pursuing happiness. By little things, she was referring to unknown entities surrounding her, ranging from a frayed seat in a taxi to the multitude of strangers she dodged while walking down the street. It seemed as though anyone or anything that might take her by surprise or be construed as unusual was a source of discomfort and a reason to refrain from either a planned activity or a necessary function. Getting to the therapist’s office, of course, was no exception, given the ride on the “dirty subway.” However, with much effort, Ariane arrived. She complained that this had always been the case, but it had become much worse in the past 10 years or so. It had effectively permeated almost every facet of her life, making it impossible for her to accomplish anything from the simplest task

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114 PERSONALIZED THERAPY FOR THE SHY/AVOIDANT PERSONALITY PATTERNS to the things she really wanted. Most notably, it prevented her from approaching a love interest for nearly 2 years. When she finally found the courage to approach him, not only was it 1 month prior to her moving away, but she found herself creating and finding aspects of this man that would force her into a repetitive attraction– repulsion pattern. She was continuously caught between admiring and respecting him, and finding small imperfections that would cause severe discomfort for her in the relationship. Clinical Assessment Phobic syndromes are seen among many and diverse personality types, and different personalities will manifest such symptomatology in vastly different ways, from agitation to panic, and for vastly different reasons, from traumatic reaction to object substitution. Ariane, a phobic avoidant, rarely achieved freedom from her state of generalized anxiety. Seeking to limit the many sources of her anguish, she was disposed to finding highly specific phobic precipitants that, though fewer in number, almost invariably overwhelmed her defenses and undid her psychic controls. When faced with the phobic object, Ariane also experienced a feeling of powerlessness against forces that seemed to surge from within herself, an intense and panicky feeling of terror and disorganization. This distress continued to mount as she became self-consciously aware of her growing tensions and her inability to surmount them. Phobic avoidants are usually a mixture of dependent and avoidant personalities. Both personality types are very desirous of close personal relationships, but shy/avoidants fear or do not trust others. Dependents are not only desirous of intimate relationships, but need them and dread their loss. When facing the possibility of such loss, the anxieties of dependents become intense, even overwhelming, mirroring the everyday state in which avoidants live. Mixed avoidant/dependents such as Ariane hesitate to exhibit these fears, lest they precipitate that which they dread. Instead of feeling trapped between desire and loss, she turned her attentions to finding a symbolic substitute, some object or event onto which she could displace and funnel her anxieties. These phobic objects enabled her to redirect and discharge her fears while neither being conscious of them nor having to deal with them forthrightly. Moreover, by maintaining a distance from her trivial phobic replacement, she could tolerate the loss of the symbol that served as a substitute for what she desperately wished to keep. In this way, she blocked from conscious awareness the deeper and hidden intrapsychic reason for her anxiety. Though this mechanism works for many others, it was only partially successful for Ariane. The objects or events to which she displaced had a clear symbolic significance. Whereas externalization enables most patients to cope with the experience of anxiety, Ariane did so with limited success in that the symbolic object often directly represented the more pervasive sources of her anxiety. Thus, she was especially prone to experience social phobias, a fear of being exposed and humiliated

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in public settings. As we know, the primary source of shy/avoidants’ anxieties is their anticipation and fear of personal rejection and humiliation. Dreading this social humiliation, she frequently searched out tangential and innocuous external objects to keep her phobias hidden and personal. Nevertheless, there may have been much to be gained by fearing something explicit and defined. Although she desired to shroud her phobia in a measure of secrecy, lest she be further humiliated, where possible she might also have attempted to use her distress to gain a degree of protection and security among those who are partially supportive. In this way, Ariane may have successfully distanced herself from anxiety-producing situations, while also having a degree of forbearance from others. She needed to be able to examine her considerable fears of social humiliation and distrust in others versus her strong need for love and attention, but she had built a protective wall against facing these difficulties. Creation of an empathic environment in therapy needed to precede any further techniques, but it would not be enough for lasting change. As trust developed, Ariane’s perpetuations (fearful actions and emotional hypersensitivity) could be challenged, while instrumental methods could work toward creating a feeling of autonomy and competence (balancing self–other difficulties, as well as the conflicting passive–active polarities). Continued work in enhancement modalities would form the basis for an improved pleasure orientation, while moderating the tendency to constantly be watchful and fearful of rejection and detraction. Domain Analysis Despite social trepidation, Ariane was most agreeable in personality assessment, with unremarkable modifying indices or other measures of test response style. Highlights of her domain analysis revealed the following: Expressively Fretful: Although she tried to hide her trepidation in her expressive behavior, Ariane displayed timorous, restive, and disquieted behaviors much of the time, never seeming to relax her sympathetic arousal and generally overreacting to even innocuous stimuli. Interpersonally Submissive/Aversive: Ariane’s trepidation extended fully to her interpersonal behavior, wherein she evidenced conflicting motives of seeking a dependent and subservient role with significant figures in her life, and pulling away and sheltering from all others for fear of being shamed or ridiculed. Vexatious Objects: Perceptions of significant figures in Ariane’s realm were uniformly troubling and conflict-ridden and lacking in healthy mechanisms to deflect external stress; this domain likely gave rise to the troubling, phobic object substitution given primacy in her presenting complaint.

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116 PERSONALIZED THERAPY FOR THE SHY/AVOIDANT PERSONALITY PATTERNS Therapeutic Course A major thrust of therapy for Ariane was enhancing her social interest and competence. She was not pushed beyond tolerable limits; rather, careful and well-reasoned cognitive methods (e.g., Beck, Meichenbaum) fostered the development of more accurate and focused styles of thinking. In addition to working toward the extinction of false beliefs about herself and the attitudes of others toward her, the therapist was alert to spheres of life in which the patient possessed positive emotional inclinations. He encouraged Ariane, through interpersonal methods and behavior skill development techniques, to undertake activities consonant with these tendencies. It was in these realms that significant progress was made at the outset of therapy. Because Ariane was very receptive to cognitive-behavioral interventions that helped her focus and gain a more measured and flexible cognitive style, a modicum of confidence was established that allowed the aforementioned behavioral/ interpersonal methods to begin modulating her fretful actions with more confidence and mastery, as well as begin to tease out the conflicting interpersonal impulses of attraction–repulsion (played out in the domains of submission–aversion). Gaining confidence, she not only reduced her fears of significant others, but felt less of a need to play a subservient role in interactions. Although the success of short-term methods may have justified an optimistic outlook, Ariane’s initial receptivity could have created the misleading perception that further advances and progress would be rapid. Care was taken to prevent early treatment success from precipitating a resurfacing of her established ambivalence between wanting social acceptance and fearing that she was placing herself in a vulnerable position. Enabling her to give up her longstanding expectations of disappointment required booster sessions following initial, short-term successes. A supportive approach was then provided to ease her fears, particularly her feeling that her efforts may not have been sustainable and would inevitably result in social disapproval again. This was counterpoised with a dynamic group modality, which was useful in encouraging and facilitating her acquisition of constructive social attitudes. In this benign but exploratory setting, she not only further altered her social image and developed motivations and skills for a more effective interpersonal style, but also began to gain insight into the root of her vexatious objects. Throughout treatment, energy was invested in enlarging Ariane’s social world, owing to her tendencies to pursue with diligence only those activities required by her job or by her family obligations. By shrinking her interpersonal milieu, she precluded exposure to new experience. Of course, this was her preference, but such behavior only fostered her isolated and withdrawn existence. To prevent such backsliding and a relapse, the therapist ensured the continuation of all constructive social activities as well as potential new ones. Otherwise, she may have become increasingly lost in asocial and fantasy preoccupations. Excessive social pressure,

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however, was avoided because Ariane’s tolerance and competencies in this area were rather limited. Initial brief, focused treatment techniques aided her in developing more skills in this area.

Case 3.4, Marialena P., 26 A Shy/Avoidant Personality: Self-Deserting Type (Avoidant with Depressive Traits) Presenting Picture Marialena was a community librarian, a woman so painfully shy that her supervisor took her aside one day and persuaded her to seek counseling. Though most of her duties revolved around stocking books rather than patron assistance, her position was in jeopardy owing to reticence and a habit of mumbling in response to what few patron information requests she did receive. In session, the therapist inquired as to what sorts of activities she enjoyed, to which she responded, “I used to like cafes and people watching, but I’m just so self-conscious now I don’t go anymore.” Marialena explained that she would like to be able to talk to and relate better to others, but she was petrified to make such a connection, and initiating a conversation in the library was beyond hope for her. The people in such public places were going about their “fulfilling” lives, and Marialena couldn’t keep up. She used to imagine what these fulfilling lives must be like, as it was easier to daydream about such things than to pursue such an end. She also disclosed, in an early session, that she worked for an elementary school library until recently, but found that she “couldn’t escape” in such a setting. She not only felt intruded on by the children’s inquisitive nature, but couldn’t “escape herself” in such a setting. Initial Impressions As with other personalities of this type, Marialena, a self-deserting avoidant, drew more and more into herself as a means of avoiding the discomforts of relating to others. In so doing, she found herself increasingly aware of the psychic contents of her inner world. Whereas she may have used fantasy initially to make her life more bearable, fantasies often brought no surcease. She began to recognize that turning inward only centered her thoughts on the misery of her life and the pain and anguish of past experiences. Yet, owing to a perceived lack of options, she continued in this manner. Although spared the difficulties of public exposure and personal humiliation, she had not been successful in avoiding her inner sorrows and torment. There were moments, of course, when her fantasies provided her with fulfilling images and longings, but these became fewer and fewer over time. Increasingly confused about

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118 PERSONALIZED THERAPY FOR THE SHY/AVOIDANT PERSONALITY PATTERNS where to turn, Marialena felt like a melancholy outsider, not only lacking in intimate and warm relationships, but also feeling like a person of minimal value to herself. What we see in this process is the merging of shy/avoidant and depressive personality features, an amalgamation of social aversion and self-devaluation, and a conflict of whether to continue protectively withdrawing (active orientation) or simply giving in to what she saw as the painfully inevitable. Although she had created a protective barrier from her real world, the inner world into which she had withdrawn proved to be no less problematic and disparaging. Totally interiorized, she could no longer escape from what made her draw into herself in the first place. Subject to her own inescapable fantasies, Marialena’s anguish mounted increasingly. More and more she could not tolerate herself, and more and more she sought to undo her own self-conscious awareness. Seeking to ensure that nothing would get to her, Marialena not only distanced from the outer world, but increasingly blocked awareness from her own thoughts and feelings. She had now become self-abandoning, increasingly neglectful of her very being, jettisoning both her psychic and physical well-being, perhaps becoming increasingly incompetent, exerting herself minimally, and ultimately failing to fulfill even the barest acts of self-care. Some self-deserting avoidants are plunged into despair and driven to suicide, deserting their own self in order to jettison the anguish and horror within. Others, like Marialena, regress into a state of affectlessness, an emotional numbness in which they become completely disconnected from themselves. This disconnection and self-desertion grew into a habitual way of life, a way of remaining in flight from both her outer and inner realities. Marialena needed to be reassured that by engaging in a therapeutic relationship, she would enter a secure and nurturing milieu, as her significantly diminished image of self, as well as her uneasy posture with others, made trust and confidence dubious constructs at best. As the objectives of therapy became tangible and less abstract, work would center on diminishing Marialena’s anticipation of pain, eventually leading to an augmentation of pleasure in later stages. It would also be necessary, from the very early stages of treatment, to undo her perpetuating tendency to hold the environment zealously at arm’s length due to her constitutional hypersensitivity to disparagement, and in the next moment to simply give up to a depleted set of defenses (a conflicting active–passive tendency). Domain Analysis The following domains were found to be most salient on Marialena’s MCMI-III Grossman Facet Scales, which were largely corroborated on the MG-PDC: Fantasy Mechanism: Wanting to escape the real world and all of its troubling stimuli, Marialena relied, for many years, on self-gratification wrought from fantastical images and projections of herself as a more competent and savvy woman of the world; lately, however, these fantasies had begun to fail, leaving her without a usual and customary defense.

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Alienated/Worthless Self-Image: Marialena always saw herself as socially inept, unappealing, and ostracized; in more recent days she had begun to conceptualize herself as lacking value altogether and found herself apologizing and guilt-ridden for her existence. Cognitively Fatalistic: Beyond a sense of pessimism, Marialena was now pronouncing thoughts in their blackest forms, looking at the future with a sense that nothing could possibly improve for the better; she was also thoroughly preoccupied with her plight in this fatalistic scheme, but giving in to the thought that she had no choice but to accept. Therapeutic Steps A first goal in therapy with Marialena was to demonstrate that the potential gains of therapy were real and that they should motivate her rather than serve as a deterrent. She feared that therapy would reawaken what she viewed as false hopes; that is, it reminded her of the humiliation she experienced when she offered her trust to others but received rejection in return. As the therapist nondirectively acknowledged these fears, Marialena was gradually able to find a modest level of comfort without having to distance herself from the therapist, and she learned to deal more effectively with her fears while maintaining a better level of adjustment than in the past. This humanistic approach introduced the idea that not all hope need be lost (addressing her cognitive fatalism) and helped her gain greater receptivity to cognitive-behavioral approaches where attention would be usefully directed toward this subject, along with her social hesitation, anxious demeanor, and self-deprecating actions, attitudes, and behaviors. She learned that these could be altered so as not to evoke the humiliation and derogation they had in the past. Cognitive efforts to reframe the basis of her sensitivity to rebuff or her fearful and unassertive behavior (e.g., Beck, Ellis) minimized and diminished not only her aversive and pessimistic inclinations but her tendency to relapse and regress. More probing, yet still circumscribed treatment procedures were useful in unearthing the roots of Marialena’s anxieties and confronting those alienating and devaluing self-perceptions that pervaded many aspects of her behavior. Family techniques were employed as well to moderate destructive patterns of communication that contributed to or intensified her self-image problems. Interpersonal techniques (e.g., Benjamin) assisted her in learning new self-attitudes and competence skills in a more benign and accepting social setting than she normally encountered. Throughout, a warm and empathic attitude was necessary because Marialena was likely to fear facing her feelings of unworthiness and because she sensed that her coping defenses were weak. The clinician drew on Marialena’s strengths (e.g., her creativity, originally used to create fantasy preoccupations as a coping mechanism) to prevent her from withdrawing from treatment before any real gains were made. Brief dynamic insight-oriented procedures along with an existential

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120 PERSONALIZED THERAPY FOR THE SHY/AVOIDANT PERSONALITY PATTERNS framework were used to explore the contradictions in her feelings and attitudes and to lift her previous fantasy preoccupations (e.g., self-view as a competent person) to the level of reality. Without proper reframing, there may have been a seesaw struggle, with periods of temporary progress followed by retrogression. Genuine short-term gains were possible, but only with careful work, a building of trust, and enhancement of Marialena’s sense of self-worth. Another realm worthy of brief intervention was associated with Marialena’s extensive scanning of the environment. By doing this, she increased the likelihood that she would encounter those stimuli she wished to avoid. Her exquisite antennae picked up and transformed what most people overlooked. Again, using appropriate cognitive methods, Marialena’s hypersensitivity was prevented from backfiring, that is, becoming an instrument that constantly brought to awareness the very pain she wished to escape. Reorienting her focus and her negative interpretive habits to ones that were more ego-enhancing and optimistic in character reduced her selfdemeaning outlook, intensified her positive experiences, and diminished her anguish.

Resistances and Risks Because of their basic mistrust of others, shy/avoidants are unlikely to be motivated either to seek or to sustain a therapeutic relationship. Should they agree to treatment, it is probable that they will engage in maneuvers to test the sincerity and genuineness of the therapist’s feelings and motives. Most often, they will terminate treatment long before remedial improvement has occurred. This tendency to withdraw from therapy stems not only from their doubts and suspicions regarding the therapist’s integrity, and their fear of social rejection and disapproval by the therapist, but also from their unwillingness to face the humiliation and anguish involved in confronting painful memories and feelings. They sense intuitively that their defenses are weak and tenuous and that to face directly their feeling of unworthiness, much less their repressed frustrations and impulses, will simply overwhelm them, driving them into unbearable anxieties and even to (as they fear) “insanity.” To add to these fears, the potential gains of therapy may not only fail to motivate the avoidant but may actually serve as a deterrent, reawakening what these personalities view as “false hopes,” reminding them of the dangers and humiliations they experienced when they tendered their affections to others but received rejection in return. Having found a modest level of comfort by detaching themselves from others, they would rather let matters stand, keep to the level of adjustment to which they are accustomed, and not rock the boat they have so tenuously learned to sail. When a shy/avoidant enters a therapeutic relationship, the therapist must take great pains not to push matters too hard or too fast. Among other things, the patient may feel he or she has but a fragile hold on reality. The therapist should seek, gently

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and carefully, to build a sense of genuine trust. Gradually, attention may be turned to the patient’s positive attributes, addressing these as a means of building confidence and enhancing feelings of self-worth. Therapy is likely to be a slow and arduous process, requiring the reworking of long-standing anxieties and resentments, bringing to consciousness the deep roots of mistrust, and, in time, enabling the patient to reappraise these feelings more objectively. On the other hand, astute therapists also have to take care that their warm empathic behavior does not result in the patient’s regarding the therapeutic relationship as so satisfying that it becomes an end in itself rather than a base for learning and venturing into other relationships. Therapists must also keep in mind throughout the therapeutic process that the patient’s intellectual understanding of problems is not enough to solve them; behavioral progress must not be neglected (Benjamin, 1993).

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Personalized Therapy for the Pessimistic/ Depressive Personality Patterns

T

he elucidation of the comorbidity of personality traits/disorders and mood disorders is of both theoretical and clinical importance. Major depression is among the most common reasons for seeking psychiatric help and hospitalization in the general population. Clarification of the interrelationship between personality and depressive symptomatology can have important implications in psychotherapeutic and psychopharmacologic interventions. An increased understanding of this relationship can also help clarify the heterogeneous nature of depressive illness and better delineate the ways these syndromes and personality disorders interact and modify each other (Klein, Shankman, & Rose, 2006; Laptook, Klein, & Dougherty, 2006). The construct of a depressive personality disorder was extensively discussed in the DSM-IV Personality Work Group. It was concluded that the depressive personality be included as an enduring type of psychological disorder that evinces a relatively early onset, demonstrates a fairly stable and long-term course, and exhibits its many clinical features across diverse situations over time (Kendler, Gardner, & Prescott, 2006; Melartin et al., 2004). In prior DSM editions, the notion of a personality variant of depressive character was conceptualized in part by the introduction of a construct termed Dysthymic Disorder (previously, the depressive neurosis). However, it was soon recognized that the dysthymic construct was rather heterogeneous, necessitating differentiations into primary and secondary, as well as early- and late-onset subtypes (Vuorilehto, Melartin, & Isometsa, 2005). Furthermore, the criteria employed for dysthymia emphasized mood symptomatology rather than a diverse set of personality traits (Stanghellini, Bertelli, & Raballo, 2006). Moreover, the symptoms elaborated in the dysthymic category were

123

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largely of a somatic or vegetative character, rather than cognitive or interpersonal in nature (Ryder, Schuller, & Bagby, 2006). The desire was expressed that a depressively centered disorder be introduced whose symptoms were less severe, more social in character, and more prolonged, if not lifelong, as compared to those encompassed in the dysthymic diagnosis (Christensen & Kessing, 2006; Francis-Raniere, Alloy, & Abramson, 2006; Huprich, 2005; Markowitz, Skodol, et al., 2005). The introduction of the self-defeating/masochistic disorder was provisionally made in part in DSM-III-R to achieve these goals. Not only has the self-defeating/masochistic personality disorder been dropped from the most recent manual, a decision not shared by the senior author of this book, but the pessimistic/depressive symptomatology it encompassed required that its features be intentionally provoked by others in response to the individual’s desire to elicit punitively rejecting responses (Huprich, Porcerelli, Binienda, & Karana, 2005). Because of this focus, as well as other reasons, it was decided that criteria be introduced, albeit provisionally, to represent a “purer” or prototypal variant of a depressive personality disorder (H. S. Akiskal et al., 2006). It is to elaborate this disorder that we have chosen to include the pessimistic/depressive prototype in the present book, an inclusion the senior author has argued is consistent with theory, clinical observation, and an extensive literature over the past many centuries (Millon, 2004). Millon (1996b) has outlined some of the key features of the disorder in terms of his polarity schema. The clinical derivations of this formulation provide a major foundation for this chapter. Figure 4.1. portrays the polarity model; the text of this chapter is based on the elements of the disorder in terms of its clinical domains, predisposing background, and therapeutic interventions. A brief summary of the clinical characteristics of the disorder is offered next, following which the features of the polarity model are discussed. Characteristics include glumness, pessimism, lack of joy, the inability to experience pleasure, and motoric retardation. There has been a significant loss, a sense of giving up, and a loss of hope that joy can be retrieved. Notable is an orientation to pain, despair regarding the future, a disheartening and woebegone outlook, an irreparable and irretrievable state of affairs in which what might have been is no longer possible. This personality experiences pain as permanent with pleasure no longer considered possible. What experiences or chemistry can account for such persistent or pervasive sadness? Clearly, there are biological dispositions to take into account. The evidence favoring a constitutional predisposition is strong, much of it favoring genetic factors. The thresholds involved in permitting pleasure or sensitizing one to sadness vary appreciably. Some individuals are inclined to pessimism and a disheartened outlook. Similarly, experience can condition a hopeless orientation. A significant loss, a disconsolate family, a barren environment, and hopeless prospects can all shape the depressive character style. (Millon, p. 11)

If we review the theoretically generated polarity model, as illustrated in Figure 4.1, we should note a strong representation in both the preservation polar extreme and

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DEPRESSIVE PROTOTYPE

Enhancement

Preservation

(Pleasure)

(Pain)

Accomodation

Modification

(Passive)

(Active)

Individuation

Nurturance

(Self)

(Other)

Weak on Polarity Dimension Average on Polarity Dimension Strong on Polarity Dimension

FIGURE 4.1 Status of the pessimistic/depressive personality prototype in accord with the Millon polarity model.

the accommodating adaptational style (K. K. Akiskal & Akiskal, 2005). This signifies an overconcern with pain and anguish. Secondarily, these elements indicate that the person has “given up,” essentially succumbing to what is judged to be the inevitability of continuing suffering and misery. Despite important similarities, this pessimistic/ depressive pattern contrasts in significant ways from the schema representing the avoidant personality (Huprich, 2005; Huprich et al., 2005). In both personality disorders there is a centering on preservation and pain reduction; similarly, in both disorders there is an inattention to the pleasures and gratifications that enhance life. The core distinction is that the avoidant actively seeks to minimize pain by anticipating its eventuality and taking steps to distance from or avoid that possibility. By contrast, the pessimistic/depressive no longer attempts to avoid the anguish and despair of life.

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DEPRESSIVE PROTOTYPE

Forsaken

Object Representations

Depleted

Morphologic Organization

Pessimistic

Melancholic Mood/Temperament

Cognitive Style

Asceticism

Disconsolate

Regulatory Mechanism

Expressive Behavior

Worthless

Self-Image

Defenseless Interpersonal Conduct

FIGURE 4.2 Salience of prototypal pessimistic/depressive domains.

Rather, he or she has accepted it as if it were inevitable and insurmountable. These individuals remain passive, resigned to the distressing realities that they have suffered, no longer seeking to deny pain, but surrendering to it.

Clinical Picture There are several aspects of the pessimistic/depressive personality that can be usefully differentiated for preliminary diagnostic purposes. The first phase of this assessment process attempts to delineate eight prototypal domains in which the clinical features of the depressive can be separately analyzed and described (see Figure 4.2). As in all of the chapters of this text, we have sorted the various components of each disordered personality’s traits and characteristics into eight domains, beginning with those that manifest themselves in the overt behavior of the individual and ending with those that are essentially hidden from observation but may be discerned inferentially and measured biologically (see Table 4.1).

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Table 4.1

127

Clinical Domains of the Pessimistic/Depressive Personality Prototype

Behavioral Level: (F) Expressively Disconsolate (e.g., appearance and posture convey an unrelievedly forlorn, somber, heavy-hearted, woebegone, if not grief-stricken quality; irremediably dispirited and discouraged, portraying a sense of permanent hopelessness and wretchedness). (F) Interpersonally Defenseless (e.g., owing to feeling vulnerable, assailable, and unshielded, will beseech others to be nurturant and protective; fearing abandonment and desertion, will not only act in an endangered manner, but seek, if not demand, assurances of affection, steadfastness, and devotion). Phenomenological Level: (F) Cognitively Pessimistic (e.g., possesses defeatist and fatalistic attitudes about almost all matters; sees things in their blackest form and invariably expects the worst; feeling weighed down, discouraged, and bleak, gives the gloomiest interpretation of current events, despairing as well that things will never improve in the future). (S) Worthless Self-Image (e.g., judges self of no account, valueless to self or others, inadequate and unsuccessful in all aspirations; barren, sterile, impotent; sees self as inconsequential and reproachable, if not contemptible, a person who should be criticized and derogated, as well as feeling guilty for possessing no praiseworthy traits or achievements). (S) Forsaken Objects (e.g., internalized representations of the past appear jettisoned, as if life’s early experiences have been depleted or devitalized, either drained of their richness and joyful elements or withdrawn from memory; feels abandoned, bereft, and discarded, cast off, and deserted). Intrapsychic Level: (F) Asceticism Mechanism (e.g., engages in acts of self-denial, self-punishment, and self-tormenting, believing that one should exhibit penance and be deprived of life’s bounties; not only is there a repudiation of pleasures, but there are harsh self-judgments, as well as self-destructive acts). (S) Depleted Organization (e.g., the scaffold for morphologic structures is markedly weakened, with coping methods enervated and defensive strategies impoverished, emptied and devoid of their vigor and focus, resulting in a diminished, if not exhausted, capacity to initiate action and regulate affect, impulse, and conflict). Biophysical Level: (S) Melancholic Mood (e.g., is typically woeful, gloomy, tearful, joyless, and morose; characteristically worrisome and brooding; the low spirits and dysphoric state rarely remit). Note: F = Functional Domains; S = Structural Domains.

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Disconsolate Expressive Behavior It is difficult not to recognize the disconsolate nature of pessimistic/depressives’ appearance. Their posture conveys a deeply forlorn and heavy-hearted quality. Their speech is somber, woebegone, if not grief-stricken in expression. Their tone of voice seems irremediably dispirited and discouraged, and they portray a visual image of unresolvable hopelessness and wretchedness. It can be said unquestionably that the depressive shows little initiative or spontaneity. Although answering questions posed in the interview process, pessimistic/depressives tend not to offer information on their own; moreover, what they do say has little variety. For the most part, speech is halting and uncertain. There is a slow, draggy element to all aspects of the depressed expressive behavior. Responses and movements take a long time, and even among those who are inclined to be agitated and irritable, there is a marked reduction in purposeful or intentional behaviors. Much of their activity appears to take place in slow motion. Defenseless Interpersonal Conduct Depressive personalities evince a constant state of feeling vulnerable, assailable, and unprotected. They act as if they were defenseless and unshielded, and hence beseech others to be protective and nurturant. Always fearing abandonment and desertion, their interpersonal behaviors are either one of two basic varieties: that of an unprotected and inadequate individual who passively withdraws from others, or that of a needy and demanding person who seeks others to provide assurances of affection and steadfastness. First and foremost, the moods and complaints of pessimistic/depressives are designed to summon nurturant responses from others (Benazzi & Akiskal, 2005). They recruit from both family and friends reassurances of their lovability and value and seek to gain assurances of others’ faithfulness and devotion to them. As with many other personality styles and disorders, the depressive’s symptoms may serve as an instrument for avoiding unwelcome responsibilities. This is especially effective with these personalities because they openly admit their worthlessness and are able to demonstrate their general sense of helplessness for all to see. In this regard, their impairment serves also as a rationalization for their indecisiveness and their failures. Their complaints may be colored with subtle accusations, claims that others have not been sufficiently supportive of them, thus fostering their sense of futility and hopelessness. Overt expressions of hostility, however, are rarely exhibited because they fear that such actions will prove offensive and lead others to rebuke or reject them. As a result, anger and resentment are discharged only in subtle or oblique forms, often by overplaying their helplessness and ineffectuality. This not only creates guilt in others, but causes others no end of discomfort as they attempt to meet these patients’ seemingly justified need for care and nurturance. Pessimistic/depressives crave the love and support of others but fail to reciprocate in ways that either gratify others or reinforce a positive relationship. The depressive’s clinging behaviors, self-preoccupation, and devious coping maneuvers may

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ultimately evoke annoyance and exasperation from others. Under these circumstances, pessimistic/depressives may be persistent in soliciting the sympathy they desperately need. Failing in this regard, they may turn inward into bitter silence and guilty selfreproach. Protestations of guilt and self-condemnation may not only come to the fore, but may be unrelieved and pervasive. Pessimistic Cognitive Style Pessimistic/depressives see life in its blackest form and invariably expect that the worst will happen (Bos et al., 2005). They give the gloomiest of interpretations about events, despairing that things will never improve in the future. They feel weighted down, discouraged, and bleak, possessing a pessimistic, defeatist, and fatalistic attitude about almost all matters. Worse, depressives seem totally preoccupied with themselves and their plight, obsessively worrying about their misfortunes, both past and present (Grilo et al., 2005). Not only are pessimistic/depressives filled with remorse for their felt inadequacies, but they occasionally imagine fantasized resolutions to their difficulties that involve some magical event or omnipotent force. At heart, however, they have little hope that any solution can ever be found. Their communications with others are stereotypical and gray. Efforts may be made to fight back depressive feelings and thoughts by consciously diverting ideas and preoccupations away from their depressive moods. For the most part, these new ruminations are replaced by equally troublesome ones. There is a tendency to reactivate and then to brood over minor incidents of the past. Thoughts and feelings that are not part of the pessimistic/depressive’s preoccupations are as clinically significant as are those that are. Retrospective falsification is not uncommon; few of the pleasures of the past are remembered, as only those of a painful and distressing nature are poignantly summoned. Similarly, new events are burdened retroactively, and future possibilities are prefigurations of an inevitable catastrophe. Depressives believe that their present state is irreversible. Troublesome events today look presciently relevant to the future. Any attitude other than pessimism or gloom is merely illusory. In what has been termed the “helplessness-hopelessness” outlook, these patients assume that they are unable to help themselves and are unlikely to be helped by outside forces either (Engel, 1968). Most personalities can endure an astounding degree of misfortune, as long as they believe that there is hope for them. In pessimistic/depressives, the pessimistic schemas that repeatedly shape their thoughts generate increasing levels of hopelessness, such that they are unable to imagine or plan conditions that could make things better. For the depressive, life seems to create an ever deeper well of hopelessness, a wrenching fact of existence. Worthless Self-Image Dependents tend to feel guilty for possessing no praiseworthy traits or achievements. They regard themselves as valueless to self and others, inadequate and unsuccessful in all aspirations of a meaningful life (Skodol, Gunderson, et al., 2005). Not only do they

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view themselves as sterile, impotent, and of no consequential value, but they judge themselves as reproachable, if not contemptible, as a person who should be criticized and derogated. Almost any minor failure can plunge moderately unhappy pessimistic/depressives into a more severe state of disconsolation; such an event only proves further their state of unworthiness. Similarly, a rather harmless critical remark may set into motion obsessive worrying and brooding, further intensifying their sense of worthlessness. Even when matters are going well, there remains a deep sense of personal inadequacy, a feeling of being deficient in a host of attractive qualities, such as being popular, intelligent, and physically appealing. Should an adverse event occur, depressives will attribute its cause to some deficiency within themselves, thereby criticizing themselves for possessing the alleged defect. When difficulties become increasingly problematic, pessimistic/depressives are prone to blame themselves for circumstances that have no connection to them. They believe that they are incapable of taking the initiative and making decisions, reflecting their fear that they will make the wrong move or display their inadequacies for others to see. Many depressive personalities reach so deep a level of self-denigration that they begin to take pity on themselves. When feelings of hopelessness and self-sympathy reach so low a state, there is a possibility that constructive outcomes may follow. In certain cases, pessimistic/depressives may feel that they have paid the price by sinking to the bottom of life, and that they can go no deeper into their depression than they have. Now may be a time for renewal, for an inner salvation that may be worth pursuing. On the other hand, it is at these times also that a formidable danger of self-destructiveness may take hold. Forsaken Object Relations We use the term “object relations” to represent a series of silent, inner assumptions about the character of significant others, as well as life in general. It relates to unconscious premises that give shape to how the individual interprets the transient events of everyday life. It comprises distinctly personal expectations and assumptions that are used to selectively interpret and integrate significant experiences, and contains unarticulated rules and dispositional inferences that serve to accurately interpret observations, as well as to repetitively and erroneously distort them. In the phenomenologically oriented world of cognitive modes that are referred to with terms such as “schemas,” these dispositional sets relate to how events are screened, differentiated, and interpreted, largely in a conscious manner. But there is an unconscious matrix of schemas as well that refers to significant intrapsychic structures that also selectively categorize and evaluate experiences, but do so beneath the level of awareness. It is these latter schemas that we refer to when we speak of “object representations,” an unconscious tendency to mold perceptions and cognitions in line with inner templates that were given shape and character early in life. These templates may remain inactive for periods of time, but become energized and prominent when

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stimulated by relevant reality experiences. Activated, they transform what is actually happening in reality so as to make it fit the unconscious template of expectancy and assumption. In the depressed, this template saturates ongoing experiences and thoughts with a pessimistic and negativistic tone. In effect, the content of the depressive’s inner world appears to be devitalized, jettisoned, or depleted. It appears overtly drained of its richness or joyful elements. What good things happened in the past, what happy memories and fulfillments may have been experienced, appear to have been withdrawn from memory, leaving the pessimistic/depressive forsaken to face the terrible complexities of life, abandoned and bereft, perhaps discarded and cast off. These forsaken objects become the locus and metaphor of loss for many. Asceticism Regulatory Mechanism The dynamic processes of the intrapsychic world of the depressive have as their primary goal the fulfillment of a belief that one should experience penance and be deprived of life’s bounties. Through the ascetic mechanism, pessimistic/depressives maneuver their inner world to achieve self-denial, self-punishment, and self-tormenting. Not only is there a diminution or repudiation of pleasurable memories, but those that persist are transformed into their opposite through harsh self-appraisals and, if need be, self-destructive acts. With so punitive an attitude toward the self, depressives allow themselves minimal pleasure, if any, and constantly appraise their own actions to determine whether they have attained more joy and satisfaction than they deserve. Driven by the feeling that they deserve less rather than more, they may be “forced” to give up totally on themselves and abdicate from life altogether. In a sense, they have adopted a mechanism of playing dead as a means of remaining alive. Self-abdication and total resignation from life have become intrapsychic maneuvers to permit them to avoid total annihilation by suicide, an act of self-jettisoning that lies but a moment ahead. Depleted Morphologic Organization The overall scaffold for the intrapsychic structures of the pessimistic/depressive appears markedly weakened, unable to withstand much stress without decompensating. Coping methods are enervated and dynamic strategies seem impoverished. Those forces that maintain psychic cohesion appear to have been emptied or devoid of focus and vigor. As a consequence, the depressive shows a diminished, if not exhausted, capacity to initiate overt action or to regulate internal affects, impulses, and conflicts. To protect against these feelings of inner ineffectuality, pessimistic/depressives struggle intrapsychically to keep their distressing feelings at as low a level as possible, to keep them out of awareness and to ignore both their origins and their current realities. By structuring their inner world in this manner, they can minimize the experience of psychic pain. Moreover, they may succeed in isolating their affect to such an extent that they manifest only the overt appearance and complaints of depression, without

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experiencing its emotional undertone. In a rather circuitous manner, it is at these times that we often find the patient inclined to self-destruction and suicide. Drained of feeling and life, these depressives may conclude that there is little meaning to life and that they can no longer control and direct it. Perhaps it is only when they act to kill themselves that they can regain the feeling of competence and autonomy. The occasionally observed phenomenon of improved mood just prior to suicide is related to this defensive maneuver. Should the preceding sentence be erroneously interpreted, let us note that suicide more commonly occurs when these patients seek to escape from painful or humiliating life circumstances. Melancholic Mood Pessimistic/depressives are characteristically gloomy, morose, and tearful. Brooding and feeling inescapably worried, with low spirits and a woeful and joyless mood, their pervasive dysphoric state may persist at a moderate level in severity, remitting only on rare occasions (Bos, et al., 2005). Their self-denigration and habitual gloom are so deeply ingrained that these have become intrinsic parts of their personality structure. Although certain subtypes may emphasize one or another aspect of the depressive constellation of symptoms—sad feelings, anguish, irritability, guilt, emptiness, longing—it is clear that these patients have a diminished interest in life, few appetites for joy and closeness, and although they go through the motions of relating, eating, sexualizing, even playing, they do so with but little enthusiasm. Their temperamentally based inertia and sadness may undermine whatever capacity they may have to smile and enjoy the humor and pleasures of life (H. S. Akiskal, 2005). Further reinforcing the belief that there are physiological underpinnings to this temperamental disposition is the variety of vegetative functions they display, even lowered metabolic rates and slowed gastrointestinal functions (Chiaroni, Hantouche, Gouvernet, Azorin, & Akiskal, 2005). Most commonly, complaints include difficulty sleeping and early morning awakening, fatigue, diminished libido and appetite, and various bodily aches and pains. For some, the dysregulation of the hormonal substrates of mood are such that they may, for brief periods of time, become euphoric and socially driven, almost to the point of crossing the threshold to hypomania. More commonly, however, we are likely to observe a more persistent dysthymic or melancholic temperament.

Self-Perpetuation Processes It must be said again that chronic depressive moods often reflect the persistence of internal mood dysregulations, continuing states of unhappiness and sadness that are driven primarily by long-term neurobiologic defects and deficiencies. Not that biological forces can display themselves manifestly without being interwoven with psychological influences, but when biogenic dysfunctions are markedly persistent and penetrant, psychological factors will play a lesser role than otherwise. Given our current state of

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Table 4.2

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Self-Perpetuating Processes: Pessimistic/Depressive Personality

Re-creation of Suffering Discontents become irrevocable unhappiness Anguish drives support away Self-narcotized into total emptiness Self-Accusation Invalidates self-worth Retroflected rage intensifies buried resentments Expiatory self-punishments lead to suicide Reinforces Hopeless Feelings Hopelessness leads to persistent failure Precludes efforts to make things better Loss of hope leads to loss of self

knowledge, we are unable at this time to differentiate conditions that have stronger or lesser biologic components (see Table 4.2). Re-creating Experiences of Suffering Pessimistic and self-devaluing schemata influence how information and relationships are processed by pessimistic/depressive individuals. Retrospective recall and future anticipations are all colored by cognitive distortions and expectancies that further reinforce their unhappy state. As noted previously, depression often recruits support and nurturance; it deflects criticism and condemnation and serves as a means of distancing from others and avoiding responsibilities about which one feels ambivalent or negative. As with the masochist, many depressives want to suffer, perhaps to suffer more than is warranted by the instrumental goals they seek to achieve. How perverse a strategy this can be. Pessimistic/depressives exaggerate their misery and submerge themselves in feelings of helplessness, unhappiness, and unworthiness. One cannot help but be struck by the fact that these self-inflicted wounds deepen the abyss of misery of these persons. Again and again, the depressive magnifies minor disadvantages and failures into signs of irrevocable humiliation. As a result of these acts of self-generated despair, pessimistic/depressives greatly impair their ability to experience a measure of life’s joy and contentment. They thereby sink into feeling helpless, needing others to care for their needs and take responsibility for their life. Although there are advantages to his disconsolation and defenselessness, these individuals have made their already problematic situation even more tormenting. In time, fewer and fewer advantages of depression are to be gained; no persons are around to be impressed,

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no more sympathy is forthcoming, and there are no triumphs in asserting one’s will. Life dwindles to a state of nothingness and loses segments of its reality. By exaggerating their claims, depressives have driven others away. Increasingly, their feelings of misery and unworthiness begin to lose a sense of reality; even the sting of depressive pain is gradually lulled and narcotized into a feeling of emptiness. Self-Accusatory Attitudes Although the overt expression of contrition and guilt may serve to deflect further condemnation by others, pessimistic/depressives further reinforces their own sense of unworthiness and despicability by these attitudes. Acts of self-accusation, by which depressives invalidate their own worth, are acts of self-derogation in which these individuals become their own worst enemy. Thus, in seeking to avoid the torment of others, pessimistic/depressives have become their own persecutor, a critical, suspicious, and clever oppressor who knows exactly what it is that they must demean within themselves to experience a measure of relief and expiation. At some level, depressives are aware that their retroflected rage is but a fac¸ade, a clever device to mislead their environmental tormentors, real or imagined. As such, they must assault themselves all the more severely, punish themselves deeply, not only as an act of contrition, as it may appear on the surface, but for their failure once again to be forthright and competent, that is, to say what they believe and to stand on their own. They have failed again to deal with their buried resentment toward their parents and their disappointment in themselves. Their conscious remorse is recognized as a mockery of the deep and lifelong roots of helplessness and unworthiness. Elements of their self-rage may be seen in their refusal to eat, their inability to engage in sex, and their general incapacity to feel any pleasure. They may be left with only one form of self-mastery and expiatory self-punishment: suicide. Reinforcing Feelings of Hopelessness The mere act of hopelessness, the ultimate product of a history of failure in eliciting care and affection, is a self-fulfilling process, an attitude that not only signifies the future persistence of failure, but alienates the person increasingly from himself or herself. Concluding that they are unable to be the active master of their fate, depressives so utterly lose faith in themselves that they give up, unwilling even to try to make matters better, to seek what is desirable; hence, they fall into a state akin to what Kierkegaard termed a “psychic death.” The vicious circle has continued; they have lost not only the hope of what could be, but of the very sense of self.

Interventional Goals Most individuals with a pessimistic/depressive personality disorder accept their chronic dysphoria and feeling of hopelessness as an inevitable life condition, and come into

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therapy only after a significant other insists that something needs to be done. Sometimes it will take a major life trauma to push them into treatment. A therapist may at first focus on the presenting symptoms and conclude that the patient is suffering from a severe bout of depression, only to later realize that the patient describes having felt this way since childhood or adolescence. The patient may consider such feelings to be justified by life circumstance or personal failings, and deny any hope of eventually feeling better; years of experience have taught depressives that even when things look relatively bright, feelings of despair lurk right around the corner. Fortunately, many individuals with a pessimistic/depressive personality disorder do respond to psychopharmacological intervention; a therapist would do well to consider antidepressants as a first inroad into alleviating the patient’s suffering. Many patients, however, who do respond to medication nonetheless continue to be skeptical about the durability of newfound improvements, having previously experienced short-lived periods of comfort. To support and consolidate gains, the therapist needs to help the patient overcome the maladaptive personality characteristics and patterns of behavior that inevitably develop as a result of the patient’s chronic depression. Although overt depressive symptomatology, including downcast mood and vegetative signs, may disappear after administration of an appropriate medication, more covert personality factors may be less affected. Interpersonal behavior, self-concept, cognitive schemas, and expectancies that have been shaped by past depressive experience need to be replaced by more adaptive variants to encourage the patient’s optimal functioning and avoid undermining affective and energy gains. Unfortunately, some patients do not respond to medication, and thus have a more challenging road to travel on the way to recovery. In these cases, the patient and therapist will have to rely directly on behavioral, cognitive, interpersonal, and/or other interventions to improve affect and increase pleasure, as well as to reconstruct the patient’s personality. A course of therapeutic intervention for a pessimistic/depressive patient should aim to accomplish several parallel yet intertwined goals. The depressive’s characteristic passivity needs to be replaced with more active interaction with the environment, and the affective and cognitive emphasis on pain needs to be shifted to a focus on pleasure. Unlike avoidants, who actively withdraw from potentially distressing situations, pessimistic/depressives have come to accept pain as unavoidable, hence their helpless immobility. Increased anticipation of pleasure could help encourage the depressive to be more proactive regarding his or her environment. Subsequent experiences with success can help alter the depressive’s pessimistic cognitive style, expectations, and melancholic mood. Cognitive interventions that directly attack the dysfunction within these domains can support the personality changes that result from new experiences with the environment, and hence ultimately help restore the patient’s lost sense of self-worth (see Table 4.3).

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136 PERSONALIZED THERAPY FOR THE PESSIMISTIC/DEPRESSIVE PERSONALITY PATTERNS Table 4.3 Therapeutic Strategies and Tactics for the Prototypal Pessimistic/ Depressive Personality Strategic Goals Balance Polarities Diminish hopelessness/pain Increase pleasure/enhancing Stimulate active/modifying Counter Perpetuations Undo pessimistic expectations Revive sense of self-worth Prompt spirited mood Tactical Modalities Utilize mood antidepressants Revive forsaken objects Promote optimistic cognitive shifts

Reestablishing Polarity Balances The hallmark of the pessimistic/depressive personality is the psychic pain and sense of hopelessness about improving the quality of his or her life. Cognitive-behavioral interventions that encourage the patient to interact in more adaptive ways with the environment can help sensitize the patient to experiences of success and pleasure, resulting in increased balance on the pain–pleasure polarity. A lessened sense of helplessness and strengthened motivation for rewarding experiences also indirectly foster more active coping strategies. These shift the patient away from the depressogenic passive end of the active–passive dimension. Countering Perpetuating Tendencies The depressive’s pessimistic expectations, lack of a sense of self-worth, and melancholic mood all serve to ensure that environmental conditions continue to reinforce his or her usual pattern of feeling, thinking, and behaving. As pessimistic/depressives appraise their future, pessimistic expectations far outweigh hopes for success and satisfaction. Rather than exert themselves in vain and open themselves up to the possibility of further crushing failures and disappointments, depressives passively resign themselves to bear the burden of their fate. Opportunities to improve their lot are received half-heartedly, further entrenching their hopelessness and self-reproach. Experiences of success are not likely under such circumstances. Their low self-esteem and self-inflicted lack of success suggest that even if there

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was a road out of this empty, cold world, depressives would not be capable of navigating around the obstacles. Believing themselves to be lacking the capacity to make improvements, they may turn, in the hope of salvation, to others. Others may react to the pessimistic/depressive’s disconsolate and defenseless behavior with initial support but, in time, they often withdraw in an attempt to avoid their own feelings of frustration regarding the depressive. Aware of the effect their melancholic mood has on others, yet feeling unable to behave in a more energetic and optimistic way, pessimistic/ depressives find their pessimistic expectations fulfilled and their poor self-image reinforced. They may vow ever more forcefully to keep to themselves to avoid further pain. The vicious circle fueled by the depressive’s pessimistic expectations can be interrupted by confronting pessimism directly, by cognitive interventions that challenge assumptions, and by behavioral experiments. Even a trickle of motivation, for some more easily mastered with the help of antidepressants, can help the patient alter his or her depressogenic interpersonal habits, especially with social skill and assertiveness training. Tasks can be broken down into small steps easy for patients to accomplish, thus exposing them to success. Feelings of self-efficacy can bolster their self-image, and supportive antidepressants may help to further lift their melancholia. Cognitive techniques can teach these patients to search for objective feedback in their environment rather than relying solely on emotional reasoning. Problem-solving skills allow them to generate alternative plans in cases of genuine disappointment or failure, thus preventing them from sinking again into apathetic despair. Identifying Domain Dysfunctions The crux of the pessimistic/depressive personality’s dysfunction rests in the interaction of a pessimistic cognitive style and a deeply entrenched melancholic mood. The timetested conviction that efforts to manipulate the environment or one’s mood are futile ensures that the depressive will be ineffectual in efforts to plan for change. Even on those occasions when he or she overcomes feelings of inadequacy and hopelessness in an attempt to secure some reward from the environment, the resistant melancholic mood and negative interpretational bias interferes with the enjoyment of life’s simple pleasures and small victories. Psychopharmacological intervention often is a useful first inroad into the pessimistic/depressive’s difficulties. Most depressives respond moderately well to medication, providing them with increased energy and a first inkling of optimism. With a renewed sense of hope, patients may be open to exploring and working toward changing attitudes and behaviors that contribute to their pessimistic/depressive pattern. These patients can be taught that helpless interpersonal behavior alienates even the most well-meaning, attracts individuals with sadistic and exploitive tendencies, or even brings out such tendencies in “regular” folks. Social skills training can teach the patient to replace disconsolate expressive behavior and defenseless interpersonal conduct with more assertive and appealing alternatives. Planning tasks by breaking

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them up into small manageable steps can also help provide depressives with successes that, along with improved quality of social interactions, can increase their sense of self-efficacy and help bolster their self-image. Improvements in these latter domains can serve to encourage the pessimistic/ depressive to reclaim forsaken object representations and dare to hope for (and hence find reason to work toward) something better than disappointment and failure. Increased subjective experience of pleasure can also help rejuvenate the personality’s depleted morphological organization and render coping mechanisms a little more vital and productive than previously. While the depressive starts out believing he or she can feel comfortable with only a self-denial pattern of existence, effective coping can, in fact, begin to occur as soon as hope becomes a part of his or her repertoire.

Selecting Therapeutic Modalities In building a relationship with a pessimistic/depressive patient, the therapist needs to carefully balance a supportive position that satisfies the patient’s dependency needs while discouraging helplessness. Most depressive patients claim to expect nothing but more unhappiness for their future, yet many in fact harbor a secret hope that the therapist has a magical solution that will put an end to their feelings of misery and incompetence. The patient with a pessimistic/depressive personality disorder has probably spent most of his or her time believing that life is an exhausting struggle that yields no rewards and metes out disappointments and punishments as a matter of course. These patients realize that life is not so cloudy for all of their peers, and they often subconsciously hope that the therapist holds the secret to joy and vitality. Although the depressive dare not risk openly assuming that such a wish could be realized, for fear of another devastating disappointment, the therapist will often be given clues about the patient’s dependent wishes in both subtle and more overt ways. The therapist will likely feel pressure to ease the patient’s distress and pain, but it is not advisable to assume too omnipotent a helping position. It is essential, however, that the therapist impart a sense of hopefulness and optimism about the possibility of the patient’s achieving improved functioning and affect. It should be made clear that the patient must engage in a lot of collaborative work with the therapist to arrive at realistic but promising solutions. Although the patient may wish for a magic helper to watch out for him or her, the therapist should emphasize developing a sense of self-efficacy and problem-solving ability. In the beginning stages of therapy, satisfying too few of the patient’s dependency needs may cause him or her to feel that the therapist is not interested or caring; this may increase the depressive’s sense of futility. With very depressed patients the therapist may find that he or she has to do more than the usual amount of work to keep the session going. Many such patients feel embarrassed, incompetent, guilty, and misunderstood. They may also lack the confidence or energy to express this. Pushing the patient too

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quickly, or even assuming a cheerful disposition, may make patients feel that their pessimistic/depressive affect will not be tolerated, resulting in feelings of shame that may lead them to terminate therapy. The essence of the truly therapeutic relationship is one in which the therapist can provide empathic support while conveying confidence in the patient’s capacity to learn to care for himself or herself. What should be the focus of the therapeutic program? Behavioral Techniques Designing a useful behavioral intervention for the depressive patient begins with a careful analysis of the patient’s interactions with the environment. Pleasant and unpleasant events need to be identified, as do problematic patterns of behavior. By keeping a record of daily events and moods, the patient can work with the therapist to devise interventions to help change depressogenic activities. Once goals have been agreed on, it is often useful for patients to choose specific reinforcers that they can employ to reward themselves when planned assignments have been carried out successfully. Interventions usually fall into one of three categories: changes in the environment (e.g., changing jobs, going to the movies); learning new interaction skills (e.g., assertiveness training, modeling); and increasing pleasure-related actions (e.g., relaxation and pleasure training). Patients are encouraged to engage in activities that they enjoy, particularly ones that activate positive moods; they may also be taught to set time aside daily for rewarding activities. Some behavioral intervention programs include the patient’s significant others to encourage communication and facilitate social interaction. Interpersonal Techniques Interpersonal approaches emphasize the place of the social environment in the development and maintenance of symptoms. The steps involved in treatment begin with reviewing symptoms and describing their usual course. Treatment is then outlined, and the therapist declares the patient to have an “illness” that can be treated with his or her cooperation. Interpersonal problems are worked out in the course of therapy. Developing positive relationships can serve to alleviate pessimistic/depressive symptoms by providing the patient with support, pleasure, and hope. Pessimistic/depressive symptoms may be related to problems found in one or more of four general areas of dysfunction: grief overreactions, interpersonal disputes, role transitions, and interpersonal deficits (Cyranowski et al., 2004; Markowitz, Kocsis, Bleiberg, Christos, & Sacks, 2005). If the difficulty is a feeling of loss from a grief overreaction or a strong sense of generalized deprivation, therapy may focus on facilitating the delayed mourning process and helping the patient substitute new relationships and interests for those that have been lost or are chronically missing. If interpersonal disputes are the issue, a plan of action and effective communication are emphasized. For patients who are having difficulties adapting to new roles, emphasis is placed on regarding the role more positively and on mastering skills needed to function effectively

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in the new capacity. Patients who have interpersonal deficits need to identify past positive relationships on which to base future ones, to practice skills, and to search for promising new situations and people. A number of strengths associated with group approaches to treatment of pessimistic/depressive disorders have been pointed out by Luby and Yalom (1992). In group therapy, depressive patients come to realize that others experience similar difficulties and that they are not alone in their vulnerability. This realization can be therapeutic in itself. Participants can be encouraged to assist each other in solving difficulties and overcoming problems, thus helping them bolster their waning sense of self-worth and interpersonal competence. Witnessing improvement in their fellow group members’ outlook can reinforce the very tenuous hope these patients have for improved functioning and help build the motivation needed to make adaptive changes. The group format also allows for role-playing, multiparticipant discussions, and behavioral interventions. Patients who lack social skills can experience corrective feedback about maladaptive behaviors. Positive reinforcement from a supportive group can give the patient confidence to experiment with new behaviors outside of therapy after practicing with group members. Family and couples approaches to treating a pessimistic/depressive’s interpersonal relationship and functioning difficulties can focus on several areas of dysfunction. The reaction of the patient’s spouse and of other family members who contribute to the patient’s depressive tendencies can be explored to improve the patient’s overall functioning. Family members can learn about helpful ways to react to symptomatic behavior. Cognitive patterns, whether the patient’s or other family members’, may contribute to the pessimistic/depressive’s pathogenesis. Distortions in problem definition, in expectancies for oneself and one’s spouse, in beliefs about change, and in attributions for behavior can be exposed and altered. Behavioral interventions can be conducted with the spouse and/or other family members to increase the patient’s social skills and to demonstrate the advantages of more adaptive interaction strategies. Hostile interactions can be reduced. Often a lack of intimacy with his or her spouse precipitates, exacerbates, or maintains the patient’s symptomatology. Teaching the couple to interact in supportive and comforting ways can alleviate acute symptoms and help the pessimistic/depressive patient replace maladaptive schemas with better attitudes and coping mechanisms. Cognitive Techniques Cognitive techniques for treating depressive personality disorders make much use of behavioral tactics as well. Combining the two approaches is a powerful medium through which to change the patient’s behavior and environmental consequences and to alter depressogenic attitudes. The cognitive approach emphasizes directly challenging the patient’s depressogenic assumptions through logical reasoning as well as with environmental data. By keeping track of events, thoughts, and moods, pessimistic/depressive

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patients can learn how much of their dysphoria is related directly to their appraisal of their environment and of themselves, as well as to their subsequent negative self-talk (M. M. Lee & Overholser, 2004; Vittengl, Clark, & Jarrett, 2004). Once negative automatic thoughts have been identified, they can be evaluated and modified. When the patient has a depressogenic thought, he or she may learn to ask such questions as “What’s the evidence?”; “Is there any other way to look at it?”; “How might alternative (less pessimistic) explanations be tested?”; and “What can I do about it (to make it better)?” The tacit beliefs on which automatic thoughts rest also need to be identified and altered for lasting change to occur and for negative thoughts not to resurface in a new form. Dysfunctional cognitive habits such as overgeneralization, arbitrary inference, emotional reasoning, and dichotomous thinking can be confronted directly, allowing patients to alter their thinking and the maladaptive behaviors that logically result from faulty thought processes. A basic strategy is to help patients realize that their thoughts are inferences about the world, not facts. Predictions can then be made and experiments devised to test their validity. Behavioral exercises are used mainly as an extension of cognitive change techniques, for example, to show that optimistic appraisal of situations is justified and can be achieved. Activities can be planned as tests of assumptions, as well as serving to provide the patient with positive experiences. Cognitive rehearsal techniques can help a patient accomplish goals by imagining the steps, predicting obstacles and conflicts, and figuring out ways to overcome them. Self-Image Techniques A useful initial approach with the pessimistic/depressive, as with all personality disorders, is the therapist’s willingness to adopt a patient-centered supportive attitude. After having lived with and accepted the inevitability of depressive symptoms since childhood or adolescence, the patient usually enters therapy at a time of crisis or when a relationship appears to be threatened by the patient’s gloomy outlook and behavior. The first goal is to alleviate the patient’s pain and to establish a solid and realistic therapeutic alliance. MacKinnon and Michels (1971) encourage the therapist to enhance the patient’s defenses in order to shield him or her against excessive pain. If the patient has suffered a recent interpersonal loss, the therapist can attempt to stand in for the lost figure until the patient stabilizes enough to regain some motivation and hope. The second objective of self-actualizing therapy is to protect the patient from selfinjury. The therapist must be careful to clarify the consequences of irrational, selfdefeating decisions. Although the therapist cannot make decisions for the patient directly, he or she can encourage the patient to “wait till feeling better,” thereby conveying concern (in itself therapeutic) and the attitude that improvement is expected. To avoid undermining the patient’s self-confidence and self-efficacy, therapists should emphasize that the “sick” role and the therapist’s advice are only temporary.

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Pessimistic/depressive patients often suffer from excessive shame. The therapist’s acknowledgment of the burden of shame and reassurance that the depressive has suffered enough can help the patient believe that forgiveness is possible and that he or she finally deserves to build a better life. Some patients feel guilty about being a burden to their family by not functioning adequately at work or in other roles. Anger at others may be denied because of such guilt, serving only to increase symptoms and interfere with relationships. Encouraging the patient to acknowledge and work through anger can be helpful. Once the patient and therapist have developed a solid alliance and the patient has realistic expectations about the advantages of working toward changes, other interventions can be initiated. Intrapsychic Techniques Psychodynamic approaches that involve short-term therapy are currently based on one of two premises. The first is that depression is largely caused by disturbed interpersonal relations; childhood experiences of disappointment with significant others predispose individuals to replicate depressogenic patterns. The second premise is that pessimistic/depressive patterns reflect difficulties in adaptive functioning that are related to inadequate self-esteem. A perceived discrepancy between aspirations and reality, or what had once been and what is now (loss), is hypothesized to cause depressive symptomatology. The crux of dynamic treatments calls for analyzing the patient’s transference toward the therapist and the patient’s developmental interpersonal history as the source of maladaptive emotional and cognitive distortions (Leichsenring, 2005). Bemporad (1999) divides the process into stages. First, the therapist and patient search for atavistic remnants of childhood interpersonal functioning, as it presents in the relationship between them. The second phase involves the patient’s working on relinquishing defenses, beliefs, and patterns that have been identified, and replacing them with more realistic and functional modes of behavior. Dreams, relationships, and feelings are all analyzed and traced to their origins. Third, a new, mature appraisal of the patient’s history and context can then help protect against continued pessimistic/depressive symptomatology. Healing is also promoted by supportive empathy, direct advice (when appropriate), and a positive relationship experience with the therapist. Pharmacologic Techniques Psychopharmacological intervention can greatly help pessimistic/depressives live normal lives by lifting their melancholic mood state. Antidepressants may not restructure the fundamental nature of the patient’s personality, but they certainly can help the patient feel more optimistic and energetic enough to take risks in experimenting with new behaviors (Kool et al., 2005; Schatzberg et al., 2005). The many antidepressants available on the market have different side effect and contraindication profiles; careful evaluation of the patient’s history and sensitivities can help in deciding which one (or two) is appropriate. To guard against the patient’s becoming discouraged during the

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usual 2 to 6 weeks’ delay, it is important for the therapist to emphasize that there is a lag between the onset of medication administration and its psychoactive effects (Markowitz, Kocsis, et al., 2005).

Making Synergistic Arrangements The first step to be considered when planning a treatment strategy for someone with pessimistic/depressive personality disorder is usually pharmacological intervention with antidepressants. Although not every patient is willing to take medication, and although several different medications may need to be prescribed before an optimal one is found, a great many depressive patients report that they feel as though a cloud has been lifted once they take an effective drug. For patients who take medication (as well as for those who do not) a useful initial approach is a supportive one. Alleviating the patient’s pain, offering empathic understanding, and protecting him or her against bad decisions can do much to inspire the patient’s hope and motivation. Behavioral intervention may next be employed, as well as combined with personalityreforming techniques, whether cognitive, interpersonal, or dynamic. Behavioral changes can help open up new experiences and reinforce more adaptive patterns. More thoroughgoing analyses of the patient’s life and difficulties can help change the fabric of depressogenic attitudes and actions, thereby immunizing the patient against relapse during times of stress. If the therapist deems adjunct family or couples intervention to be appropriate, it can begin as soon as the patient and therapist feel ready. Similarly, participation in a supportive group for pessimistic/depressive individuals can be of benefit for several reasons. Whereas the therapist may be idolized or suspected of being supportive out of professional duty, other group members usually are regarded as peers. This can result in the patient’s feeling less isolated and genuinely hopeful as others in similar situations experience improved moods and lives. An important aspect of achieving successful intervention with pessimistic/depressive personalities is focusing on major episodes and relapse prevention. Patients should be advised of the frequency with which most people reexperience intense dysphoric periods, and should be taught strategies for feeling better and keeping active. Booster sessions can be recommended to keep patients functioning at an optimal level. Patients who are on medication need to be monitored regularly.

Illustrative Cases Despite its recency as a formal DSM classification, the history of pessimistic/depressive syndromes is a long and rich one, many elements of which can be drawn on for the following personality presentations. Some exhibit their depressive mood with displays

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144 PERSONALIZED THERAPY FOR THE PESSIMISTIC/DEPRESSIVE PERSONALITY PATTERNS Table 4.4

Pessimistic/Depressive Personality Disorder Subtypes

Restive: Wrought-up despair; agitated, ruffled, perturbed, confused, restless, and unsettled; vacillating emotions and outlook; suicide avoids inescapable pain. (Mixed Depressive/Avoidant Subtype) Self-Derogating: Disparaging self for weaknesses and shortcomings; self-deriding, discrediting, censurable, dishonorable, odious, contemptible. (Mixed Depressive/ Dependent subtype) Voguish: Suffering seen as ennobling; unhappiness considered a popular and stylish mode of social disenchantment; personal depression viewed as self-glorifying and dignifying. (Mixed Depressive/Histrionic-Narcissistic Subtype) Ill-Humored: Sour; distempered, cantankerous, irritable, grumbling discontent; guiltridden and self-condemning; self-pitying; hypochondriacal. (Mixed Depressive/ Negativistic Subtype) Morbid: Profound dejection and gloom; haggard, morose, lugubrious, macabre, drained, oppressed; intensely self-abnegating. (Mixed Depressive/Masochistic Subtype)

of dramatic gesture and pleading commentary; others are demanding, irritable, and cranky. Some verbalize their thoughts in passive, vague, and abstract philosophical terms. Still others seem lonely, quietly downhearted, solemnly morose and pessimistic. Common to all, however, is the presence of self-deprecatory comments, feelings of apathy, and marked discouragement and hopelessness. Their actions and complaints usually evoke sympathy and support from others, but these reassurances provide only temporary relief from the prevailing mood of dejection (see Table 4.4). Case 4.1, Nadia M., 35 A Pessimistic/Depressive Personality: Ill-Humored Type (Depressive with Negativistic Traits) Presenting Picture Nadia presented for therapy following a complicated, hurtful relationship with her work supervisor that had lasted, on and off, for approximately 3 years. She was asked how she felt about continuing employment in her present office, to which she replied, “I’m thinking I’d like to sue him for sexual harassment, but I’ll probably just let it wash over me like I always do and not do anything.” Throughout the initial interview, Nadia had a guarded, edgy, hands-off sort of demeanor, clearly feeling she needed to protect herself from an environment that would inevitably cause her much

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distress. As she explained, “It’s not like anyone’s going to watch out for me, or even care. That’s obvious.” Recently, too, she began noticing powerful headaches, although she noted, “That’s just the latest. I’ve always got something going wrong,” further indicating that she had experienced indigestion, diffuse pain, and insomnia in the past. She described her earlier life as being nomadic, as her mother frequently moved around the country, “dragging” her along. She considered herself, throughout her childhood, a “second thought” in her mother’s eyes, invariably of less import than whoever her mother’s current boyfriend was at the time. Notably, in her own recent relationship, she described her supervisor as “unable to commit or to be intimate. He simply just doesn’t care about anyone but his own interests and nothing seems to affect him. He’s like an automaton.” However, it seemed obvious from her presentation, ranging from self-effacing hostility to resentful bitterness, that she may have created her own barriers. Initial Impressions In cases such as Nadia’s, well described by Kraepelin (1913) and Schneider (1950), we see a constant barrage of complaints, irritability, and a sour grumbling discontent, usually interwoven with hypochondriacal preoccupations and periodic expressions of guilt and self-condemnation. Nadia’s habitual style of acting out her conflicts and ambivalent feelings became more pronounced, resulting in extreme vacillations between bitterness and resentment on the one hand, and intropunitive self-deprecation on the other. She exhibited self-pity and bodily anxieties, which may serve as a basis for distinguishing her from other depressive types. A review of empirical and clinical studies suggests that the characteristics of Nadia’s pessimistic/depressive pattern, the ill-humored subtype, interweave with features seen most commonly among negativistic personalities. Although not always gloomy, Nadia found pleasure in nothing and appear contented with nothing, taking out her grumbling negativism not so much in a nagging and dissatisfied attitude toward others, as directing her ill disposition against herself. There was a self-tormenting quality, a kind of scolding attitude, and an insistence that others hear her complaints and troubles. Consistent with Kretschmer’s (1925) description, she appeared cold and selfish, irritable and critical, rejoicing in the failures of others, and never anticipating or wishing others the rewards and achievements of life. At times, she had hostile depressive complaints and a demanding and querulous irritability in which she bemoaned her sorry state and her desperate need for attention to her manifold physical illnesses, pains, and incapacities. The most pronounced of Nadia’s unbalanced polarities included a strong pain and very weak pleasure orientation, which needed timely attention focused on both reducing her despairing mood and hypersensitivity and undoing her fatalistic and cynical perpetuating tendencies in order for her to have any investment in further treatment. Trust was also most important, as Nadia’s faith in the actions of others toward her was nearly nonexistent, due not only to her characterologic feeling of

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146 PERSONALIZED THERAPY FOR THE PESSIMISTIC/DEPRESSIVE PERSONALITY PATTERNS worthlessness, but also to her view of others as malevolent. It would be necessary to very carefully rework conflicts between her compromised sense of both self and other throughout treatment, being aware that shifting responsibility too quickly could be enervating to her already guilty predisposition. Also, Nadia needed to learn healthier functions than her frequent irresolute actions, which so often were at odds with her desires. As she learned more functional habits, it would be efficacious to undo Nadia’s perpetually self-defeating feelings of guilt, as well as help revive and bolster relationships with those around her. Domain Analysis Although she complained that the testing procedure was long, arduous, and uncomfortable, Nadia did produce valid results from her testing. Significant domains, as measured by the MG-PDC and the MCMI-III Grossman Facet Scales, included the following: Temperamentally Irritable: Nadia’s moods shifted frequently, with one constant being that she became easily frustrated and disgruntled by minor annoyances; at other times, she would erratically vacillate between despair and contentiousness. Worthless Self-Image: Driving much of Nadia’s irritability and discontent was an unshakable feeling that she possessed no redeeming qualities; many of her actions also spoke to this domain as she seemed to easily find evidence in her environment that would validate her degrading and guilty self-view. Interpersonally Defenseless: Feeling assailable in the midst of a malevolent world, Nadia at once sought the protection and nurturance of others, but also tended to undo good relationships that came her way, assuming that others would only leave her lacking and vulnerable, regardless of her efforts. Therapeutic Steps Focused interventions were helpful in aiding Nadia in therapy. First, she was guided to avoid environmental pressures that aggravated her anxieties and dejection. Brief supportive therapy was employed from the beginning to augment her relief from sources of anxiety. Toward the goal of reducing the likelihood of a relapse or retrogression, the therapist did not set goals too high or press changes too quickly. Initial efforts were directed at building Nadia’s trust. Short-term procedures designed to orient her attentions to her positive traits and to enhance her confidence and self-esteem were most beneficial. Additionally, cognitive techniques were used to confront her with the obstructive and self-defeating character of her self-beliefs and expectations. Between the supportive milieu and carefully applied cognitive confrontation, the initial sessions acted as a potentiated pairing effective in undoing her worthless self-image. A pharmacological agent (specifically, an antidepressant drug, Lexapro) was employed shortly after treatment began. The cumulative effect of

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this early stage of therapy was not only improvement in self-esteem, but alleviation of her hypersensitivity and temperamental irritability. Because of her intense ambivalence between her desire for reassurance and nurturance and her fear of trusting an unknown person, Nadia required an early warm and attentive attitude on the part of the therapist. She was engaged early on; thus, she was not as disposed to employ repetitive maneuvers to test the sincerity and motives of the therapist. Efforts were also made to reduce the stressors inherent in her home life. It would have been advantageous to work with family members, but they were not motivated to do so. This situation prompted more intensive techniques to reduce the possibility of setbacks. For these preceding reasons, treatment had to progress more rapidly to ensure that a significant measure of remedial improvement could occur. Her relations with significant others were strengthened by employing several interpersonal treatment techniques (e.g., Klerman, Benjamin). With a nurturant and empathic attitude, the therapist was able to overcome Nadia’s fear of reexperiencing false hopes and disappointments and helped her to develop new skills in combating her feelings of defenselessness. It was desirable to decrease her anticipation of loss that may have prompted her into a self-fulfilling prophecy. Without focused attention, she may have defeated the chance to experience events that could promote change and growth. Additionally, circumscribed behavior modification methods were introduced, after gaining further interpersonal confidence, to focus on social behavior that could be strengthened in a relatively short time period. Such approaches had to be handled cautiously, however, lest Nadia feel that she was a failure and become unduly guilt-ridden, depressed, or possibly even suicidal. It was of great benefit to stabilize her and help her control her vacillations of mood and behavior. In this way, the therapist diminished the possibility of setbacks or deterioration in her condition.

Case 4.2, Geoffrey S., 26 A Pessimistic/Depressive Personality: Voguish Type (Depressive with Histrionic and/or Narcissistic Traits) Presenting Picture Geoffrey was a creative writer who described the world as “phony and despicable,” but simply saw this as his very accurate reflection of “seeing reality for what it is.” Despondent over his feelings of being ignored and ridiculed and unable to find comfort with friends whom he was beginning to distrust, he sought therapy, though he stated directly, “I don’t really think anything can help.” He was fueled by a fascination with a society he perceived to be in denial of inevitable downward spirals

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148 PERSONALIZED THERAPY FOR THE PESSIMISTIC/DEPRESSIVE PERSONALITY PATTERNS and an ugly demise, and viewed himself as one of only a select few who chose not to be happy in the face of this disaster. As he put it, “People have to be phony to be happy; that’s just not my path.” Geoffrey’s written work was a self-proclaimed form of release for him, but he vacillated between describing his writing as “the truth that everyone needs to hear if they want to stop this destructive path,” and his own personal release that did not need to be appreciated by anyone. This behavior had alienated him from his family, who, according to Geoffrey, just didn’t understand him. Although he denied it, stating that he was the one who sought help, it was fairly clear from his descriptions of family dynamics that his family had prompted this visit and were more or less demanding it. Initial Impressions Both Schneider (1950) and Kraepelin (1913) noted a tendency for certain depressives to display vanity and voguishness. To Geoffrey, suffering was seen as something noble, permitting him to feel special, if not elitist. He thereby acquired a philosophical refuge that could enable him to ponder “the bitterness of earthly life.” Like many voguish depressives, Geoffrey displayed an aesthetic preoccupation, a way of dressing and living that gave stature to his unhappy moods. He philosophized about his “existential sadness” and the alienation that we all share in this “age of mass society.” This use of fashionable language provided him with a bridge to others. It gave him a feeling of belonging during times when he was most isolated from the attachments he so desperately sought. As such, Geoffrey exhibited both histrionic and narcissistic personality characteristics in his vacillating attention seeking and grandiose self-statements. Moreover, his pseudosophistication about up-to-date matters not only enabled him to rationalize his personal emptiness and confusion but also allowed him to maintain his appeal in the eyes of “interesting” people. By adopting popular modes of disenchantment, he reinstated himself as a member of an “in” subgroup and thereby managed to draw attention to himself. These feeble signs of social attachment also provided a means for overcoming his deep sense of loss and isolation. However, if his expressions of connectedness failed to fulfill his attachment needs, he would likely have withdrawn quickly and replaced those expressions with soulful declarations of guilt and hopelessness. Geoffrey’s selfperpetuating difficulties were mostly manifest in an unbalanced social style, a tendency to concentrate on the perceived iniquities of the external world with little introspection (other orientation), yet using these perceptions to draw attention to a somewhat weaker self. It was as though what embodied Geoffrey, the individual, was lacking, causing a damaged self-image and morose mood; his focus on external features would draw others’ attention there and away from his empty inner self. Additionally, he perceived that his experience in chronic despondency (pain orientation) validated his status as a martyr. All this constituted a conflicted and ineffectual adjustment, requiring the therapist to help Geoffrey build more effective social skills, develop more genuine

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relationships, and dispute those beliefs that perpetuated a less-than-genuine sense of personal magnitude. Equally important would be augmentation of a rather ambiguous self-image, which would remain a central theme throughout treatment. Domain Analysis The following significant domains were identified as being targets for intervention with Geoffrey, as measured by the MG-PDC: Interpersonally Attention-Seeking: Geoffrey clearly sought approval and attention from others, utilizing his artistic expression as a vehicle for this social behavior and as a defensive shield from a deeper-seated sense of inadequacy: Should he get what he wished for (greater recognition), he might succumb to barbs and derision. Cognitively Pessimistic/Expansive: A melding of two characteristics, narcissistic and depressive, Geoffrey developed an ideology that he used as a barrier to more difficult self-feelings, in which he gave himself special status in a struggle that would end in disaster regardless of his efforts. Worthless Self-Image: Although he would be loath to admit this, Geoffrey held a great deal of contempt for himself, and, to a degree, he was able to externalize this feeling to make others culpable in the face of adverse existence; in this way, he guarded against any personal failures he felt were inevitabilities. Therapeutic Steps A primary goal of treatment with Geoffrey was to aid him in reducing his intense ambivalence and growing resentment. With an empathic and brief focus, it was possible to sustain a productive, therapeutic relationship. The therapist conveyed a genuine caring and firmness, and was thus able to overcome Geoffrey’s tendency to employ maneuvers to test the sincerity and motives of the therapist. Although he was slow to reveal his resentment because he disliked being viewed as an angry person, this was eventually brought into the open and dealt with in a kind and understanding way. He was not inclined to face his ambivalence, but his mixed feelings and attitudes were to be a major focus of treatment. To prevent him from trying to terminate treatment before improvement occurred and to forestall relapses, the therapist employed motivational interviewing techniques as a directive, humanistic approach to counter Geoffrey’s perpetual image of self as ineffectual, guilt-worthy, and worthless. Pharmacologic treatment was also considered in this early phase of treatment, but ultimately declined, as Geoffrey adamantly believed “I should feel everything I’m going through.” Although his declining this treatment may have slowed earlier progress, his connection with more difficult experiences seemed to foster an investment in the therapeutic progress, which then, paradoxically, served as a catalyst for continued, focused treatment. Circumscribed interpersonal approaches (e.g., Benjamin, Kiesler) were used to deal with the attention-seeking parallel process enacted by Geoffrey in his relationship

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150 PERSONALIZED THERAPY FOR THE PESSIMISTIC/DEPRESSIVE PERSONALITY PATTERNS with his therapist. He alternately exhibited ingratiating submissiveness and a taunting and demanding attitude. Similarly, he also solicited the therapist’s affections, but when those were expressed, he rejected them, voicing doubt about the genuineness of the therapist’s feelings. It was important to keep these inconsistencies in focus, as otherwise, Geoffrey may have appreciated the therapist’s perceptiveness verbally but not altered his attitudes. Involved in an unconscious repetition compulsion in which he re-created disillusioning experiences that paralleled those of the past, Geoffrey had to not only recognize the expectations, but had to be taught to deal with their enactment interpersonally. Toward the end of disentangling needs and beliefs that were in opposition to one another, the therapist began employing cognitive confrontations and reframing. Geoffrey’s disenchantment largely fell in the social realm, but these were tied to beliefs that both exalted himself in a false manner (cognitive expansiveness) and predetermined difficult, if not catastrophic, ends (pessimism). In this manner, he could be “above it all.” For example, he wanted the love of those on whom he depended, but rejected it on the grounds that it was phony and disingenuous. Despite this ambivalence, he entered new relationships, such as in therapy, as if an idyllic state could be achieved. He went through the act of seeking a consistent and true source of love, one that would not betray him as he believed his family and friends had in the past. Mindful of past betrayals and disappointment, he began to test his new relationships to see if they were loyal and faithful. In a parallel manner, he attempted to irritate and frustrate the therapist to check whether he would prove to be as fickle and insubstantial as others had been in the past. It was here that the therapist’s warm support commingled with structure and firmness played a significant role in reframing Geoffrey’s erroneous expectations and in exhibiting consistency in relationship behavior. This generalized, as therapy progressed, to larger social expectations as well as situational and environmental concerns.

Case 4.3, Travis R., 39 A Pessimistic/Depressive Personality: Morbid Type (Depressive with Dependent Traits) Presenting Picture Travis, a 39-year-old engineer, was laid off from the job he had held since college due to corporate downsizing and had spent the prior 8 months in a self-induced state of isolation, fearful, as he put it, “to put myself out there just to get rejected. Again.” He reported that he was absolutely lost in a hopeless fog of despondency, and this state seemed to permeate his entire being, from body language to outward verbal expression. He lamented that he had no idea where he was going and no conceivable

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hope that he had anything to look forward to in life. “I’m pathetic,” was an oft-heard, self-inflicted vituperative, and he faulted himself for the path his life had taken. “Never in a million years should I have become so comfortable, so complacent, when I knew I had nothing to safeguard me. No real skills; they do everything different now. No hope for learning anything that might be useful. I’m just a pathetic lump.” No change seemed possible, either, as he mentioned that he had always felt this way, even when employed and going to work on a daily basis, and even the most concerted effort he could muster seemed not to crack the surface of this despair. He also mentioned that he had been married for a brief time in his late 20s, but “that was just loveless; we just were two needy people that eventually drove each other crazy.” To cope with his omnipresent gloom, Travis tried to sleep as much as possible, watched television constantly, and avoided interactions with others. Initial Impressions A pessimistic/depressive paralysis characterized Travis, whose morbidly depressive personality style blends into Axis I clinical depression. His gloom and profound dejection were clearly conveyed as he slumped with brow furrowed and body stooped, his head, turned downward and away from the gaze of others, held in his hands like a burdensome weight. Various physical signs and symptoms further enabled us to distinguish Travis from other depressive personality subtypes. He had lost weight and looked haggard and drained. He followed a characteristic pattern of awakening after 2 or 3 hours of sleep, turning restlessly, fearing total aloneness and abandonment, yet experiencing a growing dread of the new day should he be challenged by anyone. Notable, also, was the content of his verbalizations, reporting a vague dread of impending disaster, feelings of utter helplessness, a pervasive sense of guilt for past failures, and a willing resignation to his hopeless fate. Features of the dependent personality permeated Travis’s psychic makeup. It was his deep and pervasive sense of personal incompetence that made him feel that he was incapable of coping; moreover, given his habitual style, he did not even hope to be able to deal with his current troubled state, resulting in the profundity of his dejection and morbidity. By contrast, other personalities that covary with the pessimistic/depressive possess sufficient feelings of competence and self-worth to enable them, at the very least, to believe that they may ultimately cope with the difficulties they experience. When not in a deep phase of gloom, Travis evinced a withering self-contempt. He demeaned everything about himself, seeing only the worst in what he had done; he was caught in an obsessive pessimism, a relentless negativism in which nothing seemed like it could get better. Feeling permanently dislocated and unworthy, he “knew” that others were as contemptuous of him as he was of himself. Travis’s mood was one of despondency and helplessness, a state akin to what other personalities exhibit when experiencing a clinical depressive syndrome. But for Travis, despair was a persistent and unrelenting state, so much so that it pervaded

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152 PERSONALIZED THERAPY FOR THE PESSIMISTIC/DEPRESSIVE PERSONALITY PATTERNS every fabric of his psychic makeup. Activity stimulation was most important with Travis, as he had, in effect, reached a point where his passive tendency allowed him to simply remain torpid and find some skewed contentment in inertia and gloom. Along with directly addressing his depressed state, it would be prudent to modify environmental factors to lift him out of his lethargic and indigent tendencies. As Travis adapted to these imposed changes, it would be possible, albeit cautiously, to begin working to increase autonomy skills, while undermining his perpetual state of being lost in pessimistic fantasy preoccupations. He needed to learn that others would not take responsibility for him, and that a healthier feeling would be derived from an enhanced sense of self, which would be facilitated by his greater independence and feelings of competence. Domain Analysis Although feeling as if there were no hope, Travis was highly amenable to assessment and took some interest in the process of understanding himself. This, in itself, appeared to be therapeutic, as it seemed he simply couldn’t otherwise fathom that there were methods available to help him feel better. As measured by the MG-PDC and the Grossman Facet Scales of the MCMI-III, Travis’s most salient domains included the following: Worthless/Inept Self-Image: A coalescing of both depressive and dependent characteristics, Travis’s very depleted self-esteem and feelings of guilt and worthlessness were fueled by his expectation that anything he did would eventually fail. He was deeply invested in the idea that he could not be counted on, or count on himself, for even the most basic of life functions. Temperamentally Melancholic: Gloomy and despondent, Travis spent most of his time in a state of worry and brooding, closing out the outside world to shelter in a state of self-exile. He was dysphoric in mood and lethargic in his actions, showing multiple neurovegetative signs of clinical depression. Cognitively Fatalistic: Pessimistic and defeatist in his beliefs about all matters, Travis saw events in their darkest form and maintained firm beliefs that regardless of what actions could potentially be taken, he could not fight his way out of his pathetic circumstances, nor could he look forward to any future optimism, as nothing could possibly improve. Therapeutic Steps Active short-term techniques with Travis took advantage of introducing environmental changes to maximize growth, to minimize continued dependency, and to provide uplifting experiences. Psychopharmacologic treatment was a useful beginning and promoted alertness and vigor and countered fatigue, lethargy,

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dejection, and melancholic states that inclined Travis to postpone efforts at independence and confidence building. His relationship with the therapist was explored also to overcome the dominance-submission patterns that may have characterized his recent history. Circumscribed treatment efforts were best directed toward countering the dependency attitudes and behaviors of this self-effacing man. A primary therapeutic task was to prevent Travis from slipping into a totally ineffectual state as he sought to rely increasingly on the supportive environment inherent in the therapy office. Owing to his anxious and morose outlook, he not only observed real deficits in his competence but also deprecated what virtues and talents he did possess. Trapped by his own persuasiveness, he had reinforced his belief in the futility of standing on his own, and therefore, he had tried less and less to overcome his inadequacies. To this end, the initial modality was largely humanistic in nature, but included an emphasis on structure and goal setting (e.g., motivational interviewing). In this way, Travis was not allowed to default to his usual ways of conceiving himself as inherently worthless or inept, but was given encouragement and empowerment to begin being more self-deterministic. Travis’s characteristic strategy had fostered a vicious circle of increased helplessness, depression, and dependency. By making himself inaccessible to growth opportunities, he effectively precluded further maturation and became more saddened and more dependent on others. To ensure the integration of competence activities and the acquisition of assertive behavior and attitudes, cognitive methods (e.g., Beck, 1976; Ellis, 1970) were then gradually introduced to reframe fatalistic erroneous beliefs and assumptions about himself and those he believed that others had of him. Effective brief, focused treatment may have created the misleading impression that progress would continue at a rapid pace. Despite initial indications of solid advances, Travis still resisted efforts to assume much autonomy for his future. Persuading him to forgo his long-standing habits was extremely slow and arduous, but these steps had to be undertaken to move forward in this regard and to provide support. Especially problematic was his feeling that an increase in the expectations of others may not be met and would thereby result in disapproval. Efforts to help him build an image of competence and self-esteem were essential in forestalling later backsliding. A program that strengthened his attributes and dislodged his habit of leaning on others was well worth the effort it took. Group therapy eventually was pursued fruitfully as a means of learning autonomous skills and as an aid to the growth of social confidence. To prevent Travis from reverting to passive incompetence and fantasy preoccupations, several other modalities were introduced as a means to practice and for infusing competency strivings. Several behavioral modification methods as well as interpersonal techniques such as those of Benjamin (2005) and Kiesler (1986) were useful in this regard. Pressure on him to show marked increases in initiative and autonomy were gradual, however, because his capacities in this area were very limited.

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Case 4.4, Lana P., 25 A Pessimistic/Depressive Personality: Restive Type (Depressive with Avoidant Traits) Presenting Picture Lana, a student teacher, was referred for counseling at the suggestion of her supervising principal. “Really, though, I think he was just trying to look nice. He doesn’t really care; he’s just trying to be a good principal.” Although she claimed to feel “okay” overall, it was overtly apparent that she was holding back a great deal of anguish and agitation, as her body language and demeanor suggested that there was a great deal that she wanted to express but could not. She spoke of “better days” with some lucidity and even somewhat brighter affect than her usual downtrodden mood, but suggested that even then, she was something of a passive observer among others who would always plan and participate in various enjoyable activities. “I never was a leader. As a matter of fact, I wasn’t even a participant, come to think of it. I was happier sometimes, but usually I would just try to stay out of the way.” Lately, Lana finally admitted, she had been particularly sad and had become somewhat scared when she was alone, fearing that her sense of isolation would not go away. She did not know what to do about this most recent state, but did seem to have some ideas about where it originated. Nevertheless, she would only allude to this cause cryptically, further stating that “it was a long time ago, and I shouldn’t still be sad about it.” At the end of the initial interview, just as the therapist noted that the session was over, she admitted, “My little sister died years ago.” She then went on to talk about how her sister always took care of her and that she had felt lost in the ensuing 10 or so years. Initial Impressions Restive depressive personalities such as Lana’s often covary with avoidant personalities, creating a pattern of characteristics that reflect the features of both. Typically anguished and agitated, Lana exhibited a wrought-up despair, vacillating between fretfulness and confusion and dysphoria and despair. She evidenced a perturbed discontent as she thought about the anguish others had caused her, venting little of the displeasure and vexation she felt. These shifting and vacillating attitudes served to discharge her tensions and relieve her of her deep unhappiness and resentfulness. Nervous, fretful, and distracted, Lana manifested a sequence of brittle moods, usually short-lived and intense, affects and attitudes that ultimately became increasingly self-destructive. As she despaired that anything in life could ever become rewarding again, she might have felt she must do something to express her deeply pessimistic view of both life and herself. Feeling defeated and helpless, seeing no way to restore her participation in a more positive existence, Lana may have been on a path to conclude that she must rid herself of the inescapable

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suffering she experienced. To a restive pessimistic/depressive such as Lana, the suicide act would not merely be a means to bring attention to herself, but a way out, a final solution to the ever-present problems she faced, a way to eliminate once and for all a persistent and painful existence. This act of self-destruction could also serve as a way of retaliating against others for not having cared enough. It would be a form of retribution, of inflicting pain on others without being either overtly hostile or having to feel guilt after the act. Lana’s hypersensitivity to pain would make it rather difficult to find inroads, as she vigilantly avoided anything that might be threatening, yet still experienced pronounced unhappiness. This, of course, made pleasure a very foreign concept, one that would eventually need to be restimulated. A careful and nonthreatening intervention would help to undo this perpetuating tendency toward hypersensitivity and perhaps open her receptors to more pleasing experience, as well as undo more typical depressive assumptions. It would also be important to address the conflicting active (avoidant tendency) and passive (depressive tendency) polarities, to find appropriate responses to environmental challenges, and to examine past actions that caused discontentment. As some sense of competency was achieved, it would then be appropriate to reverse her social detachment tendency by resolving earlier resentments toward others, as well as to undo anxieties regarding relationships. Throughout, it would be important to monitor and encourage the development of greater confidence and maintain an empathic, trusting therapeutic stance. Domain Analysis Although low in her rate of disclosure, Lana was agreeable to the domain assessment, and results of this analysis proved fruitful toward the end of finding effective and pragmatic therapeutic targets. Her most salient domains, as measured by the MG-PDC, were as follows: Interpersonally Defenseless: Lana felt very vulnerable to a world that she perceived held a great many threats, and an even greater amount of potential for interpersonal assault; without feelings of solitary interpersonal competence, which she had not effectively developed, she yearned for protection and assurance from others. Alienated Self-Image: Feeling inferior and incapable of holding her own among people in her life, Lana reflected on herself as inadequate and devoid of appeal, thinking of herself as lacking in achievement or capability and deserving of her place on the periphery of social exchanges. Expressively Disconsolate: Feeling perennially hopeless and despondent, although sometimes “steeling” herself to cover up her somberness and grief-stricken mannerisms, Lana expressed a discouragement and dispirited appearance and

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156 PERSONALIZED THERAPY FOR THE PESSIMISTIC/DEPRESSIVE PERSONALITY PATTERNS behavior; she showed little initiative in changing her somber ways, seeming to accept her plight as hopeless, although occasionally pushing herself toward a half-hearted attempt at responding. Therapeutic Steps Lana needed to understand from the outset that the goals of treatment were fully achievable and that they should motivate rather than dissuade her. She feared that therapy would reawaken what she viewed as false hopes; that is, it would remind her of the disillusionment she experienced when she aspired in the past and was rejected. Now that she had found a modest level of comfort by distancing herself from desires and withdrawing from others, it was important therapeutically not to let matters remain at the level of depressive-anxious adjustment to which she had become accustomed. Antidepressant medications may have been fruitful in moderating Lana’s persistent dejection and pessimism, but were not utilized. At the cognitive level, therapeutic attention was usefully directed to her depressogenic assumptions, anxious demeanor, self-deprecating attitudes, and behavior that evoked unhappiness, self-contempt, and derogation in the past. These techniques also focused attention on her pessimistic/depressive tendencies to demean her self-worth and subject herself to the mistreatment of others. Supportive measures were used to counteract Lana’s hesitation about sustaining a consistent therapeutic relationship. The therapist expected to see the numerous maneuvers designed to test his sincerity. A warm and accepting attitude was needed because Lana feared facing her feelings of unworthiness and because she sensed that her coping defenses were weak. With skillful supportive approaches, it was possible to prevent her proclivity to withdraw from treatment before any real gains had been made. Cognitive methods were especially useful in exploring the contradictions in her feelings and attitudes. Without reframing techniques such as these, there would have undoubtedly been a seesaw struggle, with periods of temporary progress followed by retrogression. Short-term and focused cognitive techniques such as those developed by Beck, Meichenbaum, and Ellis helped reduce her sensitivity to rebuff and her morose and unassertive style, outlooks and fears that only reinforced her aversive and pessimistic/depressive inclinations. In this way, her self-alienating strategies were brought into question, disputed in a supportive but direct manner, and she was able to begin successfully replacing these feelings of incapability and inferiority with more balanced, flexible beliefs. To continue skill building and invoke a greater sense of self-efficacy, not to mention prevent relapse, more focused procedures were useful in reconstructing the erroneous beliefs and interpersonal mechanisms that pervaded all aspects of Lana’s behavior. Interpersonal therapies such as those of Klerman and Benjamin were especially productive. Along the same lines, short-term group therapy assisted her in learning new attitudes and skills in a more benign and accepting social setting than she normally encountered, and she was able to feel as though she could adequately

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defend herself and function more autonomously among peers, family, and others. Similarly, family techniques may have been explored as circumscribed methods to moderate destructive patterns of communication that contributed to or intensified her social problems. Genuine gains were achieved, but only with a building of trust and the enhancement of her shaky sense of self-worth, both of which lent themselves well to these procedures. Another realm worthy of attention was associated with Lana’s extensive scanning and misinterpretation of the environment, leading to expressions that were, for the most part, disconsolate, behaving as though she would always face hardship, struggle, and hopelessness. By doing this, she increased the likelihood that she would encounter those troubling events she wished to avoid. Moreover, her exquisite and negatively oriented antennae picked up and intensified what most people simply overlooked. In effect, her hypersensitivity backfired, becoming an instrument that constantly brought to awareness the very pain she wished to escape. Effective, focused behavioral modification techniques were directed at reducing her vigilance and hence diminished rather than intensified her anguish.

Resistances and Risks The high success rate of antidepressants for treating symptoms of pessimistic/depressive personality disorder may lead some therapists to be prematurely reassuring that difficulties will quickly abate. Some patients who fail to respond to medication may feel pressure to do so and internalize the lack of pharmacological success as a personal failure or as confirmation that they are a hopeless case. The little motivation they had to try to improve their lot may be undone, rendering potentially helpful cognitive, behavioral, or interpersonal interventions impossible to utilize. Some patients need to try several different medications before finding one they respond to favorably. It should be understood that disappointed initial optimism can confirm their skepticism and make patients unwilling to experiment with alternatives. Other difficulties can arise from the depressive patient’s need to find a magic solution and the therapist’s willingness to provide it. Some patients may interpret their therapist’s confidence as the promise of a powerful helper, and attribute improvements in their condition to his or her skill and knowledge, increasing their sense of dependency on the therapist rather than their sense of self-efficacy. Still others may attribute past difficulties to a “chemical imbalance” and, encouraged by their therapist’s optimistic outlook, spring into new activities and relationships without having compensated for years of interpersonal and cognitive deficits. Therapists need to keep in mind that improved affect does not necessarily imply that the patient has acquired the skills needed to successfully tackle added responsibilities and to deal with the consequences of more risky interpersonal behavior. Patients may become too bold, and thereby get

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in trouble. Engaging in activities that carry great emotional risks and experiencing failure before new schemas and patterns have time to develop can send the patient into a renewed crisis of despair about the futility of both life and treatment. Encouraging patients to make the most adaptive use of increased enthusiasm and energy and helping them develop the skills needed for more socially rewarding and personally contented lives will be productive goals. The therapist must be mindful that long-standing interpersonal patterns will have to be addressed and changed for the patient to maintain improvements, and that old cognitive schemas will need more than pharmacological intervention for change to last. Patients should be warned that bad times and moods inevitably will come again, and they should be prepared to deal with them effectively, thereby preventing full relapse. Some patients may be so apprehensive about falling back into their previous state of despair that they do not truly appreciate their improved affect and will be unwilling to experiment with new behavior for fear of negative consequences. The therapist must strike a therapeutic balance between being encouraging and optimistic on the one hand, yet urging caution on the other, emphasizing that recovery is a process, and making no unrealistic promises about the possibility of future perfection and happiness.

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CHAPTER

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5

Personalized Therapy for the Aggrieved/Masochistic Personality Patterns

A

lthough clinical inclinations of a self-abasing character have been observed for centuries, it failed to gain official recognition as a personality disorder until 1987. An effort to include the psychoanalytic construct masochistic personality disorder was made in early discussions of the DSM-III (American Psychiatric Association, 1980). Given the antitheoretical orientation of that manual’s Task Force, the concept of masochistic behaviors, originally conceived as a potential Axis II disorder, was formulated instead as a feature of the Axis I affective group of syndromes. Soon after the appearance of DSM-III, several clinical theorists continued to press for an Axis II category that would encompass the self-abusive and self-undoing qualities of a depressive/masochistic personality. This proposal was taken seriously by the Work Group assigned the task of revising the DSM-III. The proposal quickly generated both professional and public controversy. To minimize substantive objections and harassing debates, the label was changed from masochistic to self-defeating (Fiester, 1995). The initially proposed criteria were then modified to rule out depressive symptomatology, as well as to minimize gender biases, for example, to exclude from the list abusive relationships in which women victims were in effect blamed for ostensibly precipitating the abuse (Widiger, 1995). It was then decided to place the diagnosis of a self-defeating personality in the DSM-III-R appendix, along with the sadistic personality diagnosis, owing to the fact that they were “new” disorders and hence required further clinical and empirical study (Heisler, Lyons, & Goethe, 1995). Although the original label “masochism” acquired a somewhat confusing array of meanings (e.g., a sexual perversion, a moral character type), the selection of “selfdefeating” as an alternative did not achieve either clarity or precision in its potential

159

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usage (Cruz et al., 2000). Moreover, all personality disorders are essentially selfdefeating in that they all set into motion self-perpetuating behaviors and reactions that further intensify the very problems that gave rise to them in the first place (Huprich & Fine, 1996). Any number of terms would have proved more apt, we believe, for example, self-abasing, deferential, obsequious, abject, servile, or self-denigrating. The need to clarify the meaning of the construct, which we prefer to label again “masochistic personality disorder,” is a central task for those who wish to extend the boundaries of the DSM, from which the disorder has been deleted. The reason for describing the masochistic/self-defeating prototype in this text is to broaden readers’ perspective by including in the scope of their clinical work a constellation of cohering self-abasing and self-undoing personality characteristics (Coolidge & Anderson, 2002). With such knowledge in hand, clinicians should be able to better understand and treat their patients. It is true that all labeling and diagnoses possess the potential for misuse, but we cannot bypass our studies because interpretations given these disorders may at times be fallacious and misguided. Personality disorders of all stripes result from interacting biogenic, psychogenic, and sociogenic factors. It is especially regrettable that such complexly formed pathologies are interpreted by some solely in terms of their potential social and political implications. We must obviate all such interpretations lest mental disorders be recast, as they have been in Germany and Russia this past century, as social defects, rather than as intrinsic clinical phenomena, in this case as one of the several persistently chronic and widely pervasive pathologies of persons. Horney’s (1939) formulation of “masochistic phenomena” bridges the theme of ambivalence first posited as central to these personalities by Abraham (1927) and the notion of spiteful suffering proposed by Reich (1949). As she views it, the masochist establishes “a value in suffering” as a means of defending against fears associated with a sense of intrinsic weakness and insignificance, both of which leave the person with an inordinate need for affection and an extraordinary fear of disapproval. In subsequent writings, Horney (1950) recognized that the suffering of the masochist often serves the defensive purpose of avoiding recriminations and responsibilities; that is, it is a way of expressing accusations in a disguised form. For some, it is a way of demanding affection and reparations. For others it is a virtue that justifies claims for love and acceptance. As in prior chapters, we briefly note the evolutionary theory as a framework for explicating the key elements of the masochistic/self-defeating pattern that were included in the DSM-III-R Appendix. Figure 5.1 provides a visual picture of the strength of the three major bipolarities of the theory. As can be seen, the major pathologic component is the reversal between the pain and pleasure segments of the first polarity. This signifies that the individual has learned to experience pain in a manner that makes it preferable to experiences of pleasure (Filippini, 2005). Of course, this preference may be a relative one; that is, the individual may be willing to tolerate significant discomfort and abuse as long as it is the lesser of greater degrees of anguish and humiliation. To be moderately

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161

MASOCHISTIC PROTOTYPE

Enhancement

Preservation

(Pleasure)

(Pain)

Accomodation

Modification

(Passive)

(Active)

Individuation

Nurturance

(Self)

(Other)

Reversal between Polarities Weak on Polarity Dimension Average on Polarity Dimension Strong on Polarity Dimension

FIGURE 5.1 Status of the aggrieved/masochistic (self-defeating) personality prototype in accord with the Millon polarity model.

distressed and disheartened may be better than to be severely pained and demoralized (Haller & Miles, 2004). The self-defeating disorder is passive and accommodating in a manner similar to the depressive personality (Garyfallos et al., 1999; Huprich & Fine, 1997; Klein & Vocisano, 1999). The distinction is a fine one, but is significant nevertheless. In the depressive, passivity indicates an acceptance of one’s fate, a sense that loss and hopelessness are justified and that depression is inevitable; further, that these experiences can never be overcome and, hence, one should accept one’s depressive state and the irretrievability of happiness. In the masochistic, there is a measure of both control and desirability in giving in to one’s suffering and discomfort. Here, a measure of moderate anguish may be a preferable state; that is, it may be the best of all possible alternatives available to the person. Passivity, therefore, indicates an acceptance of pain

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SELF-DEFEATING PROTOTYPE Abstinent Expressive Behavior

Deferential

Exaggeration

Interpersonal Conduct

Regulatory Mechanism

Dysphoric

Undeserving

Mood/Temperament

Self-Image

Diffident

Inverted Morphologic Organization

Discredited Object Representations

Cognitive Style

FIGURE 5.2 Salience of prototypal aggrieved/masochistic domains.

as a realistic choice given one’s inescapable options, not a final and irretrievable state of hopelessness.

Clinical Picture This section encompasses several perspectives in our attempt to illuminate the major characteristics of the prototypal aggrieved/masochistic personality pattern (see Figure 5.2). This section discusses the central features of the aggrieved/masochistic (selfdefeating) pattern, detailing these characteristics in accord with the major domains of clinical analysis utilized in earlier chapters (see Table 5.1). Abstinent Expressive Behavior Overtly, aggrieved/masochistic personalities are inclined to act in a self-effacing and unpresuming manner. For public consumption, they place themselves in an inferior light or abject position, reluctant to seek pleasurable experiences and refraining from exhibiting signs of enjoying life. For the most part, they present themselves as being nonindulgent, frugal, and chaste. Some appear shabby in public. Their clothes are designed to signify poverty or a disinterest in common forms of attractiveness. Others may actually abuse their bodies in ways that lead to self-starvation and anorexia. Most merely fail to dress up and appear appropriate given their socioeconomic status.

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Clinical Picture

Table 5.1

163

Clinical Domains of the Aggrieved/Masochistic Personality Prototype

Behavioral Level: (F) Expressively Abstinent (e.g., presents self as nonindulgent, frugal, and chaste; is reluctant to seek pleasurable experiences, refraining from exhibiting signs of enjoying life; acts in an unpresuming and self-effacing manner, preferring to place self in an inferior light or abject position). (F) Interpersonally Deferential (e.g., distances from those who are consistently supportive, relating to others in self-sacrificing, servile, and obsequious ways, allowing, if not encouraging, them to exploit, mistreat, or take advantage; renders ineffectual the attempts of others to be helpful and solicits condemnation by accepting undeserved blame and courting unjust criticism). Phenomenological Level: (F) Cognitively Diffident (e.g., hesitant to interpret observations positively for fear that, in doing so, they may not take problematic forms or achieve troublesome and self-denigrating outcomes; as a result, there is a habit of repeatedly expressing attitudes and anticipations contrary to favorable beliefs and feelings). (S) Undeserving Self-Image (e.g., is self-abasing, focusing on the very worst personal features, asserting thereby own worthiness of being shamed, humbled, and debased; failing to live up to the expectations of others deserves painful consequences). (S) Discredited Objects (e.g., object representations are composed of failed past relationships and disparaged personal achievements, of positive feelings and erotic drives transposed into their least attractive opposites, of internal conflicts intentionally aggravated, of mechanisms for reducing dysphoria being subverted by processes that intensify discomfort). Intrapsychic Level: (F) Exaggeration Mechanism (e.g., repetitively recalls past injustices and anticipates future disappointments as a means of raising distress to homeostatic levels; undermines personal objectives and sabotages good fortunes to enhance or maintain accustomed level of suffering and pain). (S) Inverted Organization (e.g., owing to a significant reversal of the pain–pleasure polarity, morphologic structures have contrasting and dual qualities—one more or less conventional, the other its obverse—resulting in a repetitive undoing of affect and intention, of a transposing of channels of need gratification with those leading to frustration, and of engaging in actions that produce antithetical, if not self-sabotaging consequences). Biophysical Level: (S) Dysphoric Mood (e.g., experiences a complex mix of emotions, at times anxiously apprehensive, at others forlorn and mournful, anguished and tormented; intentionally displays a plaintive and wistful appearance, frequently to induce guilt and discomfort in others). Note: F = Functional Domains; S = Structural Domains.

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What we see in these abstinent behaviors is an active expression of self-denigration, an act of frustrating their personal choices and self-respect. There is a taboo on most forms of enjoyment and self-enhancement. They are saying, in effect, that they do not wish to gain pleasure or gratification, that good things are not good for them, that any form of self-indulgence is best forbidden and denied. Some of these self-taboos are cast in the form of social concern and altruism. To them, self-denial is a sign of social conscience and responsibility, one in which material gains would be ill-gotten were they not shared equally by others. In its most extreme form, the determination to deny oneself can generate feelings of panic if one realizes that one has failed to jettison an attractive trait or material possession. Deferential Interpersonal Conduct These personalities prefer relationships in which they can be self-sacrificing, even servile and obsequious, in manner. The tendency to place themselves in a general deferential position is notable. It is not untypical for them to allow, if not encourage, others to be exploitive or mistreating, even to take advantage of them. Equally problematic is a tendency to distance from those who are supportive and helpful. At times, they may render ineffectual the attempts of others to be kindly and of assistance. Most pathologic is their inclination to solicit condemnation from others and to accept undeserved blame, as well as to court unjust criticism for their actions and performance. With self-sacrifice, the masochist aims to arouse guilt in others, and such selfdenigration helps explain relationships that would otherwise seem perplexing. Rather puzzling is the fact that this pattern of repetitive self-flagellation persists even when a hurtful partner shows no sign of guilt or remorse. Instead, masochists continue to humiliate themselves before their denigrating partner. By intensifying their selfdisparagement, they hope ultimately to provoke their unprincipled partner not only to admit his or her acts of dishonor and exploitation, but to feel contrite and loving. This signifies, in effect, masochists’ belief that they must submit and denigrate themselves in order to be loved and cared for by another. The self-contempt that masochists feel necessitates that they assume an inferior and contemptible role with others. Hence, even when making an appropriate request, masochists feel that they may be taking undue advantages of another. Either they refrain from the request or they do so apologetically and deferentially. Along this line, they will fail to defend themselves when treated in an insulting and derogatory fashion. They behave as if they were defenseless, easily exploitable, a ready prey for those who seek to take advantage. There is an inverse ratio, as Horney (1939, 1950) has put it, between success and inner security. Masochists’ achievements in relationships or an occupation do not make them more secure, but more anxious. Fearing retribution, even total annihilation for their presumption of possessing worthy gains, they will neither stand up for their rightful awards, nor counter any expression of anger and resentment directed at them.

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Their dismay can be expressed only in disguised or denied forms. Only in the most extraordinary circumstances will they reprimand, reproach, or accuse others, even in a joking or sarcastic way. Of course, to be self-effacing, to suffer and restrain oneself from success and self-assertion provides an alibi for not achieving much in life. Masochists can thereby save face, both in their mind and in the eyes of others, for their self-induced deficiencies and failings. Diffident Cognitive Style Masochists are unsure of themselves, reluctant to assert their views, and tend to be selfeffacing and restrained in their interpretation of life events. Disposed to construe events as troublesome and problematic, they are hesitant to see life in a positive light for fear that optimism will ultimately result in troublesome and self-denigrating aftermaths. As a result, masochists bring to their interpretive inclinations a habit of expressing views and anticipations that are pessimistic in orientation and contrary to favorable consequences. Not only do they express pessimistic and negative feelings, but whatever positive attitudes may be engendered are likely to be voiced without any genuine enthusiasm. One might wonder how this singularly heavy outlook can be maintained without being devastated or collapsing under its own weight. What is surprising is that masochists appear never to be undone by their persistent apologetic and self-deprecating attitudes. Observation over a period of time is likely to find that these self-reproachful attitudes are largely overdone, artificial, and forced, presenting an exaggerated fac¸ade of simulated communications. In great measure, masochists’ public posture of inadequacy, their voiced deficiencies and sense of demoralization, are designed (though unconsciously so) to deflect or defeat those who they believe may assault and demean them. An apt analogy is the forest wolf, who, concluding that a fight to the finish would result in his annihilation, effectively thwarts his enemy by admitting his inadequacy, exposing his weakest link, his jugular vein, and thereby exhibiting that he is no longer a threat to his enemy. Similarly, by overtly exaggerating their weaknesses and ineffectuality, masochists turn away the aggression of others. Undeserving Self-Image Masochists are overtly self-abasing, inclined in public to focus on their very worst personal features. As they see it, they have failed to live up to the expectations of others, despite their repeated efforts at self-sacrifice (Blizard, 2001). Hence, they deserve to suffer painful consequences and should feel shamed, humbled, and debased. In some masochists, this self-effacing, undeserving image is so extreme as to lead them to conclude that anything that exemplifies personal achievement or competence could only have been the result of good luck or the contributions of others. To have a strong personal conviction or opinion is potentially endangering, a position that masochists will quickly yield when facing an opposing viewpoint or interpretation. A public commendation of their work is usually judged to have been mistaken, an erroneous

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observation that fails to recognize their core deficiencies and inadequacies. Masochists do not seek to strive, to reach out for more than they have, because to do so challenges the fates and exposes them to potential humiliation and denigration. Nothing should ever be done just for oneself. Requiring little keeps them in a small and protective shell, one in which they can maintain to a minimum any ridicule and deprecation. As in the previously described section on cognitive style, we will find on closer examination that many self-sacrificing and unassertive masochists are preoccupied, not with the welfare of others, but with their own suffering and resentments. What appears on the surface to be a sympathetic and self-sacrificial attitude often cloaks a lack of genuine empathy and a distrust of others. Discredited Object Representations As masochists reflect on aspects of their past experience, but even more so as they transform their memories, the inner template of their objects and events comes to have a distinctly negative tone. Their past relationships are recast to signify problematic failures, and their own personal achievements are disparaged. Affectionate and erotic feelings of the past are transposed to their least attractive opposites. Adding further insult to these transmutations of past realities, unmodified internal conflicts are intentionally aggravated. In a similar fashion, mechanisms for reducing dysphoric feelings are subverted by processes that intensify the discomfort level of the masochist’s recollections. Owing to their early life experiences, masochists are likely to assume that all close relationships contain at their roots the potential of new frustrations and deprecations. In the main, they transmute their current everyday experiences to reproduce the past frustrations and cruelty that remain in their intrapsychic world. Some recognize that there are genuinely caring persons in their environment, but they judge it to be the invariable misfortune with which they are cursed in life that such persons are not the people to whom they relate. As part of their intrapsychic dissonance, masochists struggle between internal images of being a tormentor themselves, and an innocent and abused victim. Thus, the selfand other-objects of their inner world are split into opposing elements, one convinced that others seek to destroy them, one convinced that they themselves wish to destroy others. Incapable of resolving this schism and thereby provide a genuinely positive attitude, the masochist bends over backward, as in a reaction formation, attempting with every resolve to be an unambivalently reliant and ever-sacrificing partner. Exaggeration Regulatory Mechanism Whereas regulatory mechanisms are internal dynamic processes designed to resolve or soften the psychic pain of objective realities, these processes are inverted in the masochist, at least for public consumption. Rather than lessen their public discomforts, these personalities recall and exaggerate past injustices to raise their overt experience of distress. Similarly, they go out of their way to anticipate and magnify likely future

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Clinical Picture

167

disappointments as a means of raising their expectation of distress to levels consonant with their negative orientation. Furthermore, masochists often undermine their personal plans and sabotage their good fortunes so as to maintain or enhance the level of suffering and pain to which they have become accustomed. As noted by Shapiro (1981), these patients dwell on their misfortunes, not only for public purposes, but to manage their personal discomfort and private suffering. Despite the melodramatic public fashion in which they exaggerate the incidental grievances of the past, exaggeration reflects the operation of a useful defensive maneuver in that it enables the masochist to control and recast his or her sources of bitterness. By repetitively recreating in their mind early humiliations and injustices, masochists are able to diminish the actual pain and deprecation they suffered. As in the implosive therapeutic technique, excessive exposure to painful and threatening stimuli ultimately diminishes their impact and power. So too is exaggeration an inverted form of selfprotection and pain diminution. By exaggeration they have diminished their suffering. They can now control it, compartmentalize it, bring it up at will, transform and moderate it; in effect, they can now be in charge of past discomforts, play them out, manipulate them, make them less painful than they may have been, should that be their intrapsychic desire. Inverted Organization As is typical of personalities who are intrapsychically ambivalent or discordant, such as masochists, their morphological structures possess contrasting and dual qualities. One segment of their inner world is structured in a more or less conventional fashion; the other reflects opposing or contradictory components. Thus, masochists exhibit a reversal of the pain–pleasure polarity, experiencing pleasure when pain would be more appropriate and vice versa. As a consequence, they exhibit a repetitive undoing of intention and affect. There is a frequent transposition of channels of need gratification so that frustration results. Most problematic, their inverted structural organization and dynamic processes result in actions that produce perplexing, often antithetical, if not self-undoing, consequences (Parker et al., 1999). As with most complex phenomena, the structure of personality undergirds many functions in the economy of the mind. Conventionally structured, the components of the mind serve to gratify instinctual drives, impose social constraints by means of psychic expiation and punishment, and provide methods of adapting to life’s realities. As in the case of the sadist, the compulsive, and the negativist, the masochist possesses intrapsychic structures that are in intrinsic opposition. For example, structural inversion of the basic polarities results in masochists assuming that they are loved most when they suffer most, generating the conviction that when they desire love, they must first seek to suffer. Rather than pursue affection in a straightforward fashion, masochists may need to engage in a form of “naughtiness,” hoping thereby to elicit a rejecting or scolding response from the significant other; the assumption that

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carries them forward is the belief that forbidden behaviors will ultimately evoke love in return. It is often quite puzzling and perplexing to track these reversals of what are usually straightforward and natural orientations. By defeating themselves, masochists seek not only to avoid being beaten and humiliated, but to elicit nurture and affection. The direct pursuit of pleasure threatens them by evoking experiences of anxiety and guilt. Whether these processes stem from internalized bad objects is an interesting way to formulate the problem. This simply means that the person has internalized a punitive system that must be enacted when normal affectional desires are sought. One must suffer to be loved. Dysphoric Mood Masochists experience a complex of countervailing emotions. At times, they are anxiously apprehensive; at other times, they are forlorn and mournful. Many are disposed to feel anguished and tormented; these same individuals may exhibit a socially pleasant and engaging manner at other times. Some intentionally display a plaintive and wistful appearance, features that seem designed to induce discomfort and guilt in others. Suffering among masochists is not invariably designed to impress others; it serves as much to ennoble themselves. Once the fact of suffering is established, masochists effectively accuse others and excuse themselves. They seek in every way possible to dampen their own spirits, as well as those of others. At times of deepening distress, however, there is a powerful appeal for masochists to simply let things go, just giving up what they feel to be a hopeless struggle for consistent and reliable love, for meeting the self-sacrificial demands imposed on themselves, to be free of the terror of everyday life. All of these feelings can create a sense of ultimate triumph, a way to escape forever, to be done with it all. The broad dysphoric mix of emotions we often see in masochists serves to glorify their ultimate state of misery, providing proof of the fundamental nobility of their suffering.

Self-Perpetuation Processes As the interim label for masochistic personality clearly indicates, these individuals are “self-defeating”; that is, what they do further intensifies their difficulties and undoes any promising advances in their lives. Although the very notion of self-perpetuation is therefore intrinsic to the aggrieved/masochistic construct, it may be useful to specify some of the more explicit ways these personalities undermine their own healthful progress (see Table 5.2). Self-Demeaning Masochists are specialists in beating themselves down, disparaging, belittling, ridiculing, and being contemptuous of themselves. Although there are considerable differences among masochists in the degree to which they are aware of these denigrating processes,

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Self-Perpetuation Processes

Table 5.2

169

Self Perpetuating Processes: Aggrieved/Masochistic Personality

Demeaning of Self Undoes good fortunes Takes nothing of self seriously Persists in being ineffectual and hopeless Dependence on Others Self-worth determined by others’ judgments Fears abandonment when uncertain of support Tolerates abuse for fear of abandonment Intensifies Abuse Believes disparagement is deserved Increasingly accusatory of others’ treatment Becomes righteously indignant at wrongs perpetuated

they all add up to diminishing their capacity to take anything that they do seriously; they are surprised, if not astonished, when others judge their opinions and attitudes to be of consequence. Not only are they unable to appreciate their own talents and achievements, but, as has been stated previously, they seek to undo whatever good fortune may accidentally have come their way. As a consequence of demeaning their own self-worth, these individuals greatly impair themselves, preclude any form of spontaneous self-assertive behavior, exaggerate their difficulties, and, in effect, submerge themselves in a pervasive feeling of helplessness and ineffectuality. Not only do these behaviors undermine their competence and self-esteem, but they throw themselves into an abyss of lifelong misery that is quite disproportionate to the circumstances that their life experiences would justify. Hence, through their own actions and exaggerations, they place themselves repeatedly in positions of almost irrevocable disgrace and contempt. Dependence on Others In a manner similar to the dependent personality, masochists have devalued themselves to such an extent that it is only others who can judge their self-worth. Their psychic state rises or falls with the attitudes that others have of them. Devaluing themselves has made them entirely dependent on others for judging the adequacy with which their self-sacrificial behaviors have met others’ desires. Their self-minimization forces them to turn to others to provide them not only with feelings of security, but with a sense of salvation. Should their self-denigrating and self-abasing behaviors fail to be recognized,

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their search for appreciation may begin to take on a frantic character, further reducing their sense of self-esteem. Masochists’ fear of being abandoned and isolated becomes prominent at times when they are unsure of their value in the eyes of significant others. They are unable to be alone for any length of time and feel lost and rejected, cut off from the stream of life. Fearful as these insecurities may be, they can be overcome by any form of connection to others; abuse can be tolerated as long as it is kept within extreme limits. As long as masochists can remain connected and needed, regardless of how much abuse they receive, they will not feel the nameless terror of being totally abandoned. Hence, they must keep attached at all costs, regardless of the humiliation and derogation they experience. To be alone is the ultimate proof that they are not only unwanted and rejected, but disgraced and forsaken. Intensifying Self and Other Abuse Although masochists have undoubtedly experienced troublesome early relationships, we know that they also transform new life events to conform with those of the past. This distorting process creates a series of unrealities. Not only do they suffer anguish, shame, and guilt for every shortcoming or failure in their lives, but they are hyperscrupulous about their own behaviors and circumstances, such that everything they do or observe deserves to be ridiculed and disparaged (Lebe, 1997). They are “injustice collectors,” seeing unfairness, if not derogation, in those who do not appreciate their self-sacrificial behaviors. A problem that may arise here is a growing indignation felt toward those whom they see as having humiliated them. This reversal from self-denial into a more openly critical and negative attitude toward others reflects a desire to quiet their idealized self-image and conscience. Although they judge themselves to be unworthy, they do not judge themselves so unworthy as to continue to have abuse heaped on them in spite of their willingness to carry undue burdens and to persist in their self-sacrifice. As this reversal of characteristic behaviors becomes intensified, masochists begin to discharge their misery and assert a feeling of entitlement, a confused and disillusioned state that leads them to want others to make up for the injuries they feel have been perpetrated on them throughout life. No longer is the masochist merely a self-pitying person who feels unfairly treated, but he or she now rises up in a rather pathetic form of righteous indignation. The more masochists distort the actions of others as being accusatory and abusive, the more frantically are they likely to exaggerate the wrongs that have been done to them and the more deeply they feel that recompense is their due. Should their vindictive anger break into consciousness, it will mar their idealized image of being virtuous and magnanimous, violating their inner image of being self-sacrificing and all-forgiving. Hence, the expression of previously repressed resentments becomes a disruptive element of considerable magnitude. In addition to the inner turmoil it creates, masochists may

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have provoked others into rejecting them even further, leading them thereby to be doubly ignoble, both victim and perpetrator.

Interventional Goals Whereas the aggrieved/masochistic patient’s self-defeating behavior pervades all aspects (personal, social, and occupational) of his or her functioning, the self-sabotaging tendencies are seen primarily in the area of interpersonal relationships. Despite relatively adaptive adjustment in some spheres of life, there often exists a long history of abusive relationships that combines with an apparent lack of understanding of his or her role in inviting maltreatment. Although patients may lament years of undeserved victimization and suffering, they often continue to behave in excessively deferential and self-demeaning ways, making no attempt to constructively alter the dynamics of exploitive relationships (Grand, 1998). The therapist may marvel as a patient sabotages potentially positive interactions and rejects opportunities for involvement with caring and considerate individuals, dismissing them as boring or otherwise inappropriate companions. Lacking the experience of deriving rewards from behaving in an interpersonally competent and self-respecting manner, and having no coherent personal identity other than victim, the masochist is threatened with a loss of self in giving up his or her usual ways of relating. Suffering provides the masochist with an identity, a sense of value, and predictable interactions. The therapist working with a masochist has to keep in mind that much work will have to be done to provide the patient with the foundations of a healthier self-concept. Resistance to adopting new modes of interaction will be reduced as self-respecting behavior can be meaningfully incorporated, rather than posing a threat to the only identity the masochist has known. The therapist must point out behaviors that provoke hostile reactions from others, as well as empathize with the patient’s tendency to perpetuate his or her victimization. Eventually the patient may come to internalize the therapist’s empathy and positive regard, making the patient more amenable to change. Much of masochists’ difficulty is based on a pain–pleasure discordance that draws them to situations and individuals that cause them pain. Reestablishing a balance on this polarity can help patients acquire more adaptive behaviors. Also, a shift on the active–passive dimension can lead to constructive rather than self-defeating attitudes and actions. Intervention in the masochist’s dysfunctional domains is intertwined with the former objectives. Cognitive interventions that produce change in these patients’ cognitive style, exploring the developmental history of their difficulties, and behavioral interventions that teach assertiveness and social skills may allow masochists to replace customary interpersonal deference with respect-fostering relationships. Strategic plans

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172 PERSONALIZED THERAPY FOR THE AGGRIEVED/MASOCHISTIC PERSONALITY PATTERNS Table 5.3 Therapeutic Strategies and Tactics for the Prototypal Aggrieved/Masochistic Personality Strategic Goals Balance Polarities Reverse pain–pleasure discordance Strengthen active-self focus Counter Perpetuations Stop willingness to be abused Avoid self-demeaning experiences Prevent the undoing of positive events Tactical Modalities Moderate dysphoric moods Revoke undeserving self-image Unlearn interpersonal deference

of action, as well as increased insight, can help patients reduce their tendencies to allow others to abuse them (see Table 5.3). Reestablishing Polarity Balances To accomplish the goal of restructuring the masochist’s disordered personality, a balance needs to be established on the pain–pleasure and active–passive polarities. A major problem of masochists is their distorted and inverted focus on life-preserving experiences. The tendency to perpetuate unpleasant situations stems from the fact that the masochist’s identity is intertwined with suffering and the victim role. As described throughout this chapter, many masochists learned in childhood to misidentify abuse as love. To modify their self-sabotaging and abuse-perpetuating behavior, they first need to clarify and internalize the difference between loving and abusive behavior, that is, between pleasure and pain. Work must also be done to help them develop a more adaptive and positive self-image. Interventions aimed at cognitive reorientation can be effective in this regard. Once these patients become cognizant of and begin to overcome their victimized selfimage and self-inflicted pain, they may be ready to start overcoming their self-defeating passivity. Behavioral intervention, including assertiveness and social skills training, can prepare patients to relate to others in a more equity-fostering way. Patients can be taught to set aside time daily to engage in pleasurable activities, and can reward themselves in prespecified ways for appropriate interactions.

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Countering Perpetuating Tendencies A therapist working with an aggrieved/masochistic personality would be well-advised to focus efforts on helping the patient become aware of and change his or her problemperpetuating behaviors. Goals here are to counter the patient’s willingness to be abused, to be involved in self-demeaning experiences, and to engage in self-sabotage through the undoing of positive events. Cognitive interventions and exploratory therapies can help the patient expand his or her understanding of a fuller range of human interactions, allowing the patient to conceive of relational experiences that can work without victimization. Some masochists have learned to feel important or validated when others are hostile toward them. Masochists learn that a significant other’s cruelty relents when they are suffering, and from that conclude that their value increases with increments in their unhappiness. A growing understanding of this process may encourage patients to adopt new attitudes and interaction styles. Bolstering the patient’s self-esteem will further increase the likelihood that self-demeaning experiences will be avoided as they become less consistent with a changed and more positive self-image. Some patients may benefit from pharmacological intervention as an adjunct to dyadic treatment. Antidepressants may bolster improvements in self-esteem and reduce guilt. In conjunction with new ways of thinking about themselves and their environments, decreased guilt can help patients prevent the undoing of positive events that in the past had served as self-punishment for failings, as well as preserving their sense of identity. Identifying Domain Dysfunctions Central to aggrieved/masochistic personalities’ characteristic difficulties are their undeserving self-image and their dysphoric mood. Convinced that they have failed to achieve others’ expectations, masochists genuinely believe they deserve to be shamed and punished. Suffering is actively sought to ease their sense of guilt about perceived failings. Consistent with this self-image, masochists’ mood is dysphoric and ranges from anxiety to anguish. After years of believing themselves to be both inadequate and victimized, masochists display extreme self-denial and deferential interpersonal conduct. These modes of expressing themselves and relating interpersonally serve a preconscious purpose. They help maintain consistent and predictable internal and external representations of the self as a suffering, inferior individual. By behaving in a self-effacing and unpresuming manner, and by declining to participate in pleasant activities and denying any experiences of joy, masochists can also atone for inadequacies and render themselves beyond reproach. Convinced that pleasure and fun are undeserved and in fact beyond their capacity, masochists find that suffering not only eases their guilt but is the only feeling they can allow that is better than the prospect of an inner nothingness. Not only do these patients

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feel unjustified in attempting to feel better, but their suffering and helplessness serve to provide a tangible identity and social role. The role of depression in the patient’s dysphoric mood should be carefully evaluated. Psychopharmacological intervention in the form of antidepressants may be indicated for some patients. Improved affect and self-esteem can help motivate them to continue working toward more permanent structural personality changes. For some masochists, the tendency to be self-sacrificing, even to invite exploitation and accept undeserved blame, has other self-serving functions. Experiences with punitive adults in childhood may lead to equating maltreatment with love, leading some masochists to search out powerful and oppressive others and to play the complementary part to satisfy their need for affection. Others have learned that a punitive parent was in fact most loving, or at least less cruel, when the masochist’s suffering was most evident. Overt expressions of suffering in adulthood may thus serve to appease significant others or, as the only weapon in the masochist’s arsenal, to punish them and make them feel guilty for not meeting his or her needs. A therapist working with an aggrieved/masochistic personality is going to encounter much resistance in trying to modify the patient’s poor self-concept. Methods of cognitive reorientation can help patients realize that their diffident cognitive style maintains their difficulties. Self-effacing and unsure of themselves, masochists construe events as troublesome and problematic for fear that optimism will ultimately result in disappointing and self-denigrating aftermaths. More adaptive ways of thinking can help to alter the basis on which these masochistic behaviors are built. In time, the patient may stop repetitively recalling past injustices, anticipating future disappointments, and undermining personal objectives and good fortune to maintain his or her accustomed level of suffering and pain. Insight-oriented therapy can help identify the developmental causes of the masochist’s discredited object relations. The patient can learn that although his or her parents confused love and abuse, not all people do. Behavioral interventions can teach assertive social skills that provide the patient with new modes of interacting. Successful therapeutic intervention should help reorganize the patient’s personality structure so that its organization is no longer inverted. Once the pain–pleasure polarity has been rebalanced, the channels of need gratification and frustration should no longer be transposed. This adjustment can help the patient strive for reward rather than pain, resulting in more adaptive behaviors.

Selecting Therapeutic Modalities Aggrieved/masochistic patients are likely to elicit a number of antitherapeutic countertransference reactions from their therapists. However, a consistently warm and empathic alliance can provide a prototype for self-evaluation that the masochist can internalize over time and draw on in working to overcome self-defeating tendencies.

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Behavioral Techniques Behavioral interventions can help masochists change their tendency to be victimized in relationships. Social skills training can expand their interactional repertoire beyond their typical abuse-inviting and self-denigrating subservience. Assertiveness training can help patients learn how to enforce personal limits that prevent abuse. Learning to express their desires allows masochists to have their needs fulfilled directly, and obviates the need for passive-aggressive behaviors, as well as manipulative displays of martyrdom and suffering. Helping the patient overcome individual self-defeating behaviors begins with a careful analysis of the patient’s interactions. Aggrieved/masochistic behaviors need to be identified, as do the circumstances that trigger them. Enjoyable and esteembuilding events and activities should also be noted. By keeping a record of daily events, behaviors, and moods, interventions to help change self-sabotaging tendencies can be devised. The patient’s dysphoric mood also needs to be targeted. Esteem-building activities, as well as material reinforcers, can be used as rewards for behaving more adaptively and for carrying out assignments successfully. Interpersonal Techniques Some behavioral intervention programs include the patient’s significant others, who are called on to facilitate communication and to guide and support interactions in the patient’s natural environment. Toward this end, interpersonal approaches can highlight the role of the patient’s own actions in initiating and maintaining self-defeating patterns. In interpreting the patient’s behavior, the therapist needs to keep in mind that many masochists are not fully aware that they have contributed to their own abuse, nor that their own behavior leads them to fall repeatedly into the victim role. The process by which they seek abusive partners and by which they provoke benign others to denigrate them is largely unconscious. Although it is important for the therapist to point out to patients that their parents’ punitive attitudes have been internalized in the form of self-criticism, outright blaming by the therapist of the parents may create patient resistance that may interfere with therapeutic progress. Guilt over anger at idealized parents can be too much for some patients to bear. The therapist can point out to the patient his or her victim role in present relationships. The value of asserting one’s rights and of learning skills to avoid or stop maltreatment needs to emphasized. More adaptive modes of interaction should be explored. Including aggrieved/masochistic patients in treatment groups can be helpful in providing the patient both with support and with assertive role models. However, the group therapist should watch out for the possibility that the patient will sacrifice his or her own needs for the benefit of other members and inadvertently be reinforced in the martyr role. Alternatively, group members may become frustrated when, after hours of attempting to find solutions for the masochist’s difficulties and providing overt support, the masochist continues to protest that his or her situation is hopeless

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and that he or she is also hopeless. The unpleasant feedback may be destructive to a newly burgeoning sense of self. Couples intervention can be helpful if the partner is willing to cooperate, but we know that masochists often pair up with a range of abusive types. If the partner is willing, role-playing and role reversals can help the couple understand the dynamics of their interaction and how it perpetuates self-defeating tendencies. Cognitive Techniques Cognitive approaches in the treatment of the aggrieved/masochistic personality are similar to the ones employed for reducing depressive symptomatology and emphasize directly challenging the patient’s self-sabotaging assumptions through logical reasoning (Bernstein, 2002; Neziroglu, McKay, Todaro, & Yaryura-Tobias, 1996). By keeping track of events, thoughts, and moods, masochistic patients can learn how much of their suffering is directly related to their appraisal of their environment and of themselves, and how much to their self-demeaning attitudes and behaviors. Once negative automatic thoughts have been identified, they can be evaluated and modified (Beck & Haaga, 1992) by teaching patients to ask themselves such questions as “What’s the evidence?”; “Is there any other way to look at it?”; “How could alternative (less pessimistic) explanations be tested?”; and “What can I do about it (to make it better)?” The tacit beliefs on which automatic thoughts rest also need to be identified and altered for lasting change to occur and for negative thoughts not to resurface in a new form. Past experiences that have led to the patient’s poor self-image can be discussed, and the role of dysfunctional cognitive habits such as overgeneralization, arbitrary inference, emotional reasoning, and dichotomous thinking in maintaining it can be confronted directly. A basic strategy is to help patients realize that their thoughts are inferences and not facts about themselves and the world. Predictions can then be made and experiments devised to test their validity. Self-Image Techniques A useful initial approach with the masochist, as with all personality disorders, is the adoption of a supportive orientation. Most aggrieved/masochistic patients will anticipate rejection and/or humiliation by the therapist and will provoke him or her to fulfill expectations (Noyes et al., 2001). Establishing a therapeutic alliance in which the therapist expresses sympathy for the patient’s tendency to elicit negative reactions from others, and thus punish himself or herself, can help the patient adopt a less harsh self-concept. This should help these patients understand that they do not deserve to suffer and, hence, contribute to building a more positive identity. Much like depressive patients, masochists often suffer from excessive shame. The therapist’s sympathetic reassurance that the patient has suffered enough can mobilize the patient to work toward a more adaptive and satisfying way of life. Also like depressives, masochists may deny or repress their resentment of others and fail to recognize that hostility and a desire to punish others is guilt-inducing and reactivates the vicious

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circle that leads to personal suffering. Helping patients to acknowledge their feelings of resentment, and to express them more directly, can make it easier for them to develop a self-concept that is inconsistent with the victim role. Once the patient comes to trust that the therapist’s supportive empathy toward his or her self-destructive tendencies will not be transformed into abusive derision, the probability of the patient’s benefiting from other interventions is greatly increased. Intrapsychic Techniques Psychodynamic approaches to treating the aggrieved/masochistic personality tend to conceptualize the patient’s behavior to be a result of his or her childhood relationship to a withholding or cruel parent (Lebe, 1997). The child defended against his or her greatest fear—abandonment by the parent—by assuming a self-deprecating and defeated position that served to complement the parent’s behavior (Gladstone et al., 2004). As in most other approaches, the importance of the patient-therapist relationship is emphasized (Slote, 2000). Whereas the classic psychodynamic therapist stance is neutral and reserved, it has been suggested that, with the masochistic patient, this approach may create an atmosphere of inequality that is too conducive to aggrieved/masochistic transference reactions reminiscent of the parent-child relationship (Glickauf-Hughes & Wells, 1995). Instead, the therapist’s conscious self-presentation as a fallible human being may help prevent the patient from trying to act out the unconscious wish for submission to avoid abandonment (Magnavita, 1997). Regardless of the therapist’s sensitivity, aggrieved/masochistic patients will likely seek to frustrate the therapist’s efforts with negative therapeutic reactions, as well as challenge the therapist by claiming that nothing can help them (sometimes even blaming the therapist for making them worse). Brenner (1959) sees masochistic tendencies as serving four separate functions: repetition of the patient’s reactions to childhood conflict, defense against feelings of loss or helplessness, expiation, and unconscious gratification. Persistent yet sympathetic interpretations of the patient’s self-defeating attitudes are recommended, as objective statements are likely to leave the patient feeling criticized and worthless. The realistic need to point out the patient’s less attractive tendencies should be balanced by a warm and relatively self-revealing therapeutic stance to avoid having the patient internalize the therapist’s interpretations as insults. Berliner (1947) suggests that the therapist begin to bring the patient’s self-defeating behaviors to awareness through examination of relationships outside of therapy. By pointing out that the patient’s accusations and complaints all relate to individuals the masochist loves or cares about, the therapist can avoid an intense transference reaction that might lead to excessive acting-out. Once the patient achieves some insight into his or her aggrieved/masochistic patterns, any acting-out that does occur in the context of the therapy becomes easier to interpret. Berliner (1947) suggests that the patient and therapist can then proceed to work through the patient’s identification with the aggressor (Berman & McCann, 1995). The patient can thus come to appreciate how much of his or her self-criticism is due

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to external reinforcement, and can thus learn to differentiate between love and cruelty. Eisenbud (1967) suggests that another avenue that leads to therapeutic success is to target the masochist’s feelings of inadequacy and need for efficacy. Pharmacologic Techniques Self-defeating personalities often develop depression after years of abuse and selfsabotaging, which then serves to maintain the aggrieved/masochistic tendencies. Evaluating the appropriateness of psychopharmacological intervention for the patient may serve as a useful first step to regulate mood. To guard against the patient giving up in the interim, it is important for the therapist to emphasize that there is a lag between the onset of antidepressant medication and its psychoactive effects.

Making Synergistic Arrangements What arrangements should be planned to maximize the efficacy of the individual domain-oriented techniques one might employ with these difficult patients? Aggrieved/masochistic patients tend to have negative reactions to therapy and to resist change, making a supportive stance a useful way for the therapist to establish initial rapport. Patience and consistency, despite the patient’s provocations, can aid in solidifying the masochist’s trust that the therapist will not abuse his or her “superior” position in the relationship. If after careful evaluation the patient is judged to be suffering from a concomitant depression, appropriate antidepressant medication can help provide him or her with the motivation to persevere through more anxietyprovoking exploratory and cognitive work. If the patient’s partner is amenable to entering couple therapy, this can help provide the patient with a supportive home environment and insight into interaction patterns. Behavioral couples intervention can teach the couple more adaptive ways of relating. Group treatment is another potential adjunct that can help increase the patient’s social appropriateness and assertiveness skills. If it is deemed more preferable, behavioral interventions can also be integrated into the primary dyadic therapy.

Illustrative Cases As noted previously, there has been considerable controversy concerning the concept of a masochistic or self-defeating personality disorder. The decision to delete this personality pattern from the DSM-IV nosology is an unfortunate one, as we perceive it. That the original formulation was interpreted in a specific and narrow manner by psychoanalytic thinkers early in this century was also unfortunate. The intense reaction by feminists to the original psychoanalytic formulation was justified. The solution favoring dropping the disorder from the official classification, however, was not a wise one, in our estimation. A better solution would have been to illustrate the

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Table 5.4

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Aggrieved/Masochistic Personality Disorder Subtypes

Self-Undoing: Is “wrecked by success”; experiences “victory through defeat”; gratified by personal misfortunes, failures, humiliations, and ordeals; eschews best interests; chooses to be victimized, ruined, disgraced. (Mixed Masochistic/Dependent Subtype) Oppressed: Experiences genuine misery, despair, hardship, anguish, torment, illness; grievances used to create guilt in others; resentments vented by exempting from responsibilities and burdening “oppressors.” (Mixed Masochistic/Depressive Subtype) Virtuous: Proudly unselfish, self-denying, and self-sacrificial; self-asceticism; weighty burdens are judged noble, righteous, and saintly; others must recognize loyalty and faithfulness; gratitude and appreciation expected for altruism and forbearance. (Mixed Masochistic/Histrionic Subtype) Possessive: Bewitches and ensnares by becoming jealously overprotective and indispensable; entraps, takes control, conquers, enslaves, and dominates others by being sacrificial to a fault; control by obligatory dependence. (Mixed Masochistic/Negativistic Subtype)

many roots that individuals travel to become manifestly “self-defeating,” only one of which reflects the developmental theme proposed by analytic thinkers. Almost all of the personality disorders are self-defeating in the sense that they engage in self-perpetuating patterns that foster the continuation of their already established pathologies. Hence, we have also argued that the original term assigned this personality type, “masochistic,” would be the better choice of the two designations. As we have stressed, the original analytic conception describes only one of several types of masochistic behavior. Its developmental dynamics are manifold, and it is the purpose of the following cases to illustrate a number of the subtypes of the personality, subtypes that differ not only in the descriptive picture they manifest, but in the developmental course that leads to the clinical state (see Table 5.4).

Case 5.1, Randi P., 30 An Aggrieved/Masochistic Personality: Self-Undoing Type (Masochistic with Dependent Avoidant Traits) Presenting Picture Randi could be described as the quintessential team player, contributing with excellence to the good and welfare of others, but generally tripping herself up or somehow undoing her good standing. She was referred through her employee assistance program after a period of turning in important projects late, or even

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180 PERSONALIZED THERAPY FOR THE AGGRIEVED/MASOCHISTIC PERSONALITY PATTERNS leaving them incomplete. Her company did value her highly, owing to her outstanding work on group tasks that she did not lead, but she seemed to have become totally incapable of getting her own work accomplished. She quickly became agitated and teary-eyed in therapy at the mention of completing a task for which she might receive accolades, and this extended in duties from the mundane to the sublime. Whether it was an important document that she wouldn’t turn in because she was “too intensely involved with it to call it finished just because of a deadline,” or her disorderly apartment, which she would get almost perfectly clean before returning it to a state of disarray, Randi found extraordinary discomfort in anything remotely resembling success. As therapy continued, Randi disclosed various problematic encounters with her parents, particularly with her mother. It seemed that in various exchanges, her mother had instilled Randi with a sense of guilt for taking any credit for any accomplishment that included anyone else’s input, but also had routinely rewarded sick or helpless behavior. An attractive and intelligent woman, she also complained that in her dating life, she would almost always “blow it” just as a relationship was getting off the ground. Initial Impressions A major manifestation of aggrieved/masochistic behaviors is found in what has been termed the “success neurosis”; here, the deeper layers of psychic experience react to being successful by provoking intense anxieties and guilt, rather than pleasure and happiness. Success is responded to as if it were a horrible disaster. Rather than suffering these consequences, Randi undid herself, behaving in ways that provoked failure, humiliation, or punishment, which is what characterizes Randi as a selfundoing masochist. In effect, she repetitively did the opposite of what objectively was in her best interest. Although striving to achieve and perform her best, she either stopped short of its attainment, quickly proving herself insufficient to the task or undeserving of its rewards. For Randi, there was more relief in sharing her troubles and failures than there was reward in experiencing the pressure of trying to live up to being successful and happy. In many regards, she was akin to avoidant personalities in that avoidants anticipate that they will ultimately fail or be disillusioned, even when matters appear to be going well for the moment. Rather than be disappointed when things “inevitably” would turn sour, Randi quickly undid herself before she could be undone by others. She would rather be seen as a victim of unfortunate circumstances, largely self-created, of course, than someone who had sought rewards and gains and was expected thereby to maintain them and to behave in a valued and proud way. Moreover, in her developmental background, her life had been better for her when she was suffering than when things were going well for her. Thus, as a young child, Randi learned that her otherwise mean-spirited and critical mother stopped her abusive behaviors when she was ill, and so Randi also learned that being ill was the

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more comfortable state. She acquired a general belief that suffering was greatest when things were apparently going well rather than when she was in pain and discomfort. Hence, when faced in later life with opportunities for achievement and happiness, she stepped back from these possibilities, fearing that more suffering would happen in “good” circumstances than when things were apparently problematic. Randi would likely have difficulty accepting rapid challenges to her deeply ingrained coping mechanisms, which kept her in a comfortable state of helplessness and disillusionment. Concrete goal setting would need to follow the establishment of comfort, inclusive of treatment of her dysphoric mood. More tangible, focused methods could be utilized carefully in these early stages to begin exposing her to competent responses rather than self-sabotage. As her level of comfort increased, she would be able to start reversing her expectations of failure that hastened “inevitable” catastrophe (actively circumventing pressures to succeed), as well as perpetuated her view of self as unworthy or undeserving of happiness. In later stages, she could start to reexamine objects that she has assimilated as discrediting, as well as further correct her reversed pain–pleasure spectrum. Concurrently, techniques would be implemented to bolster social confidence and satisfaction in relationships (enhancement of self and other). Domain Analysis Randi acceded to assessment procedures readily and produced valid profiles that were unremarkable in terms of response style. The combination of masochistic and avoidant traits revealed in the analysis of her MG-PDC included the following highlights: Expressively Abstinent: Randi seemed to demonstrate a phobic’s avoidance of pleasure, along with a reluctance to pursue goals in which she might have “run the risk” of receiving some recognition, accolade, or even validation of her accomplishments. Cognitively Diffident: There was a distinct tendency for Randi to avoid positive impressions of external events; she felt that should she view observations positively, she would endanger her well-being by becoming vulnerable to attack, criticism, or humiliation. By contrast, she held a deep belief that ineptitude on her part would be rewarded by safety and security. Alienated Self-Image: Randi did not embrace the positive social experiences necessary to view relationships and events in an optimistic manner; her reflections of feeling unappealing and inferior led regularly to her anticipation of rejection and derogation. Note that this implicit self-view corresponds closely with her more explicit cognitive domain, creating an enduring self-perpetuation.

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182 PERSONALIZED THERAPY FOR THE AGGRIEVED/MASOCHISTIC PERSONALITY PATTERNS Therapeutic Course Supportive therapy was all Randi could tolerate in the very first sessions, that is, until she was comfortable dealing with her most painful feelings. Psychopharmacologic treatment was employed from the outset as a means of diminishing her depressive feelings and controlling her anxiety stemming from anticipated rejection. Not only did she precipitate real difficulties through her self-demeaning attitudes, but she also perceived and anticipated difficulties where none in fact existed. She believed that good things did not last and that the positive feelings and attitudes of those from whom she sought support would probably end capriciously and be followed by disappointment and rejection. These assumptions were gradually undermined by a steadfast and reassuring, but not enabling, stance by her therapist. Validating her feelings while not reinforcing her concerns was effectively accomplished via motivational interviewing techniques aimed at clarifying some of these conflictual self-reflections. What had to be undone was the fact that each time she proclaimed her defectiveness, she saved herself from the pressure of potentially succeeding but also convinced herself as well as others of her failings, and thereby deepened her discontent and her alienated self-image. Trapped by her own persuasiveness, Randi repeatedly reinforced her belief in the futility of standing on her own and was therefore likely to try less and less to overcome her inadequacies. This therapeutic strategy aimed at undoing this vicious circle of increased despondency and dependency. As trust in her therapist developed, she became amenable to methods of cognitive reframing to alter dysfunctional attitudes and depressogenic social expectations (i.e., her diffident cognitive style); particularly appropriate were the methods proposed by Beck and Meichenbaum. An important self-defeating belief that this cognitive approach sought to reframe was Randi’s assumption that she must appease others and apologize for her incompetence to ensure that she would not be abandoned. The therapist showed her that this behavior exasperated those on whom she leaned most heavily. This exasperation and alienation then served only to increase her fear and neediness. She came, then, to recognize that a vicious circle was created, making her feel more desperate and more ingratiating. With increasing vigor, as she could tolerate it, therapeutic challenges and confrontations illustrating her dysfunctional beliefs and expectations were used to break the circle and reorient her actions less destructively. With changing beliefs, Randi was able not only to modify these perceptions, but to begin to put these new beliefs into more effective, less abstinent expressed acts. The interpersonal focus proposed by Benjamin and Klerman and formal behavioral modification procedures provided a means of learning autonomous skills and the growth of social confidence. To decrease the potential of a recurrence, later stages of therapy saw a shift in emphasis to focused dynamic methods, explored to rework her more troubled object attachments and to construct an even more solid base for competency strivings.

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Skillful attention was also needed to alter Randi’s ambivalence about dependency and her willingness to be used, if not abused. Unless checked, she had difficulty sustaining a consistent therapeutic relationship and was prone to deteriorate or experience relapses. Maneuvers designed to test the dependability of the therapist were frequently evident. To prevent such setbacks, empathic warmth was expressed to help her overcome her fear of facing her own feelings of unworthiness. Similar support levels were necessary to undo her wish to retain her image of being a selfdenying person whose security lay in suffering and martyrdom. She needed to be guided into recognizing the basis of her self-contempt and her ambivalence about dependency relationships. She was helped to see that not all nurturant parental figures would habitually become abusive and exploitive. Efforts to undo these self-sabotaging beliefs paid considerable dividends in short-term and possibly more substantial long-term progress.

Case 5.2, Lourdes D., 28 An Aggrieved/Masochistic Personality: Possessive Type (Masochistic with Negativistic Features) Presenting Picture Lourdes was unhappy with everyone, and she sought therapy because “I just give up. I want to do something like have you teach me how to hypnotize myself so I can pretend I’m somewhere else most of the time and then just keep on doing for everyone like I do. Or if you have any ideas on how I can change them, I’m all ears.” She was no stranger to pronounced and pervasive dissatisfaction with others; in fact, by her own admission, she experienced frustration and distress with just about every significant relationship in her life. It was also evident, both by objective assessment and subjective report, that she was doggedly determined to change only those around her and rather loath to examine her own expectations and behaviors. Most of her dissatisfaction, however, was focused on her husband, Eduardo, whom she described as “the perennially sloppy student,” as well as recently becoming “the embodiment of the ‘absent-minded professor.’ ” Lourdes claimed to have been single-handedly responsible for his completion of his doctoral degree, and she seemed quite convinced (and resentful) that her indispensable contributions as caretaker, confidante, personal secretary, homemaker, and “adult nanny” allowed him to be the man that he was. At the same time, she was adept at making sure her

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184 PERSONALIZED THERAPY FOR THE AGGRIEVED/MASOCHISTIC PERSONALITY PATTERNS influence was known to him and that certain aberrations from the norm would not occur. For example, Lourdes was quite instrumental in her husband’s sabotage of a lengthy friendship he had with another woman. Similar behavior occurred outside of the marriage, as well. A notable example was her choice of employment as a personal assistant to a “clueless and slovenly” business executive. “All men are really little boys” seemed to be the catchphrase of her attitudes and, at the same time, determined her role in life as an underappreciated “Gal Friday.” She revealed that she had honed her caretaking skills as a child herself, as her father left when she was an adolescent, her mother had to work to support the family, and she had to assume the role of mother for several little brothers. She felt that this was a role that kept repeating itself throughout many years and situations. Clinical Assessment As with other masochists, Lourdes was constantly giving of herself and constantly reinforced by how much that giving of herself cost her, though this had a secondary gain. She was unable to let go of those to whom she was attached. Her need to be indispensable was so intensely self-sacrificial that others were unable to withdraw from her without feeling irresponsible, unkind, or guilty. Lourdes then effectively entrapped others, drawing them into a reciprocal dependency, disarmed by the depth of concern and interest she felt for them. Sacrificial to a fault, she found ways to make others feel simultaneously needy and fulfilled, less capable of functioning without the kindness and labors she would engage in to meet their desires. In effect, she controlled others by an obligatory dependence. Moreover, she was jealously overprotective and an indispensable collaborator, dominating those she possessed by sacrificing herself in every way they desired. This pattern of behaviors is seen in personality admixtures composed of core aggrieved/masochistic components permeated by characteristics most common to the negativistic style. Making ostentatious sacrifices, Lourdes insinuated herself repeatedly into the daily affairs of her spouse, friends, and employer. She made it her business to always be there, to be a vital and necessary contributor and advice giver. In this way, she sought to induce so profound a sense of obligation on the part of others that they would be unable either to repay her fully or to function effectively without her. This stratagem was effective; it created an emotional and obligatory dependence that forced others to be both submissive and yielding by virtue of psychic need and personal guilt. As a result of her maneuvers, Lourdes believed she had proprietary rights and was justified in enveloping and possessing others. She had suffered and had been kind and giving, all for the benefit of others. Whatever she, a possessive masochist, had done had been done for others, so she said; her kindnesses were intended to advance and better rather than to control and dominate their lives. On the surface, what she did appeared to be the opposite of what her ulterior motives may have been. In essence, she bribed others to love her, gave to others to control them, and became indispensable and hence possessive of them.

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Lourdes’s initial strategies of externalizing blame but seeming to thrive on her martyr status suggested that she was discomforted by the notion of focusing on herself, and a supportive approach would gradually help her feel more at ease. As Lourdes became more invested in processing personal issues, the therapist would begin to focus on faulty perceptions and beliefs, such as automatically interpreting events as negative, or arranging expectations in ways that she knew would fail (pain–pleasure discordance). Her actions would also need to be modified, providing healthier responses and interactions. Further in this vein, her self–other conflict, typical of her negativistic qualities, would require examination of her relational deference. Domain Analysis Lourdes initially balked at the prospect of her own domain analysis, until the therapist noted that “understanding yourself, which this will help you do, will assist us in understanding more precisely your expectations of others.” She acquiesced to the domain assessment at this point. The MCMI-III Grossman Facet Scales and MG-PDC revealed the following highlights: Expressively Resentful: Although this is a negativistic domain, Lourdes’s expression differed somewhat from the traditional quality. Instead of resisting expectancies from others in a passive-aggressive manner, she regularly fulfilled requests beyond expectation, openly expressing resentment at being underappreciated. Temperamentally Dysphoric: Lourdes’s emotional states were somewhat unpredictable, wavering between anxiously apprehensive, bitterly angry and grumbling, and tormented and forlorn; she appeared to express these emotions somewhat instrumentally, inducing guilt in others. Exaggeration Mechanism: Homeostasis for Lourdes was to be achieved in feeling acutely painful states, especially in terms of interpersonal disappointment. Immediate response to current let-downs invariably included invocations of past injustices to raise her dysphoria to validating levels. Therapeutic Steps A first goal in therapy with Lourdes was to demonstrate that the potential gains of therapy were real and that they should motivate her, rather than serve as a deterrent. Lourdes feared that therapy would reawaken what she viewed as false hopes; that is, it reminded her of the humiliation she experienced when she offered her trust to others but received rejection in return. As the therapist nondirectively acknowledged these fears, Lourdes was able to find an adequate level of comfort without having to distance herself from the therapist, learning to deal more effectively with her fears while maintaining a better level of adjustment than she had become accustomed to.

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186 PERSONALIZED THERAPY FOR THE AGGRIEVED/MASOCHISTIC PERSONALITY PATTERNS Through supportive, largely nondirective measures, Lourdes was able to talk through her expectations in a manner that was devoid of judgment, something she was likely to have anticipated from the therapist, although she may not have been aware of this. This approach also addressed Lourdes’s tendencies to demean her self-worth and to mistrust others, especially evident in her aversion to sustaining a consistent therapeutic relationship. Establishing the groundwork in this nondirective, unconditionally accepting person-centered paradigm began to dislodge perpetuations supporting her exaggeration mechanism, albeit indirectly. More focused and timelimited dynamic approaches would continue this work at a later stage. During this period, this supportive approach was also augmented by the use of Cymbalta, an antidepressant with some pain-blocking properties. Although not the focus of treatment, Lourdes had, as a part of some dysphoric feelings, mentioned vague and diffuse bodily aches often associated with mood-spectrum disorders. This pharmacologic agent was able to address physiologic and temperamental aspects of these complaints. These early-stage modalities were followed by a cognitive-behavioral approach, where attention was usefully directed toward resentful behaviors that, until now, had combined with her dysphoric temperament to perpetuate and reinforce her homeostatic expectations. Lourdes’s anxious demeanor and self-undoing actions, attitudes, and behavior could, in fact, be altered so as not to call up behaviors aimed at cutting off at the pass those humiliating and derogating feelings of long ago. Cognitive efforts to reframe the basis of her sensitivity to rebuff or her fearful behavior (e.g., Beck, Ellis) minimized and diminished not only her aversive inclinations but her tendency to relapse and regress. Another realm worthy of brief intervention was associated with Lourdes’s extensive scanning of the environment. By doing this, she increased the likelihood that she would encounter those stimuli she wished to avoid. Her exquisite antennae picked up and transformed what most people overlooked. Again, using appropriate cognitive methods, her hypersensitivity was prevented from backfiring, that is, becoming an instrument that constantly brought to awareness the very pain she wished to escape. Reorienting her focus and her negative interpretive habits to ones that were more ego-enhancing and optimistic in character reduced her self-demeaning outlook, intensified her positive experiences, and diminished her anguish. More probing yet circumscribed and focused dynamic techniques and procedures were useful in unearthing some of the roots of her anxieties and confronting those assumptions and expectations that pervaded many aspects of her behavior. This process began shortly after the initiation of the foregoing cognitive-behavioral interventions. These, as alluded to before, were aimed primarily at instilling alternatives to her exaggeration mechanism, but also provided insight and new understanding regarding the basis for her current difficulties. Couples therapy was employed as well, at this stage, to moderate destructive patterns of communication that contributed to or intensified her relationship problems.

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Case 5.3, Wanda K., 40 An Aggrieved/Masochistic Personality: Oppressed Type (Masochistic with Depressive Traits) Presenting Picture Wanda had just passed her fortieth birthday and was, to say the least, downtrodden by the state of her existence. She viewed life as though it was simply her destiny to be punished, and she “may as well just bring it on,” because escape from punishment was inevitable, and she “well deserved every last dollop.” Continually discouraged by repeated “failed” attempts to do anything well, she always assumed that the more benevolent efforts of others to assist her were simply tactics utilized to make her go away. “They all probably feel as though they’ve done their charity work by coming to my birthday dinner; no one has to deal with Wanda for a while now.” She even expressed this nuance to the therapist, stating to him, “You just want me to be happy so you can get rid of me; that’s all you want.” When the point was effectively refuted through skillful interviewing techniques, Wanda then very flatly and “automatically” expressed that she knew that the therapist, indeed, wanted to help her pursue happiness. She remarked that her husband (who had “put her up” to the visit) seemed to always be blaming her for the unhappiness in their apartment. According to Wanda, her husband felt that she was a very poor homemaker, and, by association, this accounted for their lack of friends, because “how can we possibly entertain people in a dirty shack?” She continued to elucidate that she did nothing well, be it work at home, duties as a wife, or tasks at the various jobs she had held in the past few years. Furthermore, despite her constant efforts to improve herself and her abilities, she felt that no one seemed to like her and that she was predisposed to failure and suffering in all of her undertakings. Clinical Assessment Oppressed masochists such as Wanda make use of all kinds of psychic symptoms and physical diseases to dominate and make their families and friends feel guilty. Anyone who was not responsive to the maneuver of psychological or medical illness was quickly prompted to fall in line by her guilt-inducing moans and groans, saying, in effect, “Don’t let my suffering make you think twice about me; overlook my suffering if you will, and do only what you think is best for you.” Ultimately, the ostensive victim, that is, Wanda, effectively triumphs over her true victims by making them feel guilty and obligated. To be clear, Wanda was not merely feigning her anguish; she experienced genuine misery and despair, felt tormented, and was often physically ill. However, these grievances were used secondarily, but quite effectively, to create guilt in others, enabling her to vent the resentments she felt and exempting her from responsibilities she may normally have been asked to carry out. As can be inferred from the preceding, Wanda, an oppressed masochist, formed an amalgam with features seen most prominently in the depressive personality disorder.

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188 PERSONALIZED THERAPY FOR THE AGGRIEVED/MASOCHISTIC PERSONALITY PATTERNS At times, hypochondriacal manipulations came to the fore with Wanda, when no other method of gaining love and dependence had been constructively achieved. Symptoms of illness were an effective and reliable way of assuring the receipt of attention and appreciation. Becoming a sorrowful invalid was a self-created suffering that forced others to be caring and nurturing. Wanda did not actually enjoy her state of suffering; it was merely a necessary, if discomforting, instrumentality to produce small benefits. By exaggerating real but minor discomforts, she was not merely making them public but, in effect, intensifying and making her suffering greater. It was the small secondary gains that made the process somewhat worthwhile. Not to be overlooked was the fact that the state of being oppressed exempted her from fulfilling responsibilities, and also allowed her to discharge resentments toward others for not having been sufficiently caring or supportive in the past. Feeling victimized by the ingratitude of others, she sought to make them feel guilty and to act responsibly and caring, attitudes and feelings they had failed to demonstrate previously. Wanda’s depressogenic state required immediate addressing of her downtrodden and depressed mood, as it would be nearly impossible to mobilize her from her presenting passive, lethargic orientation. A safe, empathic, and supportive stance from the therapist would be required from the outset, continuing throughout the therapeutic process. As the relationship developed and Wanda demonstrated her ability to focus on more difficult schemas inherent in her characterologic makeup, perpetuating tendencies to consider herself worthless and cast aspersions inward would be addressed, as well as the assumption that it was safer and more comfortable to be passively discontent (reduce pain orientation, strengthen self). She could then learn more competent skills and reduce the frequency of sabotaging positive events, as well as develop social skills that could lead to more positive interactions. Domain Analysis Wanda did not resist any of the assessment measures introduced for this intervention, and her response style was largely unremarkable, although she could be characterized as giving in rather easily, saying things like, “Well, you do know what’s best, doctor.” Highlights from the domain analysis, as gleaned from the MG-PDC, were as follows: Temperamentally Melancholic/Dysphoric: Very clearly, Wanda’s moods were, as she described, “heavy.” Most of the time they took on the “giving up” quality of the depressive style, with joylessness and tearfulness characterizing her affect, but on occasion, this would modulate to a worrisome and apprehensive quality. Worthless Self-Image: Beyond the typical “undeserving” quality of most masochists, Wanda made direct statements that characterized the most depressive and

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pessimistic self-view of considering herself “disposable,” valueless, and without even a singular meritorious quality. Cognitively Diffident: Whereas the depressive premonition is for a universally negative outcome, Wanda’s masochistic view anticipated the worst of outcomes for her personally, regardless of anything she felt she (or anyone) could or could not do to help. Therapeutic Steps In her thoroughly disconsolate state, Wanda feared that therapy might reawaken what she viewed as false hopes; that is, it might remind her of the disillusionment she experienced when she aspired in the past and was rejected. It was of primary importance to illustrate that therapeutic goals were, in fact, achievable, and that they could serve as motivation. As she had now found at least a perceived modest level of comfort by distancing herself from desires and withdrawing from others, it was important therapeutically not to let matters remain at the level of depressiveanxious adjustment to which she had become accustomed. Short-term techniques focused attention on her depressive tendencies to demean her self-worth and subject herself to the mistreatment of others. An antidepressant medication (in this circumstance, the SSRI Lexapro) was initiated at the outset of treatment to moderate her persistent dysphoria and pessimism. Directive humanistic measures (e.g., motivational interviewing) were used to counteract Wanda’s hesitation about sustaining a consistent therapeutic relationship, as she frequently and evidently employed maneuvers designed to test the sincerity of the therapist. This was expressing and symbolizing her fears that she would be found wanting, even by someone “who is paid to like her, like a therapist.” To state this in terms aligned with Wanda’s presenting domains, she felt herself to be worthless, and measures at this stage needed, in a more directive and focused manner than can be achieved with traditional humanistic approaches, to bring to light those ambivalences about “deserving” to get better. A warm and accepting attitude was needed because Wanda feared facing her feelings of unworthiness and because she sensed that her coping defenses were weak. With these skillful and supportive approaches, it was possible to prevent her tendency to withdraw from treatment before any real gains were made. At the cognitive-behavioral level, therapeutic attention was usefully directed to Wanda’s diffident assumptions, anxious demeanor, self-deprecating attitudes, and behavior that may have evoked unhappiness, self-contempt, and derogation in the past. Short-term and focused cognitive techniques such as those developed by Beck, Meichenbaum, and Ellis helped reduce her sensitivity to rebuff and her morose and unassertive style, outlooks, and fears that only reinforced her aversive and depressive inclinations. Cognitive methods were especially useful in exploring the contradictions in her feelings and attitudes. Without reframing techniques such as these, there

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190 PERSONALIZED THERAPY FOR THE AGGRIEVED/MASOCHISTIC PERSONALITY PATTERNS would have been a seesaw struggle, with periods of temporary progress followed by retrogression. Genuine short-term gains were achieved, but only with a building of trust and an enhancing of her shaky sense of self-worth, both of which lent themselves well to brief cognitive procedures. To diminish or even prevent relapse, more focused procedures were useful in reconstructing the interpersonal mechanisms that pervaded all aspects of her behavior, and she was taught, toward the end, replacement behaviors that were more characteristically competent than her previous tendency to appear incapable or inept. To augment this, Wanda also joined a group modality that helped her learn new attitudes and skills in a more benign and accepting social setting than she normally encountered.

Case 5.4, Helen M., 49 An Aggrieved/Masochistic Personality: Virtuous Type (Masochistic with Narcissistic Traits) Presenting Picture Helen had been a nun her entire adult life; she had wished to become a nun ever since early childhood Sunday school. She reported that she had always been “driven to help” those who she perceived to be truly in need, and had engaged in charitable initiatives since middle school. However, at the time of service, Helen had just left her order, promising her Mother Superior that she would seek counseling, although she refused to state why she was asked to do this. “There are some things we need to keep private, even in here, doctor.” While in the order, Helen mentioned, she had started a soup kitchen as her own “pet project.” To hear her describe the venture, it seemed as though the organization wanted nothing to do with this project until it started receiving very good press. At that point, Helen claims, the sisters wanted to make it their own and “take over,” and this seemed to be at the center of their rift. Again, she alluded to “something pretty big happening” from there, but she would not discuss the details of this. She had taken great pride in the amount of work that went into creating a service so expansive, and she marveled to the therapist about how she, personally, would serve all three daily meals, thereby making her commitment 24 hours a day, 7 days a week. She went on to describe how the patrons of the kitchen had it easier than even she did, emphatically noting, “They had coats before even I had a coat. I saw to that!” A mere thank you from the order, Helen said, was just “simply too much to ask.” As she continued to describe the circumstances surrounding the rift, her rancor became remarkably ostensible. Clinical Assessment Masochists such as Helen are proudly unselfish and self-sacrificial. Her self-denial and asceticism were judged, at least by her, to be noble and righteous acts signifying

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that she was, in essence, meritorious, if not saintly. Rather than negate her altruism, depreciate her esteem in the eyes of others, and accept the inferior status that typifies most other masochists, this prideful or virtuous masochist asserted a sense of specialness and the high status and veneration in which she should have been seen. Had she not consistently demonstrated her concern for the welfare of others, had she not deprived herself of the good life, had she not sacrificed herself at the altar of others? Turning her life pattern on its heels, she cried out that others had been ungrateful and thoughtless and should be mindful of how faithful and loyal and giving she had been to them. In effect, she, the self-sacrificing servant, should have been seen as the master, should have been the one to receive a constant stream of gratitude and attention, deserving to be repaid for her lifelong sacrifices, real or imagined. The overt demonstration of self-sacrifice was turned periodically into a display of pride and egocentrism. Having submerged herself in and been indispensable to others, she praised herself and became self-congratulatory: “I am good and virtuous. I am special and deserve special considerations.” However, the depth of these narcissistic displays was but shallow. Beneath the surface, there remained a low sense of self-esteem, as well as uncertainty about her self-assertions, that whatever recognition she got was manipulated and solicited rather than genuinely felt by others. For reasons consistent with the foregoing, Helen would, at times, exhibit overt narcissistic features and occasionally appeared to display dependent qualities. Hence, despite her self-approval and self-congratulatory tone, she continued to be self-sacrificing, persistently doing for others what she wished others would do for her—but more genuinely so. A rather depleted self-orientation was what was most striking about Helen; her desperation for fulfillment needed immediate support, as well as some environmental adjustment that would allow her to feel meaningful. Helen appeared rather edgy, yet seemed as though she would just allow that anxious demeanor to thrive (passive stance), and it would be advantageous to explore new response alternatives that would be more effective. She had a perpetuating tendency to invite abuse, yet she also garnered attention through her downtrodden plight (reversed pain–pleasure tendency); directive measures would be useful at a pace that would allow her to reorganize these fallacies and develop less dependent, autonomous skills. In looking toward permanency in change, it would be necessary to reorganize objects and internal structures in a more realistic and mature fashion. Domain Analysis Helen’s domain assessment via the MG-PDC revealed the following most salient areas for intervention: Admirable/Undeserving Self-Image: It was clear from her presentation that Helen more genuinely resonated with more masochistic, “undeserving” self-reflections, but she routinely donned the mask of self-admiration, ostensibly as a maneuver to defend more vulnerable feelings about herself.

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192 PERSONALIZED THERAPY FOR THE AGGRIEVED/MASOCHISTIC PERSONALITY PATTERNS Discredited Objects (Intrapsychic Content): Helen’s inner world seemed filled with disappointments where there may have once been hope, and anguish as a result of subverted positivity, all likely stemming from feelings of emotional abandonment as a child; she seemed driven to symbolically rectify this through her own personal subversions aimed at bettering the lives of others. Exaggeration Mechanism (Intrapsychic Mechanism): Supporting many of her fixed structures was Helen’s perpetual tendency to tie disappointment to a grander context of lifelong and environmentally determined disillusionment; this tendency regularly upended potential for legitimate and germane accolades, but did draw attention to her. She hoped it would elicit the response, “Look at all she does!” Therapeutic Steps The first strategy utilized with Helen was a contextual one: to arrange for a more rewarding environment that might help her with image-enhancing opportunities. Until some aspects outside of the therapeutic relationship were under control, supportive therapy was all her exceedingly vacillating sense of self could tolerate. Of particular note, attention needed to be directed toward altering Helen’s tendency to invite abuse through this vacillation of admirability and undeservingness. Unless checked, Helen at times would have assumed a very subservient role in therapy, and this would have eventually made her prone to relapse. At other times, it was quite obvious that she would test the therapist’s reliability. An empathic stance was expressed consistently to help her overcome her fear of addressing uncomfortable feelings. Similar support was necessary to undo her image of herself as one whose security relied entirely on martyrdom. She was alerted to the basis of her selfdeprecating tactics, as well as her ambivalence toward others. Efforts to undo these self-sabotaging reflections were most fruitful in terms of both short- and long-term growth. As her environmental situation improved, she became more comfortable dealing with her painful feelings. Although psychopharmacologic treatment was considered as a means of diminishing her anxious feelings, Helen opted against this intervention. Without this modality, which would have quickly augmented and undermined Helen’s characteristic passivity, it was necessary to employ a series of measures aimed at more functional domains (e.g., cognitions, interpersonal transaction, behavior) than those found in the highlights of her domain analysis. Behavior modification was employed to help her choose less abstinent responses to environmental stress. As the therapeutic relationship became more secure, she was also able to tolerate cognitive reframing methods, specifically those proposed by Beck and Meichenbaum, to alter problematic diffident attitudes and deferential social expectations. One of Helen’s most damaging schemas, though not directly expressed, was that she needed to always appease others and compensate for her perceived inabilities so that she would never be abandoned. Another facet of Helen’s overall picture was an interpersonal

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expression: Not only did she bring real problems to herself through her selfdestructive actions, but she also sensed and predicted difficulties when they were nonexistent. Her axiom might as well have been “Good things don’t last”; in other words, positive feelings and attitudes of those around her were but fleeting fantasies that would end, ultimately, in abrupt rejection. These elements were confronted by demonstrating how this behavior ended up alienating others as they became exasperated by her actions, and this served only to increase her fear and neediness. Benjamin’s and Klerman’s interpersonal techniques provided for the development of autonomy skills and self-confidence. Helen came to recognize this perpetuating cycle and became invested in a vigorous intervention to break the circle and reorient her actions less destructively. Combining cognitive restructuring with interpersonal skill building proved most effective, not only for the foregoing, but to alleviate excessive exaggeration in many of her dynamic responses that served to perpetuate expectations and continue a homeostatic state of discomfort. Finally, to address some of the sources of her attitudes and difficulties, as well as decrease the likelihood of regression, psychodynamic methods were used to focus on modifying discredited object attachments.

Resistances and Risks Most therapists may initially be able to empathize with the masochistic patient’s low self-esteem and complaints of years of abuse. However, as the patient’s tendency to arrange situations to ensure the continuation of pain becomes increasingly evident, the therapist may come to harbor the suspicion that the patient enjoys suffering. The patient’s pathetic self-presentation and ineffectual implementation of the therapist’s suggestions begin to call forth an almost sadistic therapeutic style. Many masochists provoke defensiveness by devaluing both the therapeutic process and the therapist. Many a well-meaning therapist can be seduced in this manner to complement their aggrieved/masochistic patient’s role with subtly punishing comments. Although a defensive reaction on the part of the therapist is understandable, challenging the masochist’s negative distortions too early in the therapeutic process may be counterproductive. Such confrontation may prove too threatening to the patient’s undeserving self-image, which requires that anything the patient is involved in must not be very good, including therapy. If the therapist can resist the temptation to insist that his or her therapy may be very helpful or valuable, the patient will not be as threatened by the possibility of being judged a failure by the “superior” therapist. Countertransferential anger is often also provoked as constructive suggestions are met with replies that the patient’s suffering cannot be overcome, that he or she is passively helpless, and succumbs to a defensive sullenness. Even worse, the patient’s negative

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therapeutic reactions and regressions may be interpreted as being staged to serve as proof that the therapist can be of more harm than help. To prevent this antitherapeutic interaction from developing, it is important for therapists to understand that masochists’ apparent need to suffer is based not in their perverse enjoyment of pain, but rather in their belief that they will experience less of it by doing what they do. Defensiveness only confirms and perpetuates the patient’s expectation that all significant others are cruel and insensitive. Conversely, being overly encouraging rarely serves to snap these patients out of their behavior or into taking a more assertive and confident stand for themselves. Therapists should also remember that pushing these patients too fast can precipitate too much distress, possibly resulting in a psychotic decompensation. Before the masochist can give up his or her self-defeating patterns, a slow process of building up a new identity and new attitudes must first take place. Negating the patient’s problematic sense of identity without offering integratable alternatives can leave a psychic void that may foster even more difficulties. Pitying the patient and harboring rescue fantasies toward him or her can also lead to disappointment when the patient fails to live up to the therapist’s expectations. Countertransference reactions toward a patient’s resistance or slow progress often include defensiveness and hostility. Harm to patients can be avoided by sympathizing with their tendency to sabotage their own potential, and by keeping in mind that success threatens their identity and instigates strong feelings of guilt. Patients should not be blamed for their failures.

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CHAPTER

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Personalized Therapy for the Eccentric/ Schizotypal Personality Patterns

T

he hallmark of this disorder is a variety of peculiarities of behavior and cognitive dysfunctions in speech, thought, and perception, neither of which are severe enough to warrant the diagnosis of Schizophrenia. There is considerable variability in the presentation of these symptoms (e.g., occasional magical thinking, momentary ideas of reference or suspiciousness, incidental illusions, some depersonalization, and periodic anxious hypersensitivity), with no single feature invariably present. It is our contention that the eccentric schizotypal pattern is most frequently an advanced dysfunctional personality (akin in severity to the borderline or paranoid types) and that it is often best understood as a more pathological variant of schizoid or avoidant patterns. Such a framework allows a greater appreciation of the schizotypal characteristics of social impoverishment and the tendency toward distant rather than close interpersonal relationships. In fact, the observed oddities in behavior and thought, such as paranoid ideation, magical thinking, and circumstantial speech, stem in part from the schizotypal’s withdrawn and isolated existence (Handest & Parnas, 2005; Pickup, 2006). Without the stabilizing influences and repetitive corrective experiences that come with frequent human contact and social interactions, these individuals may lose their sense of behavioral judgment and gradually begin the process of acting, thinking, and perceiving in peculiar and eccentric ways (Siever & Davis, 2004). In the advanced stages of such a dysfunctional progression, schizotypals may merely drift aimlessly from one activity to another, leading meaningless and ineffectual existences and remaining on the periphery of societal life (Bedwell & Donnelly, 2005).

195

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Depending on which of the two major detached patterns (i.e., schizoid or avoidant) the schizotypal resembles, he or she may be emotionally flat, sluggish, and apathetic, or hypersensitive, anxious, and socially apprehensive (Badcock & Dragovic, 2006). In a similar fashion, schizotypal personalities’ vulnerability to depression or other symptom disorders is, in part, dependent on whether they have evolved from the sensitive and suffering avoidants or the innately bland, unfeeling schizoids (Fossati, Citterio, et al., 2005). Clearly manifest in the eccentric/schizotypal personality are a variety of persistent and prominent peculiarities of behavior, thought, and perception (Ettinger et al., 2005; Raine, 2006). These characteristics mirror—but fall short of, in either severity or peculiarity—features that would justify the diagnosis of clinical Schizophrenia. It is the senior author’s early contention (Millon, 1969) that these “odd” schizotypal symptoms contribute to and are derivatives of a more fundamental and profound social isolation and self-alienation (Collins et al., 2005). Although the schizotypal syndrome should be seen as an advanced form of structural pathology, akin in severity to both the borderline and paranoid types, it may also be understood as a more grave form of the pathologically less severe schizoid and avoidant patterns. As noted, these three syndromes—schizoid, avoidant, and schizotypal—are characterized by an impoverished social life, a distancing from close interpersonal relationships, and an autistic, but nondelusional, pattern of cognitive dysfunctions (Harvey, Reichenberg, Romero, Granholm, & Siever, 2006). To paraphrase what was stated in an earlier chapter, the more individuals turn inward, the more they lose contact with the styles of behavior and thought of those around them. As they become progressively estranged from their social environment, they lose touch with the conventions of reality and with the checks against irrational thought and behavior that are provided by reciprocal relationships. Increasingly detached from the controls and stabilizing influences of repetitive, though ordinary human affairs, they may lose their sense of behavioral propriety and suitability and gradually begin the process of acting and thinking in unreal, and somewhat “crazy” ways—hence their manifest and prominent eccentricities. The DSM-III text and criteria for the syndrome were based on a study carried out and reported by Spitzer, Endicott, and Gibbon (1979) to clarify distinctions that might be drawn between what were then tentatively termed in the deliberations of the DSM-III Task Force the “unstable (borderline)” and “schizotypal” personalities. Following guidelines established earlier by relevant Task Force members, Spitzer et al. consulted other theorists and researchers at work in the field for further advice toward the goal of constructing two subsets of potentially discriminating criterion item lists. Although procedures for data gathering, analyzing, and cross-validating these criterion sets were carried out with exceptional diligence, the final item lists were found to highly correlate when utilized with a heterogeneous patient population. However, within a select group of more disturbed or dysfunctional patients, borderline and schizotypal item subsets did show a high degree of independence.

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197

SCHIZOTYPAL PROTOTYPE

Enhancement

Preservation

(Pleasure)

(Pain)

Accomodation

Modification

(Passive)

(Active)

Individuation

Nurturance

(Self)

(Other)

Reversal between Polarities Weak on Polarity Dimension Average on Polarity Dimension Strong on Polarity Dimension

FIGURE 6.1 Status of the eccentric/schizotypal personality prototype in accord with the Millon polarity model.

As an illustration of contemporary proposals, we turn briefly to the evolutionary polarity model as presented in Figure 6.1. The primary theme illustrated is the vacancy or weakness that exists in each of the six polarity boxes. Notable, however, are the reversal signs between each of the three pairs. In essence, this signifies that none of the survival motives and aims of the eccentric/schizotypal has a firm grounding. Rather, schizotypals are feeble in their intensity and focus and can be easily reversed or distorted in their usual objectives and goals (Sch¨urhoff, Laguerre, Sz¨oke, M´eary, & Leboyer, 2005). The figure portrays their rather ineffectual existence, as well as the meaningless and eccentric character of their activities. Possessing little spark or drive, these individuals become increasingly estranged from social conventions, resulting in the purposeless nature of their behaviors, the curious character of their thoughts, and the frequent inappropriateness of the emotions they express.

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In line with the view that this severe personality disorder is primarily structural rather than stylistic in its pathology, an understanding of these patients requires that we combine the particular structural pathology of the patient with the less severe personality style with which it is fused. Schizotypals usually demonstrate either a schizoid or an avoidant stylistic pattern. The features of these somewhat less severe pathological styles then conflate with the pathology of structure that typifies the schizotypal, thereby producing the particular configuration of characteristics of the patient under study.

Clinical Picture Several clusters of symptoms are found in common among patients classed in the eccentric/schizotypal category; these are noted before arranging them into clinical domains and specifying characteristics that differentiate the two major subvarieties. Three aspects of the schizotypal picture are described in this and following sections: the source of anxiety that tends to prompt psychotic episodes, characteristic cognitive processes and preoccupations, and general mood and behavior (see Figure 6.2). Depersonalization Anxiety The deficient or disharmonious affect of these patients deprives them of the capacity to relate to things or to experience events as something other than flat and lifeless phenomena. Eccentric/schizotypals suffer a sense of vapidity in a world of cold and

SCHIZOTYPAL PROTOTYPE Estranged Distraught or Insentient

Self-Image

Undoing

Mood/Temperament

Regulatory Mechanism

Eccentric

Autistic

Expressive Behavior

Cognitive Style

Secretive Fragmented

Interpersonal Conduct

Chaotic Object Representations

Morphologic Organization

FIGURE 6.2 Salience of prototypal eccentric/schizotypal domains.

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199

washed-out objects. Moreover, they feel themselves to be more dead than alive: insubstantial, foreign, and disembodied. As existential phenomenologists might put it, schizotypals are threatened by “nonbeing.” Detached observers of the passing scene, these patients remain uninvolved, looking from the outside not only with regard to others but with regard to themselves. Many people may have experienced moments of inner void and social detachment at one time or another, but the feeling of estrangement and depersonalization is an ever-present and insistent feature of the eccentric/schizotypal’s everyday existence. This persistent detachment or disavowal of self distinguishes the unreal and meaningless quality of his or her life and may give rise to a frightening sense of emptiness and nothingness. Every so often, the eccentric/schizotypal may be overwhelmed by the dread of total disintegration, implosion, and nonexistence. These severe attacks of depersonalization may precipitate wild psychotic outbursts in which the patient frantically searches to reaffirm reality. Cognitive Autism and Disjunctiveness The slippage and interference in thought processes that characterize the milder detached patterns are even more pronounced in eccentric/schizotypals. When motivated or prompted to relate to others, they are frequently unable to orient their thoughts logically, and they become lost in personal irrelevancies and tangential asides that have no pertinence to the topic at hand. They are out of touch with others and are unable to order their ideas in terms relevant to reciprocal, social communication. This pervasive disjunctiveness, this scattered and autistic feature of thinking, only further alienates them from others. Deficient Social Behaviors and Impoverished Affect Examination of the developmental achievements of the typical eccentric/schizotypal will indicate an erratic course in which the person has continually failed to progress toward normal social attainments. School and employment history of these patients shows marked deficits and irregularities, given their intellectual capacities as a base. Not only are they frequent dropouts, but they drift from one source of employment to another, and, if married, often are separated or divorced. This deficit in social competence and attainment derives from, and in part contributes to, their lack of drive and their feelings of unworthiness. The colorfulness of personality is lost in the schizoid-based eccentric/schizotypal; there is a blandness of affect, a listlessness and a lack of spontaneity, ambition, and interest in life. These patients are able to talk about only a few relatively tangible matters, usually things that demand immediate attention; rarely do they initiate conversation or pursue it beyond what is necessary to be civil. Not only do they lack the spark to act and participate, but they seem enclosed and trapped by some force that blocks them from responding and empathizing with others. They are unable to take hold of life, to

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become a member of society, and to invest their energies and interests in the world of others. Although important distinctions exist among subvariants of the schizotypal syndrome, they do share a number of features, and it is these to which attention is directed in the following sections (see Table 6.1). Eccentric Expressive Behavior What is most distinctive about eccentric/schizotypal personalities is their socially gauche and peculiar mannerisms and their tendency to evince unusual actions and appearances (Mittal et al., 2006). Many dress in strange and unusual ways, often appearing to prefer a “personal uniform” from day to day, for example, wearing a baseball cap with the visor in the back and invariably dressed in a horizontally striped T-shirt, always draped over a khaki pants belt. The tendency to keep to peculiar clothing styles sets them distinctively apart from their peers (Berenbaum et al., 2006). As a consequence of their strange behaviors and appearances, eccentric/schizotypals are readily perceived by others as aberrant, unobtrusively odd, curious, or bizarre. Some eccentric/schizotypals are aloof and isolated and behave in a bland and apathetic manner because they experience few pleasures and have need to avoid few discomforts. It would appear, then, that they should have little reason to acquire instrumental behaviors (Migo et al., 2006). Other eccentric/schizotypals more actively control expressions of intense affect because they fear being humiliated and rejected. They are inexpressive and socially isolated for protective reasons. Their constricted affect and interpersonal reserve do not arise because of intrinsic emotional or social deficits but because they have bound their feelings and relationships to protect against the possibility of rebuff (Sellen, Oaksford, & Gray, 2005). Secretive Interpersonal Conduct Perhaps as a consequence of their unusual cognitive dysfunctions, eccentric/ schizotypals may have learned to prefer privacy and isolation. Unable to achieve a reasonable level of interpersonal comfort and satisfaction, they may have learned to withdraw from social relationships, to draw increasingly into themselves, with just a few very tentative attachments and personal obligations (Appels, Sitskoorn, Vollema, & Kahn, 2004; Calkins, Curtis, Grove, & Iacono, 2004). Depending on the difficulty they have experienced in these limited social relationships, they may have drifted over time into increasingly peripheral vocational roles, finding a degree of satisfaction in unusual and clandestine social activities. The social achievements of the typical eccentric/schizotypal usually indicate an erratic course in which the person has failed to make normal progress (Hans et al., 2004). School and work histories show marked deficits and irregularities, given their intellectual capacities as a base (Bergida & Lenzenweger, 2006; Kerns, 2005). Not only are they frequent dropouts, but they tend to drift from one job to another and

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Clinical Picture

Table 6.1

201

Clinical Domains of the Eccentric/Schizotypal Prototype

Behavioral Level: (F) Expressively Eccentric (e.g., exhibits socially gauche and peculiar mannerisms; is perceived by others as aberrant; disposed to behave in an unobtrusively odd, aloof, curious, or bizarre manner). (F) Interpersonally Secretive (e.g., prefers privacy and isolation, with few highly tentative attachments and personal obligations; has drifted over time into increasingly peripheral vocational roles and clandestine social activities). Phenomenological Level: (F) Cognitively Autistic (e.g., capacity to read thoughts and feelings of others is markedly dysfunctional; mixes social communications with personal irrelevancies, circumstantial speech, ideas of reference, and metaphorical asides; often ruminative, appearing self-absorbed and lost in daydreams with occasional magical thinking, bodily illusions, obscure suspicion, odd beliefs, and a blurring of reality and fantasy). (S) Estranged Self-Image (e.g., exhibits recurrent social perplexities and illusions as well as experiences of depersonalization, derealization, and dissociation; sees self as forlorn, with repetitive thoughts of life’s emptiness and meaninglessness). (S) Chaotic Objects (e.g., internalized representations consist of a piecemeal jumble of early relationships and affects, random drives and impulses, and uncoordinated channels of regulation that are only fitfully competent for binding tensions, accommodating needs, and mediating conflicts). Intrapsychic Level: (F) Undoing Mechanism (e.g., bizarre mannerisms and idiosyncratic thoughts appear to reflect a retraction or reversal of previous acts or ideas that have stirred feelings of anxiety, conflict, or guilt; ritualistic or magical behaviors serve to repent for or nullify assumed misdeeds or “evil” thoughts). (S) Fragmented Organization (e.g., possesses permeable ego boundaries; coping and defensive operations are haphazardly ordered in a loose assemblage of morphologic structures, leading to desultory actions in which primitive thoughts and affects are discharged directly, with few reality-based sublimations, and significant further disintegrations into a psychotic structural level, likely under even modest stress). Biophysical Level: (S) Distraught or Insentient Mood (e.g., excessively apprehensive and ill at ease, particularly in social encounters; agitated and anxiously watchful, evincing distrust of others and suspicion of their motives that persists despite growing familiarity); or (e.g., manifests drab, apathetic, sluggish, joyless, and spiritless appearance; reveals marked deficiencies in face-to-face rapport and emotional expression). Note: F = Functional Domains; S = Structural Domains.

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are often separated or divorced, if they ever married. Their deficits in achievement competence derive from and, in part, contribute to their social anxieties and feelings of unworthiness. Moreover, there is a listlessness and a lack of spontaneity, ambition, and interest in life. Eccentric/schizotypals are able to talk about only a few relatively tangible matters, usually those things that demand their immediate attention. If they do sustain a conversation they may press it beyond what is appropriate or suitable, digressing into highly personal, odd, or metaphorical topics (Goulding, 2004). More commonly, they lack the spark to initiate action or to participate socially, seemingly enclosed and trapped by some force that blocks them from responding to and empathizing with others. This inability to take hold of life to become a member of a real society, and to invest their energies and interests in a world of others, lies at the heart of their pathology. Disorganized Cognitive Style Crucial to the pathology of eccentric/schizotypals is their inability to organize their thoughts, particularly in the realm of interpersonal understanding and empathy. They interpret things differently than most of us. The capacity to differentiate what is salient from what is tangential seems lacking in these personalities (Bates, 2005; Uhlhaas, Silverstein, Phillips, & Lovell, 2004). They attribute unusual and special significance to peripheral and incidental events, construing what transpires between persons in a manner that signifies a fundamental lack of social comprehension and logic. They do not evince a general deficit in cognitive capacity, one that is pervasively awry or is broadly deficient (K. Lee, Dixon, Spence, & Woodruff, 2006; Morgan, Bedford, & Rossell, 2006). Rather, their distortions and deficiencies appear limited to the interpersonal facets of the cognitive domain. As a consequence of their misrenderings of the meaning of human interactions, they construct idiosyncratic conceptions regarding the thoughts, feelings, and actions of others (Barch et al., 2004; Kawasaki et al., 2004). They are unable to grasp or resonate with the everyday elements of human behavior and thought. Daily transactions are transformed in bizarre ways, rendering them odd and peculiar to most observers. In sum, the capacity to read the thoughts and feelings of others is markedly distorted. They interpose personal irrelevancies, circumstantial speech, ideas of reference, and metaphorical asides in ordinary social communications. Lacking in the ability to implicitly understand the give-and-take of interpersonal transactions, they may gradually withdraw from such transactions, becoming highly ruminative, self-absorbed, lost in daydreams. Owing to their problematic information gathering and disorganized processing, their ideas may result in the formation of magical thinking, bodily illusions, odd beliefs, peculiar suspicions, and cognitive blurring that interpenetrate reality with fantasy. Why else do they develop superstitions, referential ideas, and illusions and engage at times in frenetic activity and vigorous coping? In essence, eccentric/schizotypals have enough awareness of the fruits of life to realize that other people do experience joy, sorrow, and excitement, whereas they are empty and barren. They desire some

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203

relatedness, some sensation, and some feeling that they are part of the world about them (Linscott & Knight, 2004). Although avoiding more than they can handle comfortably, they also feel considerable discomfort with less than they need, especially as less brings them close to nothing. Their recurrent illusions, their magical and telepathic thinking, and their ideas of reference may be viewed as a coping effort to fill the spaces of their emptiness, the feeling that they are going under and are bereft of all life and meaning. Alienated from others and themselves, they too may sense the terror of impending nothingness and of a barren, depersonalized, and nonexistent self (Gooding & Braun, 2004). Such feelings prompt them also to engage in bizarre behaviors, beliefs, and perceptions that enable them to reaffirm reality. It is for this reason among others that we observe the ideas of reference, the clairvoyance, the illusions, and the strange ideation that typify the eccentric/schizotypal. Owing to their unsatisfactory social and cognitive dysfunctions, most eccentric/schizotypals evidence recurrent social perplexities as well as self-illusions, depersonalization, and association. Many see themselves as alienated from the world around them, as forlorn and estranged beings, with repetitive ruminations about life’s emptiness and meaninglessness. The deficient cognitions and disharmonious affects of schizotypals deprive them of the capacity to experience events as something other than lifeless and unfathomable phenomena. They suffer a sense of vapidness in a world of puzzling and washed-out objects, of being more dead than alive. Many pathological personalities experience periods of inner void and social detachment, but the feeling of estrangement and depersonalization is an ever-present and insistent feature of the schizotypal’s everyday existence (Takahashi et al., 2005). Chaotic Objects The inner world of the eccentric/schizotypal is grounded in a piecemeal jumble of early memories, perceptions, and feelings. The inner template that comprises this chaotic m´elange of objects, impulses, and thoughts is almost random, resulting in an ineffective and uncoordinated framework for regulating these patients’ tensions, needs, and goals. Perhaps for the greater part of their lives, these internalized representations have been only fitfully competent for accommodating to their world, binding their impulses, and mediating their interpersonal difficulties (Voglmaier et al., 2005). When motivated or prompted to relate to others, schizotypals are frequently unable to orient their inner dispositions in a logical manner; as noted previously, they become lost in personal irrelevancies and tangential asides that seem vague, digressive, and with no pertinence to the topic at hand. They are out of touch with others and are unable to order their ideas in terms relevant to reciprocal, social communication. The pervasive disjunctiveness of their inner templates, the scattered, circumstantial, and autistic elements of their thinking, only further alienate these patients from others (Koenigsberg et al., 2005).

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Undoing Mechanism It appears that many of the bizarre mannerisms and idiosyncratic thoughts of the eccentric/schizotypal reflect a retraction or reversal of previous acts or ideas. Intrapsychically, this regulatory mechanism may serve to counteract feelings of anxiety, conflict, or guilt. By utilizing this dynamic process, these patients repent for or nullify the ostensive misdeed or “evil thought.” The outcropping of this undoing process may be seen in their magical beliefs and ritualistic behaviors. This persistent undoing mechanism, combined with eccentric/schizotypals’ periodic disavowal of self, may come to characterize the unreal and meaningless quality of their lives and may give rise to their frequent and frightening sense of emptiness and nothingness. As already noted, schizotypals are often overwhelmed by the dread of total disintegration, implosion, and nonexistence—feelings that may be countered by imposing or constructing new worlds of self-made reality, an idiosyncratic reality composed of superstitions, suspicions, and illusions. The more severe attacks of depersonalization may precipitate psychotic episodes, irrational outbursts in which these patients frantically search to build a sense of reality to fill their vacant existence. Fragmented Organization If one looks into the intrapsychic organization of the eccentric/schizotypal’s mind, one is likely to find highly permeable boundaries among psychic components that are commonly well segregated. There is a haphazardly ordered and loose assemblage of morphologic structures (Gooding, Matts, & Rollmann, 2006; Mohr, Blanke, & Brugger, 2006; Takahashi et al., 2006). As a consequence of these less than adequate and poorly constructed defensive operations, primitive thoughts and impulses are usually discharged in a helter-skelter way, more or less directly and in a sequence of desultory actions. The intrinsically defective nature of the eccentric/schizotypal’s internal structures results in few reality-based sublimations and few successful achievements in life. These defects make the patient vulnerable to further decompensation—even under modest degrees of stress. The inner structures of eccentric/schizotypals may be overwhelmed by excess stimulation (Haznedar et al., 2004). This is likely to occur when social demands and expectations press hard against their preferred uninvolved or withdrawn state. Unable to avoid such external impositions, some schizotypals may react either by blanking out, by drifting off into another world, or by paranoid or aggressive outbursts. Undue encroachments on their complacent world may lead them to disconnect socially for prolonged periods, during which they may be confused and aimless, display inappropriate affect and paranoid thinking, and communicate in odd, circumstantial, and metaphorical ways. At other times, when external pressures are especially acute, they may react with a massive and psychotic outpouring of primitive impulses, delusional thoughts, hallucinations, and bizarre behaviors. Many eccentric/schizotypals

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have stored up intense repressed anxieties and hostilities throughout their lives. Once released, these feelings burst out in a rampaging flood. The backlog of suspicions, fears, and animosities has been ignited and now explodes in a frenzied cathartic discharge. Distraught or Insentient Mood Although variable in nature, eccentric/schizotypals tend to display one of two predominant affective states. The insipid schizotypal, to be discussed shortly, manifests a drab, apathetic, sluggish, and joyless demeanor, a pattern of behaviors that appears to overlie an intrinsically spiritless and affectless temperament. Rarely do they display an ease in emotional expression; as a consequence, they exhibit marked deficiencies in their face-to-face rapport with others (Koo et al., 2006). Whether this deficit derives from some inborn constitutional disposition or a lack of affective attachment experiences in early life cannot be ascertained readily; more has been said regarding this matter in earlier books (Millon, 1969, 1996a). A contrasting predominant mood may be seen among patients labeled timorous schizotypals; these actively detached persons exhibit many features of the avoidant personality as well. These eccentric/schizotypals are excessively apprehensive and ill at ease, particularly in social encounters, and evidence a generally agitated and anxious watchfulness. Many exhibit a distrust of other persons and are suspicious of their motives, a disposition that rarely recedes despite growing familiarity.

Self-Perpetuation Processes The future of the eccentric/schizotypal is perhaps the least promising of all personality types. This section briefly summarizes factors that contribute toward the downward progression (see Table 6.2). In the preceding discussion we referred to several of the strategies employed by the eccentric/schizotypal personality. This reflects the assertion that the adaptive efforts utilized by pathological personalities are themselves pathogenic, that is, that many of their coping strategies are self-defeating and foster new difficulties; all pathological patterns are alike in this regard. The central distinction between the more and less severe patterns is the fact that the strategies of the former group are instrumentally less successful and more self-defeating than those of the latter, either because they were never learned adequately, or because they have faltered under persistent and cumulative stress. Because their adaptive facilities are instrumentally so deficient, it seems best to focus on the restitutive and defensive efforts these patients employ; thus, these patients are distinguished from their milder counterparts, not in their strategies but in what they do to shore up these strategies when they begin to crumble, albeit to minimal avail. As formerly effective strategies begin to falter, the eccentric/schizotypal may be driven to engage in a variety of extreme and frequently dramatic restitutive maneuvers;

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206 PERSONALIZED THERAPY FOR THE ECCENTRIC/SCHIZOTYPAL PERSONALITY PATTERNS Table 6.2

Self-Perpetuating Processes: Eccentric/Schizotypal Personality

Faltering Controls Dormant thoughts and impulses become overt Feels dead and empty Senses pressure and encroachment Compensates for Depersonalization Flight into chaotic ideas to avoid nothingness Bizarre outbursts counter loss of self Terrified by impending nonexistence Deflects Overstimulation Drifts off into confusion Experiences prolonged physical disappearance Outbursts of protective aggression

these are often displayed in the form of brief psychotic episodes in which previously dormant or controlled thoughts and impulses break into consciousness, producing primary process symptoms of bizarre ideation and behavior. If sufficient tension is discharged during these upsurges, and if environmental pressures are adequately relieved, individuals may regain their composure and equilibrium; their temporary disordered state has ended, and they return to their previous level of pathological personality functioning. For the present, we focus our attention on the coping aims of eccentric/schizotypals, that is, what they attempt to do to cope with stress now that their former strategies have failed them. Earlier, we noted two sets of conditions that precipitate the eccentric/schizotypal into temporary psychotic disorders. One occurs when the individual feels a frightening sense of petrifaction, deadness, depersonalization, and emptiness, that is, a degree of outer and inner stimulation that is much less than that to which he or she is accustomed (Folley & Park, 2005). The second occurs when the individual feels an oppressive sense of being encroached upon, pressured, and obligated to others, that is, a degree of external stimulation that is much more than that to which he or she is accustomed. Let us next discuss the restitutive measures these patients employ to deal with these conditions. Depersonalized Disintegration To cope with depersonalization, the eccentric/schizotypal frequently bursts into frenetic activity, becomes hyperactive, excited, and overly talkative, spews forth a flight of chaotic ideas, and is unrestrained, grabbing objects and running hurriedly from one thing to another, all in an effort to reaffirm his or her existence, to validate life, to avoid the catastrophic fear of emptiness and nothingness.

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Insipid (schizoid style) schizotypals generally behave in a bland and apathetic manner, as they experience few positive reinforcements and seek to avoid few negative reinforcements. As a result, they have little reason to acquire instrumental behaviors. Why, then, do they become active, frenetic, and feverish and engage in vigorous coping efforts? Insipid schizotypals realize that other people experience joy, sorrow, and excitement, whereas they are empty and barren. They seek to maintain their modest level of sensation and feeling by avoiding more than they can handle comfortably, yet they are left with feeling close to nothing. Their frantic, erratic, and bizarre outbursts may be viewed, then, as a coping effort to counter the feeling that they are going under, bereft of all life and meaning. Timorous (avoidant style) schizotypals control their affect because they fear humiliation and rejection; they are bland and socially withdrawn for protective reasons. Their overt appearance is similar to the insipid schizotypal’s, not because of an intrinsic affectivity deficit, but because they have bound their emotions against possible rebuff. However, the consequences of their coping strategy are the same as those experienced by the insipid schizotypal. Alienated from others and themselves, they may sense the terror of impending nothingness and of a barren, depersonalized, even nonexistent self. Such feelings prompt them to engage in a frenetic round of behaviors to reaffirm reality. Deflecting Overstimulation At the other extreme, both insipid and timorous schizotypals may be faced with excess stimulation. When faced with unavoidable external impositions, insipid schizotypals may either blank out, drift off into another world, or exhibit wild and aggressive outbursts (Nakamura et al., 2005). They may disappear for prolonged periods of time, during which they seem confused and aimless and which they only vaguely recall. If pressure is especially acute, they may instrumentally turn away these pressures by reacting with a massive outpouring of primitive impulses, delusional thoughts, hallucinations, and bizarre behaviors. As with insipid schizotypals, external pressures may be too great for timorous schizotypals, going beyond their tolerance limits and leading them also either to drift away or to become wild and uncontrollable. During these outbursts, the probability of delusions, hallucinations, and bizarre and aggressive behaviors is even greater than that found in the insipid schizotypal (Chang & Lenzenweger, 2005). The timorous schizotypal has stored up intense repressed anxieties and hostilities throughout his or her life. Once released, they flood forth in a frenzied, cathartic discharge.

Interventional Goals Eccentric/schizotypal individuals are one of the easier personality disorders for clinicians to diagnose. Odd speech, cognitive slippage, peculiar mannerisms, and even unusual dressing patterns hint at the correct personality diagnosis. Confusion

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208 PERSONALIZED THERAPY FOR THE ECCENTRIC/SCHIZOTYPAL PERSONALITY PATTERNS Table 6.3 Therapeutic Strategies and Tactics for the Prototypal Eccentric/ Schizotypal Personality Strategic Goals Balance Polarities Stabilize erratic pain/pleasure Stabilize erratic self/other Counter Perpetuations Prevent social isolation Undo excessive dependency Reduce fantasy preoccupations Tactical Modalities Alter eccentric behaviors Reverse autistic cognitive style Reconstruct estranged self-image

can sometimes arise, however, in attempting to differentiate between an eccentric/ schizotypal experiencing a temporary psychotic break and an individual with Schizophrenia. In general, however, schizotypals do not exhibit the delusions, hallucinations, and loose associations of those with either schizophreniform or schizophrenic disorder. Therapists are likely to find themselves giving a lot more advice to schizotypals than to other patients. If the aim of therapy is to help patients help themselves, many eccentric/schizotypals will need repeated lessons, as they have trouble generalizing from one situation to another. Despite the probability that personality reconstruction is not a likely outcome, except with mild cases of the disorder, many eccentric/schizotypal patients benefit from the therapeutic relationship owing to the limits it provides on realitydistorting social isolation and for the lessons it teaches about more adaptive functioning. When formulating the therapeutic goals for a particular patient, the therapist would do well to keep in mind that eccentric/schizotypals can be either active or passive regarding their characteristic social isolation and detachment; the cognitive dysfunctions and behavioral eccentricities that are the hallmark of the disorder usually map onto less pathological Avoidant or Schizoid Personality Disorders (Shea et al., 2004). Although the avoidant variant is more likely to be seen clinically, the therapist needs to distinguish between the two types to maximize treatment goals and strategies (see Table 6.3). Reestablishing Polarity Balances As one of the three more severe and structurally defective personality disorders, eccentric/schizotypals are burdened with disturbances in several polarity realms. As discussed

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previously, the constellation of these disturbances falls into one of two general patterns: the active-detached (avoidant/timorous) or the passive-detached (schizoid/insipid) variants. Those who fall into the passive category are unlikely to be motivated by either pain or pleasure; their capacity for feelings appear to be markedly reduced. Those of the actively detached type, on the other hand, are highly sensitive to environmentally produced and intrapsychically generated painful experiences, leading them to feel selfalienated and to withdraw from social interactions. Internally, however, anxiety and shame unremittingly continue to intrude. Neither the active nor the passive variant balances social disengagement with an adaptive self-strategy. Daydreaming, magical thinking, and ideas of reference serve either to replace the turmoil and anxiety of the timorous schizotypal or to fill the frightening inner void of the insipid variant. An increase in an adaptive other-oriented focus can be achieved with behavioral interventions such as social skills training and modeling. One potential benefit is to limit cognitive distortions through socially provided reality controls. Quality of life may be improved by increasing sensitivity to pleasure. Should these goals be realized, the passive subtype will probably also shift toward the active end of the active–passive dimension, and the active subtype will likely channel energy into more gratifying goals and may become more passive in relation to avoiding potential (mostly illusory) threats. In the case of timorous schizotypals, decreasing their fear of rejection or insult may be achieved by making them aware of the common and usual mutually rewarding rules of social exchange. Countering Perpetuating Tendencies Both social isolation and dependency training not only perpetuate the eccentric/ schizotypal personality style, but in fact intensify deficits in cognitive organization and social skills. Environmental conditions that foster dependency can develop easily in the schizotypal’s home, where well-intentioned family members may, with the best intentions for the patient’s welfare, inadvertently coddle and patronize him or her. Eccentric/schizotypals who relinquish their activities and learn to depend on others too much are likely to regress further into an amotivated and isolated state. Patients who remain in understaffed hospitals for extended periods of time are likely to end up in a similar condition. In the latter case, this is likely to result from staff neglect and a failure to encourage involvement with friends, relatives, fellow patients, and staff, even though basic needs are provided for. Finally, many eccentric/schizotypals contribute to their own deterioration by consistently avoiding social interactions that could provide the stimulation and feedback that can keep them functional. One main objective when working with an eccentric/schizotypal patient is to encourage the development and maintenance of relatively normal social relationships through social skills training, cognitive reorientation, and environmental management. Patients should be taught basic skills and encouraged to do as much for themselves as possible. Contact with a therapist is in itself helpful in preventing deterioration. Compensating for isolation through fantasy can sustain schizotypals for but brief periods before

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preoccupations turn to past misfortunes and injustices. Unable to escape misery by turning inward, they may disavow their own existence, scramble what organization there is between thoughts and feelings, and sink into nothingness. Identifying Domain Dysfunctions The eccentric/schizotypal’s most salient personologic domain dysfunctions are evidenced in cognitive style and expressive behavior. Disorganized cognitive functioning underlies disturbances in almost all of the other domains. Schizotypals mix social communication with personal irrelevancies and perceive the environment as imbued with material that feeds their ideas of reference and their metaphorical mental tangents. Nonproductive daydreaming often supports magical thinking and irrational suspicions and obscures the line between reality and fantasy. Such thinking is the foundation for aberrant expressive behavior. Paired with a lack of human interaction that could provide normalizing feedback about thinking and behavior, this disorganization leads the eccentric/schizotypal to exhibit socially gauche habits and peculiar mannerisms. The estranged self-image contributes to permeable ego boundaries and increases the tendency to be perplexed by social interactions and to experience depersonalization, derealization, and dissociation. A preference for privacy and isolation tends to drive the eccentric/schizotypal toward clandestine activities and peripheral roles. A result of this secretive interpersonal conduct is that others usually find the schizotypal odd, although unobtrusive. As a result of consistent misperception of the world (and of possible early abusive experiences), the eccentric/schizotypal’s object representations tend to be chaotic. Schizotypals’ main stress-reducing regulatory mechanisms are bizarre mannerisms and idiosyncratic thoughts that reflect a retraction or reversal of previous acts or ideas that have stirred conflict or anxiety. Their ritualistic or magical thinking is meant to counteract “evil” thoughts and deeds, both of self and others. All of these dysfunctions contribute to the fragmented morphologic organization of the schizotypal’s personality. Few reality-based sublimations bind primitive thoughts and affect. Mood is typically distraught in active schizotypals and insentient in the passive ones. Complaints of being ill at ease, agitated, and watchful of others’ motives is typical of active variants. Drab, apathetic, or otherwise markedly deficient face-to-face rapport and emotional expression are typical of passive variants. In the case of the insipid schizotypal, a primary goal is to help the patient identify those spheres of life toward which some positive inclination exists. Even if enthusiasm is not likely, increased participation in such activities can decrease the need for bizarre internal gratifications. It may also provide a window of reality-based experiences through which to objectively examine cognitive dysfunctions and distorted object relations. Psychopharmacological intervention can be helpful in increasing affectivity and laying the groundwork for increased motivation and active adaptation. Group and/or behavioral interventions can help the patient develop social and other skills, leading to more satisfying social interactions that may strengthen other-oriented and active

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behaviors. Vocational and other areas of functioning can be enhanced, even if real intimacy with others is not likely to be achieved. Interventions that foster feelings of self-worth and that encourage active schizotypals to realistically appraise their positive attributes and capacities can help provide patients with an improved self-image and motivation. Energy previously channeled into avoidance strategies can now be more productively directed into securing pleasure via craved-for social contact and/or vocational accomplishments. Improved social skills and increased self-esteem can help prevent extreme isolation and the cognitive distortions that result from the subsequent lack of socially provided reality checks, difficulties that so readily lead to decompensation.

Selecting Therapeutic Modalities Most eccentric/schizotypals seen by therapists are of the active-detached or timorous variant. Their extreme social anxiety and frequent paranoia can make it difficult for the therapist to establish a solid relationship, as these patients will try to defensively distance themselves. Many eccentric/schizotypals interpret the therapist’s behavior in unusual ways that may not be conducive to a positive therapeutic alliance. Because schizotypal patients often believe that they can read minds or influence others through telepathic means, the therapist would do well to inquire about previous therapy experience to make sure that the patient’s perception mirrors reality. Behavioral Techniques Many of eccentric/schizotypal’s behaviors are amenable to behavioral interventions. Marked peculiarities of speech, dress, and mannerism can be reduced through modeling, social skills training, and simple advice. Especially useful for schizotypals in inpatient settings are techniques such as aversive learning and selective positive reinforcement. No less helpful are social skill training procedures. Here, the therapist may serve as a model the patient can imitate to function more skillfully and efficiently than heretofore. Peculiarities of belief may be dealt with either behaviorally or cognitively. In the behavioral strategy, efforts can be employed to counteract extreme and irrational anxieties by the use of imaginal or in vivo exposure procedures. Interpersonal Techniques Benjamin’s outline for interpersonal intervention with schizotypal patients focuses largely on the role of undoing aspects of the patient’s history. Magical thinking is seen as being provoked by placement in situations in which the young child was led to believe that he or she had control when in fact he or she had none. In other circumstances, the child may have been given undue or inappropriate responsibility, for example, being led to believe that abuse could be prevented by certain behaviors that did not achieve this end. It is suggested that the patient needs to see how the content

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of such ideas mirrors past interpersonal dynamics before he or she will be willing to attempt to interpret and cope with life differently. In the early stages of therapy, a supportive approach may be the only kind of therapy that a eccentric/schizotypal patient can handle. Although other approaches can be used concomitantly, a realistic positive outcome may involve increasing the patient’s pleasure in living rather than changing fundamental aspects of personality style or structure. The therapist’s acceptance, empathic understanding, and benevolent advice can serve to realize this aim. The therapist may need to serve as the patient’s realitytesting auxiliary ego for a very long time. As a consequence of establishing a genuine rapport, the schizotypal patient might develop sufficient trust to give up his or her magical and ritualistic beliefs. Cognitive Techniques Cognitive approaches are more directly focused on altering the content of the eccentric/schizotypal’s thoughts. Beck and Freeman’s (1990a, 1990b) outline of their cognitive intervention procedures for treating schizotypal personality disorders suggests that a first therapeutic step is to identify the patient’s dysfunctional automatic thoughts. Examples of such thoughts include “Is that person watching me?”; “I can feel the devil in her”; and “I am a nonbeing.” Dysfunctional thoughts generally fall into one of four categories: ideas of reference, in which the patient believes that unrelated events are related to him or her, paranoid ideation; magical thinking, such as a conviction that a dead relative is present; or illusions, such as seeing people in shadows. Another common cognitive distortion seen among eccentric/schizotypals is emotional reasoning, which causes them to believe that emotions are “evidence” about circumstances; for example, if they feel bad they believe that there is necessarily a problem, and vice versa. Schizotypals also engage in personalization, in which they believe that they are responsible for external circumstances when in fact they are not. Teaching the eccentric/schizotypal to recognize when he or she is distorting reality can be done in the context of the therapeutic relationship, as these patients usually harbor unrealistic ideas about the therapist’s communication and intent. Many eccentric/schizotypals may even fear that harm will befall the therapist because of the therapeutic association. As ideas and predictions are countered, more realistic thinking can be learned. As new cognitive skills are learned, maladaptive patterns can be altered as the patient gives up the pathogenic wish, which Benjamin sums up as “the wish to magically protect the self and others while maintaining loyalty to early abusers” (2003). Interpreting symptomatic behavior, such as suicidal fantasies that reflect this underlying wish, can help the patient realize the function of these behaviors. Benjamin’s example of such an interpretation is “Well, he (abusive father) would sure be happy to see what a good job you are doing of punishing yourself this time. This will prove that you love him and want to stay with him forever” (2003). As long as the therapist consistently displays sympathy for these patients’ “terror of defying the internalized wishes and fears implanted by abusers” (2003), as well as convincing them that they

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can think about themselves and others differently, more adaptive patterns may come to replace the old. An important first step is to establish a good therapeutic alliance. In the context of a solid relationship the patient is less likely to be handicapped by the deleterious effect of social isolation on his or her reality testing and is more likely to be receptive to cues and interventions to improve social appropriateness. Social skills training, including modeling of appropriate behavior and speech, can be very helpful in reducing the patient’s social anxiety and awkwardness. Beck and Freeman (1990b) suggest that a group setting can be ideal for identifying and challenging automatic thoughts about social functioning, as well as for learning and practicing new skills. They also point out that keeping the session structured is helpful with these patients, as their rambling cognitive style can result in little getting accomplished. Teaching patients to evaluate their thoughts against environmental evidence, rather than against their feelings, can help reduce emotional reasoning and drawing incorrect conclusions about life circumstances. Although dysfunctional thoughts are not likely to disappear, it may be possible for the patient to learn to disregard them rather than to respond either emotionally or behaviorally. Instead, a cognitive coping statement can be employed to counter the dysfunctional one. An example of such a statement is “There I go again. Even though I’m thinking this thought, it doesn’t mean that it’s true.” A particularly useful suggestion is to keep track of the patient’s predictions and systematically test them. The patient can then see that emotion does not predict or necessarily reflect circumstance. Communication style problems, whether they include circumstantiality, tangentiality, or fixation on or exclusion of detail, can usually be reduced when the patient can identify the reason the particular style is used. It is also recommended that the patient be taught practical ways to improve his or her life, whether this means learning about personal hygiene, finding employment, or initiating relationships. Self-Image Techniques A primary focus of therapy should be to enhance these patients’ self-worth and to encourage them to recognize their positive attributes. Taking pride in themselves and valuing their constructive capacities are necessary in rebuilding patients’ motivation. No longer alienated from themselves, they will have a basis for overcoming their alienation from others. Once they have a sense of self-worth, the therapist may guide them to explore positively rewarding social activities. Initiating such experiences may be crucial in preventing what otherwise might be a downward progression. Schizotypals often discuss problematic early experiences without expression of any affect. It is recommended that sympathizing and empathizing with others who experienced similar treatment can help lead the patient to understand his or her own position, as well as to generate appropriate affect. These patients also have a tendency to do the opposite of what was intended therapeutically, for example, identifying with the perpetrator of aggression and experiencing guilt or feeling the need for punishment as

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a result of having traitorous thoughts, or what they interpret as their part in instigating an abusive situation. Alternatively, the feelings can be projected on the therapist, who may be seen as an enemy. It has been suggested further that the process of forging a good relationship can be greatly aided by the therapist’s respect for the schizotypal patient’s particular sensitivities. Not pushing the patient too hard or too fast can prevent him or her from experiencing severe anxiety and paranoid reactions. Eccentric/schizotypals’ peculiar and rambling cognitive style can make it difficult for them to maintain focus in therapy sessions. Providing well-structured interventions and sessions can be very helpful with this group of individuals. Others recommend that group therapy is appropriate for schizotypals who do not display prominently eccentric behavior, thereby causing other group members too much discomfort. Similarly, if the patient has paranoid features, these attributes may cause more turmoil than desirable. If the patient is appropriate for group therapy, the experience can help him or her overcome social anxiety and awkwardness by providing a supportive environment and an opportunity to realize that others have similar insecurities. Intrapsychic Techniques Psychodynamic approaches focus on the need for the eccentric/schizotypal patient to internalize a healthy related bond with another person, often the therapist. Gabbard (1994) suggests that the therapist should expect the patient to react to increased closeness with silence and emotional distance. This silence should be accepted as a legitimate part of the patient’s personality. It is also suggested that the patient may then begin to reveal hidden aspects of the self and integrate them in adaptive ways. However, offering classic psychodynamic interpretations of their behavior is not likely to be very helpful to these patients. Most schizotypals find psychotherapy to be quite challenging and stressful. There is great need, according to analytic thinkers, to adopt a very permissive and tolerant attitude with these patients. Rather than viewing their silence as a form of resistance, it should be seen as a generalized style of “nonrelating.” When the eccentric/schizotypal’s communications are confusing, or when silence is prolonged, therapists must guard against their own frustrated feelings and their potentially troublesome countertransferences. Pharmacologic Techniques Psychopharmacological intervention can prove very helpful in controlling many of the symptoms of the eccentric/schizotypal personality disorder. Illusions, ideas of reference, phobic anxiety, obsessive-compulsive symptoms, and psychoticism have all been shown to respond favorably to low doses of clozapine, risperidone, or olanzapine without serious side effects (Goldberg et al. 1986; Joseph, 1997; Serban & Siegel, 1984). Anxiolytics in modest doses appear to be advisable in patients who experience distinct anxious feelings during the early stages of treatment (H. S. Akiskal, 1981). Amoxipine,

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a combination antidepressant and antipsychotic, has been recommended for schizotypal patients with depressive symptomatology (Markovitz, 2004). Some patients, however, appear to tolerate such medications poorly due to excessive sedation. The SSRIs may also reduce concurrent depressive symptoms, interpersonal sensitivities, and paranoid ideation, as well as improve peculiar secondary features such as obsessions and compulsions. Stone (1993) recommends that patients who show relatively good functioning and exhibit only the milder signs of the disorder (cognitive slippage, odd speech) probably need no or few medications at most times in their treatment (Keshavan, Shad, Soloff, & Schooler, 2004). Institutionalization, when necessary, should be brief. Hospital settings too often breed isolation, reward quiet behaviors, and provide models of eccentric belief and perception, each of which can lead to increased detachment and bizarre preoccupations.

Making Synergistic Arrangements Establishing a good relationship with an eccentric/schizotypal patient is a necessary first objective. In fact, providing a healthy, steady relationship is therapeutic in and of itself. A good alliance is most likely to result from an initial, almost exclusively supportive therapist stance. Silence may need to be tolerated, empathy expressed, and encouragement of participation in pleasurable activities emphasized. The therapist’s practical advice often can provide structure and foster improvements in the patient’s life. When the patient comes to trust the therapist, cognitive and behavioral interventions can help the patient learn to identify distortions in his or her interpretation of the environment and provide the skills necessary for more enhancing relationships. As noted earlier, patients who evidence psychotic thinking above and beyond the oddities of speech and mannerism may benefit from low doses of neuroleptics. This is likely to be more true of timorous than of insipid schizotypals. If behavioral eccentricities are not too great, the patient may also benefit from group therapy, particularly if a major presenting problem is social anxiety and a lack of social skills. Unfortunately, most eccentric/schizotypals are not likely to undergo substantial changes in the structure of their personality, or in the level of intimacy involved in their relations with others. Gains are more likely to be made in nonintimate interactions, in reality testing, and in participation in activities that the schizotypal can enjoy.

Illustrative Cases There are two major variants of the defective eccentric/schizotypal personality. The first derives from the passive-detached style, termed the schizoid personality; the second reflects an active-detached style and has been termed the avoidant personality. Although there are several adult subtypes of each of these broad personality styles (e.g., “languid”

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216 PERSONALIZED THERAPY FOR THE ECCENTRIC/SCHIZOTYPAL PERSONALITY PATTERNS Table 6.4

Eccentric/Schizotypal Personality Disorder Subtypes

Insipid: Sense of strangeness and nonbeing; overtly drab, sluggish,inexpressive; internally bland, barren, indifferent, and insensitive; thoughts obscure, vague, and tangential; bizarre telepathic powers. (Mixed Schizotypal/Schizoid-Depressive-Dependent Subtype) Timorous: Warily apprehensive, watchful, suspicious, guarded, shrinking; deadens excess sensitivity; alienated from self and others; intentionally blocks, reverses, or disqualifies own thoughts. (Mixed Schizotypal/Avoidant-Negativistic Subtype)

and “remote,” to represent two of the schizoid subtypes), we limit our discussion to the two broad variations of the defective-schizotypal disorder (see Table 6.4).

Case 6.1, Kevin B., 39 An Eccentric/Schizotypal Personality: Insipid Type (Schizotypal with Schizoid Features) Presenting Picture Kevin was a night security guard at a warehouse, where he had worked since his high school graduation more than 20 years ago. His parents, both successful professionals, had been worried for many years, as Kevin seemed entirely disconnected from himself and his surroundings and had never taken initiative to make any changes, even toward a shift supervisory position. They therefore made the referral for therapy, and Kevin simply acquiesced. He explained that he liked his work, as it was a place where he could be by himself in a quiet atmosphere, away from anyone else. He described where he worked as “an empty warehouse; they don’t use it no more but they don’t want no one in there. It’s nice; ‘homey.’” Throughout the initial interview, Kevin remained aloof, never once looking at the counselor, usually answering questions with either one-word responses or very short phrases, and usually waiting to respond until a second question was asked or the first question was repeated. He described, in these short, bizarre answers, a life devoid of almost any human interconnectedness, almost his only tangible contact being his brother, whom he saw only during major holidays. Living alone, he could only remember one significant relationship, and that was with a girl in high school. Very simply, he stated, “We graduated, and then I didn’t see her any more.” He expressed no apparent loneliness, however, and appeared entirely emotionless regarding any aspect of his life. Initial Impressions Notably insensitive to feelings, Kevin, an insipid schizotypal personality, often seemed to experience a separation between his mind and his physical body. There

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was a strange sense of nonbeing or nonexistence, as if his floating conscious awareness carried with it a depersonalized or identityless human form. Behaviorally, his tendency was to be drab, sluggish, and inexpressive. He possessed a marked deficit in affectivity and appeared bland, indifferent, unmotivated, and insensitive to the external world. Cognitive processes seemed obscure, vague, and tangential. He was either impervious to or missed the shades of interpersonal and emotional experience. He responded to social communications minimally or with inappropriate affect or peculiar ideas, or in a circumstantial and confused manner. His speech was often monotonous, listless, or inaudible. Most people considered him to be an unobtrusive and strange person who drifted on the periphery of life or who faded into the background, self-absorbed, woolgathering, and lost to the outside world. Personalities such as Kevin derive from and coalesce with the schizoid pattern, although on rare occasions there is a fusion with depressive and/or dependent personality features. Detached from the world and insensitive to his own feelings, Kevin may have felt that he was losing himself, becoming a petrified object without meaning or purpose. It is possible that such feelings overwhelmed him, driving him into a bizarre psychotic state in which he created tangible illusions to which he could relate, self-referential ideas that gave him a significance he otherwise lacked. Bizarre “telepathic” powers enabled him to communicate with mythical or distant others, all in a desperate effort to reaffirm his existence in reality. Sinking into a lifeless void, he would catch himself struck by a sense of becoming a thing and not a being. This dread, this catastrophic sense of nothingness, caused him to grasp at anything, real or fantasized, by which he could convince himself that he did, in fact, exist. Kevin also occasionally decompensated when faced with too much, rather than too little, stimulation. Painfully uncomfortable with social obligations or personal closeness, he felt encroached upon when pressed into responsibilities beyond his limited tolerance. He would simply fade out, becoming blank, losing conscious awareness, and turning off the pressures of the outer world. To work toward reorienting Kevin to the here and now and away from bizarre fixations, it would be necessary first to demonstrate connectedness within the therapeutic relationship as a safe and realistic construct. A less wavering active orientation then would be fostered by addressing beliefs that perpetuated fantasies and indifference to his context by requiring a deadened approach to perceived dejection (wavering pain–pleasure polarity conflict). His tendency to retract and undo associations, typical of his passive nature, would be countered with more effective social skills. More effective and steadfast orientations toward self and other would be encouraged as well. Domain Analysis Kevin completed the MCMI-III and several other measures; he showed somewhat surprising focus and attention to psychological testing, seeming to almost become lost in exploring the test stimuli. Highlights of his domain analysis, as gleaned from

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218 PERSONALIZED THERAPY FOR THE ECCENTRIC/SCHIZOTYPAL PERSONALITY PATTERNS the Grossman Facet Scales and the MG-PDC, included the following troubling areas for focused intervention: Interpersonally Secretive/Unengaged: According to family reports, Kevin displayed the schizoid disengagement from social and personal relationships, caring little for socialization; in adult years, it seemed, he began showing a strong preference for secrecy and privacy, shunning and even showing mild hostility toward social pressures and expectations. Temperamentally Insentient: Sluggish and joyless in his demeanor and affect, Kevin manifested apathetic mannerisms and highly detached interpersonal vibes, showing almost no connection to others and evidencing no affective attachment capacity in even close relationships. Cognitively Impoverished: Kevin displayed a deficient fund of knowledge, although records indicated a high-average IQ; his thought content and process appeared to be vague, diffuse, mildly disorganized, and evidencing a relative frequency of circuitous logic and magical thinking. Therapeutic Steps The first notion Kevin needed to grasp in order for this treatment to work was that realistic goals were not only desirable, but fully achievable, and that they need not be impossible fantasies. Kevin feared that therapy may reawaken what he viewed as false hopes; that is, goal setting may remind him of the frustration he experienced with previous ambitions. Now that he had found a perceived level of comfort by distancing himself from desires and withdrawing from others, it was important therapeutically not to let matters remain at the level of depressive-anxious adjustment to which he had become accustomed. To this end, antidepressant medication was a useful targeted instrument in moderating his persistent apathy, sluggishness, and affective absence (insentient temperament). A supportive approach utilizing several existential techniques also focused attention on his tendencies to demean his self-worth and subject himself to neglect by others. These supportive measures were used collectively to counteract his hesitation about sustaining a consistent therapeutic relationship. A warm and accepting attitude was needed because Kevin feared facing his feelings of unworthiness and because he sensed that his coping defenses were weak. With skillful supportive approaches, it was possible to prevent his tendency to withdraw from treatment before any real gains were made. At the cognitive-behavioral level, therapeutic attention was usefully directed to Kevin’s impoverished style of vague and sometimes chaotic logic that may have evoked unhappiness, self-contempt, and derogation in the past. Short-term and focused cognitive techniques such as those developed by Beck, Meichenbaum, and

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Ellis helped reduce his sensitivity to rebuff and his morose and unassertive style, outlooks and fears that only reinforced his aversive and depressive inclinations. These methods were especially useful in exploring the contradictions in his feelings and attitudes. To diminish or even prevent relapse, more focused procedures were used in reconstructing the erroneous beliefs and interpersonal secretiveness/ disengagement that pervaded all aspects of his behavior. Interpersonal therapies such as those of Klerman and Benjamin were especially productive. Similarly, short-term group therapy assisted him in learning new attitudes and skills in a more benign and accepting social setting than he normally encountered. Had they been agreeable, family techniques may have been employed as circumscribed methods to moderate destructive patterns of communication that contributed to or intensified his social problems.

Case 6.2, Drew S., 29 An Eccentric/Schizotypal Personality: Timorous Type (Schizotypal with Avoidant Traits) Presenting Picture From the very outset, Drew appeared to be entirely displaced from reality. He was referred for treatment as an alternative to prison, after causing a disturbance at a public park during an elementary school’s visit, with several parents demanding punishment. Little could be made, at first, of his short utterances and disjointed thoughts, but it soon became apparent that he was indulging in a self-constructed fantasy that provided temporary shelter from reality and also drew outside stimuli from others that validated him as someone real. Little historical or biographical information could be gleaned from his self-report, and his legal record did not shed much light on this either. He was brought to therapy by his parole officer, who Drew said was always on his case. He further remarked that he could feel the police officers’ collective desire to “bust his head,” and that they were typical of everyone and everything in their desire to be antagonistic. Drew’s stream-of-conscious utterances seemed constructed with the intention of confusing and bewildering anyone else, and he seemed to find some peace and solace in the realization that he was alone in this fantasy, a place where no one else could invade, for the time being. By these bizarre withdrawal tactics, he not only disconcerted others, but managed to evoke unusual responses that fed his need to be validated. Clinical Assessment As with his less severe avoidant counterparts, Drew, a timorous schizotypal personality, was restrained, isolated, apprehensive, guarded, and shrinking.

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220 PERSONALIZED THERAPY FOR THE ECCENTRIC/SCHIZOTYPAL PERSONALITY PATTERNS Protectively, he sought to kill his feelings and desires, bind his impulses, and withdraw from social encounters, thereby defending himself from the pain and anguish of interpersonal relationships. His surface apathy and seeming indifference was not, as it is in the insipid schizotypal, owing to an intrinsic lack of sensitivity but to his attempt to restrain, damp down, or deaden excessive sensitivity. In addition, there was an abandonment of self and a disowning and remoteness from feeling and desire. His “real” self had been devalued and demeaned, split off, cast asunder, and rejected as humiliating or valueless. Not only was he alienated from others, then, but he found no refuge or comfort in turning to himself. His isolation was thus twofold; so little was gained from others, and only a despairing sense of shame was found within himself. Without the rewards of self or others to spur him, Drew drifted into personal apathy and social isolation. Having little hope of gaining affection and security, he learned that it was best to deny real feelings and aspirations. Cognitive processes were intentionally confused in an effort to disqualify and discredit rational thinking. In their stead were fantasy worlds that provided some respite from the anguish of realistic thought. But this, too, held brief interest, as the outer world kept intruding and shaming him back to reality. Disharmonious affects, irrelevant and tangential thoughts, and an increasingly severe social bankruptcy developed. Drew was forced to build an ever-tighter armor around himself. His characteristic eccentricities derived from this wall of isolation and insularity that he had constructed. Like the insipid schizotypal, he was subject to the devastating terror of nothingness, the feeling of imminent nonexistence. By insulating himself, shrinking his world, and deadening his sensitivities, he had laid the groundwork for feeling emptiness and unreality. To counter the anxieties of depersonalization and derealization, he was driven into excited and bizarre behaviors to draw attention and affirm his existence as a living being. He maneuvered irrationally just to evoke a response from others. Failing in this effort to quiet his anxieties, he turned to a make-believe world of superstitions, magic, and telepathy—anything that he could fashion from his imagination that would provide him with a pseudocommunity of fantasized persons and objects to which he could safely relate. Establishment of a safe environment would be a primary goal in the initial phases of treatment for Drew, as he demonstrated a very high active-pain orientation, which manifested in very erratic reactions. Affect stabilization would decrease the frequency and intensity of phobic anxieties and illusory scenarios. Supportive inroads would begin a gradual process toward more focused milieus. As trust developed, the therapist would work toward undermining perpetuating beliefs that kept him in a constant state of actively withdrawing. Efforts would be made to enhance self, which would also encourage autonomy and social interaction. Adjunctive treatments (e.g., group, family) would be helpful, as well, especially as Drew would become less disjointed and increase his investment in an other orientation.

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Domain Analysis Drew could not produce a valid MCMI-III, as was evident after several tries. The domain analysis applied in this intervention was derived from the MG-PDC: Cognitively Autistic: Drew was markedly deficient in ordinary ability to gauge others’ intentions, moods, or beliefs, and disengaged from common through-lines of interpersonal logic. His thought patterns reflected irrelevancies, ruminations, odd beliefs, and blurring of reality. Temperamentally Distraught: Drew was frequently mistrustful and apprehensive, reacting with alarm and near panic to the most innocuous of stimuli from others, and even flinching at imagined stimuli; he was ill at ease even in familiar circumstances and despite the normalizing effect of being in a given situation for a period of time (e.g., the therapy office). Fantasy Mechanism: A most common defense for Drew was to block out the real world with inventions and contexts contrived by himself; beyond the avoidant’s defense of escapism, however, Drew thoroughly indulged these fantasies, clearly losing his grip on reality and blurring the lines of real and imagined. Therapeutic Steps A first goal in therapy with Drew was to demonstrate that the potential gains of therapy were real and that they should motivate him rather than serve as a deterrent. Drew feared that therapy would reawaken what he viewed as false hopes; that is, it would remind him of the humiliation he experienced when he offered his trust to others but received rejection in return. As the therapist nondirectively acknowledged these fears, Drew was able to find a modest level of comfort without having to distance himself from the therapist, learning to deal more effectively with his fears while maintaining a better level of adjustment than previously. Additionally, a pharmacologic (antianxiety) regimen helped to alleviate his more distraught affective presentation, allowing him a modicum of freedom from apprehensiveness and agitation. In a short-term cognitive-behavioral approach, attention was usefully directed to Drew’s social hesitation, anxious demeanor, and self-deprecating actions, attitudes, and behavior that could be altered so as not to evoke the humiliation and derogation they had in the past. Another realm worthy of brief intervention was associated with Drew’s extensive scanning of the environment. By doing this, he increased the likelihood that he would encounter those stimuli he wished to avoid. He exhibited a hypersensitivity to what most people simply overlooked or were not even aware of. Again, using appropriate cognitive methods, his extreme sensibility was prevented from backfiring, that is, becoming an instrument that constantly brought to

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222 PERSONALIZED THERAPY FOR THE ECCENTRIC/SCHIZOTYPAL PERSONALITY PATTERNS awareness the very pain he wished to escape. Reorienting his focus and his negative interpretive habits to ones that were more ego-enhancing and optimistic in character reduced his self-demeaning outlook, intensified his positive experiences, and diminished his anguish. Efforts to reframe the basis of his sensitivity to rebuff and his fearful and unassertive behavior (e.g., Beck, Ellis) minimized and diminished not only his aversive inclinations but his tendency to relapse and regress. Gradually, these cognitive procedures shifted focus to a more macro level and were used to explore contradictions in his feelings and attitudes that gave rise to his autistic style. Without proper reframing, there may have been a seesaw struggle, with periods of temporary progress followed by retrogression. Genuine short-term gains were possible, but only with careful work, a building of trust, and enhancement of the patient’s sense of self-worth. Insight-oriented procedures (specifically, those combining well with brief dynamic interventions) were useful in unearthing the roots of Drew’s anxieties and confronting those assumptions and expectations that caused him to revert to fantasy in defense. The therapist then provided him with several alternative strategies, and these new experiences significantly increased Drew’s competency and feelings of self-efficacy. Had it been feasible, family techniques may also have been employed to moderate destructive patterns of communication that contributed to or intensified his withdrawal and sheltering behaviors. Interpersonal techniques (e.g., Benjamin) and group therapy may have assisted him in learning new attitudes and skills in a more benign and accepting social setting than he normally encountered.

Resistances and Risks Both insipid and timorous schizotypals have poor prognostic prospects. Although great therapeutic gains can be made with some mildly affected individuals, many more do not alter their core personality. The pattern is deeply ingrained, if not strongly genetically predisposed. These patients rarely live in an encouraging or supportive environment. Probing into personal matters is experienced as painful or even terrifying. Schizotypals distrust close personal relationships such as occur in most forms of psychotherapy. Therapy sets up what they see as false hopes and necessitates painful self-exposure. Most would rather leave matters be, keep to themselves, and remain insulated from the potential of further humiliation and anguish. Should they enter treatment, timorous schizotypals tend to be guarded, constantly testing the therapist’s sincerity. Excessive probing into the patient’s sensitivities or another “false move” is likely to be interpreted as an attack or as verification of the disinterest and deprecation the patient has learned to anticipate from others.

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Trust is therefore essential. Without a feeling of confidence in the genuineness of the therapist’s motives, these patients will block the therapist’s efforts and, ultimately, terminate treatment. Equally important is that the patient find a supportive social environment. Treatment will be difficult enough, a long and an uphill battle, unless external conditions are favorable.

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CHAPTER

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7

Personalized Therapy for the Capricious/ Borderline Personality Patterns

F

rom our perspective, the borderline component of the capricious/borderline spectrum concept is best seen as representing a structurally defective or severe level of functioning that may emerge in virtually any of the less severe personality disorders (perhaps with the exception of the schizoid and compulsive styles). Most frequently, however, the borderline personality level of pathology appears as an advanced dysfunctional variant of the dependent, histrionic, antisocial, sadistic, and, most commonly, the negativistic personality. Regardless of the background personality history, the spectrum we call the capricious/borderline is characterized by intense, variable moods and irregular energy levels, both of which frequently appear to be only tangentially related to external events. The affective state characteristically may be either depressed or excited, or noted by recurring periods of dejection and apathy, interspersed with episodes of anger, anxiety, or euphoria (Bradley, Conklin, & Westen, 2005). There is a notable fear of separation and loss, with considerable dependency reassurance required to maintain psychic equilibrium. Dependence on others is colored with strong ambivalent feelings, such as love, anger, and guilt. Chronic feelings of anxiety may be present as capricious/borderlines struggle between feelings of anger and shame at being so dependent, and fears that self-assertion will endanger the security and protection that they so desperately seek (Bennett & Ryle, 2005). In an attempt to secure their anger and constrain their resentment, capricious/borderlines often turn against themselves in a self-critical, condemnatory manner, which at times may lead to selfmutilating and suicidal thoughts as well as self-damaging behaviors (Janis, Veague, & Driver-Linn, 2006; Paris, 2005a, 2005b, 2005c).

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As a result of their instability of both affect and behavior, borderlines are prone to rather checkered histories in their personal relationships and in school and work performance (Chessick, 2006; Holmes, 2005). Most exhibit repeated setbacks, a lack of judgment and foresight, tendencies to digress from earlier aspirations, and failure to utilize their natural aptitudes and talents (C. Allen, 2004). For the most part, despite their setbacks, capricious/borderlines manage to recoup and regain their equilibrium before slipping into a more pernicious and serious decompensation (Benvenu & Brandes, 2005; Fossati, Feeney, et al., 2005). At times, however, when overwhelmed with mounting internal pressures, the borderline’s tenuous controls may break down, resulting in an eruption of bizarre behaviors, irrational impulses, and delusional thoughts (Conklin, Bradley, & Westen, 2006; Dowson et al., 2004; Nigg, Silk, Stavro, & Miller, 2005). These mini psychotic episodes tend to be brief and reversible and seem to assist borderlines in regaining their psychic balance (Jang, Dick, Wolf, Livesley, & Paris, 2005). Afterward, such episodes are usually recognized by the individual as being peculiar or deviant. As noted earlier, overt and direct expressions of hostility in capricious/borderlines tend to be exhibited only impulsively, for fear that such actions might result in abandonment or rejection (Crowe, 2004; de Bruijn et al., 2006; Wilson, Fertuck, Kwitel, Stanley, & Stanley, 2006). A characteristic form of anger control in these individuals is to turn feelings of resentment inward into hypochondriacal disorders and mild depressive episodes. Capricious/borderlines tend to overplay their helplessness and anguish, employing their depression as a means of avoiding responsibilities and placing added burdens on others. Their exaggerated plight causes guilt and discomfort among family and friends, as they try to meet the borderline’s “justified” need for attention and care (Sansone, Songer, & Miller, 2005). As with negativistic personalities, the dour moods and excessive complaints of the borderline may evoke exasperation and rebuke from others (Minzenberg, Poole, & Vinogradov, 2006). In this event, borderlines may turn their anger on themselves even more intensely, voicing a flood of self-deprecatory comments about their worthlessness, evilness, and inordinate demands on others (Joyce et al., 2006; Pompili, Girardi, Ruberto, & Tatarelli, 2005). This self-derision may be accompanied by thinly veiled suicidal threats (Chapman, Specht, & Cellucci, 2005; Gutheil, 2004; S¨oderberg, Kullgren, & Renberg, 2004), gambling, drug abuse, or other impulsively self-damaging acts that not only serve to discharge anger, but often succeed in eliciting forgiveness and reassurance, if not compassion, from others (Chapman, Gratz, & Brown, 2006; Oldham, 2006a, 2006b). Agitated depressions are common, with the capricious/borderline exhibiting an apprehensive and tense despondency, accompanied by a querulous irritability and hostile depressive complaints (Minzenberg, Fisher-Iving, Poole, & Vinogradov, 2006). Some borderlines may demonstrate a more intropunitive, self-deprecatory depression, manifest by expressions of self-doubt, feelings of unworthiness, delusions of shame and sin, and suicidal thoughts. In other borderlines, a retarded form of depression is expressed, where shame and self-disparagement is accompanied by lethargy, feelings of

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emptiness, boredom, and deadness (Andover, Pepper, Ryabchenko, Orrico, & Gibb, 2005). As capricious/borderlines’ moods are quite changeable and inconsistent with their thoughts and actions, it is virtually impossible for others to comprehend or empathize with their experiences. In their more euphoric moments, their zestful energy and joviality may temporarily engage and entertain others. However, the irrational, selfexpansive quality of their forced sociability, along with their lapses into irritability, eventually exasperate and drain others, destroying any patience or goodwill that was previously evoked (Paris, 2004a, 2004b; Zanarini, Frankenburg, Hennen, Reich, & Silk, 2005). One group of contemporary biological researchers, led by H. S. Akiskal (1981, 1983; Ruocco, 2005a, 2005b), has also argued strongly for the inclusion of the capricious/borderline syndrome within the subaffective spectrum. On the basis of affective family history, positive dexamethasone suppression test findings, major affective episodes, and high risk of suicide during prospective follow-up, H. S. Akiskal (1983) has suggested that approximately 50% of patients with severe characterologic disturbances, subsumed under the borderline rubric, seem to suffer from lifelong affective disorders (Gunderson et al., 2006; D. J. Smith, Muir, & Blackwood, 2004). He suggests that whereas about one fifth of borderline patients do suffer severe, primary characterological pathology in the form of Somatization Disorder and sociopathy, the largest group of borderlines exhibit “atypical, chronic and complicated forms of affective disorder with a secondary personality dysfunction” (1981, p. 31). Akiskal argues that although such patients may superficially present the picture of a personality disorder, an underlying biological affective illness may be masked by characterologic disturbances. He proposes a variety of subaffective disorders that may fall within the capricious/borderline realm. According to Akiskal, subaffective disorders, as opposed to major affective disorders, manifest only subsyndromal and intermittent (often lifelong) affective psychopathology, which only infrequently crystallizes into discrete syndromal episodes (Ben-Porath, 2004; Leichsenring, 2004; Paris, 2004a, 2004b). The mood changes associated with such disorders may be quite subtle, with behavioral and interpersonal disturbances (in part resulting from the affective instability) dominating the clinical picture (Benvenuti et al., 2005). Both H. S. Akiskal and Millon have proposed that the unstable sense of self that is characteristic of the borderline may be less an ego development problem than a consequence of a constitutional affective disorder with associated unpredictable, uncontrollable mood swings. It is further suggested that the capricious/borderline’s relatively poor response to psychotherapy may result, in many cases, from a failure to provide pharmacologic treatment of the underlying affective disorder (Gunderson et al., 2004). Stone (1993) also cites the similarities of the two disorders, observing that a large number of cyclothymic patients, in addition to having depressive and hypomanic bouts, favorably respond to lithium, and that relatives with bipolar or unipolar illness also exhibit characteristics that meet the criteria for Borderline Personality Disorder.

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As described by H. S. Akiskal (1981, p. 25), the borderline personality features an unstable sense of self, stemming from disturbances in the individuation-separation phase of development: “The disorder is conceptualized in characterologic terms and defined by impulsivity, drug-seeking behavior, polymorphous sexuality, affective lability (i.e., display of unmodulated affects such as rage and panic), boredom, anhedonia, bizarre attempts at self-harm and ‘micropsychotic episodes.’” It will be of interest to review the capricious/borderline personality construct with reference to the evolutionary model presented in the polarity schema of Figure 7.1. Worthy of note is that all of the usual motives and aims reflected in the model are present, albeit to a moderate degree. What is most significant is that all three pairs of polarities are in conflict, as indicated by the double-pointed arrows between them. This signifies the intense ambivalence and inconstancy that characterizes capricious/

BORDERLINE PROTOTYPE

Enhancement

Preservation

(Pleasure)

(Pain)

Accomodation

Modification

(Passive)

(Active)

Individuation

Nurturance

(Self)

(Other)

Conflict between Polarities Weak on Polarity Dimension Average on Polarity Dimension Strong on Polarity Dimension

FIGURE 7.1 Status of the capricious/borderline personality prototype in accord with the Millon polarity model.

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borderlines, their emotional vacillation, their behavioral unpredictability, and the inconsistency they manifest in their feelings and thoughts about others (Gregory, 2004; Sansone, 2004). This conflictual pattern contrasts with the other two severe or structural pathologies, the schizotypal and paranoid. The capricious/borderline possesses distinct inclinations, but they clash and are disharmonious; hence, the borderline switches back and forth, going in one direction and then opposite (Brendel, Stern, & Silbersweig, 2005; Gutheil, 2004). By contrast, the intensity of the polarity inclinations in the schizotypal is diffuse and undirected, hence producing the randomness and eccentricity that characterize his or her thoughts, feelings, and behaviors. In paranoids, the structural problem is one of rigidity and compartmentalization; there is an unbending and unvarying character to their polarity inclinations, an unwillingness to change their attitudes, behaviors, and emotions despite good reasons to do so. No such difficulty is evident in capricious/borderlines. In their case, each polarity position is but a temporary one, quickly jettisoned for its opposite. As has been noted, the severe or structural pathologies, which include the schizotypal, paranoid, and borderline disorders, almost invariably coexist with one or another of the stylistic personality disorders, for example, avoidant, histrionic, or negativistic. Hence, in evaluating a patient with distinct but conflictual structural defects that characterize the capricious/borderline, it is necessary to consider which stylistic personality pattern is also present (Paris et al., 2004). The polarity model requires the integration of both stylistic polarity features and structural borderline defects. A fusion of the two, style and structure, is necessary for a thorough and accurate assessment.

Clinical Picture Patients categorized as capricious/borderline personalities display an unusually wide variety of clinical symptoms. However, certain elements stand out and are common to most; these will be noted shortly. As with the preceding structurally defective personality, the schizotypal, we introduce these features first by dividing them into three broad categories: primary source of anxiety, cognitive processes and preoccupations, and general mood and behavior. Further differentiations are made in terms of the eight basic clinical domains (see Figure 7.2). Separation Anxiety Capricious/borderline personalities are exceedingly dependent; not only do they require a great deal of protection, reassurance, and encouragement from others to maintain their equanimity, but they are inordinately vulnerable to separation from these external sources of support. Separation and isolation can be terrifying not only because borderlines do not value themselves or use themselves as a source of positive reinforcement, but because

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BORDERLINE PROTOTYPE Incompatible Object Representations

Regression Regulatory Mechanism

Uncertain

Paradoxical

Self-Image

Interpersonal Conduct

Capricious Cognitive Style

Spasmodic

Expressive Behavior

Split

Morphologic Organization

Labile Mood/Temperament

FIGURE 7.2 Salience of prototypal capricious/borderline domains.

they lack the wherewithal, the know-how and equipment for independence and selfdetermination. Unable to fend for themselves, they not only dread signs of potential loss, but they anticipate loss, and distort their perceptions so that they see it happening when, in fact, it is not. Moreover, because capricious/borderlines devalue their own self-worth, it is difficult for them to believe that others can value them; as a consequence, they are exceedingly fearful that others will depreciate them and cast them off. With so shaky a foundation of self-esteem, and lacking the means for an autonomous existence, these patients remain constantly on edge, prone to the anxiety of separation and ripe for feelings of inevitable desertion. Any event that stirs up feelings of depression or excitement may precipitate a psychotic episode. Cognitive Conflict and Guilt Matters are bad enough for capricious/borderlines, given their separation anxiety, but these patients are also in conflict regarding their dependency needs and often feel guilty for having tried to be self-assertive. In contrast to their mildly pathological counterparts who have found a measure of success utilizing their strategies, borderline patients have been less fortunate and have struggled hard to achieve the few rewards they have sought. Moreover, in their quest for security and approval, most have been subjected to periods of isolation and separation; as a result, many have acquired feelings of distrust and hostility toward others. Capricious/borderlines cannot help but be anxious. To assert themselves would endanger the rewards they so desperately seek from others and perhaps even provoke others to total rejection and abandonment; yet, given borderlines’ past experiences, they know they can never fully trust others nor hope to gain all the affection and

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support they need (Shi-jie, 2006). Should they be excessively anxious about separation and therefore submit to protect themselves against desertion, they will still feel insecure; moreover, they will experience anger toward those on whom they depend because of the power these others hold over them and for “forcing” them to yield and acquiesce. To complicate matters, this very resentment becomes a threat to borderlines; if they are going to appease others as a means of preventing abandonment, they must take great pains to assure that their anger does not get out of hand. Should these resentments be discharged, even in so innocuous a form as displays of self-assertion, their security may be undermined and severely threatened. Thus, borderlines find themselves in a terrible bind: Should they go it alone, no longer depending on others who have been so unkind, or should they submit for fear of losing what little security they can eke out? To secure their anger and constrain their resentment, capricious/borderlines often turn against themselves and are self-critical and self-condemnatory. They begin to despise themselves and to feel guilty for their offenses, their unworthiness, and their contemptibility. They impose on themselves the same harsh and deprecatory judgments they anticipate from others. Thus, we see in these patients not only anxiety and conflict but overt expressions of guilt, remorse, and self-belittlement. Mood and Behavior Vacillation The most striking feature of the capricious/borderline is the intensity of moods and the frequent changeability of behaviors (Perseius, Ekdahl, Asberg, & Samuelsson, 2005). These rapid swings from one mood and behavior to another are not typical of the borderline; they characterize periods in which there is a break in control, or what we have referred to as a psychotic episode. More commonly, these patients exhibit a single dominant mood, usually a self-ingratiating and depressive tone that, on occasion, gives way to brief displays of anxious agitation, euphoric activity, or outbursts of hostility (Lenzenweger & Castro, 2005). Patients categorized as capricious/borderline personalities display a wide variety of clinical features. Certain elements do stand out as relatively distinct; these are the prime focus in this section. As in prior chapters, these characteristics are separated into several domains of clinical significance (see Table 7.1). Spasmodic Behavior Although the erratic qualities of the borderline are conceived as primarily of an emotional character, it is in all aspects of behavior that we see high levels of inconsistency and irregularity. Borderlines’ dress and voice show this pattern of vacillation and changeability. One day they are dressed quite appropriately and attractively; the next they are sloppy and disheveled. One day their voice has a spirited and energetic quality to it; the next they are hesitant, slow, and monosyllabic. Capricious/borderlines display a desultory energy level, at times with sudden, unexpected, and impulsive outbursts (Chabrol & Leichsenring, 2006; Davids & Gastpar, 2005). Their activation and emotional equilibrium seems to be in constant jeopardy, with endogenous shifts in mood,

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Table 7.1

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Clinical Domains of the Capricious/Borderline Personality Prototype

Behavioral Level: (F) Expressively Spasmodic (e.g., displays a desultory energy level with sudden, unexpected, and impulsive outbursts; abrupt, endogenous shifts in drive state and inhibitory controls; not only places activation and emotional equilibrium in constant jeopardy, but engages in recurrent suicidal or self-mutilating behaviors). (F) Interpersonally Paradoxical (e.g., although needing attention and affection, is unpredictably contrary, manipulative, and volatile, frequently eliciting rejection rather than support; frantically reacts to fears of abandonment and isolation, but often in angry, mercurial, and self-damaging ways). Phenomenological Level: (F) Cognitively Capricious (e.g., experiences rapidly changing, fluctuating, and antithetical perceptions or thoughts concerning passing events, as well as contrasting emotions and conflicting thoughts toward self and others, notably love, rage, and guilt; vacillating and contradictory reactions are evoked in others by virtue of own behaviors, creating, in turn, conflicting and confusing social feedback). (S) Uncertain Self-Image (e.g., experiences the confusions of an immature, nebulous, or wavering sense of identity, often with underlying feelings of emptiness; seeks to redeem precipitate actions and changing self-presentations with expressions of contrition and self-punitive behaviors). (S) Incompatible Objects ( e.g., internalized representations comprise rudimentary and extemporaneously devised but repetitively aborted learnings, resulting in conflicting memories, discordant attitudes, contradictory needs, antithetical emotions, erratic impulses, and clashing strategies for conflict reduction). Intrapsychic Level: (F) Regression Mechanism (e.g., retreats under stress to developmentally earlier levels of anxiety tolerance, impulse control, and social adaptation; among adolescents, is unable to cope with adult demands and conflicts, as evident in immature, if not increasingly infantile, behaviors). (S) Split Organization (e.g., inner structures exist in a sharply segmented and conflictful configuration in which a marked lack of consistency and congruency is seen among elements; levels of consciousness often shift and result in rapid movements across boundaries that usually separate contrasting percepts, memories, and affects, all of which leads to periodic schisms in what limited psychic order and cohesion may otherwise be present, often resulting in transient, stress-related psychotic episodes). Biophysical Level: (S) Labile Mood (e.g., fails to accord unstable mood level with external reality; has either marked shifts from normality to depression to excitement, or has periods of dejection and apathy, interspersed with episodes of inappropriate and intense anger, as well as brief spells of anxiety or euphoria). Note: F = Functional Domains; S = Structural Domains.

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drive, and inhibitory controls. Given this lack of control and the intensity of their emotional states, it should not be surprising that they are vulnerable to recurrent suicidal or self-mutilating impulses. It is the unpredictability and the impetuous, erratic, and unreflected impulsivity that characterizes the borderline’s tempers and actions, rather than the presence of a pattern of smoothly and repetitively swinging emotions that go from one end of the affective continuum to the other (Travers & King, 2005). This brittle, labile, and unsustainable quality is distinct from the cyclical regularity of contrasting moods that is often believed to typify these patients. Paradoxical Interpersonal Conduct Although capricious/borderlines need attention and affection, they act in an unpredictably contrary, manipulative, and volatile manner in their interpersonal relationships. These paradoxical behaviors frequently elicit rejection rather than the support they desperately seek (Meyer et al., 2005). In an unpredictable and frantic reaction to their fears of abandonment and isolation, borderlines become mercurially angry and explosive, hence damaging their security rather than eliciting the care they seek. As a secondary consequence of their unsure or unstable self-identities, borderlines have become exceedingly dependent on others, if they were not so already. Not only do they need protection and reassurance to maintain their equanimity, but they become inordinately vulnerable to separation from these external sources of support. Isolation or aloneness may be terrifying not only because capricious/borderlines lack an inherent sense of self but because they lack the wherewithal, the know-how, and equipment for taking mature, self-determined, and independent action. Unable to fend adequately for themselves, they not only dread potential loss but often anticipate it, seeing it happening when, in fact, it is not. The capricious/borderline is more ambivalent about relationships with others than are most personality syndromes. Moreover, these individuals have been less successful in fulfilling their dependency needs, suffering thereby considerably greater separation anxieties. Their concerns are not simply those of gaining approval and affection but of not submitting to others, yet preventing further loss. Because borderlines already are on shaky ground, their actions are directed less toward accumulating additional reserves of support and esteem than toward preserving the little security they still possess. At first, borderlines will employ their characteristic coping styles with increased fervor in the hope that they will regain their footing. Some may become martyrs, dedicated and self-effacing persons who are “so good” that they are willing to devote or sacrifice their lives to some greater purpose. The usual goal of these capricious/borderlines is to insinuate themselves into the lives of others who will not merely use them but need them, and therefore not desert them. Self-sacrificing though they may appear to be, these borderlines effectively manipulate others to protect against the separation they dread. Moreover, by sacrificing themselves, they not only assure continued contact

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with others but serve as implicit models for others to be gentle and considerate in return. Virtuous martyrdom, rather than a sacrifice, is a ploy of submissive devotion that strengthens the attachments borderlines need. The intolerance of being abandoned and the feeling of emptiness and aloneness consequent to the capricious/borderline’s failure to maintain a secure and rewarding dependency relationship cumulate into a reservoir of anxiety, conflict, and anger (Sieswerda, Arntz, & Wolfis, 2005). Like a safety valve, these tensions must be released either slowly or through periodic and often impulsive outbursts against others. Because borderlines seek the goodwill of those on whom they depend, they will try to express their inner tensions subtly and indirectly at first. Depression is among the most common of these covert expressions. Thus, the pleading anguish, despair, and resignation voiced by borderlines serve to release tensions and to externalize the torment they feel within themselves. For some, however, depressive lethargy and sulking behavior are a means primarily of expressing anger. Depression serves as an instrument for them to frustrate and retaliate against those who have “failed” them or “demanded too much.” Angered by the “inconsiderateness” of others, these capricious/borderlines employ their somber and melancholy sadness as a vehicle to get back at them or teach them a lesson. Moreover, by exaggerating their plight and by moping about helplessly, they effectively avoid responsibilities, place added burdens on others, and thereby cause their families not only to take care of them but to suffer and feel guilty while doing so. In addition, the dour moods and excessive complaints of these borderlines infect the atmosphere with tension and irritability, thereby upsetting what equanimity remains among those who have “disappointed” them. Similarly, suicidal threats, gambling, and other impulsively self-damaging acts may function as instruments of punitive blackmail, a way of threatening others that further trouble is in the offing, and that they had best make up for their prior neglect and thoughtlessness. Capricious Cognitive Style It is characteristic of borderlines to experience rapidly changing, fluctuating, and antithetical perceptions and thoughts concerning persons and passing events. Not only do they experience contrasting emotions, but they have ambivalent attitudes toward themselves and others; for example, they may love their spouse one moment, feel rage the next, and then experience guilt thereafter. Most problematic is that their vacillating and contradictory perceptions evoke in others similarly conflicting and confusing feedback (Fertuck, Lenzenweger, Clarkin, Hoermann, & Stanley, 2006; Ruchsow et al., 2006). This perpetuates the vicious circle of experiencing again and again that which prompted their behavior in the first place. A major problem for the borderline is the lack of a consistent purpose or direction for shaping attitudes, behaviors, or emotions (Dinn et al., 2004; Judd, 2005; Stevens, Burkhardt, Hautzinger, Schwarz, & Unckel, 2004). Unable to give coherence to their existence, borderlines have few anchors or guideposts to either coordinate their actions, control their impulses, or construct a goal-oriented means for achieving their desires.

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Feeling scattered and unintegrated, they vacillate, responding as a child would to every passing interest or whim and shifting from one momentary course to another. In effect, borderlines appear to have deteriorated increasingly toward primary-process thinking. Under the press of surging affects and their inability to maintain a clear focus, they regress to a psychoticlike thought process, occasionally reflected in quasi-paranoid ideation and severe dissociated symptoms. Uncertain Self-Image It is typical of borderlines to experience the confusions of an immature, nebulous, or wavering sense of identity, often with underlying feelings of emptiness. They have considerable difficulty maintaining a stable sense of who they are, conveying rapidly shifting presentations of self, or in formulating any clear sense of their personal image (Tolpin, Gunthert, Cohen, & O’Neill, 2004; Whewell, Lingam, & Chilton, 2004; Zeigler-Hill & Abraham, 2006). They remain aimless, unable to channel their energies or abilities, incapable of settling down on some path or role that might provide a basis for fashioning a unified and enduring sense of self (Berlin & Rolls, 2004; Chabrol, Rousseau, & Callahan, 2006). Seeking to redeem their precipitate actions and changing self-presentations accounts in part for their expressions of contrition and for their self-punitive behaviors. Likewise, borderlines demonstrate highly contradictory selfrepresentations. These reflect their lack of inner cohesion and the so-called splitting maneuvers that they employ. Portions of their schismatic psyche may be split off and projected onto others as a means of bewildering or controlling them, a defensive maneuver designed in part to create confusion in others that mirrors their own inner ambivalence. Incompatible Objects Inferring the internalized representations of capricious/borderlines on the basis of their thoughts and behaviors suggests that their inner objects comprise rudimentary and extemporaneously derived dispositions and images. Early learnings regarding significant others are likely to have been repetitively aborted, resulting in conflicting memories, discordant attitudes, contradictory needs, erratic impulses, and clashing strategies for conflict resolution. In effect, their inner templates for perceiving and thinking about current events are composed of complex antithetical dispositions (Kremers, Spinhoven, Van der Does, & Van Dyck, 2006). Because borderlines are very likely to devalue their self-worth, it is difficult for them to believe that those on whom they have depended in the past could ever have thought well of them. Consequently, at a deep intrapsychic level, they are exceedingly fearful that others will inevitably depreciate them and perhaps cast them off. With so unstable an inner template of self-esteem, and lacking the means for assuring their autonomous existence, capricious/borderlines remain constantly on edge, prone to the anxiety of separation and ripe for anticipating inevitable desertion. Being anchored to these internalized objects stirs up deep fears that efforts at restitution such as idealization,

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self-abnegation, and attention-gaining acts of self-destruction or, conversely, selfassertion and impulsive anger, will inevitably fail. As a result of the schisms that characterize both their overt and covert psychic processes, borderlines fail to recognize that other persons possess a mix of both positive and negative feelings and attitudes. Instead, the inner templates of borderlines are sharply divided, split, so to speak, into polar extremes, so others are seen either as totally good or totally bad. Consequently, borderlines may alternate on a regular basis between idealizing these persons and abruptly devaluing them, a process that reflects their inner schisms and creates erratic shifts in the reactions of others. Matters are bad enough for capricious/borderlines, given their identity diffusion and separation anxieties, but their internalized images and impulses are in intense conflict regarding dependency needs. Not only do they feel guilt for past attempts at selfassertion and independence, but these quests for self-determination and self-identity may have been subjected to ridicule and isolation, resulting in increased feelings of distrust and resentment toward others. Moreover, should they seek to become close to another, two contrasting but distressful consequences come to mind. First, they fear that they will be engulfed by the person, thereby losing what little sense of autonomy and identity they possess. Second, they fear that they will, without forewarning, be precipitously abandoned. Regression Mechanism Most significant among the regulatory mechanisms employed by the capricious/ borderline is the tendency to retreat under stress to developmentally earlier levels of anxiety tolerance, impulse control, and social adaptation. Among adolescents who exhibit borderline tendency, we find an inability to cope with adult demands and life’s conflicts, as evident in immature, if not increasingly infantile, behaviors. The hostility expressed by borderlines poses a serious threat to their security. To experience resentment toward others, let alone to vent it, endangers them as it may provoke the counterhostility, rejection, and abandonment they fear. Angry feelings and outbursts must not only be curtailed or redirected toward impotent scapegoats, but may be intrapsychically reversed and condemned. To appease their conscience and to assure expiation, they may reproach themselves for their faults and purify themselves to prove their virtue. To accomplish this regulatory goal, their hostile impulses may be dynamically inverted. Thus, aggressive urges toward others may be turned on themselves. Rather than vent their anger they will openly castigate and derogate themselves and voice exaggerated feelings of guilt and worthlessness. These capricious/borderlines become notably self-recriminating. They belittle themselves, demean their abilities, and derogate their virtues, not only as a means of diluting their aggressive urges but to assure others that they themselves are neither worthy nor able adversaries. The self-effacement of these borderlines is an attempt, then, both to control their own hostility and to stave off hostility from others.

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Among other borderlines, where hostile impulses are more deeply ingrained as a form of self-expression, these feelings must be counteracted more forcefully. Because these patients are likely to have displayed their anger more frequently and destructively, they must work all the harder to redeem themselves. Instead of being merely selfeffacing and contrite, they will often turn on themselves viciously, claiming that they are despicable and hateful persons. These condemnatory self-accusations may at times reach delusional proportions, and such patients may reject every rational effort to dissuade them of their culpability. In these cases, it is the struggle to redeem oneself that often leads to self-mutilation and physical destruction. Split Organization The structural concept termed “split” is especially apt in characterizing the intrapsychic organization of capricious/borderlines. Their mind comprises inner structures that exist in sharply segmented and conflictful configurations. There is a marked lack of systematic order and congruency among these elements. Levels of consciousness often shift to and fro. Similarly, rapid movements take place across boundaries that should separate contrasting perceptions, memories, and affects (Hazlett et al., 2005; Mauchnik, Schmahl, & Bohus, 2005). This lack of control and cohesion produces periodic but serious schisms in psychic order and cohesion, resulting in a susceptibility to transient, stress-related psychotic episodes. Capricious/borderlines cannot help but be intrapsychically ambivalent. To assert themselves endangers the security and protection they desperately seek from others by provoking others to reject and abandon them. Yet, given their past, they know they can never entirely trust others nor fully hope to gain the security and affection they need. Should their anxiety about separation lead them to submit as a way of warding off or forestalling desertion, they expose themselves to even further dependency and, thereby, an even greater threat of loss. Moreover, they experience intense anger toward those on whom they depend, not only because dependency shames them and exposes their weakness, but also because of others’ power in having “forced” them to yield and acquiesce. This very resentment becomes a threat in itself. If they are going to appease others to prevent abandonment, they must take pains to assure that their anger remains under control. Should this resentment be discharged, even in innocuous forms of selfassertion, their security will be severely threatened. They are in a terrible bind: Should they strike out alone, no longer dependent on others who have expected too much or have demeaned them, or should they submit for fear of losing what little security they can gain thereby? To secure their anger and to constrain their resentment, borderlines often turn against themselves in a self-critical and self-condemnatory manner. Despising themselves, they voice the same harsh judgments they have learned to anticipate from others. They display not only anxiety and conflict but overt expressions of guilt, remorse, and self-belittlement. It is these feelings that occasionally take hold, overwhelm them, and lead to the characteristic self-damaging and self-destructive acts.

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Labile Mood The most striking characteristic of capricious/borderlines is the intensity of their affect and the changeability of their actions. Most fail to accord their unstable mood levels with external reality. They tend to show marked shifts from normality to depression to excitement. There are periods of dejection and apathy, interspersed with episodes of inappropriate and intense anger, followed by brief spells of anxiety or euphoria. Rapid shifts from one mood and attitude to another are not inevitable aspects of the everyday behavior of the borderline, but they do characterize extended periods when there has been a break in control. Most borderlines exhibit a single, dominant outlook or frame of mind, such as a self-ingratiating depressive tone, which gives way periodically to anxious agitation or impulsive outbursts of temper or resentment (Irle, Lange, & Sachsse, 2005; Schmahl & Bremner, 2006). Self-destructive and self-damaging behaviors are usually recognized subsequently as having been irrational and foolish.

Self-Perpetuation Processes As in prior chapters, this section describes how aspects of the behavioral style of the personality pattern under discussion perpetuate and intensify the difficulties that characterize that personality. It is difficult to see the utility of any of the capricious/borderline’s characteristic behaviors, let alone to grasp what gains the patient may derive by vacillating among them. Clinging helplessness, resentful stubbornness, hostile outbursts, pitiable depression, and self-denigrating guilt seem notably wasteful and self-destructive. Although these genuinely felt emotions are instrumentally useful in eliciting attention and approval, releasing tensions, wreaking revenge, and avoiding permanent rejection by redeeming oneself through contrition and self-derogation, they ultimately intensify and subvert the borderline’s efforts for a better life. Despite short-term gains, these behaviors are self-defeating in the end. By their affective instability and self-deprecation, these patients avoid confronting and resolving their real interpersonal difficulties. Their coping maneuvers are a double-edged sword, relieving passing discomforts and strains but in the long run fostering the perpetuation of faulty attitudes and strategies. It will be instructive to outline several of the dysfunctional efforts the borderline exhibits in seeking to overcome his or her difficulties (see Table 7.2). Countering Separation In contrast to their milder counterparts, capricious/borderlines have been less successful in fulfilling their dependency needs, thereby suffering considerably greater separation anxieties. As a consequence, their concerns are not simply those of gaining approval and affection, but of preventing further loss; because they already are on shaky grounds,

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Self-Perpetuating Processes: Capricious/Borderline Personality

Countering Separation Insinuates self into lives of others Demeans self to gain empathic attention Repeatedly reverses coping strategies Releasing Tensions Externalizes inner fright and torment Sulking expresses anger and retaliation Moping makes others feel guilty Redemption through Self-Derogation Resentments may provoke abandonment threats Reproaches self to achieve expiation Castigates self to justify worthless feelings

their actions are directed less toward accumulating a reserve of support and esteem than of preserving the little security they still possess. At first, borderlines will employ their characteristic strategies with even greater vigor than usual. Whichever style typifies their established personality pattern will be applied with increased fervor in the hope of regaining their footing with others. Thus, borderlines with self-destructive and discouraged styles may begin to view themselves as martyrs, dedicated and self-effacing persons who are “so good” that they are willing to sacrifice their lives for a higher or better cause. This they do, but not for the reasons they rationalize. Their goal is to insinuate themselves into the lives of others, to attach themselves to someone who will not only use them, but need them, and therefore not desert them. Self-sacrificing though they may appear to be, these capricious/borderlines have effectively manipulated the situation to ensure against the separation they dread. Furthermore, by demeaning themselves, they not only assure contact with others, but often stimulate others to be gentle and considerate in return. Their virtuous martyrdom is a means of exploiting the generosity and responsibility of others, thus strengthening attachments. But what if the borderline’s efforts fail to counter the anxiety of separation? What occurs when exaggerations of his or her characteristic strategy fail to produce or strengthen the attachments he or she needs? Under these conditions, we often observe a brief period in which the patient renounces his or her lifelong coping style. For example, discouraged borderlines, rather than being weak and submissive, may reverse their more typical behaviors and assert themselves, becoming frivolous, demanding, or aggressive. They may employ a new and rather unusual mode of coping as a substitute method for mastering the anxiety of

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separation. Unable to quiet their fears, faced with situations that refuse to be solved by their habitual adaptive style and discouraged and annoyed at the futility, they disown the old strategies, divest themselves of these deficient coping devices, and supplant them with dramatically new instrumentalities. Their goal remains the same, that of denying or controlling their anxiety, but they have found a new strategy by which to achieve it, one that is diametrically opposed to that used before. It is this shifting from one strategy to another that accounts in part for the variable or capricious/borderline pattern observed in these patients. These novel efforts are not only often bizarre, but typically are even less effective in the long run than the more established strategies. These borderlines have sought to adopt attributes and behaviors that are foreign to their “natural” self; unaccustomed to the feelings they try to simulate and the behaviors they strive to portray, they act in an “unreal,” awkward, and strained manner with others. The upshot of this reversal in strategy is a failure to achieve their goals, leading to increased anxiety, frustrations, dismay, or hostility. Not only have their simulations alienated them from their real feelings, but the pretensions they display before others have left them vulnerable to exposure and humiliation. Releasing Tensions The ever-present fear of separation and the periodic failure of the capricious/borderline to achieve secure and rewarding dependency relationships cumulate an inner reservoir of anxiety, conflict, and hostility. Like a safety valve, these tensions are released either slowly and subtly or through periodic and dramatic outbursts. Because borderlines seek to retain the goodwill of those on whom they depend, they try, at first, to express indirectly the inner tensions they experience. Dejection and depression are among the most common forms of such covert expressions. The pleading, the anguish, and the expressed despair and resignation of borderlines serves to release inner anxieties and to externalize and vent the fright and torment they feel. But of even greater importance, depressive lethargy and sulking behaviors are means of expressing anger. In certain borderline styles, for example, depression may serve as an instrument to frustrate and retaliate against those who now seek to buoy the patient’s spirits. Angered by their previous failure to be thoughtful and nurturant, these borderlines employ their somber depression as a vehicle to get back at others or to teach them a lesson. By exaggerating their plight and by moping about helpless and exhausted, they effectively avoid responsibilities, place added burdens on others, and thereby cause their families not only to care for them, but to suffer and feel guilty while doing so. The impulsive (histrionic) borderline vents his or her anger in similar ways. Because others are accustomed to his or her gregarious and affable manner, the glum moroseness and sluggish and gloomy manner become doubly frustrating. By withdrawing into a dismal and sullen attitude, he or she constructs a barrier between self and others in which they can no longer experience the pleasures of the borderline’s dramatic and

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cheerful behaviors. Thus, in the form of recalcitrant depression, the borderline gains revenge, punishes, sabotages, and defeats those who have failed to appreciate him or her. Other borderlines are equally adroit in venting their tensions and expressing their angers. Their frequent fatigue and minor somatic ailments force others not only to be attentive and kind, but, by making them carry excess burdens, to suffer as well. Moreover, the dour moods and excessive complaints of these borderlines infect the atmosphere with tension and irritability, thereby upsetting the equanimity of those who have disappointed them. In the same way, this borderline’s cold and stubborn silence may function as an instrument of punitive blackmail, a way of threatening others that further trouble is in the offing or a way of forcing others to make up for the inconsideration they previously had shown. Despite the temporary gains achieved by these indirect forms of tension and hostility discharge, they tend to be self-defeating in the long run. The gloomy, irritable, and stubborn behavior of this borderline wears people down and provokes them to exasperation and anger, which, in turn, will only intensify the anxieties, conflicts, and hostilities the patient feels. As these more subtle means of discharging negative feelings prove self-defeating, the patient’s tensions and depressions mount beyond tolerable limits and he or she may begin to lose control. Bizarre thoughts and psychotic behaviors may burst forth and discharge a torrential stream of irrational emotion. For example, these borderlines may shriek that others despise them, are seeking to depreciate their worth and are plotting to abandon them. Inordinate demands for attention and reassurance may be made; they may threaten to commit suicide and thereby save others the energy of destroying them slowly. Under similar circumstances, the usually restrained preborderlines may burst into vitriolic attacks on their loved ones as their deep and previously hidden bitterness and resentment surge into the open. Not unjustifiably, these patients accuse others of having aggressed against them, protesting that others are contemptuous of them and unjustly view them as a deception, a fraud, and a failure. Utilizing the distorting process of intrapsychic projection, preborderlines ascribe to others the weakness and ineptness they feel within themselves; it is others who have fallen short and who should be punished and humiliated. With righteous indignation these patients rail outward, castigating, condemning, and denouncing others for their frailty and imperfections. Redemption through Self-Derogation The capricious/borderline’s hostility poses a serious threat to his or her security. To experience resentment toward others, let alone to vent it, endangers the patient as it may provoke the counterhostility, rejection, and abandonment he or she dreads. Angry feelings and outbursts must not only be curtailed but condemned. To appease their conscience and to ensure expiation, borderlines must reproach themselves for their faults, purify themselves, and prove their virtue. To accomplish this goal, hostile

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impulses are inverted; thus, aggressive urges toward others are turned on oneself. Rather than express their anger they castigate and derogate themselves and suffer exaggerated feelings of guilt and worthlessness. Many borderlines are notably self-recriminating; they belittle themselves, demean their competence, and derogate their virtues, not only in an effort to dilute their aggressive urges, but also to assure others that they are neither worthy nor able adversaries. The self-effacement of these borderlines is an attempt, then, to control their hostile outbursts and to stave off aggression from others. Other borderlines, whose hostile urges are profound and enduring, must counteract these behaviors more forcefully. Furthermore, because they have displayed anger more frequently and destructively, they must work all the harder to redeem themselves. Instead of being merely selfeffacing and contrite, they may turn on themselves viciously, viewing themselves as despicable and hateful. Condemnatory self-accusations may reach delusional proportions in these patients; moreover, they often reject rational efforts to dissuade them of their culpability and dishonor. In some cases, the struggle to redeem oneself may lead to self-mutilation and destruction.

Interventional Goals Capricious/borderlines are notoriously difficult patients for therapists (Conklin & Westen, 2005). They run through the whole gamut of emotions in therapy, and their erratic and frequently threatening behaviors stir countertransference responses in many therapists. Because the risk of burnout is so high, therapists should limit the number of borderline patients in their caseload, if possible. This having been said, however, it should be noted that working with a borderline can prove to be a gratifying experience (Chiesa, 2005). Unlike working with some personalities, such as antisocials or schizotypals, with whom the therapist can hope at best only for modestly increased levels of adaptive behavior, borderline disturbances are much more amenable to personality change and reorganization. Many capricious/borderlines have a range of highly developed social skills, along with the intrinsic motivation to restrain contrary and troublesome impulses. Therapeutic gains can lead to extended periods of productive functioning and interpersonal harmony in the patient’s life and can provide the therapist with an unusual, if not satisfying, relationship, as well as the opportunity to see therapeutic goals realized. As noted previously, and before gauging the patient’s prognostic picture and recommending a remedial course of therapy, it is well to remember that borderlines, despite their common defining characteristics, are frequently more severe variants of other personality disorders, notably the negativistic, depressive, histrionic, antisocial, sadistic, and avoidant. As a result, they are even less homogeneous a classification than are other personality disorder categories. Some are well-compensated; most are not. Some are bolstered by supportive families; others face destructive environmental

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Table 7.3 Therapeutic Strategies and Tactics for the Prototypal Capricious/ Borderline Personality Strategic Goals Balance Polarities Reduce conflict between pain–pleasure Reduce conflict between active–passive Reduce conflict between self–other Counter Perpetuations Reduce capricious emotionality Moderate inconsistent attitudes Adjust unpredictable behaviors Tactical Modalities Stabilize paradoxical interpersonal conduct Rebuild unstable self-image Steady labile moods

conditions. Despite symptom commonalities, these differences in the clinical picture must be attended to closely to produce effective remedial intervention. Reorganizing the structure of the capricious/borderline personality is no trivial undertaking. The clinical picture represents a state of imbalance on all four of the passive–active, other–self, pain–pleasure, and thinking–feeling polarities. Not only are borderlines’ coping mechanisms ineffective and problem-perpetuating, but their lack of consistency leads to identity confusions as well. Personologic domain dysfunctions include the morphological structure of the personality itself, handicapping the borderline above and beyond the difficulties presented by disturbances in the other domains. These many deviations from optimal functioning make the borderline, along with the schizotypal and paranoid personalities, one of the three more severe disorders of personality. The capricious/borderline’s characteristic desire for gratifying relationships (unlike the schizotypal) and flexibility in the personality structure (unlike the paranoid), however, work to the borderline’s advantage and give him or her an edge over the other two severe variants (see Table 7.3). Reestablishing Polarity Balances Capricious/borderlines vacillate between being motivated by pain and by pleasure, turning to others and to self for gratification, and taking an active and passive stance in regard to manipulating their environments. Most borderline patients do have fundamental tendencies toward particular orientations within the polarities, but they often adopt diametrically opposed strategies when they find that their usual behavior patterns do not result in the desired consequences. For example, a borderline who tends toward

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dependency can become suddenly aggressive and independent in an effort to bully the partner into caretaking behavior. Fluctuation between extremes of dependency and aggression are not likely to produce desired results, however, as they tend to leave significant others confused, frightened, or worse. Additionally, such behavior on the part of the capricious/borderline leads to repeatedly undoing and even reversing previous actions. This leaves the patient with distress from failing to secure nurturing responses from others, and increasing feelings of emptiness and confusion from being without a clear sense of who he or she is. Therapeutic interventions help patients to moderate their vacillations between extreme polarity behaviors until they are stabilized in a more adaptive balance between the active–passive, self–other, and pain–pleasure polarities. An important first step is to gently illustrate the inevitably unfavorable consequences of extreme behaviors and to help the borderline patient learn more moderate and adaptive coping strategies. Considering the particular environmental context, whether deciding between relying on self or others or between passive and active strategies, can prove to be an invaluable skill. Ultimately, a decrease in vacillation between extremes can serve to stabilize not only the capricious/borderline’s life, but his or her uncertain self-image, providing thereby a more solid grounding to prevent painful and disruptive breaks with reality. Countering Perpetuating Tendencies Teaching the capricious/borderline patient to overcome the tendency to engage in deeply ingrained problem-perpetuating behavioral strategies is only a first step; the therapist faces the additional challenge of overcoming the largely unnatural behaviors that borderlines desperately adopt when their more or less typical behaviors fail to produce desired results (Fonagy & Bateman, 2006). The tactic of reversing their habitual attitudes and roles, whether these be clinging helplessness, resentful stubbornness, hostile outbursts, pitiable depression, or self-denigrating guilt, serves to alienate borderlines even further from their fragile sense of self and their relationships with others. In addition, most people can sense the unreal quality of these dramatic behavioral changes and often fail to respect or respond to the capricious/borderline’s needs. Even when these momentary reversals provide the patient with attention and support, the long-term effect of these forced strategies will likely wear down and exasperate others. Borderlines sense the growth of these unpleasant sentiments in others, becoming thereby more conflicted about what they should do, and leading them to be increasingly anxious about potential abandonment. Once the counterproductive nature of the patient’s strategies is grasped, a major therapeutic goal is to help the capricious/borderline tolerate the anxiety that causes him or her to switch from one extreme behavior to another. These extremes represent a frantic desire to discharge anxiety. Learning to contain these feelings long enough to delay responses will provide the time to evaluate whether the perceived threat is real and to choose a healthier response. This serves to eliminate the negative effects of failing

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to cope adequately, including diminished self-esteem and interpersonal dislocations. A painful and disruptive break with reality thereby becomes less likely, extreme reactions more moderate, and opportunities for healthier emotional experiences more probable. Identifying Domain Dysfunctions The three most salient domain dysfunctions of the capricious/borderline personality are a paradoxical interpersonal conduct, split morphologic organization, and uncertain self-image. The borderline’s paradoxical interpersonal conduct is the hallmark of the disorder, the immediate source of the chaos and uncertainty that typifies his or her life. The borderline’s overwhelming motivation is to secure attention and nurturance, yet a fundamental split in the morphologic organization of his or her personality leads to nonintegrated emotional functioning and cognitive black-and-white thinking. The result is often inconsistent and paradoxical behaviors, such as seen in displays of anger when the prospect of separation is threatened. Although such hostile acts sometimes elicit the desired nurturance in the short term, they greatly increase the probability of abandonment over time. Such erratic tendencies are further aggravated by the capricious/borderline personality’s uncertain self-image. This tentative sense of identity creates confusion regarding what behavior is appropriate. When behavioral strategies do not yield desired results, the borderline intensifies them; that is, he or she will try harder, not necessarily more wisely. Ultimately, failure compels these patients to redeem themselves with expressions of contrition and self-punitive behaviors that seek to forestall further rejection. Unfortunately, they also negate important aspects of the self, intensify the uncertainty about their identity, and reinforce the vicious circle of personality decline. Therapeutic interventions that aim to solidify the patient’s identity can indirectly lead to decreases in the anxiety produced by the threat of abandonment, and thus can serve to undermine maladaptive behaviors at their source. A stable and solid self-image can also provide grounding and security needed for the capricious/borderline to risk exploring the validity of long-held and ingrained assumptions, to face the futility of his or her behavioral patterns, and to motivate the patient to tolerate useful interventions that may produce temporary increases in anxiety. One consequence of helping the patient tolerate anxiety long enough to explore inner conflicts and to experiment with moderate behaviors can be to initiate the integration of the many splits within the morphological structure of the personality. Tolerance for unpleasant reactions can also diminish the tendency to regress to earlier modes of coping and anxiety reduction. Improvements in the primary domain dysfunctions can be bolstered by intervention into the secondary dysfunctional domains. Focusing on altering the borderline’s capricious style will help the patient assess whether the anxiety-provoking environment is actually a product of his or her own misperceptions and misinterpretations. Life events have been perceived in contradictory ways, leading to inconsistent responses. In turn, individuals associated with the patient have also responded in conflicting ways, leaving

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the patient with the distressing reality of an unpredictable and seemingly irrational world. Coming to realize that the world is not structured in black-and-white categories is a large part of overcoming the tendency to overreact. If people are seen as either all good or all bad, the appropriate reaction is to either love or hate them; if they do one imperfect thing to negate their goodness, they must by default be bad, and need to be treated as such. Extreme and categorical behavior is thus built on the foundation of extreme categorical thinking. The borderline’s incompatible object representations are an example of such thinking. Examining early memories can lead to insight into antithetical emotions, contradictory needs, and readily aborted schemas about others. Spasmodic expressive acts that reflect impulsive outbursts and abrupt endogenous shifts in drive state also can be stabilized by the former interventions. While the capricious/borderline’s labile temperament can often be somewhat stabilized with medication, therapeutic gains in other domains help bring about stability in the structure of the personality that will be reflected in less fluctuating mood states.

Selecting Therapeutic Modalities Despite changes in the borderline diagnostic conceptions and definitions over time, one aspect has remained stable: therapists have many difficulties dealing with borderline patients (Spurling, 2005; Swartz, Pilkonis, Frank, Proietti, & Scott, 2005). Despite the near inevitability of therapist frustrations, the importance of a solid alliance between therapist and patient cannot be overestimated. More than other personality disorders, capricious/borderlines have erratic interpersonal relationships that take a great toll on their lives and that will be mirrored in their relationship with a therapist (Livesley, 2004; Oldham, 2006a, 2006b). These patients’ strong positive and negative reactions and their rapidly fluctuating attitudes toward the therapist can evoke powerful countertransference responses. The patient may have bouts with therapist idealization and devaluation, threats of legal repercussions, suicidality, self-harm, and other uncontrollable behaviors, each of which may evoke in the therapist empathy, anger, frustration, fear, and feelings of inadequacy (Bender, 2005; Gregory, 2004). In the course of either of these troublesome sequences, the therapist may experience a blurring of personal boundaries, an invasion of privacy that leaves him or her at a loss as to what to do. Capricious/borderlines may not hesitate to intrude into the therapist’s space, ask the therapist to lunch, call him or her at home, or use abusive tactics to manipulate and set him or her up. The patient may plead for inappropriate intimacies and then turn the tables and accuse the therapist of taking advantage of his or her more powerful position. These difficulties should be avoided as much as possible by making it clear at the beginning of therapy that the goal of treatment is to foster independence and that limits will have to be set to aid its achievement. This does not imply that the therapist should refuse to help or to provide support in a crisis, but rather that help should also support

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the goal of strength building; long hand-holding phone calls and special arrangements should be replaced with a supportive but brief reminder of treatment goals, contracts, and gains in therapeutic work. In short, clear limits should be set in the first few sessions. Then the therapist should be as responsive and supportive as possible within those clear limits. A failure to be responsive will lead to accusations of abandonment and hypocrisy; overstepping agreed-upon boundaries will lead to further testing of the therapist by the patient. Some potential clients may decide from the beginning that they need a therapist to provide a more nurturant position. If the patient accepts the therapist’s terms, the two can begin working on building an alliance. A good therapeutic relationship can take quite some time to develop. Much can be gained therapeutically as the borderline realizes that not all individuals are dangerous and that not all self-disclosure necessarily leads to being judged unacceptable and worthy of abandonment. Beck and Freeman (1990a, 1990b) note that the patient’s difficulty trusting the therapist cannot be resolved quickly and easily. Explicit acknowledgment of the patient’s difficulty with trust, special care to communicate clearly, assertively, and honestly, and especially the maintenance of congruity between verbal and nonverbal cues by the therapist can all help. The importance of behaving in a trustworthy manner cannot be overestimated. Although it may not be appropriate for the therapist to flood the client with information regarding his or her reactions, any strong emotions that the therapist fails to contain should be partially acknowledged, lest the patient find reason to mistrust the therapist. Many borderlines are uncomfortable with intimacy (due to their basic mistrust of others) and can become quite anxious in therapy if their boundaries are overstepped (Aviram, Hellerstein, Gerson, & Stanley, 2004). Beck and Freeman (1990a, 1990b) suggest that the therapist solicit the client’s feedback regarding how to make therapy more comfortable for him or her. Many borderlines experience greater comfort with the intimacy involved in the therapeutic process if they feel that they have some control over the pace and the topics discussed in therapy (Bland & Rossen, 2005). It is very important to make it clear from the beginning of therapy that getting better will not mean that the patient will be thrown out of treatment, and that termination will be a mutual decision (Stone, 2004). Otherwise, the therapist will be faced with the threat that the patient will feel the need to regress or resist progress to get attention from the therapist. Benjamin suggests that in the event of such manipulation by the client, whether in the form of lethal attacks or seductive gestures, the appropriate response is to be firm yet nonattacking. The terms of the therapy and its goals should be stated clearly and in a supportive tone, giving the patient safe grounding despite his or her habitual emotional turmoil. Behavioral Techniques Dialectic behavior therapy (Arntz, 2005; Ben-Porath & Koons, 2005; Linehan, 1987, 1992) is conceptually related to several cognitive approaches in that it emphasizes a dialogue between patient and therapist that seeks through persuasion to bring the

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patient’s worldview in line with that of the therapist. To this end, therapist selfdisclosure is considered a valid and useful technique (Ben-Porath, Peterson, & Smee, 2004; Robins & Chapman, 2004; Sunseri, 2004). The ultimate goal of therapy is to create a responsible autonomy in the patient’s attitudes and behaviors; this aim is arrived at gradually by moving through a series of hierarchical steps designed to prevent suicidal and self-injurious behavior, secure a therapeutic alliance, deal with symptoms that disrupt functioning (e.g., substance abuse), counter less disruptive problems in living, and contend with the patient’s cognitive schemas (hopes, ambitions, beliefs) and explore healthy psychic reorganization. Linehan’s (1992) outline for individual therapy includes adjunct group therapy in which behavioral interventions such as skill training, rehearsal, and didactic analysis aim to decrease dependency and improve tolerance for negative feedback and affect (Bohus et al., 2004). Proposing an alternative behavioral formulation, Turkat (1990) centers his efforts on strengthening the “problem-solving deficiencies” among borderlines; for example, he recommends systematic training in concept formation, processing speed, and skill training in developing well-structured categories. Interpersonal Techniques Benjamin (1993) sees the interactional pattern of borderline relationships as deriving from the patient’s long history and expectation of abandonment and as a recent consequence of therapist burnout after prolonged but failed attempts to effect significant therapeutic changes. It is when the patient realizes that the therapist will never be able to provide enough nurturance that desperate and extreme behaviors, such as suicidal gestures, cause the therapist to begin to withdraw. The borderline in turn accuses the therapist of not caring and often ends therapy in a dangerous and dramatic way. At times, the therapist is held responsible or even threatened with lawsuits. If the patient decides to return to treatment the therapist may have lost enthusiasm but may fear legal repercussions or charges of professional irresponsibility. The vicious circle for continued failure is now set. Another possible pattern is one in which the patient starts to get better but fears that improvements will lead to being kicked out of therapy. He or she will therefore preemptively regress. The approach outlined by Benjamin (1993) places great emphasis on the development of a solid alliance. The next therapy objective is for the patient to recognize his or her maladaptive patterns. Dream analysis, free association, role-plays, and discussion may all help achieve this goal. Helping the borderline understand the connection between his or her present symptomatic behavior and early history can bring relief and generate motivation. Validating the patient’s sense of reality about having been victimized (often refuted by family members) can also help set the patient on the path toward healing. Any guilt the borderline feels needs to be acknowledged as normal, although his or her role in supposedly asking for early abuse needs to be clarified as patently false. Once the maladaptive patterns are recognized, the therapist and patient need to work on blocking them. The therapist can point out to the borderline that

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a nose dive often follows periods when things go well in therapy. Plans can be made for averting or at least minimizing damaging actions. The reasons for self-destructive behavior can be uncovered by examining internal fantasies; for example, parents are appeased, and abusers realize that they are still loved and will be good to the patient. Benjamin suggests strengthening the will to resolve old attachments by asking penetrating questions, such as “Do you still love your brother (or any significant other) enough to give him this (self-destructive result)?” Family intervention is often useful when the capricious/borderline has frequent interaction with parents or other family members who are overinvolved but not supportive of the patient’s individual therapy (Coyle, 2006; Hoffman et al., 2005). In these cases, borderlines often feel guilty about being disloyal to the family and terminate therapy prematurely. Involving the family in helping patients with their problem by not reinforcing dependent behavior can help tremendously in meeting treatment objectives. In families where abuse and/or incest have led to symptomatology (more common), there is often strong resistance to participate. Independent meetings with the parents may be required to emphasize that family intervention will be focused on increasing the patient’s independence, and not on blaming parents or other family members (Anderson & Crump, 2004). Group approaches have some benefits that are not provided by dyadic therapy and therefore often serve as a useful adjunct to individual intervention. A peer group is less likely than an individual therapist to be accused of being controlling or of having bad intentions when confronting maladaptive patterns. This rich interpersonal setting also provides a wealth of opportunities for these patients to act out and their patterns to be identified as erratic and labile. On the other hand, new behaviors can often be actively encouraged by the group and can be practiced in this generally supportive setting. However, the capricious/borderline may need individual therapeutic support to deal with group-generated stress, as well as to internalize the feelings the group often provokes. It is not uncommon for borderlines to be scapegoated owing to their behavioral and emotional inconsistencies; also troublesome are competitive and envious feelings regarding the presumed success of others in attracting the leader’s affections. Horowitz (1997) suggests that the individual therapist not be the group therapist in order to reduce the likelihood that fantasies of favoritism may be engendered. Also wise is that groups be composed of heterogeneous participants, preferably with most of members being higher functioning than the borderline. On the other hand, some therapists suggest that homogeneous groups composed entirely of borderlines may also prove successful. Cognitive Techniques In their book outlining cognitive interventions with personality disorders, Beck and Freeman (1990a, 1990b) note that one of the initial setbacks in working with borderlines is that their lack of clear identity makes it difficult for them to set goals and maintain priorities from week to week. Beck and Freeman suggest that a focus on

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concrete behavioral goals is a useful initial therapeutic intervention for several reasons. The patient does not need to reveal deeply personal thoughts and feelings before trust can be established, and initial success can provide motivation to continue in therapy. As therapy shifts to more extensive goals, the therapist may find that the patient’s concerns and goals change from week to week; discussion about the advantages of keeping focused or about setting aside time in each session for immediate as well as long-term problems can be very helpful. The therapist should make a special effort to point to underlying commonalities among problems as they come up, attempting thereby to illustrate to the patient the presence of persistent behavioral and cognitive patterns. It is sometimes difficult to convince capricious/borderline patients to complete homework assignments. Discussing the advantages and disadvantages of trying out new behaviors often helps patients feel as though the therapist is not trying to control or manipulate them (Kellogg & Young, 2006; Kr¨oger et al., 2006). Asking patients to pay attention to their thoughts when they decide not to do their homework can help identify what may be disturbing or obstructing progress. Sometimes therapists find that they are ascribing incorrect intentions to patients, thinking that they do not want to get better. The patient’s understanding of noncompliance may need to be evaluated before these difficulties can be overcome (Giesen-Bloo et al., 2006). A main therapeutic focus of cognitive therapy with borderline clients is decreasing their dichotomous thinking (Brown, Newman, Charlesworth, Crits-Christoph & Beck, 2004; Wenzel, Chapman, Newman, Beck, & Brown, 2006). Capricious/ borderlines tend to think in terms of discrete categories, such as “good,” “bad,” “reliable,” and “unreliable,” rather than more realistic continuous dimensions. Beck and Freeman (1990a, 1990b) recommend pointing out to patients examples of their black-and-white thinking, and then asking them to consider whether it is reality-based in their experience (D. M. Allen & Whitson, 2004; M. M. Lee & Overholser, 2004). One example involves asking a patient to provide a description of the salient polarities “trustworthy” and “not trustworthy.” After the patient defines these extremes operationally, the therapist and client examine whether people actually exhibit constant trustworthy or untrustworthy behavior, and the patient realizes that although some may be more trustworthy than others, very few are always or never reliable (Salsman & Linehan, 2006). Examination of the patient’s own behavior and motivation can help clarify that not all instances of so-called unreliable behavior are motivated by bad intentions or lack of concern for others (Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006). Effecting a decrease in dichotomous thinking leads to a decrease in the intensity and vacillation of moods, as problem situations are not evaluated in such extreme terms (Rosenthal, Cheavens, Lejuez, & Lynch, 2005). Additional methods to control nonadaptive emotional symptoms can also be taught (Guzm´an, 2005). Many borderlines believe that if they express anger or other unpleasant emotions they will jeopardize their relationships. They suppress those feelings until they erupt in ways that generate

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negative consequences and reinforce the conviction that expressing emotions causes problems. The therapist can encourage the patient to express negative feelings in moderate ways and provide feedback and consequences that help speed the accomplishment of therapeutic goals. Building a collaborative relationship is most difficult with these emotionally unstable patients. Significant in fostering this goal is the therapist’s willingness to both acknowledge and accept the patient’s untrusting attitude (Markowitz, Skodol, & Bleiberg, 2006). Therapists should communicate their thoughts honestly and clearly, as well as display consistency by following through on all implicit or explicit agreements. Believing that the world is an inconsistent and troublesome place, most capricious/borderlines fear that they will inevitably be abandoned by others. Despite the borderline’s inconsistent behaviors and erratic emotions, change should be pressed, but only in a series of small steps. Fears about treatment termination may be cloaked in a stream of antagonistic comments and actions, but these fears derive from a longestablished sense of potential abandonment. The patient should be led to recognize that abandonment fears often set off a sequence of self-destructive behaviors, such as self-mutilation or suicidal acting-out. In helping the patient learn to control impulses, it is important to first address the borderline’s need not to be under the control of anyone, including the therapist. Once these patients understand ways to control their own impulses and can thereby improve their life, they are less likely to be resistant to cognitive intervention. The therapist and patient need to work on identifying the first hints of impulsive inclinations; through self-instructional training (Meichenbaum, 1977) useful steps can be taken to help patients implement new and appropriate attitudes and feelings. Self-destructive impulses, particularly, need to be addressed cognitively. Once the intent of and tendencies toward acting-out are understood, other means to the same ends can be developed. Hospitalization may have to be considered if the impulse to self-mutilate or suicide is strong. Self-Image Techniques An empathic approach is often the best intervention strategy in the beginning phases of therapy. Therapist sympathy, reassurance, education about interpersonal dynamics, advice, limit setting, and safeguarding of the patient’s self-disclosure and secrets make up the larger body of patient-therapist interactions within this initial approach. All the following interventions should help strengthen the capricious/borderline’s sense of identity and point out strengths and accomplishments that will serve to further this goal. Discussions about what constitutes self can also be helpful. Basic beliefs about life’s inherent dangers and the borderline’s helplessness can be addressed through behavioral experiments and the development of new coping skills (Bland, Williams, Scharer, & Manning, 2004). Certain ideas can be confronted using contrary evidence from the patient’s own life. Most capricious/borderline patients strongly believe that self-disclosure will lead to inevitable rejection. The therapeutic relationship can serve as a good example that this assumption is not universally true. Discussing fear of rejection

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and helping the patient understand that a certain amount of rejection is a normal part of living can help the patient feel less singled out and that rejection or personal slight need not be testimony to inherent flaws. Although efforts should be made to counteract the patient’s diffuse sense of self, as with Rogerian or gestalt procedures, progress in strengthening a more cohesive selfimage may have to wait for other transformations to occur first. While the patient is freely moving from one labile state to another, there is little that can be done to create the kind of structure required for a distinctive self-image to occur. Intrapsychic Techniques Intrapsychic therapists believe that the borderline will give up self-destructive behavior if he or she can “divorce” the “internalized abusive attachment figure” (Horowitz, 2006). A dislike of the internalization can be fostered, or an attachment to someone else can serve to replace it. The therapist can become an “emotional cheerleader” who encourages healthy life choices and behaviors; direct attachment to the therapist as a significant other, however, should be avoided (Gratz, Lacroce, & Gunderson, 2006; Vaslamatzis, Coccossis, Zervis, Panagiotopoulou, & Chatziandreou, 2004; Zeeck, Hartmann, & Orlinsky, 2006). On the other hand, if patients can permit themselves to trust the therapist enough, they can internalize the therapist’s compassion for them as a young abused child and help build self-protective and self-nurturing inclinations (M. J. Horowitz, 2006; Sachsse, Vogel, & Leichsenring, 2006). If direct blaming of the abuser is avoided, the capricious/borderline can for the first time dare to be “disloyal” to the abuser by emotionally detaching from his or her internalized figure (Silk, 2005). Pushing the borderline in this direction too quickly, however, can precipitate great anxiety, self-sabotaging behavior, and withdrawal from therapy (Leichsenring, 2005). The therapist should make it clear that the goal of therapy is for patients to make their own decisions and know that they can stay on good terms with the abusive person(s) if needed, as long as their welfare is not jeopardized (Chatziandreou, Tsani, Lamnidis, Synodinou, & Vaslamatzis, 2005). Approaches of a psychodynamic character emphasize the need to monitor and control countertransference reactions (Giesen-Bloo et al. 2006; Levy et al., 2006). Capricious/borderline patients tend to have intense negative as well as positive reactions toward the therapist that can easily disrupt the therapeutic process. These must be properly handled. Controversy abounds regarding how strict the therapist’s personal limits should be, how to handle crises appropriately, and how soon and how much confrontation is effective. Classic approaches such as free association and minimal therapist action are tolerated poorly by most borderline patients, who have poorly structured psychic boundaries. Their natural proclivity toward psychoticlike episodes may be prompted by such methods. The usual length of treatment by psychodynamic techniques appears to be needlessly time-consuming given the availability of equally effective alternatives.

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Pharmacologic Techniques Psychopharmacological medications are often prescribed to capricious/borderline personalities in line with their multiple symptom disorders (Hollander, Swann, Coccaro, Jiang, & Smith, 2005; Markovitz, 2004). Depression is a common presenting complication. A study by Soloff et al. (1986) suggests that different presenting depressions warrant different classes of antidepressant medication: Irritable and hostile patients may do better when treated with MAOIs; others may do just as well, if not better, on SSRIs, tricyclic medications, or low doses of antipsychotics (olanzapine, clozapine, risperidone). The last appear to be most useful when depression, hostility, and anxiety are accompanied by psychoticlike symptoms such as illusions, ideas of reference, derealization, and depersonalization (Nickel et al., 2006). Anxiety and panic may be controlled with benzodiazepines, though some borderlines become more irritable when taking these anxiolytics (Cowdry & Gardner, 1988). In general, polypharmacy is not wise and perhaps should be avoided, if at all possible (Oldham et al., 2004). The mixture of diverse and changing symptoms among these patients often invites the clinician to organize medication combinations that mirror, but may intensify, the imbalanced emotions of these patients (Bogenschutz & Nurnberg, 2004; Nickel et al. 2005). Where possible, only one or two major symptom groups should be considered primary; most attention should be directed to modulate specific upsetting effects (Tritt et al., 2005). Discretion must be exercised when prescribing any medications. For example, when evaluating the possible benefits of MAOIs for suicidal patients, it is particularly important to consider that they are lethal in overdose. Another factor therapists should keep in mind is that many capricious/borderlines are noncompliant with medications; others often report feeling worse when the medications seem objectively to be fostering improvements (Grootens & Verkes, 2005; Ruocco, 2005a, 2005b). One possible explanation is that borderlines may feel that they will be abandoned by the therapist if they truly get better; another suggests that decreases in anxiety and/or depression may lead to disinhibited behavioral controls.

Making Synergistic Arrangements The most important first step in helping a capricious/borderline begin progress toward adaptive personality change is to establish a solid working alliance that can help alter the patient’s schema about the inherent dangers of relationships. Supportive interventions are a useful way to accomplish this first goal (Apter-Danon & Candilis-Huisman, 2005). To bolster motivation without delving into anxiety-provoking self-exploration, helping the patient to realize behavioral goals may provide him or her with an initial success in treatment. Severe anxiety and depression can then be evaluated as reasons for psychopharmacologic intervention (Black, Blum, Pfohl, & Hale, 2004; McKay, Gavigan, & Kulchycky, 2004). Behavioral interventions, in conjunction with

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psychopharmacological agents, may then help bring about a measure of predictability in the borderline’s social relationships. At this point, the therapist may decide that a group approach would be a useful adjunct. Here, objective feedback and a supportive environment can help keep the patient from feeling attacked as more searching cognitive and emotional work begins. When the therapist feels that the patient has a grasp on some of the main issues, family therapy can help speed the healing process and solidify control over the patient’s maladaptive and erratic patterns.

Illustrative Cases Both theory (Millon, 1969, 1981, 1990) and research (Millon, 1977, 1987a, 1987b) show that the capricious/borderline pattern overlaps almost invariably with every other personality disorder; the schizoid and compulsive types are about the only significant exceptions; narcissists and avoidants are also infrequent covariants of the borderline structure. Among the other stylistic personality disorders, it often develops insidiously as a structurally advanced or structurally more defective pattern. However, what we observe in a number of personality styles are brief episodes of impulsivity and affective instability that mimic the more intrinsic and persistent traits of the capricious/borderline. A key notion here is brevity, that is, the evanescent nature with which these covariant symptoms exhibit themselves. Impulsive anger, affective instability, and self-destructive acts are not, nor do they appear to become, integral character traits of these nonborderline personalities. Some succumb to these behaviors fleetingly following severe psychic deflation, that is, a loss of a significant source of status or fantasized self-esteem; during these transitory episodes they will appear borderline, but only until they can regain their more benign composure. Others may also succumb to the borderline’s more overtly exhibitionistic symptoms following a painful psychic blow. However, these personalities are much more apt to decompensate, if at all, along schizotypal or paranoid lines. They intensify at these times their established pattern of social anxiety and isolation, their self-created cognitive interference, and their flat and constricted affect. The discussion returns now to those subtypes of the capricious/borderline that share its prime features in a more enduring and integrated fashion. It is our contention that we will find the same complex of determinants in the capricious/borderline syndrome as we do in several of its less structurally defective variants: the avoidant, depressive, dependent, histrionic, antisocial, sadistic, and negativistic personalities. The primary differences between them are the intensity, frequency, timing, and persistence of a host of potentially pathogenic factors. Those who function at the borderline level may begin with less adequate constitutional equipment or be subjected to a series of more adverse early experiences. As a consequence of their more troublesome histories, they either fail to develop an adequate coping style in the first place or decompensate slowly under the weight of repeated and unrelieved difficulties. It is our view that

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Table 7.4

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Capricious/Borderline Personality Disorder Subtypes

Discouraged: Pliant, submissive, loyal, humble; feels vulnerable and in constant jeopardy; feels hopeless, depressed, helpless, and powerless. (Mixed Borderline/ Avoidant-Depressive-Dependent Subtype) Self-Destructive: Inward-turning, intropunitively angry; conforming, deferential, and ingratiating behaviors have deteriorated; increasingly high-strung and moody; possible suicide. (Mixed Borderline/Depressive-Negativistic Subtype) Impulsive: Capricious, superficial, flighty, distractible, frenetic, and seductive; fearing loss, becomes agitated and then gloomy and irritable; potentially suicidal. (Mixed Borderline/Histrionic-Antisocial Subtype) Petulant: Negativistic, impatient, restless, as well as stubborn, defiant, sullen, pessimistic, and resentful; easily slighted and quickly disillusioned. (Mixed Borderline/Negativistic Subtype)

most borderline cases progress sequentially through a more adaptive or higher level of functioning before deteriorating to the structurally defective state. Some patients, however, notably childhood variants, never appear to get off the ground and give evidence of a borderline pattern from their earliest years. The capricious/borderline’s typical, everyday mood and behavior reflect his or her basic personality pattern. In the following cases we note some of the clinical features that differentiate the several subtypes of the disorder (see Table 7.4). Case 7.1, Patty C., 26 A Capricious/Borderline Personality: Discouraged Type (Borderline with Dependent and/or Avoidant Traits) Presenting Picture Patty, a graduate student in physics, sought professional help due to her selfproclaimed lack of social ability. “I’ve always been by myself, that’s nothing new. But I’m just suddenly noticing, I’m really lonely.” Being in her 3rd year of her degree program, she had not made friends, “and it was the same in college; I went to parties but I just stood there and didn’t talk.” Although she enjoyed her solitary activities in the lab, she had always been acutely aware that she lacked any kind of social connectedness; now, it was starting to become something she would obsess about and beat herself up over. As she put it, “I just am so mad that I didn’t learn how to talk to people a lot younger. Now I’m this dork who doesn’t have a clue.” She tried very hard to create a favorable impression on her peers, but she noted that others

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256 PERSONALIZED THERAPY FOR THE CAPRICIOUS/BORDERLINE PERSONALITY PATTERNS really didn’t show any interest in her. More expressively, at one point, she stated, “They don’t want me around.” Intensely uncomfortable in her physical being, as evidenced by her closed posture and her incessant arm rubbing, she approached her teaching assistantship with great dread of “all those people looking at me!” Living off campus by herself in a small apartment, she did almost nothing socially and longed for companionship, but continued her secluded activities in a self-induced vacuum, which, to her, seemed very much impervious to change. Clinical Assessment Discouraged borderlines such as Patty typically show traits likely to be seen in mixed clinical pictures composed of deteriorated dependent and/or avoidant and structurally defective borderline personalities. Patty, as it turned out, had attached herself some time ago to one or two family members on whom she depended, with whom she was able to display affection and thoughtfulness, and to whom she had been loyal and humble. However, Patty’s strategy of quiet cooperation and compliance had not been notably successful. As a consequence, she exhibited a perennial preoccupation and concern with security; her pathetic lack of inner resources and her marked self-doubts led her to cling tenaciously to whomever she could find and to submerge every remnant of autonomy and individuality she possessed. This insecurity precipitated conflict and distress. She easily became dejected and depressed and felt hopeless, helpless, and powerless to overcome her fate. Everything became a burden; simple responsibilities demanded more energy than she could muster; life seemed empty but heavy; she could not go on alone; and she began to turn on herself, feeling unworthy, useless, and despised. At times, Patty reversed her habitual strategy and sought actively to solicit attention and security. For short periods, she would become exceedingly cheerful and buoyant, trying to cover up and counter her sense of underlying despondency. At other times, she disowned her submissive and acquiescent past and displayed explosive outbursts of angry resentment, a wild attack on others for failing to see how needful she had been of encouragement and nurturance. At these times, a frightening sense of isolation and aloneness would overwhelm and panic her, driving her to cry out for someone to comfort and hold her, lest she sink into the oblivion and nothingness of self. Ultimately, contrary impulses created anxiety because she jeopardized her security, that is, her basic dependency on others. Hostility was doubly dangerous; not only may it have led to an attack on the very persons on whom she depended, thereby undermining the strength of those to whom she looked for support, but it may have provoked their wrath, which may have resulted in outright rejection and desertion. To counter these hostile impulses, Patty evolved a deep restraint over all of her interactions. Guilt and self-condemnation frequently became dominant features. Struggling feverishly to control her aggressive impulses, she would likely turn her feelings inward and impose on herself severe punitive judgments and actions.

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Treatment with Patty would require a consistent, genuine, and empathic approach, establishing a safe and supportive environment that would contradict her disappointment expectation. Also effective in this early stage would be examination of her wavering dominant-submissive patterns of reacting, as well as investigation and remediation of her mood shifts, which were paradoxical to her perceived needs. As Patty’s emotional stability increased, inconsistencies in her belief patterns could be monitored and modified. Perpetuations that would be countered in this manner included erroneous and inconsistent assumptions regarding herself and the futility of seeking autonomy (lability of self–other polarities derived from a dearth of selfvalue). Also, changes in her manipulative helplessness and isolation would be appropriate in this working stage (stabilizing an active–passive split, as well as a tendency to avoid pain). These combined approaches would be an effective preamble to more effective, permanent pattern changes. Domain Analysis Patty completed several measures prior to commencing working stages of therapy. Scores on the MCMI-III Grossman Facet Scales and the MG-PDC indicated the following most salient domains: Uncertain Self-Image: Confused deeply in terms of her sense of self, Patty would try on different personas and waver between them, hoping for the best fit in terms of current needs, but all the while losing any sense of genuineness she may have once had and ultimately left with feelings of emptiness. Interpersonally Aversive/Paradoxical: Vacillating between outward fear and avoidance of others, and contrary, unpredictable acts, Patty created stressful social interactions that took on the characteristic either of personal repulsion from transactions or of manipulative and covert hostility, both of which created distancing and alienation. Cognitively Distracted/Capricious: Patty experienced ever-changing and overwhelming cognitive content and patterns, often coming across unintegrated and at times antithetical themes that would then shift haphazardly to something else; the emotional charge from this led to inability to retain thoughts or to make sense of the cacophony of conflicting beliefs she held. Therapeutic Steps Active short-term techniques took advantage of introducing Patty to environmental changes to maximize growth, to minimize continued dependency, and to provide uplifting experiences. Psychopharmacologic treatment was initiated as a precursor to focused treatment techniques, as it was believed that these would promote alertness and vigor and would counter fatigue, lethargy, dejection, and anxiety states that may

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258 PERSONALIZED THERAPY FOR THE CAPRICIOUS/BORDERLINE PERSONALITY PATTERNS have inclined the patient to postpone efforts at independence and confidence building. The relationship between therapist and patient was also carefully poised to overcome the dominance-submission patterns that may have characterized Patty’s recent history. Nondirective, humanistic approaches began the catalytic sequence of treatment modalities that would be oriented toward fostering growth in autonomy and self-confidence and toward gradually rebuilding her uncertain self-image throughout the course of treatment. Other modalities would follow suit as Patty became progressively more capable of pragmatically applying them. To prevent Patty from becoming passively incompetent and lost in fantasy preoccupations, a major though short-term approach was progressively instituted. Circumscribed treatment efforts were directed toward countering the dependency attitudes and behavior of this self-effacing woman. A primary therapeutic task was to prevent her from slipping into a totally ineffectual state as she sought to rely increasingly on a supportive environment and created further obstacles in terms of thinking clearly and effectively. Owing to her anxious and morose outlook, she not only observed real deficits in her competence but also deprecated what virtues and talents she possessed. Trapped by her own capriciousness and blocked by persistent distractibility, she reinforced her belief in the futility of standing on her own and was therefore inclined to try less and less to overcome her inadequacies. Cognitive methods (e.g., Ellis, Beck) were especially helpful in reframing erroneous beliefs and assumptions about herself and those she believed others had of her. Her strategy had fostered a vicious circle of increased helplessness, depression, and dependency. By making herself inaccessible to growth opportunities, she effectively precluded further maturation and became sadder and more dependent on others. The aforementioned techniques ensured the continuation of competence activities and the acquisition of assertive behavior and attitudes to replace those antithetical beliefs, contrasting emotions, and rapidly cycling thoughts. As these more focused and effective thought patterns were enhanced, it was possible to introduce a potentiated pairing of interpersonal and behavioral modification methods to learn less paradoxical social skills and to alleviate aversive responses. Effective brief, focused treatment may have created the misleading impression that progress would continue and be rapid. Despite initial indications of solid advances, Patty still resisted efforts to assume much autonomy for her future. Persuading her to forgo her long-standing habits proved to be extremely slow and arduous, but it was important that steps were undertaken to move forward in this regard and to provide support. Especially problematic was the feeling she had that she would be unable to meet an increase in the expectations of others, resulting in their disapproval. Efforts to help her build an image of competence and self-esteem was an essential step in forestalling later backsliding. A program that strengthened her attributes and dislodged her habit of leaning on others was worth the effort it took.

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Case 7.2, Dwayne T., 33 A Capricious/Borderline Personality: Impulsive Type (Borderline with Histrionic and/or Antisocial Traits) Presenting Picture Dwayne had found himself at a crossroads in his life when his girlfriend told him, “You really need to talk to somebody; you’re not doing anything and I’m not having it!” He acknowledged that he was getting older and that it might be time to “do something more logical with myself, have a plan, maybe.” He had been a perennial drifter for many years, doing pretty much whatever he felt like doing from day to day, pursuing different but dithering career lines, enrolling in and dropping out of college, and seeking ways to keep as much excitement in his life as was possible, by any means possible. Although very much aware of his predicament, his ideas concerning future plans were markedly without much forethought. At one moment, he spoke of his desire to go back to school for medicine, but within seconds, he was speaking of continuing to “ramble” throughout the world, as there was much he had yet to see. Dwayne paid lip service to concerns about his life decisions, assigning them limited importance; still, it seemed as though there was more pressure on him to seek help than just his girlfriend’s ultimatum. Also notable was his agitation with his therapist, as he dismissed the questions regarding his plans as “pretty dumb.” He liked to describe himself as someone with a “short fuse,” not possessed of great tolerance. Obviously defensive about his decision making, Dwayne seemed to want to brush over the issues as quickly as possible, thereby not necessitating any deep exploration. Clinical Assessment Impulsive borderlines such as Dwayne are typically structurally defective variants of certain of their less pathological counterparts, primarily the histrionic and antisocial personalities. Each is capricious, evasive, superficial, and seductive; the characteristics Dwayne displayed, favoring the self polarity, leaned more toward the antisocial variant. At the borderline level of functioning, however, such strategies are instrumentally less successful. Consequently, more extreme efforts to cope with events were evident, many of which served only to perpetuate and deepen his difficulties. For example, Dwayne may not have mastered the techniques of ensuring a stream of support and encouragement; because of an excessively irresponsible style of personal relationships, he may have experienced long periods in which he lacked a secure base and a consistent source of reinforcement. Deprived of the attentions and rewards he sought, he would intensify his strategy of seductiveness and irresponsibility. He evidenced extreme hyperactivity, flightiness, and distractibility. At moments, he may have exhibited an exaggerated boastfulness and an insistent and insatiable need for excitement. Frightened lest he lose attention, he may, at

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260 PERSONALIZED THERAPY FOR THE CAPRICIOUS/BORDERLINE PERSONALITY PATTERNS times, have displayed a frantic conviviality, an irrational and superficial euphoria in which he lost all sense of propriety and judgment. With Dwayne’s stronger antisocial history, he may have engaged in a series of restless, spur-of-the-moment acts, failing to plan ahead or to consider more pragmatic alternatives, much less to heed the consequences of his actions. Having lost confidence in his seductive or exploitive powers and dreading a decline in vigor, charm, and youth, he began to worry, to have doubts about his worth and attractiveness. Anticipating desertion and disillusioned with himself, he began to ponder his fate. Because worry begets further worry and doubts raise more doubts, his agitation eventually turned to gloom, to increased self-derogation, and to feelings of emptiness and abandonment; this may have been what prompted Dwayne to move ahead in seeking therapy rather than ignore the admonition of others. Immediate attention in treating Dwayne would center on building the therapeutic relationship as a model of parallel alliance, particularly challenging given his generally negative view of others. This would serve as a guide to begin the process of adjusting social patterns to a less defensive style, and would continue throughout treatment. As his characterologic defenses diminished, more confrontive and directive measures would be employed. Dwayne’s need to dominate relationships from moment to moment and his assumption of others’ ignorance (self–other discordance, deriving from earlier disparagement, leading to an unsturdy but overemphasized assertion of self) would be a perpetuating construct worthy of challenge. Additionally, it would be beneficial to confront his flighty, carpe diem approach to his circumstances (active-pleasure tendency) in favor of less impulsive, more security-oriented interactional strategies of coping with his environment. Domain Analysis Dwayne began filling out the self-report measures, but grew bored in a short time and refused to complete them. The only measure utilized for this domain analysis, then, was the MG-PDC, which identified the following salient targets for intervention: Autonomous/Uncertain Self-Image: Dwayne often successfully employed the self-belief that he needed nobody and operated only by his own rules, although this was a thin veil to mask deeper needs related to his wavering sense of self, which, at times, felt very empty. Interpersonally Irresponsible: Often, Dwayne would be manipulative, seductive, and charming, but this would give way under the weight of having to follow through with social obligations; he was able to successfully employ charm most of the time, but would become, more like the paradoxical borderline domain, easily angered and reactive when distressed by social stress.

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Cognitively Capricious: Dwayne was someone who could turn on a dime in terms of how he perceived events in the world around him; deeply ambivalent about his ability to remain autonomous and the threat that others may cause, he moved quickly but not stealthily through anger, love, rage, guilt, and so on.

Therapeutic Steps Essential to the success of a short-term approach with Dwayne was the therapist’s readiness to see things from the patient’s point of view and to convey a sense of trust and create a feeling of alliance. To achieve reasonable short-term goals, this building of rapport could not be interpreted as a sign of the therapist’s capitulation to his bluff and arrogance. Brief treatment with him required a balance of professional firmness and authority, mixed with tolerance for Dwayne’s less attractive traits. By building an image of a fair-minded and strong authority figure, the therapist successfully employed methods that encouraged Dwayne to explore different possibilities than his expectations had mandated. Through reasoned and convincing comments, the therapist provided a model for him to learn the mix of power, logic, and fairness. Of particular importance, this first stage was aimed at disbalancing a currently tenuous and inflexible pathological balance in his uncertain self-image that was only maintained by an air of autonomy. Although the therapist did not push Dwayne far outside of his comfort zone, which would have likely prompted an early termination, it was important to at once create the safe environment of the therapeutic relationship, and then call into question some of the absolute self-beliefs that pervaded his consciousness. This was an early transition to cognitive methods aimed at alleviating his capriciousness. Less confrontive cognitive approaches then provided Dwayne with opportunities to vent his anger, even in short-term therapy. Once drained of these hostile feelings, he could be led to examine his habitual behavior and cognitive attitudes and was guided into less destructive perceptions and outlets than before. Interpersonal methods, such as those of Benjamin and Kiesler, provided a means to explore more socially responsible behavior. A useful short-term goal for Dwayne was to enable him to tolerate the experience of guilt or to accept accountability for difficulties he may have caused. These methods employed a small measure of cognitive confrontation as well, and helped him undermine his tendency to always trace problems to another person’s stupidity, laziness, or hostility. When he accepted responsibility for some of his difficulties, it was important that the therapist was prepared to deal with Dwayne’s inclination to resent the therapist for supposedly tricking him into admitting it. Similarly, the therapist had to be ready to be challenged and to avoid the patient’s efforts to outwit him. Dwayne consistently tried to set up situations to test the therapist’s skills, to catch inconsistencies, to arouse ire, and, if possible, to belittle and humiliate the therapist. Restraining impulses to express condemning attitudes was a major task for the therapist, but one

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262 PERSONALIZED THERAPY FOR THE CAPRICIOUS/BORDERLINE PERSONALITY PATTERNS that was used for positive gains, especially when tied into the application of combined cognitive (e.g., Beck, Ellis) and interpersonal interventions. It should be noted that the precipitant for Dwayne’s treatment was largely situational rather than internal. Hence, he did not seek therapy voluntarily, and he had convinced himself, to an extent, that had he been simply left alone, he would work all matters out on his own. Such beliefs were confronted, albeit carefully. Similarly, had treatment been self-motivated, it would have probably been inspired by a series of legal entanglements, family problems, social humiliations, or achievement failures. For this domineering and often intimidating man, complaints were readily expressed in the form of irritability and restlessness. To succeed in his initial disinclination to be frank with authority figures, he wandered from one superficial topic to another. This inclination had to be monitored and prevented. Moreover, contact with family members may have been fruitful as they may have reported matters quite differently than did Dwayne. To ensure that he took discussions seriously, he was confronted directly with evidence of his contribution to his troubles. Treatment was best geared to short-term goals, reestablishing his psychic balance, and strengthening his previously adequate coping behavior with cognitive methods, unless his actions were frankly antisocial. In general, short-term approaches with this patient were best directed toward building controls rather than insights, toward the here and now rather than the past, and toward teaching him ways to sustain relationships cooperatively rather than with dominance and intimidation.

Case 7.3, Shari W., 29 A Capricious/Borderline Personality: Petulant Type (Borderline with Negativistic Traits) Presenting Picture Shari had been referred for therapy following a series of difficult interpersonal events, the last of which was a volatile in-car argument with her boyfriend ending with her jumping out of the car while it was still moving. “I just wanted to see what would happen,” was her simplistic rationalization of this event, also revealing that she was high at the time, so she figured that this might be “a way to feel something.” Following a trip to the emergency room, where she was fortunately cleared of any physical harm, a physician’s assistant made the recommendation. Prior to this incident, Shari had dropped out of college for the third time, thus angering her boyfriend and inciting him to put pressure on her to “get her act together.”

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Apparently, following the car argument incident, her boyfriend broke up with her. What had Shari visibly upset, however, was that her father, who had been markedly absent emotionally for much of her life, suddenly appeared at the hospital with her stepmother. “They sent me away to boarding school at age 12,” she complained, “why the hell do they care now?” Throughout her life, it seemed, people would leave Shari just when she needed them, or when she was just developing stronger bonds with them. Friends from boarding school also fit this pattern; they could not be relied on in times of need. Thus, she had a very difficult time trusting anyone or allowing anyone to become close, as this compromised her safety. Initial Impressions Petulant borderlines such as Shari are often difficult to distinguish from certain of their less structurally defective counterparts, most notably the negativistic personality. Overall, Shari’s overt symptoms were more intense and depressive psychotic episodes occurred with somewhat greater frequency than in the negativist. She may have been best characterized by her extreme unpredictability and by her restless, irritable, impatient, and complaining behaviors. Enthusiasms were short-lived; she was easily disillusioned and slighted, tended to be envious of others, and felt unappreciated and cheated in life. Despite this anger and resentment, Shari feared separation and was desirous of achieving affection and love; in short, she was ambivalent, trapped by conflicting inclinations to move toward, away, or against others, as Horney (1950) might have put it. She oscillated perpetually, first finding one course of action unappealing, then another, then a third, and back again. To give in to others was to be drained of all hope of independence, but to withdraw was to be isolated. Shari always resented her dependence on others, and railed against those to whom she had turned to plead for love and esteem. In contrast to other borderline subtypes, she did not have even a small measure of consistency in the support she received from others; she had never had her needs satisfied on a regular basis and had never felt secure in her relationships. She was erratic and continued to vacillate between apologetic submission on the one hand, and stubborn resistance and contrariness on the other. Unable to get hold of herself and unable to find a comfortable niche with others, she became increasingly testy, bitter, and discontent. For long periods, she expressed feelings of worthlessness and futility, became highly agitated or deeply depressed, developed delusions of guilt, and was severely self-condemnatory and even self-destructive. At other times, her habitual negativism crossed the line of reason, broke out of control, and drove her into rages in which she distorted reality, made excessive demands of others, and viciously attacked others. After these wild outbursts, she would turn her hostility inward, become remorseful, plead for forgiveness, and promise to behave and make up for her unpleasantness.

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264 PERSONALIZED THERAPY FOR THE CAPRICIOUS/BORDERLINE PERSONALITY PATTERNS Before any challenges could be made to Shari’s maladaptive strategies and extremely volatile inner conflicts, the therapist would need to assure, through an empathic posture, that she could consider this therapeutic relationship resilient and secure. It would also be prudent from the beginning, and throughout the process, to be alert to signs of mood decompensation and be ready to respond to possible depressive or psychotic episodes in a timely and effective manner. Her need to test others in her environment, and her expectation that they would fail due to her unworthiness (conflictual self–other tendency), was a key perpetuating feature in her characterologic makeup. Instilling healthier and less active-pain-oriented attitudes and strategies, would be a most fruitful approach. As she achieved greater levels of comfort, other constructs that might be addressed in this combined approach would include examining and disputing long-term interactional patterns.

Domain Analysis The following most problematic domains were gauged by the MG-PDC and the MCMI-III Grossman Facet Scales: Temperamentally Labile: Shari had a great deal of trouble stabilizing her mood, showing high reactivity to all external reality, leading to long- or short-range periods of depression, anxiety, anger, excitement, and euphoria, in an unpredictable manner and usually in an inappropriate context. Interpersonally Contrary: Continually vacillating in her roles with others, Shari could manipulatively change from polite acquiescence to unprompted hostility, based on immediate perceptions of others’ malevolence/benevolence, whether or not justified. Mostly, this domain was instrumental, but she would sometimes lose control and show some of the less-calculated paradoxical interpersonal qualities of the borderline. Uncertain/Discontented Self-Image: Feeling misunderstood and unappreciated by most, and embittered and disillusioned by most of her circumstances, Shari generally reflected on herself as purposely jinxed, although at times she would lose sight of her externalization mechanism in this domain and succumb to feelings of confusion, loss of identity, and wavering perceptions of her role in her life, leaving her with a sense of emptiness.

Therapeutic Steps Serious efforts to alter Shari’s current symptoms and basic psychopathology were attempted by employing focused and short-term techniques. Primary goals in brief therapy included the facilitation of autonomy, the building of confidence, and the overcoming of fears of self-determination. There was, not surprisingly, a period of

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initial resistance. As a commencing part of this stepwise approach, it was important to counter Shari’s feeling that the therapist’s efforts to encourage her to assume responsibility and self-control were a sign of rejection (discontentment in self-image). A trusting, warm, and empathic atmosphere was absolutely necessary to prevent disappointment, dejection, and even rage. These potential reactions were anticipated, given Shari’s characteristic style, and they were appropriately responded to with equanimity as fundamental changes needed to be explored and relapses prevented. When a sound and secure therapeutic alliance had been established, she learned to tolerate her contrary feelings and even her uncertainty in terms of self, allowing her to be freer to accept challenges as they materialized. Learning how to face and handle her unstable emotions was coordinated with the strengthening of healthier attitudes through cognitive methods such as those of Beck and Meichenbaum. Additionally, the therapist needed to serve as a model to demonstrate how feelings, conflicts, and uncertainties could be approached and resolved with reasonable equanimity and foresight. As an adjunct to individual work, explorations were provided for in a family modality; these were useful in testing these newly learned attitudes and strategies in a more natural setting than that found in individual treatment, and to learn less contrary interpersonal skills. As implied by her affective instability and self-deprecation, Shari avoided confronting and resolving her real interpersonal difficulties whenever possible. Her coping maneuvers were a double-edged sword, relieving passing discomfort and strains but perpetuating faulty attitudes and strategies. These distorted attitudes and faulty behaviors were the main targets of cognitive and interpersonal therapeutic interventions. Special care was called for in this short-term treatment regimen to counteract the anticipated occurrence that Shari’s hold on reality would disintegrate and that her capacity to function would wither. Similar care was taken as the attention and support that she required were withdrawn and when her strategies proved wearisome and exasperating to others, precipitating their anger. Pharmacologic agents were employed as she experienced her labile moods, running the gamut of depression, excitement, and occasional erratic surges of hostility. Particular attention was given to anticipate and quell the danger of suicide during these episodes. A major concern during these early periods was the forestalling of a persistent decompensation process. Among the early signs of breakdown were marked discouragement and melancholic dejection. At this phase, supportive therapy was called for, and cognitive reorientation methods were actively implemented. Efforts were made to boost Shari’s sagging morale, to encourage her to continue in her usual sphere of activities, to build her self-confidence, and to deter her from being preoccupied with her melancholy feelings. She was not pressed beyond her capabilities, however, because her failure to achieve any goals would only strengthen her conviction of her incompetence and unworthiness. Properly executed cognitive methods oriented to correcting erroneous assumptions and beliefs were especially helpful.

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Case 7.4, Allison L., 34 A Capricious/Borderline Personality: Self-Destructive Type (Borderline with Masochistic and Depressive Traits) Presenting Picture Allison came to therapy after friends noticed scars on her arms. “Not just one; I mean, a few of them did, so I thought I’d better come in because more people are noticing.” As she explained, though, she was only scratching herself, and this was not indicative of a suicide attempt, “this time.” Having a long history of therapy, her tendency to hurt herself dated back to childhood. Many times previously, she had wanted to die. Allison was thoroughly convinced that she was a bad person and that people were always leaving her due to her unworthiness as a human being. Most recently, her boyfriend had left after what Allison described as a fairly lengthy relationship (3 months), because “I just was too needy with him, I just need and need and need, I need so much, and I was no fun anymore, just a drag on him and everybody else too.” This pattern of people leaving and her self-accusations led directly back to her father, who abruptly left after Allison stood up to him for the first time against his long history of physical and sexual abuse of her and her mother. “Really, I wasn’t a good daughter,” is how she conceptualized this. From then on, she had sensed that her mother was angry with her for ruining her marriage, and that she tormented her with new boyfriends that her mother always seemed to leave her alone with. Throughout therapy, the theme of “better off dead” pervaded. At the outset of therapy, when the counselor asked for a commitment not to harm herself, she immediately responded with defensiveness, projecting that he would throw her out of therapy “just like all the others.” However, rather bitterly, she gave this commitment and began work. Initial Impressions As with other borderline subtypes, Allison, a self-destructive borderline, vacillated perpetually through multiple courses of action. To give in to others was to lose hope of independence, but to withdraw was to be isolated. Oscillating between apologetic submission and stubborn resistance and contrariness, her indecisiveness rendered her unable to “get hold of herself” and find any comfortable niche with others. Unlike other subtypes, however, she became more inward-turning and expressed her anger in an intropunitive way. She had a long history of depressive and masochistic traits, and these features interpenetrated her defective psychic structure. In earlier days, Allison’s surface appearance may have presented a veneer of sociability and conformity, but this only masked a fear of genuine autonomy and a deeply conflictual submission to the expectations of others. To control these oppositional tendencies, she struggled to maintain self-restraint and a self-sacrificial affability. Failures to evoke needed emotional support and approval led to periods of depression and chronic anxiety. Allison became high-strung and moody, straining to

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express attitudes contrary to her inner feelings of tension, anger, and dejection. To avoid these discomforts, she became overly sensitive to the moods and expectations of others. Although viewing herself as self-sacrificial and submissive, the extreme other-directedness utilized in the service of achieving approval resulted in an increasingly unstable lifestyle. In the past she paid attention to the signals that others transmitted, and thereby usually avoided disapproval. Not only had this preoccupation become less and less successful over time, but it resulted in a growing sense of personal impotence and social dependency. Allison sought to deny an awareness of her inner deficiencies because to acknowledge them would point to the fraudulence that existed between the overt impressions she sought to create and her internally felt sterility and emotional poverty. This tendency to seal off and deny the elements of her inner life further intensified her dependence on others, a dependency that had become increasingly insecure. With the persistence of these ambivalent feelings, Allison began to suffer somatic discomforts, voicing growing distress about a wide range of physical symptoms. Increasingly upset, labile in mood and impulse, she turned her anger inward, seeking to maintain her earlier image of propriety and responsibility. Anger became intropunitive rather than extrapunitive. Although abrupt outbreaks of contrary feelings occasionally emerged, for the most part there were only increasingly self-destructive and self-depreciating patterns of behaviors and attitudes. The possibility of suicide was almost always present. Consistency and genuineness in attitude would be most important on the part of the therapist, as Allison would likely approach the therapeutic relationship with the conviction that it would ultimately disappoint and fail, as might any other significant bond. The therapist would need to be mindful of Allison’s submissive (extreme passive-other-oriented) habits, which were routinized, as she might tend to play a well-rehearsed role rather than invest in a process. With this posture as a backbone, the therapist would begin by addressing perpetuating beliefs that undermined her already low sense of self: Modifying her habit of setting up disappointments, as well as responding submissively to social engagement and following with considerable resentment, would work toward providing more realistic expectations and active autonomous skills. These changes would also foster an orientation more open to enhanced pleasure. Domain Analysis Allison arranged for, then canceled, her assessment appointments several times, all the while regularly reporting for therapy appointments. This ambivalence eventually expressed itself on self-report measures; therefore, the MG-PDC was the primary instrument for this domain analysis: Uncertain Self-Image: Feelings of emptiness and abandonment pervaded Allison, to the point that her sense of self frequently appeared to go through a regressive process (see “Regression Mechanism,” earlier); she would often reflect on herself with shame and ambiguity, being entirely insecure, and would exhibit self-flagellation during her most guilt-ridden moments.

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268 PERSONALIZED THERAPY FOR THE CAPRICIOUS/BORDERLINE PERSONALITY PATTERNS Interpersonally Defenseless/Deferential: Allison’s social behavior could be described as an amalgamation of those of the depressive/masochistic patterns, essentially attempting to meet demands of others to the point of self-harm, but doing so because her interpersonal skills had become thoroughly depleted over the course of many painful exchanges, and over years. Expressively Spasmodic: Although Allison was not energetic in expression and rarely displayed outbursts, her impulsive and uninhibited behaviors were articulated in self-punishing and inward-turning hostility, accompanied by self-mutilation and expressions of suicidal ideation, reinforcing her increasing emotional disequilibrium. Treatment Course The first goal in therapy with Allison was to demonstrate that the potential gains of therapy were real and that they should motivate her rather than serve as a deterrent. Allison feared that therapy would reawaken what she viewed as false hopes; that is, it would remind her of the humiliation she experienced when she offered her trust to others but received rejection in return. Once the therapist had nondirectively acknowledged these fears, Allison was able to find a modest level of comfort, as well as a greater sense of self-certainty, without having to distance herself from the therapist. In other words, this early process focused on learning to deal more effectively with her fears while maintaining a better level of adjustment than she has become accustomed to. Focused techniques also addressed Allison’s tendencies to demean her self-worth and to mistrust others. Short-term supportive methods were used to counteract her aversion to sustaining a consistent therapeutic relationship. As noted, maneuvers designed to test the sincerity of the therapist were frequently evident. A warm and empathic attitude was necessary because the patient was likely to fear facing her feelings of unworthiness and because she sensed that her coping defenses were weak. Commendable skills of hers were drawn on to prevent her from withdrawing from treatment before any real gains were made. By adding short-term cognitive-behavioral methods gradually as she was able to be challenged, the therapist was able to attend to Allison’s uncertainty, as seen in her social hesitation, anxious demeanor, and self-deprecating actions, attitudes, and spasmodic behavior that could be altered so as not to evoke the humiliation and derogation they had in the past, nor to provoke the self-flagellating behaviors she had adopted in her decompensation. Cognitive efforts to reframe the basis of her sensitivity to rebuff or her fearful and unassertive behavior (e.g., Beck, Ellis) helped minimize and diminish not only her aversive inclinations but her tendency to relapse and regress. The next set of interpersonal (e.g., Benjamin) treatment procedures was useful in unearthing the roots of her anxieties and confronting those assumptions and expectations that pervaded many aspects of her social behavior. By examining her recurrent social roles, Allison began noting her irresolute and intimidated public

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persona, and she started to imagine herself (e.g., by integrating some gestalt techniques into this interpersonal modality) as capable of more assertive socialization. Further group therapy assigned as an adjunct to her primary individual sessions assisted her in learning competency attitudes and skills in a more benign and accepting social setting than she normally encountered. As a result, she became less defenseless and deferential in her social transactions. Another realm worthy of brief intervention was associated with Allison’s extensive scanning of the environment. By doing this, she increased the likelihood that she would encounter the very malevolent social stimuli she wished to avoid. Her exquisite antennae picked up and transformed what most people overlooked. Again, with the therapist using appropriate cognitive and interpersonal methods, her hypersensitivity was prevented from backfiring, that is, becoming an instrument that constantly brought to awareness the very pain she wished to escape. Reorienting Allison’s focus and her negative interpretive habits to ones that were more ego-enhancing and optimistic in character reduced her self-demeaning outlook, intensified her positive experiences, and diminished her anguish.

Resistances and Risks If borderlines find an emotionally nurturant environment and are reinforced in their need for acceptance and attachment, they can live in relative comfort and tranquility, maintaining a reasonably secure hold on reality. However, should the attention and support that capricious/borderlines require be withdrawn, and should their strategies prove wearisome and exasperating to others, precipitating their anger and lack of forgiveness, then their tenuous hold on reality often disintegrates and their capacity to function withers. Many therapists worry that somber depression and explosive hostility, which often signify acute breaks with reality, can lead to a more permanent decompensation process. Among the early signs of a growing breakdown are marked periods of discouragement and a persistent dejection. At this phase, it is especially useful to employ supportive therapy and cognitive reorientation. Efforts should be made to boost these patients’ sagging morale, to encourage them to continue in their usual sphere of activities, to build their self-confidence, and to deter them from being preoccupied with their melancholy feelings. Of course, they should not be pressed beyond their capabilities, nor told to snap out of it, as their failure to achieve these goals will only strengthen their growing conviction of their own incompetence and unworthiness. Should depression be the major symptom picture, it is advisable to prescribe any of the suitable antidepressant agents as a means of buoying the patient’s flagging spirits. Should suicide become a threat, or should the patient lose control or engage in hostile outbursts, it may be

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advisable to arrange for brief institutionalization in the hope of obviating future needs for more serious institutional intervention. Some therapists may overreact to a capricious/borderline patient’s tendency toward psychoticlike experiences or actual breaks with reality. To avoid biasing therapeutic work against the client it is important for the therapist to remember that brief hospitalizations should not be interpreted by the patient as a sign that he or she is “crazy” and that outpatient therapeutic work is futile. When therapists do feel that their efforts are futile or feel threatened by a patient’s behavior, countertransference can include a variety of problematic reactions. Therapists who realize they are experiencing such feelings need to examine them to ensure that they do not bias their interaction with the patient against his or her best interest. It may be best for the therapist to seek consultation with a colleague if this becomes a pattern in the therapy with a particular client. On the other hand, some patients become excessively dependent owing to the lack of responsibilities during a period of hospitalization. Therapists working with such borderline patients can help break this dependency by suggesting that hospitalization is not a cure, but just a life preserver that will keep the patient from sinking. Not conducting therapy while the patient is hospitalized can help him or her view hospitalization as a temporary solution to problems, and thereby strengthen the will to return to a more functional lifestyle.

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CHAPTER

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Personalized Therapy for the Suspicious/ Paranoid Personality Patterns

T

he suspicious/paranoid personality is frequently a more structurally defective and dysfunctional variant of the avoidant, sadistic, compulsive, and narcissistic patterns, with each sharing a preoccupation with matters of adequacy, power, and prestige. Among the more prominent features of the suspicious/paranoid personality pattern, mild or moderately severe types, are a pervasive and unwarranted mistrust of others, hypersensitivity to signs of deception or malevolence, and restricted affectivity (Ravindran, Yatham, & Munro, 1999). These individuals are fearful of external sources of influence and may be resistant to form intimate relationships for fear of being stripped of their power of self-determination (J. J. Johnson, Smailes, Cohen, Brown, & Bernstein, 2000; Rasmussen, 2005). In spite of their air of self-importance, invincibility, and pride, paranoid personalities tend to experience extreme jealousy and envy at the good fortune of others. To justify these feelings of resentment, they constantly search for signs of deception and actively construct situations to test the sincerity of others (R. G. Harper, 2004). Inevitably, their provocative and abrasive behaviors elicit the very signs of malice that they project on others. Even the slightest, most trivial cues are seized on and magnified to justify their preconceptions (Rawlings & Freeman, 1997). Data that contradict their perceptions are ignored, with the paranoid accepting no responsibility or blame for his or her role (Bernstein, Useda, & Siever, 1995; Williams, Haigh, & Fowler, 2005). This distortion of events, though personally logical, is irrational, at times verging on delusional. In their attempts to remain constantly on guard and mobilized, paranoids may exhibit an edgy tension, irritability, and rigid defensive posture (Blackburn & Coid, 1999; Sinha & Watson, 2006). To protect themselves from the sadistic treatment and

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betrayal that they anticipate, these individuals maintain an interpersonal distance and attempt to desensitize themselves from tender and affectionate feelings toward others (Camisa et al., 2005). They become hard and insensitive to the suffering of others, as well as alienated from their own emotions and inner conflicts (McHoskey, 2001). Although dysfunctionally rigid, this stance of social withdrawal, callousness, and projection of personal malevolence and shortcomings onto others provides the suspicious/paranoid pattern with a glorified self-image and relative freedom from intrapsychic distress (Birkeland, 2003). Under circumstances of real or imagined threats to their autonomy or challenges of their competency, however, paranoids’ tenuous sense of self-determination and superiority can be badly shaken (Waska, 2002). Initially, these individuals may construct new “proofs” to fortify their persecutory fantasies, while vigorously struggling to reestablish their former autonomy and esteem (Palermo & Scott, 1997). During the course of their self-assertion, considerable hostility may be unleashed on others (Coolidge, DenBoer, & Segal, 2004). In paranoids with prominent narcissistic features, threats to their illusion of omnipotence and superiority may elicit a self-exalted and pompous variant of manic disorder (Noonan, 1999). With an exaggerated cheerfulness, excitement, and buoyancy, reminiscent of their former state of complacency, these individuals are frantically driven to recover their lost exalted status. In some instances, their previous sense of self-determination and confidence cannot be easily reconstructed. Time and again, paranoids’ competencies have been shown to be defective, and they have been made to look foolish (T´ızon Garc´ıa, 2003). Defeated and humiliated, their past arrogance and self-assurance now submerged, a deep sense of helplessness and major depression may ensue (Fuchs, 1999). A feature that justifies considering suspicious/paranoids among the more structurally defective personalities is the inelasticity and constriction of their coping skills. The obdurate and unyielding structure of their personality contrasts markedly with the lack of cohesion and instability of the borderline personality. Whereas borderlines are subject to a dissolution of controls and to a fluidity in their responsiveness, paranoids display such inflexible controls that they are subject to having their rigid fac¸ade shattered. Entirely insignificant and irrelevant events are often transformed by suspicious/paranoids to have personal reference to themselves (Porcerelli, Cogan, & Hibbard, 2004). They may begin to impose their inner world of meanings on the outer world of reality. As Cameron (1963) once put it, they create a “pseudo-community” composed of distorted people and processes. Situations and events lose their objective attributes and are interpreted in terms of subjective expectations and feelings. Unable and unwilling to follow the lead of others and accustomed to drawing power within themselves, paranoids reconstruct reality so that it suits their dictates (Reid, 2005). Faced by a world in which others shape what occurs, they construct a world in which they determine events and have power to do as they desire. In contrast to their less structurally defective counterparts, suspicious/paranoids’ need for autonomy and independence has been undermined often and seriously. These personalities counter the anxiety their experiences create by distorting objective reality and

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constructing in its stead a new reality in which they can affirm their personal stature and significance. Stone (1993) brings together a number of features of several varieties of the paranoid disorder. In his usual insightful and descriptively articulate manner, he writes: The grandiosity . . . may be either secret or blatant, [and reflects] the paranoid person’s intense fear of dissolution of self (loss of identity) as a central dynamic. . . . The characteristic hypervigilance of paranoid persons has relevance both to their hostility and to their fear of boundary-loss. The need for a wide psychological and even geographical space between paranoid persons and those with whom they interact is a reflection of both (a) fear of hostile invasion by others (for which real distance has survival value) and (b) fear of being “unduly” influenced by others, to the point of losing a sense of separate self (for which extra psychological “space”—not getting intimate with others—is a solution). (p. 200)

We turn to contemporary conceptions by referring to the evolutionary model of the paranoid personality, as seen in Figure 8.1. What is most notable here is the

PARANOID PROTOTYPE

Enhancement

Preservation

(Pleasure)

(Pain)

Accomodation

Modification

(Passive)

(Active)

Individuation

Nurturance

(Self)

(Other)

Block between Polarities Weak on Polarity Dimension Average on Polarity Dimension Strong on Polarity Dimension

FIGURE 8.1 Status of the suspicious/paranoid personality prototype in accord with the Millon polarity model.

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presence of a block between each pair of the polarity groups. This signifies the rigid compartmentalization of suspicious/paranoids’ thoughts and feelings about themselves and others, as well as the unyielding and constricted nature with which they perceive and relate to the world. Whatever motives and aims they have developed in life remain firmly fixed, unchangeable and uninfluenced by life circumstances. It is the obduracy and inelasticity of their polarity inclinations that characterizes paranoids and distinguishes them from the two other severe/structural pathological types, the schizotypal and the borderline. Despite commonalties in the eccentricity of their beliefs and attitudes, the schizotypal comes to this characterization by virtue of excessive structural fluidity, whereas in the suspicious/paranoid it reflects an unwillingness to adapt to external realities, a fixity in one’s psychic structure that is unbending and inelastic. Similarly, the paranoid’s inflexibility and rigidity differs from the borderline’s extraordinary inconstancy and changeability. As with the two other severe/structural pathologies, the suspicious/paranoid disorder almost invariably covaries with one or more of the usually less severe personality styles. In reviewing MCMI cases of most paranoids we are likely to see a conflation of paranoid structural pathologies combined with a stylistic disorder, for example, paranoid-avoidant, paranoid-narcissist, paranoid-obsessive-compulsive. The task of the clinician is not to disentangle these components, but to recognize that they almost invariably coexist as a stylistic/structural fusion. It is these mixtures that result in what we have described as prototypal variants or subtypes.

Clinical Picture Certain symptom characteristics are shared in common among suspicious/paranoids. As in the two previous structurally defective patterns, we shall divide these characteristics initially into three broad areas of clinical significance: primary sources of anxiety, cognitive processes and preoccupations, and typical moods and behaviors. Five of the major subtypes that develop into variants of the paranoid personality are discussed in detail shortly. Characteristics that will further aid in distinguishing the prototypal paranoid in accord with our schema of eight clinical domains immediately follows this section (see Figure 8.2). Attachment Anxiety The suspicious/paranoid detests being dependent not only because it signifies weakness and inferiority, but because he or she is unable to trust anyone. To lean on another is to expose oneself to ultimate betrayal and to rest on ground that will only give way when support is needed most. Rather than chance deceit, paranoids aspire to be the maker of their own fate, free of entanglements and obligations. It’s bad enough to place one’s trust in others; even worse is to be subject to their control and to have one’s power curtailed and infringed upon.

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PARANOID PROTOTYPE Inviolable

Irascible Mood/Temperament

Self-Image

Projection Regulatory Mechanism

Defensive

Mistrustful

Expressive Behavior

Cognitive Style

Unalterable Inelastic Morphologic Organization

Provocative

Object Representations

Interpersonal Conduct

FIGURE 8.2 Salience of prototypal suspicious/paranoid domains.

To be coerced by external authority and attached to a power stronger than themselves provoke extreme anxiety. Suspicious/paranoids are acutely sensitive to threats to their autonomy, resist all obligations, and are cautious lest any form of cooperation be a subtle ploy to seduce them and force their submission to the will of others. It is this attachment anxiety, with its consequent dread of losing personal control and independence, that underlies the suspicious/paranoid’s characteristic resistance to influence. Ever fearful of domination, these individuals watch carefully to ensure that no one robs them of their will. Any circumstance that prompts feelings of helplessness and incompetence, decreases their independence and freedom of movement, or places them in a vulnerable position subject to the powers of others may precipitate a psychotic episode. Trapped by the danger of dependency, struggling to regain their integrity and status and dreading deceit and betrayal, they may strike out aggressively, accuse others of seeking to persecute them, and ennoble themselves with grandiose virtues and superiority. Should they find themselves thinking, feeling, and behaving in ways that are alien to their preferred self-image, they will claim that powerful sources have manipulated them and coerced them to submit to others’ malicious intent. That these accusations are pathological is evident by their vagueness and irrationality; for example, the paranoid safely locates these powers in unidentifiable sources, such as “they,” “a voice,” “communists,” or “the devil.”

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The suspicious/paranoid’s dread of attachment and fear of insignificance are similar to the anxieties of the schizotypal. Both shy from close personal relationships and are vulnerable to the threat of nothingness. These commonalities account, in part, for the difficulties that clinicians have faced in differentiating between these syndromes. There is, however, a crucial difference between these patients. Schizotypals find little reinforcement in themselves; their fantasies generate feelings of low self-worth. Moreover, they turn away from others and from themselves; thus, they are neither attached nor possess a sense of self. Though paranoids likewise turn away from others, they find reinforcements within themselves. Accustomed to self-determination, they use their active fantasy world to create a self-enhanced image and rewarding existence apart from others. Faced with the loss of external recognition and power, they revert to internal sources of supply. Thus, in contrast to the schizotypal, their inner world compensates fully for the rebuffs and anguish of experience; through delusional ideation they reconstruct an image of self that is more attractive than reality. Cognitive Suspicions and Delusions The paranoid’s lack of trust colors his or her perceptions, thoughts, and memories. No doubt, all people selectively perceive events and draw inferences based on their needs and past experiences. But the feelings and attitudes generated in the life history of paranoids have produced an intense mistrust of others, creating within them a chronic and pervasive suspiciousness; they are oversensitive, ready to detect signs of hostility and deception, tend to be preoccupied with them, and actively pick up, magnify, and distort the actions and words of others to confirm their expectations (D. J. Harper, 1996). Moreover, they assume that events that fail to confirm their suspicions only prove how deceitful and clever others can be. In their desire to uncover this pretense, they explore every nook and cranny to find justification for their beliefs, constantly testing the honesty of their friends. Finally, after cajoling and intimidating others, the paranoid provokes them to exasperation and anger (Shopshire & Craik, 1996). In short, the preconceptions of suspicious/paranoids rarely are upset by facts; they disregard contradictions, confirm their expectations by seizing on real, although minute and irrelevant facts, or create an atmosphere that provokes others to act as they anticipated. The unwillingness of the paranoid to attach himself or herself to others or to share their ideas and points of view leaves this personality isolated and bereft of the reality checks that might restrain his or her suspicions and fantasies. Driven to maintain independence, he or she is unable to see things as others see them. Apart from others and with no one to counter the proliferations of his or her imagination, the paranoid concocts events to support his or her fears or wishes, ponders incessantly along a single deviant track, puts together the flimsiest of evidence, reshapes the past to conform to his or her beliefs, and builds an intricate logic to justify his or her anxieties and desires. Thus, left to their own devices, paranoids cannot validate their speculations and ruminations; no difference exists in their mind between what they have seen and

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what they have thought; fleeting impressions and hazy memories become fact; a chain of unconnected facts is fitted together; conclusions are drawn. The inexorable course from suspicion to supposition to imagination has given birth to a delusion; a system of invalid and unshakable beliefs has been created. Delusions are a natural outgrowth of the suspicious/paranoid personality pattern. Two conditions, dependence on self for both stimulation and reinforcement, are conducive to the emergence of mini-delusions. Insistent on retaining their independence, paranoids isolate themselves and are unwilling to share the perspective and attitudes of others. They have ample time to cogitate and form idiosyncratic suppositions and hypotheses; these then are “confirmed” as valid because it is the paranoid alone who is qualified to judge them. The delusions of the suspicious/paranoid differ from those seen in other pathological patterns. Accustomed to self-reinforcement and independent thought and convinced of his or her competence and superiority, the paranoid is both skillful in formulating beliefs and confident in their correctness; his or her delusions tend, therefore, to be systematic, rational, and convincing. In contrast, the occasional delusions of the schizotypal and borderline appear illogical and unconvincing, tending to arise under conditions of unusual emotional duress; moreover, in further distinction, they are usually bizarre, grossly irrational, scattered, and unsystematic. Defensive Vigilance and Veiled Hostility Paranoids are constantly on guard, mobilized and ready for any emergency or threat. Whether faced with real dangers or not, they maintain a fixed level of preparedness, an alert vigilance against the possibility of attack and derogation. There is an edgy tension, an abrasive irritability, and an ever-present defensive stance from which they can spring to action at the slightest hint of threat. This state of rigid control never seems to abate; rarely do they relax, ease up, or let down their guard. Beneath the surface mistrust and defensive vigilance in the suspicious/paranoid lies a current of deep resentment toward others who have made it. To the paranoid, most people have attained their status unjustly; thus, he or she is bitter for having been overlooked, treated unfairly and slighted by the high and mighty, “the cheats and the crooks” who duped the world. Only a thin veil hides these bristling animosities. Unable to accept their own faults and weaknesses, suspicious/paranoids maintain their self-esteem by attributing their shortcomings to others. They repudiate their own failures and project or ascribe them to someone else. They possess a remarkable talent for spotting even the most trifling of deficiencies in others; both subtly and directly they point out and exaggerate, with great pleasure, the minor defects they uncover among those they despise. Rarely does their undercurrent of envy and hostility subside; they remain touchy and irascible, ready to humiliate and deprecate anyone whose merits they question and whose attitudes and demeanor evoke their ire and contempt. There are no universal attributes that may be spoken of as the essence of the suspicious/paranoid personality. The great majority of these patients evidence the

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constellation of anxieties, cognitions, and behaviors described here, but we must be careful not to let our focus on these common symptoms obscure the variety of forms into which this impairment unfolds or the different coping patterns that underlie them. In the section on “Prototypal Diagnostic Domains” we describe some of the features that differentiate five basic subtypes of the paranoid personality. Despite the distinctions we draw, we must be mindful that distinctions are not well defined in reality; there are overlappings, with traces of the more distinctive features of each subvariety often found in the others. Few pure textbook cases ever are met. As in prior chapters, the characteristics of the personality under review are divided into the eight domains that are this text’s standard format (see Table 8.1). Defensive Behavior Suspicious/paranoids appear tense and guarded. Eyes tend to be fixed, sharply focused on whatever facet of their world draws their attention. It is not uncommon for them to make quick movements should they hear or see something they view as untoward; otherwise, they are likely to remain fixed and unmovable. These characteristics represent the vigilant quality of paranoids’ attention to their environment. They are notably alert to anticipate and to ward off any potential malice, deception, or derogation of themselves. It also signifies that they are tenaciously and firmly resistant to external influence and control. Suspicious/paranoids are constantly mobilized, ready for any real or imagined threat. Whether faced with danger or not, they maintain a fixed level of preparedness, an alert vigilance against the possibility of attack and derogation. They exhibit an edgy tension, an abrasive irritability, and an ever-present defensive stance from which they can spring into action at the slightest offense. Their state of rigid control never seems to abate, and they rarely let down their guard. Provocative Interpersonal Conduct Suspicious/paranoids not only bear grudges and are unforgiving of those with whom they have related in the past, but they are also likely to display a quarrelsome, fractious, and disputatious attitude toward recent acquaintances. Interpersonally, they tend to be provocative in their transactions with others, precipitating exasperation and anger by testing their loyalty and by intrusive and searching preoccupations with possible hidden motives. Beneath the obvious mistrust and defensive vigilance of the paranoid stirs a current of deep resentment toward successful persons. To suspicious/paranoids, most people have attained their status unjustly. To make matters worse, they feel that they have been personally overlooked and are bitter for having been treated unfairly and slighted by those who have cheated to gain power. Every trivial rebuff is a painful reminder to suspicious/paranoids of their past, a history that includes early mistreatments. Trapped in what they see as a timeless web of deceit and malice, the fears and angers of paranoids may mount to monumental proportions. Should their defenses fall into shambles, their controls dissolve, and their fantasies of doom run rampant, their underlying dread and fury may surge into the

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Table 8.1

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Clinical Domains of the Suspicious/Paranoid Personality Prototype

Behavioral Level: (F) Expressively Defensive (e.g., is vigilantly guarded, alert to anticipate and ward off expected derogation, malice, and deception; is tenacious and firmly resistant to sources of external influence and control). (F) Interpersonally Provocative (e.g., not only bears grudges and is unforgiving of those of the past, but displays a quarrelsome, fractious, and abrasive attitude with recent acquaintances; precipitates exasperation and anger by testing loyalties and an intrusive and searching preoccupation with hidden motives). Phenomenological Level: (F) Cognitively Mistrustful (e.g., is unwarrantedly skeptical, cynical, and distrustful of the motives of others, including relatives, friends, and associates, construing innocuous events as signifying hidden or conspiratorial intent; reveals tendency to read hidden meanings into benign matters and to magnify tangential or minor difficulties into proofs of duplicity and treachery, especially regarding the fidelity and trustworthiness of a spouse or intimate friend). (S) Inviolable Self-Image (e.g., has persistent ideas of self-importance and self-reference, perceiving attacks on own character not apparent to others, asserting as personally derogatory and scurrilous, if not libelous, entirely innocuous actions and events; is pridefully independent, reluctant to confide in others, highly insular, experiencing intense fears, however, of losing identity, status, and powers of self-determination). (S) Unalterable Objects (e.g., internalized representations of significant early relationships are a fixed and implacable configuration of deeply held beliefs and attitudes, as well as driven by unyielding convictions that, in turn, are aligned in an idiosyncratic manner with a fixed hierarchy of tenaciously held but unwarranted assumptions, fears, and conjectures). Intrapsychic Level: (F) Projection Mechanism (e.g., actively disowns undesirable personal traits and motives and attributes them to others; remains blind to own unattractive behaviors and characteristics, yet is overalert to, and hypercritical of, similar features in others). (S) Inelastic Organization (e.g., systemic constriction and inflexibility of undergirding morphologic structures and rigidly fixed channels of defensive coping, conflict mediation, and need gratification create an overstrung and taut frame that is so uncompromising in its accommodation to changing circumstances that unanticipated stressors are likely to precipitate either explosive outbursts or inner shatterings). Biophysical Level: (S) Irascible Mood (e.g., displays a cold, sullen, churlish, and humorless demeanor; attempts to appear unemotional and objective, but is edgy, envious, jealous; quick to take personal offense and react angrily). Note: F = Functional Domains; S = Structural Domains.

279

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open. A flood of hostile energies may erupt, letting loose a violent and uncontrollable torrent of vituperation and aggression. These psychotic outbursts are usually brief. As the surge of fear and hostility is discharged, these patients typically regain their composure and seek to rationalize their actions, reconstruct their defenses, and bind their aggression. This subsiding of bizarre emotions does not lead to a “normal” state but merely a return to their former personality pattern. Mistrustful Cognitive Style Perhaps the most distinctive feature of paranoids is their pervasive suspiciousness. Moreover, they are unwarrantedly skeptical, cynical, and mistrustful of the motives of others, including relatives, friends, and associates (H. Lee, 1999). Innocuous events are construed as signifying hidden or conspiratorial intent. Most reveal tendencies to search for hidden meanings in completely benign matters and to magnify tangential or minor difficulties into proofs of duplicity or treachery, especially regarding the fidelity of a spouse or intimate friend. As noted previously, all of us are selective in what we perceive and infer, based on our pattern of needs and past experiences. Unfortunately, the learned feelings and attitudes of paranoids produce a deep mistrust and pervasive suspiciousness of others. They are notoriously oversensitive and disposed to detect signs everywhere of trickery and deception; they are preoccupied with these thoughts, actively picking up minute cues, then magnifying and distorting them so as to confirm their worst expectations. To complicate matters further, events that fail to confirm their preformed suspicions only prove how deceitful and clever others can be. In an effort to uncover the assumed pretense, they will test others to find some justification for their beliefs. These preconceptions rarely are upset by facts. Suspicious/paranoids dismiss contradictions and confirm their expectations by seizing on real, although trivial or irrelevant, data. Even more problematic is that they create an atmosphere that provokes others to act as they anticipated. After testing the honesty of their friends and constantly cajoling and intimidating others, paranoids will provoke almost everyone into exasperation and anger. The unwillingness of suspicious/paranoids to trust sharing their doubts and insecurities leaves them isolated and bereft of the reality checks that might restrain their suspicions. Driven to maintain secrecy, they become increasingly unable to see things as others do. Lacking closeness and sharing, and with no one to counter the proliferations of their imagination, they concoct events in support of their fears or wishes, pondering incessantly over deviant ideas, putting together the flimsiest of evidence, reshaping the past to conform to preconceptions, and building an intricate logic to justify their distortions. Left to their own devices, paranoids are unable to validate their speculations and ruminations. Little difference exists in their mind between what they have seen and what they have thought. Momentary impressions and hazy memories become fact. Chains of unconnected facts are fitted together. An inexorable course from imagination to supposition to suspicion takes place, and soon a system of invalid and unshakable beliefs has been created.

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Inviolable Self-Image The majority of suspicious/paranoids have persistent ideas of self-reference and selfimportance. They perceive attacks on their character not apparent to others, asserting as personally derogatory and scurrilous, if not libelous, entirely innocuous actions or events. As a consequence, they seek to be inviolable, are pridefully independentminded, and are reluctant to confide in and be dependent on others. This highly insular attitude derives from their intense fear of losing their identity and, more important, their powers of self-determination. Paranoids detest being dependent, not only because it signifies weakness and inferiority but because they dare not trust anyone. To lean on another is to be exposed to ultimate betrayal and to rest on ground that will give way when support is needed most. Rather than chance being deceived, suspicious/paranoids strive to be the makers of their own fate, free of all personal entanglements and obligations. As a further means of assuring self-determination, suspicious/paranoids assume an attitude of invincibility and pride. Convincing themselves that they have extraordinary capacities, they can now master their fate alone, as well as overcome every obstacle, resistance, and conflict. All traces of self-doubt are dismissed, and they repudiate all nurturant overtures from others. Thus assured, they will never dread having to need or to depend on anyone. To be coerced by a power stronger than they provokes extreme anxiety. Paranoids are acutely sensitive to any threat to their autonomy, resist all obligations, and are cautious lest any form of cooperation be but a ploy to seduce them and force their submission to the will of others. This attachment anxiety, with its consequent dread of losing personal control and independence, underlies much of the suspicious/paranoid’s characteristic resistance to influence. Fearful of domination, these personalities watch carefully to ensure that no one robs them of their will. Circumstances that prompt feelings of helplessness and incompetence or that decrease their freedom of movement or place them in a vulnerable position subject to the powers of others may precipitate a sudden and ferocious counterattack. Feeling trapped by the dangers of dependency, struggling to regain their status, and dreading deceit and betrayal, they may strike out aggressively and accuse others of seeking to persecute them. Should others accuse them accurately of thinking, feeling, or behaving in ways that are alien to their self-image, they are likely to claim that powerful and malevolent sources have coerced them with malicious intent. These accusations may become grossly pathological and signify the presence of an incipient psychotic disorder, as when they locate these powers among an unidentifiable “they” or as “a voice,” “communists,” or “the devil.” Unalterable Objects The internalized representation of significant early relationships among most suspicious/paranoids is limited and rigidly fixed. There is an implacable configuration of objects representing firmly held images, beliefs, and attitudes. These intrapsychic

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components are driven to yield unwarranted convictions regarding the attitudes and dispositions of others with whom they interact. What is most notable about this inner template of objects is their idiosyncratic character and the fixed and tenaciously held assumptions of which they are composed. The experiential history of paranoids often gives them reason to be mistrustful and to fear betrayal or sadistic treatment. To counter these sources of threat, they have learned to distance themselves from others and to remain strong and vigilant, not only as a protective stance but as a means of vindication and triumph over potential attackers. To ensure their security, they go to great pains to avoid any weakening of their resolve and to develop new and superior powers to control others. As must be evident from the foregoing, the confidence and pride of suspicious/paranoids cloak but a hollow shell. Their arrogant pose of autonomy rests on insecure internal footings. Extremely vulnerable to challenge, their defensive fac¸ade is constantly weakened by real and fantasized threats. In their efforts to reassert their power and invincibility, they will resort to any course of action that will shore up their defenses or thwart their detractors. Projection Mechanism Perhaps second only to their suspiciousness as a sign of the paranoid disorder is their use of the projection regulatory mechanism. These personalities actively disown their undesirable personal traits and motives, attributing them freely to others. Not only are they blind, therefore, to their own unattractive behaviors and characteristics, but they are hyperalert to similar features that may be present to a limited degree in others. Thus, troubled by mounting and inescapable evidence of inadequacy and hostility, suspicious/paranoids are driven to go beyond mere denial. They not only disown these personally humiliating traits but throw them back at their real or imagined accusers. Through the mechanism of projection, they are able to claim that it is others who are stupid, malicious, and vindictive. Moreover, the patient himself or herself is an innocent and unfortunate victim of the incompetence and malevolence of others. Unable to accept faults and weaknesses within themselves, paranoids maintain their self-esteem by attributing their shortcomings to others. Repudiating their own failures, they project or ascribe them to someone else. They possess a remarkable talent for spotting the most trifling deficiencies in others. Both indirectly and directly they point to and exaggerate the minor defects they uncover among those they learn to despise. Rarely does their envy and hostility subside. They are touchy and irritable, ready to humiliate and deprecate anyone whose merits they question and whose attitudes and demeanor evoke their ire or contempt. By a simple reversal, suspicious/paranoids not only absolve themselves of fault but find a “justified” outlet for their resentment and anger. If paranoids are found to have been in error, others should be blamed for their ineptness. If they have been driven to become aggressive, it is only because the evil of others has provoked them. They are innocent, and justifiably indignant, unfortunate and maligned scapegoats for the blundering and the slanderous.

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Faced with persistent derogation and threat, suspicious/paranoids will seek vigorously to redeem themselves and reestablish their sense of autonomy and power. However, they may have no recourse to achieve these ends except through fantasy. Unable to face their feelings of inadequacy and insignificance, they may begin to fabricate an image of superior self-worth. Left to ruminate alone, they may construct proofs of their eminence through intricate self-deceptions. Renouncing objective reality, they supplant it with a glorified self-image. They endow themselves with limitless powers and talents, and hence need no longer be ashamed of themselves or fear others. They can now rise above petty jealousies, understanding all too clearly why others seek to undermine their stature and virtue. The meaning of the malicious and persecutory attacks of others is obvious: It is the paranoid’s eminence and superiority that they envy and seek to destroy. Inelastic Organization The structural organization of the intrapsychic world of the suspicious/paranoid is composed of highly controlled and systematically arranged images and impulses. Particularly notable is its constriction and inflexibility such that channels for defensive coping are few and persistently employed; similarly, processes for conflict mediation and need gratification are fixed and immutable. This inelastic structure creates an overstrung and taut frame that is so uncompromising in its accommodation to changing circumstances that unanticipated stressors are likely to precipitate either explosive outbursts or inner shatterings. In contrast to other severe personality disorders, the defective nature of the paranoid’s structural organization is not its lack of cohesion, but rather its overly constrained and rigid character. To preclude the possibility of external outbursts or internal shatterings, suspicious/paranoids seek to transform the ongoing events of their everyday life to make them fit their interior structures and objects. As noted previously, they utilize the projection mechanism and its variants (e.g., projective identification) to achieve these ends. Moreover, even those patients who are noted for their rigidity and their hyperalertness to the environment may begin to lower their controls and loosen their usually firm boundaries between reality and fantasy. This process of blurring formerly segregated features of their psychic world will inevitably create new and troublesome consequences. Irascible Mood Underlying many of the suspicious/paranoid’s more general characteristics appears to be a cold, sullen, churlish, and humorless temperament. Whether this outlook is learned or constitutionally based, paranoids tend to be unemotional and “objective.” On the other hand, they are typically edgy, envious, jealous, and quick to take personal offense, reacting angrily with minimal provocation. One of their major goals is to desensitize their tender and affectionate feelings. They become hard, unyielding, and insensitive to the suffering of others. By so doing they protect themselves against entrapment and against being drawn into a web of anticipated deceit and subjugation. To assume a

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callous and unsympathetic stance is not difficult for suspicious/paranoids. Not only is it a successful defensive maneuver against entrapment, but it also allows them to discharge their resentments and angers. Hostility serves both defensive and restitutive measures. Not only is it a means of countering threats to their equilibrium, but it helps restore their image of selfdetermination and autonomy. Once released, this hostility draws on a reserve of earlier resentments. Present angers are fueled by animosities from the past. Desire for reprisal and vindication spurred by prior humiliations are brought to the surface and discharged into the stream of current hostility.

Self-Perpetuation Processes The instrumental behaviors of the structurally defective patterns are less adaptive and more self-defeating than those of the less severely ill. Moreover, structurally defective personalities are more vulnerable to the strains of life and are easily precipitated into psychotic disorders. Situations that promote the anxieties of attachment or expectations of sadistic treatment or the loss of self-determination result in defensive vigilance, withdrawal, and ultimately the delusions that are so characteristic of the suspicious/paranoid personality. Not infrequently, the isolation and fantasy ruminations of the patient become deeply entrenched, leading to more permanent psychotic habits and attitudes. For the present, we will discuss the coping efforts of paranoids, that is, the means by which they seek to prevent further decompensation, but that only intensify their difficulties (see Table 8.2). Table 8.2

Self-Perpetuating Processes: Suspicious/Paranoid Personality

Counters Attachment Distances from dependence on others Desensitizes or denies tender feelings Repudiates overtures of kindness Discharges Hostility Hostility protects jeopardized autonomy Anger fueled by resentment of past injustices Pent-up anger leads to violent discharges Reconstructs Reality Disowns objectionable traits, projects onto accusers Creates an inescapable hostile environment Fabricates superior self-worth

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Countering Attachment Suspicious/paranoid individuals have reason to be mistrustful and to fear betrayal and sadistic treatment. To counter these sources of anxiety, they have learned to keep their distance from others and to remain strong and vigilant, not only as a protective stance but as a means of vindication and triumph over potential attackers. To ensure their security, they engage in a variety of measures both to prevent the weakening of their resolve and to generate new powers for controlling others. One of the major steps in this quest is a desensitization of tender and affectionate feelings. Paranoids become hard and insensitive to the suffering and pleading of others. By so doing they secure themselves against entrapment and against being drawn into the web of deceit and subjugation. Assuming a callous and unsympathetic posture is not difficult for the paranoid; not only does it serve as a defensive maneuver against attachment, but it also allows for the discharge of resentments and angers. As a further means of affirming their self-determination, suspicious/paranoids assume an air of invincibility and pride. They convince themselves that they have extraordinary capacities, that they can master their fate alone and overcome every obstacle, resistance, and conflict. They dismiss all traces of self-doubt and repudiate the nurturant overtures of others; in this way they need never dread having to lean on anyone. But paranoids’ autonomy is spurious. They maintain an illusion of superiority by rigid self-conviction and exaggerated bluff. Time and again, their competencies are proved defective and they are made to look foolish; thus, their precarious equilibrium, their self-appointed certainty and pride are upset too easily and too often. To redeem their belief in their invincibility, they begin to employ extreme and grossly pathological measures. Rather than accepting their obvious weaknesses and faults, they assert that some alien influence is undermining them and causing them to fail and be humbled before others. Frailty, ineffectuality, shame, or whatever predicament they find themselves in must be attributed to an irresistible destructive power. As their suspicion of a foreign force grows and as their vigilance against belittlement and humiliation crumbles, they begin increasingly to distort reality. Not only can they not accept the fact that their failures are self-caused, but they are unwilling to ascribe these failures to pedestrian powers and events; rather, their loss reflects the malicious workings of devils, X-rays, magnetism, poisons, or other pernicious forces. Their delusions of influence and persecution signify both their dread of submission and their need to bolster pride by attributing their shortcomings to the action of insidious deceits or supernatural forces. Discharging Hostility As we have just noted, the confidence and pride of the suspicious/paranoid are but hollow shells; his or her pose of independence stands on insecure footings. These individuals are extremely vulnerable to challenge, and their defensive fac¸ade

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is constantly weakened by real and delusional threats. To reassert their power and invincibility, they must resort to some course of action that will shore up their defenses and thwart their attackers. Hostility in the paranoid is such a defensive and restitutive measure, a means of countering threats to his or her equilibrium and a means of reestablishing his or her image of self-determination and autonomy. Once released, the paranoid’s hostility draws on a deep reserve of earlier resentments. The fires of present angers are fed by animosities reactivated from the past; intense impulses for reprisal and vindication are brought to the surface and discharged into the stream of current hostility. Every trivial rebuff by others is a painful reminder of the past, part of a plot whose history he or she traces back to early humiliations and mistreatments. Trapped in this timeless web of deceit and malice, the paranoid’s fears and angers may mount to monumental proportions. With defenses down, controls dissolved, and fantasies of doom running rampant, his or her dread and fury increase. A flood of frantic and hostile energies may erupt, letting loose a violent discharge, an uncontrollable torrent of vituperation and aggression. These psychotic outbursts are usually of brief duration. As the swell of fear and hostility is discharged, these patients regain their composure and seek to rationalize their actions, reconstruct their defenses, and bind their aggression. But this subsiding of bizarre emotions does not lead to “normality”; rather, the patient merely returns to his or her former less severe paranoid personality pattern. Reconstructing Reality The suspicious/paranoid transforms events to suit his or her self-image and aspirations; delusions may be seen as an extreme form of this more general process of reality reconstruction. Even the passive-ambivalent, noted for excessive rigidity, exhibits this lowering of controls, this loosening of boundaries between what is real and what is fantasized. These reconstructions take many forms, but it will suffice for us to describe the two that are most commonly found among paranoids: denial of weakness and malevolence and their projection on others, and aggrandizement of self through grandiose fantasies. Troubled by the mounting and inescapable evidence of inadequacy and hostility, suspicious/paranoids must go further than mere denial; they not only disown these objectionable traits, but throw them back at their accusers, real or imagined. It is others who are stupid, malicious, and vindictive; the paranoid, in contrast, is an innocent and unfortunate victim of the ineffectuality and malevolence of others (Beck et al., 2001). With this simple reversal, paranoids not only absolve themselves of fault, but find an outlet and a justification for their resentment and anger. If they are in error, others should be blamed for ineptness; if they have been aggressive, it is only because the evil in others has provoked them. They have been an innocent, and justifiably indignant, scapegoat for the blundering and the slanderous.

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But the gains of the projection maneuver are short-lived; moreover, it ultimately intensifies the paranoid’s plight. By ascribing slanderous and malevolent urges to others, he or she now faces threat where none in fact existed; thus, by subjective distortion, the paranoid has created an ever-present hostile environment that surrounds him or her and from which there is no physical escape. Furthermore, paranoids’ unjust accusations are bound to provoke in others feelings of exasperation and anger; thus, their strategy of projection has transformed what may have been overtures of goodwill from others into the hostility paranoids feared. Faced with genuine derogation and threat, suspicious/paranoids must redeem themselves and reestablish their sense of autonomy and power. Once more, they may have no recourse but to turn to fantasy. Unable to confront their feelings of inadequacy and insignificance, they fabricate an image of superior self-worth and importance. Left alone to ruminate, they unfold proofs of their eminence through intricate self-deceptions. They renounce or distort objective reality and supplant it with a glorified image of self. Having endowed themselves with limitless virtues, powers, and talents, they need not now be ashamed of themselves or fear anyone; they can rise above petty jealousies and can understand all too clearly why others seek to undermine and persecute them. The meaning of others’ malicious attacks is obvious: It is the paranoid’s eminence—his or her infinite superiority—which they envy and seek to destroy. Step by step, paranoids’ self-glorifications and persecutory delusions form into a systematic pattern; the whole picture comes into sharp relief. One delusion feeds on another, unchecked by the controls of social reality. Fabrications, employed initially to cope with the despair of reality, become more real than reality itself; it is at this point that we see the clear emergence of a psychotic phase.

Interventional Goals Not unlike other structurally defective personality patterns, the future prospects for paranoids are not promising (Bender, 2005). Their habits and attitudes are deeply ingrained and pervade the entire fabric of their functioning. Modest improvements are possible, of course, but these are likely to diminish the frequency of troublesome episodes rather than revamp the basic personality style. Impairment in the suspicious/paranoid is more likely to be of an interpersonal than an intrapsychic nature, and tends to be less disturbing to the patient than to others. Most paranoid personalities do not succumb to serious and persistent delusions and tend to come in contact with psychological services only at the request of others or when their defenses crumble, triggering the onset of a more severe condition. They are regarded by most associates as suspicious and testy people. A very small number do attain considerable success, especially if they are unusually talented or happen by good fortune to attract a coterie of disciples.

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Despite difficult social relationships, the long-range prognosis for the paranoid is not as poor as that of the schizotypal, a structurally defective counterpart. Suspicious/ paranoids can obtain satisfactions from themselves; schizotypals do not. Faced with external derogation, paranoids can nurture themselves until their wounds are sufficiently healed. Schizotypals, lacking faith both in themselves and others, remain empty-handed. Compared to borderlines, their other structurally defective counterpart, paranoids have both a disadvantage and an advantage insofar as prognosis is concerned. Borderlines characteristically maintain reasonably good, if erratic, interpersonal relations. Paranoids do not. As a consequence, borderline personalities may gain some of the support and encouragement they need. Furthermore, unlike the suspicious/ paranoid, they turn to others during difficult periods, often soliciting enough affection and security to forestall a further decline. In contrast, paranoids tend to remain socially difficult and keep to themselves when relationships turn sour. Behaviors such as these increase their isolation, not only resulting in an intensification of their suspicions and secretiveness but giving rise to further social estrangement. To borderlines’ disadvantage is their lack of internal reserve, which leads them to slip into a state of helplessness should they fail to evoke external support. This is not the case with suspicious/paranoids. Not only will they refuse to submit to weakness and indolence, but they will struggle to pull themselves up by their own bootstraps. Despite each patient’s unique combination of presenting complaints, reasons for entering therapy, and personality presentation, a cardinal aim of synergistic therapy with paranoid personalities is to loosen up the extreme constriction and inflexibility that pervades all clinical domains. Concurrently an attempt must be made to balance the confused mix of polarity reversals that may have contributed to perpetuating the suspicious/paranoid pattern. If paranoids can learn to let down their guard and obtain satisfaction and reinforcement from interpersonal relationships, instead of being constantly on the defensive, they may open themselves up to many life-enhancing experiences (see Table 8.3). Reestablishing Polarity Balances The suspicious/paranoid personality displays an extreme sensitivity to psychic pain, anticipating rejection and humiliation at every turn. For this reason, he or she tries to avoid situations that are aversive or negatively reinforcing. Always wary of what others can do to hurt them and fearful of external control, paranoids have learned to withdraw from others and turn to themselves. Therapy should focus on reducing the predominant self-orientation as well as attenuating the extreme insensitivity to the needs of others. Countering vigilant paranoid mistrust of others is fundamental to balancing the pain–pleasure polarity. Gradually aiding these patients in identifying possible rewards from interactions with others will fuel their desire to seek positive experiences within the realm of interpersonal contact.

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Table 8.3 Therapeutic Strategies and Tactics for the Prototypal Suspicious/ Paranoid Personality Strategic Goals Balance Polarities Reduce pain Increase other Counter Perpetuations Stop provocations of rejection Modify rigid mini-delusions Undo self-protective withdrawals Tactical Modalities Alter inviolable self-image Moderate irascible mood Reorient cognitive suspiciousness

Countering Perpetuating Tendencies The suspicious nature and extreme distrust of others are at the core of this personality’s problems. They remain so vigilant to signs of rejection that they inevitably uncover them. Accusations and provocations, combined with projection of personal insecurities onto others, cannot help but antagonize people. Interrupting the cycle that perpetuates the suspicious/paranoid may best be accomplished in an indirect manner. Beck and Freeman (1990a, 1990b) suggest increasing the paranoid’s sense of self-efficacy. This in turn will reduce the likelihood that projection will be employed as a defense. Empowering the self may take the edge off the extreme hypervigilance the paranoid uses to scan the environment for the expected signs of hostilities. As a result of these delusional thought patterns, suspicious/paranoids tend to turn from others to avoid rejection and rebuff. Withdrawal thus serves a self-protective function, yet it also makes them more susceptible to reality distortions, leaving them to ruminate and construct elaborate fabrications without the necessary reality checks. Inadequate reality testing combined with a suspicious attitude toward others fosters the development of delusional thought processes. A major goal of personologic therapy with this disorder is to minimize the paranoid’s tendency to engage in self-protective withdrawal by encouraging him or her to gather additional information from the environment before reevaluating assumptions about others. When it is established that suspicious/paranoids’ perceptions about the dangers in their surroundings are largely inaccurate, the use of self-protective withdrawals may decrease, thereby further attenuating their pathology.

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Identifying Domain Dysfunctions The suspicious/paranoid personality displays prominent dysfunctions in the cognitive style and expressive behavior domains. Their suspicious nature extends rigidly, inflexibly, and virtually indiscriminately to all situations encountered. Helping the paranoid see that most fears are imaginary and invalid will assist in alleviating this guardedness. It will furthermore diminish the need to engage in self-protective withdrawal. The projective thinking displayed by suspicious/paranoids not only protects their self-image, but it often elicits attack and rejection. As personal faults are disavowed and attributed to others, the belief that the source of all misery lies in the malevolent nature of their adversaries becomes stronger. Therapeutic efforts must aim to strengthen the paranoid’s self-sufficiency, gradually encouraging the patient to accept minor faults in himself or herself. Affectively, paranoids display a touchiness and irritability that, combined with their interpersonally provocative style, will be experienced as abrasive even by otherwise affable individuals. Interventions must teach suspicious/paranoids to express anger and criticism in a more subtle, socially accepted manner, as well as encourage the expression of positive emotions. Early relational experiences have been internalized and have left suspicious/paranoids with a set of fixed, unyielding, and unwarranted beliefs about others. The systemic constriction and inflexibility of their morphological organization and their tenacious and unalterable coping styles present a major dilemma. Work in this area must emphasize the acquisition of more diverse coping mechanisms. It is also essential that new relational experiences be encountered.

Selecting Therapeutic Modalities What is a good approach to take with suspicious/paranoid patients? Essentially, the therapist must build trust through a series of slow and progressive steps. A quiet, formal, and genuine respect for the patient as a person must be shown (Meissner et al., 1996). The therapist must accept, but not confirm, these patients’ unusual beliefs and allow them to explore their thoughts and feelings at a pace they can tolerate. The major initial goal of therapy is to free paranoids of mistrust by showing them that they can share their anxieties with another person without the humiliation and maltreatment to which they are accustomed. If this can be accomplished, suspicious/paranoids may learn to look at the world not only from their own perspective but through the eyes of others. If they can trust the therapist, they can begin to relax, relinquish their defenses, and open themselves to new attitudes. Once they have accepted the therapist as someone they can trust, they may be able to lean on him or her and accept his or her thoughts and suggestions. This may become a basis for a more generalized lessening of suspicions and for a wider scope of trusting and sharing.

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Behavioral Techniques The goals of behavioral treatment have been designed to diminish paranoids’ hypersensitivity to criticism and to modulate their behavioral reactions. A variety of information-processing and social skills training programs may be employed with paranoids who appear particularly resistant to advice-giving cognitive approaches. Skills training may include such techniques as role-playing, behavioral rehearsals, and modeling via videotape methods (Oades, Zimmerman, & Eggers, 1996). Central to this task is having the patient learn to interpret what others say in a nondefensive and noncounteracting way. Behavioral interventions can be of use to target the suspicious/paranoid’s need to be constantly on guard, actively resisting sources of external control. Because paranoids are so fearful of being externally influenced, behavioral techniques will need to emphasize personal control. Contingency management programs that rely on others to provide reinforcement are likely to fail and should be avoided. In situations where others represent a threat to their autonomy, paranoids may lash out aggressively in an attempt to regain control and relieve anxiety. The immediate gains, however, are temporary, and ultimately serve only to perpetuate the suspicious/paranoid style. Achieving a reduction in defensiveness as well as enhancing feelings of competence and self-control can be achieved through assertiveness training. The therapist may have to educate the patient about the differences between aggression and assertiveness. Teaching paranoids that they can express thoughts in a constructive manner, without the intensity of the negative affect, will take the edge off their explosive nature. Relaxation training can help them feel more at ease and may also lessen the need for alternative modes of relaxation such as substance abuse. A functional analysis often will reveal particular environments or people that promote paranoid reactions. Impulse control can be strengthened by assisting the patient to recognize these contextual determinants and subsequently avoid them if the situation cannot be handled. If possible, environmental irritants should be removed. To gain the patient’s cooperation, the therapist can use verbal reinforcers, emphasizing that the skills to be acquired enhance self-control. Some behaviorists focus on diminishing the patient’s anxiety about criticism. Components of the anxiety reduction approach include constructing a fear hierarchy, teaching progressive muscle relaxation, and developing a repertoire of adaptive cognitions in response to fear-eliciting stimuli. Criticism and negative feedback may be the result of deficits in interpersonal skills; therefore, anxiety management training procedures should be followed by social skills training. Suspicious/paranoids are often extremely self-absorbed, unable to tune in to other’s thoughts and feelings. Assisting them in overcoming this inattentiveness can be accomplished by communication skills training. The therapist can engage the client in role-playing, providing immediate feedback. In summary, treatment with these patients is aimed at diminishing hypersensitivity to social evaluation and eliminating those behaviors that invited criticism.

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Interpersonal Techniques Interpersonal approaches may be well-suited to establishing a collaborative relationship between the suspicious/paranoid and the therapist. An important goal of interpersonal therapy with this disorder is to facilitate what Benjamin (1993) calls pattern recognition. She notes, however, that paranoids often are hesitant to discuss family history. This reluctance is thought to stem from fear that talking about family issues will elicit punishment (Kantor, 2004). Nevertheless, paranoid patients needs to learn that, although the expectations of attack are understandable considering their early learning experiences, such expectations are no longer appropriate or adaptive in their current environment, especially in the therapeutic relationship. When a genuine collaboration takes place, much of paranoid thinking begins to wane; that is, the patient no longer perceives the therapist as being judgmental and critical. The task of all therapists is to convey kindness and patience that do not suggest either criticism or appeasement. With a solid basis of trust in hand, the patient may begin to recognize that the expectation of hostility from others is no longer appropriate and that his or her own feelings of anger and hostility only provoke counterhostility from others. The abuse and harassment the suspicious/paranoid suffered at the hands of his or her parents can have a profound impact on child-rearing practices; if intervention does not target this area, future generations may repeat the pattern of abuse. Benjamin suggests helping paranoids recall how it felt to be abused; this can foster a more empathic attitude toward their own children. Substituting maladaptive patterns will require paranoids to exchange their identification with their former aggressors for differentiation from them, while rechanneling their anger, which often has been misdirected. Paranoids’ behavior signifies the internalization of childhood figures who were excessively controlling and abusing; reducing their fearfulness and hostility is a central goal of therapy. One tactic suggested by Benjamin is showing these patients that they are now acting like their despised parent; this observation may prompt some paranoids to try to be quite different. The therapist may at times have to draw back to allow for interpersonal breathing space. Intensive therapy, as Stone (1993) notes, encourages self-revelation and transference reactions that are extremely anxiety-provoking. Allowing more space between appointments may prevent premature dropout. Once the patient feels safe, however, there are opportunities to help him or her learn attitudes about trust and to think more benignly about life matters in the present. Assisting the patient in reviewing past experiences to establish that the world is not unrelievedly dangerous will additionally facilitate the development of a more flexible interpersonal style. Reluctance to engage in close relationships can be addressed by encouraging the patient to explore the benefits of being alone versus having intimate relationships. When suspicious/paranoids can accept that interactions with others may actually have something positive to offer, an important step in reducing isolation has been achieved.

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With most personality disorders, group therapy can provide an ideal forum for reality testing. Yet, because of the paranoid’s obstinate and accusatory attitudes, as well as his or her intrinsic mistrust, rigidity, and refusal to examine interpersonal distortions, group methods are generally contraindicated (Yalom, 1985). The tendency to misinterpret feedback or contributions from other group members may provoke hostility, putting a strain on the group’s cohesion and placing the paranoid at risk for premature dropout. Paranoids may, however, benefit from examining group processes while maintaining a secure distance. Possibly allowing the paranoid to be a passive observer can encourage the patient to examine different hypotheses for people’s behavior without actually having to defend his or her own actions (Karterud et al., 2003). Similarly, marital and family techniques risk running aground if careful attention is not paid to paranoid processes. Suspicious/paranoids may question the fidelity and trustworthiness of their partner and may see the therapist as combining forces with the other family members; therefore, it would be wise to use cotherapists. The predominance of negative affect in family dynamics, as well as in interactions with others, must be counterbalanced by encouraging the patient to express more positive statements and emotions. On the other hand, once the patient has achieved a reasonable level of impulse control, it is often wise to support the nonparanoid spouse to stand up for his or her beliefs, if not to directly challenge the pervasive mistrust of the paranoid. Cognitive Techniques Cognitive techniques can additionally help suspicious/paranoids gain insight into their dysfunctional beliefs that others cannot be trusted and will intentionally try to hurt them. These beliefs are the root cause of this disorder. However, schema-driven cognitive distortion must not be directly challenged because confrontation will be seen as a personal attack. Beck and Freeman (1990a, 1990b) note that modifications of the patient’s basic assumptions require the patient to relax enough to reduce his or her hypervigilance and defensiveness. Increasing the paranoid’s sense of self-efficacy must precede attempts to modify other aspects of his or her automatic thoughts, interpersonal behavior, and basic assumptions. These authors propose two ways of accomplishing this goal. First, if the suspicious/paranoid overestimates the threat posed by the situation, or underestimates his or her capacity to solve the problem, interventions that promote a more realistic appraisal of coping ability will increase his or her sense of self-efficacy. Second, if it is determined that the appropriate skills to contend with the situation are lacking, interventions that cultivate coping skills will serve to increase self-efficacy. The paranoid’s suspicious cognitive style manifests itself in cognitive errors frequently characterized by dichotomous thinking and overgeneralizations. For example, others are likely to be viewed as trustworthy or totally untrustworthy, as fully competent or entirely incompetent. Such beliefs are reinforced because paranoids tend to

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reason backward from preconceived ideas to the evidence. Several techniques can be employed to help establish a new perspective on people. Initially, the patient can be instructed to monitor interpersonal experiences along with the cognitions and emotions that accompany these interactions. Gathering more information can help fill in the inevitable gaps that exist in the paranoid’s fund of knowledge about others’ motives. Alternative explanations can then be explored. The therapist must take care not to interpret the assumptions as being faulty, but must seek instead to shift the weight of probability the paranoid attributes to the alternative hypothesis. The therapist should strive to introduce an element of doubt in the paranoid’s mind regarding the validity of his or her beliefs (Stone, 1993). Self-Image Techniques Beneath the flimsy exterior that conveys a sense of grandiosity and self-importance, paranoids carefully shelter a fragile self-image (Dimaggio, Catania, Salvatore, Carcione, & Nicolo, 2006). Unable to admit to personal faults, they project them onto others. Cognitive interventions can address the patient’s need to blame others and utilize projection as a defense. Some theorists suggest that toward the end of therapy, the therapist can help the patient refine his or her interpersonal skills by improving the ability to empathize with others and see things from their perspective. This can be done by asking the patient to anticipate the impact of his or her actions on others and to imagine what it would feel like to be in their shoes. The validity of the patient’s belief about the feelings and thoughts of others can be examined by investigating how closely that belief matches the available evidence. Especially valuable in this regard may be the introduction of an existentially based perspective, one that helps patients recognize that some of their suspicions and their fearful outlook may have a measure of merit in them. The therapist can then use the patient’s growing sense of affirmation as a vehicle to explore distinctions between the past and contemporary realities. Regarding specific modes of therapy, it is simplest to say that technique is secondary to building trust. There are, however, a variety of procedures that can be employed along the way. Regardless of the particular approach used at any given time, the therapist can avoid arousing further suspicion by carefully explaining each move to the patient. The treatment rationale should be straightforward and clear, and treatment planning must acknowledge the paranoid’s need for control. At no time should the patient be directly confronted with his or her delusions. Intrapsychic Techniques Gabbard (1994) highlights the goals of psychodynamic interventions with this disorder as helping patients shift their beliefs about the origin of their problems from an external cause to an internal one. This will be no mean feat, however; the therapist’s willingness to tolerate the paranoid’s distortions and hostile feelings, as well as his or her empathic

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sensitivity, must provide a basis for developing genuine rapport. As the therapist asks for the patient’s life details, he or she must avoid challenging the patient’s perception of events. Most important, the therapist must restrain tendencies to react in a problematic countertransferential way. Salzman (1980) states that the patient should come to see the therapist as a benign and friendly helper. Letting go of their rigid defensive structure can free up energy to help paranoids acquire more satisfying interpersonal relationships. They also spend a great deal of energy on ruminating about the past and feeling that they should receive retribution for past wrongs. Goals in this area center on having the patient accept reality (Millon, Simonsen, Birket-Smith, & Davis, 1998). Frustrations are an inevitable part of everyone’s life, and suspicious/paranoids must relinquish these claims at compensation. As the paranoid’s defenses gradually ease up, the innermost feelings of vulnerability, inferiority, and worthlessness come to the foreground. Depression may result, calling for a shift in the focus of therapy to resolve these depressive components. At times, the therapeutic balance may be challenged by the patient’s attempts to elicit a counterreaction from the therapist. Gabbard (1994) emphasizes that the therapist must contain feelings instead of acting on them, thereby providing the patient with a new object relationship unlike those previously encountered. Gradually, these new experiences may be internalized. Pharmacologic Techniques Despite the relative paucity of research reporting therapeutic benefit from pharmacological intervention, trials with medication may be indicated when the suspicious/paranoid’s characterologic defenses fail and specific symptoms such as anxiety or depression occur. Often useful in this regard are SSRI antidepressants (e.g., fluoxetine, sertraline) and low-dose regimens of one or another benzodiazepine (e.g., alprazolam, diazepam). Only when contact with reality worsens and a psychotic breakdown is imminent are low dosages of antipsychotics called for (risperidone, olanzapine). Medication may represent a threat to the paranoid’s need for internal control, and as a result resistance can be expected. With medications, as with other therapeutic efforts, the therapist must involve the patient in treatment planning, outlining in detail the potential benefits as well as the possible side effects. To gain collaboration, the therapist must emphasize how the medication can help increase self-control and moderate tension.

Making Synergistic Arrangements Early on in therapy, focus should be placed on developing the therapeutic relationship. Other techniques can have the desired effect only when the patient has developed enough trust in the therapist and when the alliance has stabilized. Nondirective

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cognitive approaches that focus on increasing self-efficacy may be indicated as a first course of action, to be followed, where appropriate, by other measures. The choice of second-stage therapeutic methods depends on both practical and ultimate goals. At best, therapy is likely to control or moderate rather then reverse the basic personality pattern. Developing a trusting relationship and increasing the patient’s feelings of self-esteem will lay the groundwork for other therapeutic modalities and have profound effects across clinical domains. Feeling more secure with their own strengths, for example, will lessen the need for patients to engage in projective defense. Other cognitive techniques can subsequently be employed to target the suspicious/paranoid’s unrealistic perception of his or her environment. Creating an element of doubt in the patient’s mind about the accuracy of his or her beliefs will encourage him or her to explore potentially positive characteristics of others in interpersonal relationships. At the same time, behavioral methods can teach the patient to be less defensive and to inhibit expressions of hostility. Equipped with a better outlook on life and the potential for obtaining reinforcement from others, these patients may then be able to handle the more searching psychodynamic procedures. Rebuilding the paranoid’s basic personality structure necessitates the careful utilization and sequencing of these techniques and must proceed slowly and carefully to uncover unconscious elements. If it is determined that the family contributes to the suspicious/paranoid pattern or that the marital partner bears the brunt of the malicious accusations, marital or family therapy should be pursued concurrently. In the course of therapy, medication should be considered when anxiety crops up or when the paranoid becomes extremely hostile or starts acting out. Institutionalization may be required if reality controls break down. At this point, the carefully orchestrated therapeutic efforts that may have led to some progress will have to be put on hold. If the patient decides to continue therapy, the therapist will likely have to start form scratch with rebuilding the fragile trusting bond that may have been severed by the decision to institutionalize the patient.

Illustrative Cases Several attributes may be loosely considered the core features of the suspicious/paranoid personality. The great majority of these patients evidence the constellation of anxieties, cognitions, and behaviors described in prior sections, but we must be careful not to let our focus on these common symptoms obscure the variety of forms into which this disorder unfolds. In what follows we describe some of the features that differentiate four of the adult subtypes of the paranoid personality. Despite the distinctions we draw, we must be mindful that distinctions are not well-defined in reality; there are overlappings, with traces of the more distinctive features of each subvariety often found in the others. Few pure textbook cases ever are met (see Table 8.4).

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Table 8.4

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Suspicious/Paranoid Personality Disorder Subtypes

Insular: Reclusive, self-sequestered, hermitical; self-protectively secluded from omnipresent threats and destructive forces; hypervigilant and defensive against imagined dangers. (Mixed Paranoid/Avoidant Subtypes) Malignant: Belligerent, cantankerous, intimidating, revengeful, callous, and tyrannical; hostility vented primarily in fantasy; projects own venomous outlook onto others; persecutory delusions. (Mixed Paranoid/Sadistic Subtypes) Obdurate: Self-assertive, unyielding, stubborn, steely, implacable, unrelenting, dyspeptic, peevish, and cranky stance; legalistic and self-righteous; discharges previously restrained hostility; renounces self–other conflict. (Mixed Paranoid/Compulsive Subtypes) Querulous: Contentious, caviling, fractious, argumentative; fault-finding, unaccommodating, resentful, choleric, jealous, peevish, sullen, whiny, waspish, snappish; endlessly wrangles. (Mixed Paranoid/Negativistic Subtypes) Fanatic: Grandiose delusions are irrational and flimsy; pretentious, expansive; supercilious contempt and arrogance toward others; lost pride reestablished with extravagant claims and fantasies. (Mixed Paranoid/Narcissistic Subtypes)

Case 8.1, Jacqueline M., 51 A Suspicious/Paranoid Personality: Fanatic Type (Paranoid with Narcissistic Traits) Presenting Picture Jacqueline felt persecuted by all of her colleagues and agents and could not understand why “everybody just loathes me so!” With her flamboyant style and flair for the dramatic, she felt from an early age that she had a “special destiny.” Considering herself a visionary, she painted works “from her soul,” where she harbored special insights into people. She knew she could paint people’s faces with a deep understanding of who they were, even if she had never spoken with them. For this reason, she was dumbfounded that she couldn’t figure out their hostilities, because, as she put it, “I can draw their very essences and I don’t see the source of it.” She also had a special sensitivity to light that she discovered while studying art in Italy. There she became aware of this “natural ability” that set her apart from the teeming masses of artists she studied with. While reluctantly admitting that her commissions for paintings were drying up and that she had few prospects on the horizon, she was quick to add that others still showed resentment toward her extraordinary talents and seemed to be undermining her efforts at every turn. The

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298 PERSONALIZED THERAPY FOR THE SUSPICIOUS/PARANOID PERSONALITY PATTERNS only problem she could identify was that she was just too brilliant and forwardthinking for others to understand her. After all, “a great artist must suffer,” and this was her time for suffering. This did not dissuade her from continuing to pursue her mission and fulfill her calling to be a great artist. Clinical Assessment The fanatic paranoid is similar to the less structurally defective parallel, the narcissistic personality, with whom this personality structure is often interwoven. Both seek to retain their admirable self-image, act in a haughty and pretentious manner, are naively self-confident, ungenerous, exploitive, expansive, and presumptuous, and display an air of supercilious contempt and benign arrogance toward others. In contrast to the narcissist, who shows successes with an optimistic veneer and exploitive behaviors, Jacqueline had run hard against reality. Her illusion of omnipotence had periodically been shattered, toppling her from her vaulted image of eminence. Accustomed to being viewed as the center of things and being a valued and admired figure, at least in her own eyes, she could not tolerate the lessened significance circumstances had now assigned to her. Her narcissism had been profoundly wounded. Not only did Jacqueline need to counter the indifference, the humiliation, and the fear of insignificance generated by reality, but she was trying to reestablish her lost pride through extravagant claims and fantasies. Upset by assaults on self-esteem, she reconstructed her image of herself and attempted to ascend once more to the status from which she had fallen. To do this, she endowed herself by illusory self-reinforcement with superior powers and exalted competencies and dismissed events that conflicted with her self-designated importance. These grandiose assertions became fixed and adamant; they were too important to Jacqueline’s need to regain status and to become an identity of significance and esteem. She went to great lengths to convince herself and others of the validity of her claims, insisting against obvious contradictions and the ridicule of others that she deserved to be catered to and that she was entitled to special acknowledgment and privileges. But the evidence in support of Jacqueline’s assertions was flimsy and easily collapsed by the slightest incursion. Unable to sustain this image before others, and rebuffed and unable to gain the recognition she craved, she turned more and more toward herself for salvation. She began to assume the role and attributes of some idolized person, someone whose repute could not be questioned by others. Grandiose missions were proposed for “saving the world”; plans were made for solving insurmountable perplexities. These schemes were worked out in minute detail; they corresponded to objective needs and were formulated with sufficient logic to draw at least momentary attention and recognition from others. For these reasons, Jacqueline would be likely to show marked resistance in therapy, given that she was seeking a therapist who would validate what she already “knew” to be the correct course of action. A genuine, trusting, and honest posture

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would be required from the beginning, though a measure of steadfast nondefensive confrontiveness would accompany this stance. The primary modality with Jacqueline would be working toward identifying faulty perpetuating beliefs, including her grandiosity and withdrawal from the “common folk,” which masked a lacking sense of self while protecting her from pain. Not surprisingly, these actions provoked greater levels of rejection from others; her tendency to devalue and distrust others needed to be modified in order to engage in more parallel, give-and-take social relations. Domain Analysis Jacqueline eagerly attended to the various assessments utilized in this domain analysis, but was rather surprised to see the results during the feedback session, although this session was handled prudently, with an emphasis on strengths rather than nonstrengths. Results from the MG-PDC and MCMI-III Grossman Facet Scales revealed the following: Cognitively Expansive/Mistrustful: This domain represented a feedback loop in its own right, with Jacqueline’s narcissistic beliefs of greatness and grandiosity being fueled by her unwarranted cynicism and mistrustfulness that had run amok with conspiracy theories and accusations of duplicity. Interpersonally Provocative: Jacqueline was most surprised by this domain, which pointed out to her that she may have been testing people in her everyday interactions, thus “proving” to her that no one was to be trusted and that everyone was somehow conspiring against her. Inviolable Self-Image: Persistent ideas of self-importance pervaded Jacqueline’s self-reflections, in which she painted herself as a hapless victim of imagined plots of ruination, all focused, somehow, on her and all of her benign, worldly efforts. Therapeutic Steps Whereas short-term methods were optimally suited to Jacqueline, the techniques of environmental management, psychopharmacologic treatment, and behavior modification would not be of substantive value in effecting change. Altering her attitudes toward herself and her less than socially acceptable behavior was best attempted through procedures of cognitive reorientation. A baseline of rapport was established with supportive measures oriented toward exploration of the theme of her victimization, thereby loosening her inviolable self-image. Jacqueline was then able to withstand these more directive methods that confronted her dysfunctional beliefs and expectations. At the outset, though, care was taken not to stress her deficiencies because this may have endangered the therapeutic relationship. She maintained a

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300 PERSONALIZED THERAPY FOR THE SUSPICIOUS/PARANOID PERSONALITY PATTERNS well-measured distance from the therapist, trying to resist the searching probes of personal exploration, especially those that implied deficiencies on her part. Efforts were made, however, not to allow her to assume a dominant posture in treatment after her initial discomfort had receded. Confronted early on was her belief that she did not need to consider changing her views because she already was as perfect as any human could be (cognitive expansiveness). An effective cognitive confrontation method countered her efforts to shift responsibility for her own deficiencies to others. Unless dealt with directly, yet without disapproval on the part of the therapist, her evasiveness and unwillingness would have seriously interfered with short-term progress. With a firm but consistently honest and confrontive technique, the therapist avoided struggles in which Jacqueline sought to invoke her characteristic suspiciousness, thereby projecting her personal misgivings onto others. A strong cognitively based method to undo distorted expectations focused on extinguishing her tendency to devalue others, not to trust their judgments, and to think of them as naive and simpleminded. Rather than question the correctness of her own beliefs, she assumed that the views of others were always at fault. The therapist confronted her habit of assuming that the more disagreements she had with others, the more convincing was her own superiority and the more arrogant and presumptuous she was likely to become. The therapist maintained great patience and equanimity to establish a spirit of genuine confidence and respect. The introduction of interpersonal methods (e.g., Kiesler, Klerman) came at a later stage, following a difficult but ultimately successful stage of altering beliefs, to probe and modify her provocative attitudes and social habits. More expressive and time-extended techniques may have been useful in some ways, but they would have been difficult to justify in that the patient’s self-illusions may have been reinforced too strongly by the imaginative freedom these methods foster. Focused interpersonal methods, such as brief group and family therapy, may also have helped her view herself in a more realistic social light and assisted her in learning more cooperative social skills, but these were not available at the time of intervention. Although efforts were made to rebuild Jacqueline’s recently depleted self-esteem, the therapist took care not to appear subservient in the process. Her self-confidence was able to be restored rapidly by merely allowing her to recall past achievements and successes, and this was attained in a few sessions. A goal more likely to prevent recurrences, however, was guiding Jacqueline into becoming more sensitive to the needs of others and accepting the constraints and responsibilities of shared social living. This required strengthening her capacity to face her shortcomings frankly. Care was taken in this regard not to be deceived by mere superficial compliance with these efforts. Unusual for a problem of this nature, Jacqueline’s treatment was self-motivated, though it followed a period of unaccustomed achievement failures. More typically, brief confrontive therapy would be called for to counter the belief that, if left alone, a fanatic paranoid such as Jacqueline would be able to solve her own problems.

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Whatever the promptings, her pride appeared to be in jeopardy in submitting to the role of patient. Though she accepted therapy in its early stages, this attitude was rather fragile and tenuous until she came to respect the therapist as forthright and not easily intimidated.

Case 8.2, George S., 49 A Suspicious/Paranoid Personality: Malignant Type (Paranoid with Sadistic Traits) Presenting Picture George was arrested after a violent altercation at a bar. In lieu of a prison sentence or fine, as this was a first offense, he was offered the option of treatment, which he grudgingly accepted. Initially unwilling to self-disclose, George eventually acceded when he realized that his commuted sentence was contingent on his compliance, but he muttered, “I ain’t gonna tell you about Mommy or any of that crap.” He explained that he was settling into a new lifestyle, prompted by an employment change. Until recently, he had worked for a moving company, but decided that he wanted to freelance, using his own truck both for moving jobs and for repossession contracts. His new business arrangements required that his customers were people he knew, “or at most, people that know someone I know well and they vouch for them,” and that they pay cash up front. George continued to explain that he had no reason to trust outsiders, and that even so-called trusted friends were usually unscrupulous. As he continued to explain his motivation for these protective measures, it became clear that George, having a childhood marked by oppressive parents, was suspicious of everyone and believed that there was an ulterior motive to every action. Above and beyond self-driven motives, according to him, people had a desire to persecute him. These delusions carried a strong desire for retribution, and George envisioned that there would come a day when all these people would “get theirs,” and that he would see to this personally. Initial Impressions Malignant paranoids such as George tend to be structurally defective variants of the sadistic personality, whose features frequently commingle and blend with those of the paranoid. He would be best characterized by his power orientation, his mistrust, resentment, and envy of others, and by his autocratic, belligerent, and intimidating manner. Underlying these features was a ruthless desire to triumph over others, to vindicate himself for past wrongs by cunning revenge or callous force, if necessary. In contrast to his less structurally defective counterpart, George had experienced that, in his efforts to abuse and tyrannize others, he had only prompted further hostility

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302 PERSONALIZED THERAPY FOR THE SUSPICIOUS/PARANOID PERSONALITY PATTERNS and harsh punishment of the sort to which he was subjected in childhood. His strategy of arrogance and brutalization had backfired too often, and he sought retribution, not as much through action as through fantasy. Repeated setbacks confirmed his expectancy of aggression from others; by his own hand, he evoked further hostility and disfavor. Isolated and resentful, he increasingly turned to himself, to cogitate and mull over his fate. Left to his own ruminations, he began to imagine a plot in which every facet of his environment played a threatening and treacherous role. Moreover, through the intrapsychic mechanism of projection, he attributed his own venom to others, ascribing to them the malice and ill will he felt within himself. As the line drew thin between objective antagonism and imagined hostility, the belief took hold that others intentionally persecuted him; alone, threatened, and with decreasing self-esteem, George had transformed his suspicions into delusions. George desperately needed to retain his independence; despite all adversity, he clung tenaciously to the belief in his self-worth. This need to protect his autonomy and strength was seen in the content of his persecution delusions. Malevolence on the part of others was viewed neither as casual nor random; rather, it was designed to intimidate, offend, and undermine his self-esteem. Others were seeking to weaken his will, destroy his power, spread lies, thwart his talents, conspire to control his thoughts, and to immobilize and subjugate him. His persecutory themes were filled with fears of being forced to submit to authority, of being made soft and pliant, and of being tricked to surrender his self-determination. Averse to self-exploration, George would need to begin with very concrete and tangible social goals accomplished through modifying his actions. As these methods provided for less troublesome social interactions, the therapist would be able to begin engaging him in deeper exploration through challenges aimed at his tendency to project and disown his own malice and follow this with retribution-oriented fantasies. Such perpetuations as George’s perceived satisfaction from exerting power over others and causing them duress (active-pain orientation, devaluation of other) would also be addressed in this manner. It would follow that the diminishing of his chip-on-the-shoulder attitude would create a more affable persona and decrease the likelihood of being confronted by a troublesome attitude from others. Further social change would serve to alleviate George’s constant perception of danger from others and help bolster healthier, positive social interactions.

Domain Analysis George incessantly questioned the motivation for “putting my life on record with all these questions, and these better not make it back to the judge like you promise.” After assurances that the only records released would be a summary of assessment and treatment that he would review, along with a further reassurance by the therapist that “you can sue me and I’ll lose my license if I disclose anything I don’t

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review with you first,” he acceded to testing. MCMI-III scores were invalid, unfortunately, owing to an extremely high desirability rate, but the MG-PDC identified several target domains for intervention: Expressively Precipitate: George’s quiet grumblings would sporadically and unexpectedly give way to explosions of hostility and malice, even when he clearly sensed that he was subject to extreme retaliation; these, in turn, would provoke further hostilities from others and perpetuating scenarios of anger, mistrust, cynicism, and provocations. Projection Mechanism: In George’s eyes, he had done no wrong, but he was fully assured that everyone else in his interactions and, for that matter, anyone who was a stranger was filled with the malicious feelings and vitriolic potential that he himself kept hidden away from his own consciousness. Interpersonally Abrasive/Provocative: Combining elements of the satisfaction experienced by the sadist in humiliating and damaging others, with the testing behaviors of the paranoid designed to provoke the very hostilities he wished to unfurl, George found many opportunities to make social exchanges as contentious and uncomfortable as possible, seeming to wish others into outbursts. Therapeutic Course A short-term and circumscribed focus optimally suited George. He was not a willing participant in therapy and agreed to treatment only under the pressure of external difficulties. A strong and determined attitude was able to overcome George’s desire to outwit the therapist by setting up situations to test the therapist’s skills, to catch inconsistencies, to arouse ire, and, if possible, to belittle and humiliate the therapist. For the therapist, a most important task was to restrain the impulse to express a condemning attitude. An important step in building rapport with George was to see things from his viewpoint. If success was to be achieved in a short-term intervention, the therapist needed to convey a sense of trust and a willingness to develop a constructive alliance. A balance of professional authority and tolerance was useful in diminishing the probability that he would relapse or impulsively withdraw from treatment. Goal-directed in this intervention, the therapist was able to check any hostile feelings, keeping in mind that George’s difficulties were not fully under his control. Formal behavior modification methods were fruitfully explored at the outset to achieve greater consistency and interpersonal harmony in his social behavior. As he requested, deeper probing was restrained in favor of specific goal-directed interventions aimed at learning alternatives to his more hostile, precipitate behaviors. George expressed his feelings about these methods, calling them “nonsense,” until one day, when he noted, “I gotta hand it to you. Just on a whim I tried one of these suggestions and I’m surprised where it got me.” Apparently, the other person seemed disarmed by his action.

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304 PERSONALIZED THERAPY FOR THE SUSPICIOUS/PARANOID PERSONALITY PATTERNS Although this was a hopeful start, it did not ensure that everything would then go smoothly only with this modality; therefore, brief directive cognitive-dynamic techniques were added to challenge the obstructive and self-defeating character of his expectations and his personal relations, and to provide further new experiences aimed at unearthing his characteristic projective defenses. Although the deeply rooted character of these problems impeded the effectiveness of most therapeutic procedures, it was fruitful to explore the more incisive techniques of both this brief dynamic modality and interpersonal therapies (e.g., Benjamin, Kiesler), which worked well in teaching social skills that were less abrasive and therefore less provocative. A thorough reconstruction of personality was not the only means of altering George’s deeper pathologies. Together with cognitive reframing procedures, they proved to be among the most useful techniques to help him recognize the source of his own hurt and angry feelings and to appreciate how he provoked hurt and anger in others. George learned to see the benefits of reframing his attitudes and the consequences of doing so. For example, he experienced interpersonal difficulty as a consequence of his aggressive behavior and incessant quarreling, but these tendencies were diminished by viewing his behavior differently and by acquiring other means of fulfilling the needs that drove him. With brief dynamic methods, George learned not to assume that a problem could always be traced to another person’s hostility. As he found it possible to accept a measure of responsibility for his difficulties, he didn’t need to conclude that the therapist tricked him into admitting it. In this situation, the therapist restrained any impulse to react to him with general disapproval or criticism.

Case 8.3, Carlos R., 32 A Suspicious/Paranoid Personality: Obdurate Type (Paranoid with Compulsive Traits) Presenting Picture Carlos, a high school physical education teacher, was zestfully self-assertive and assiduous in his manner, yet he had nearly flat affect. His school administrators requested an evaluation because, as Carlos perceived it, they wanted an excuse to find him incompetent and “they just can’t find any other way to do it.” He had his own set of rules and policies that he expected his students to follow. Unfortunately, these often collided head-on with school board policies. Carlos believed that the school’s standards were far too lax and that he was entitled to enforce his own, more stringent rules for the good of his students. “They’ll never learn to be adults without me; they’ll never learn self-care without me; they’ll never learn discipline and responsibility without me. I’m all they’ve got.” He went on to criticize the

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administration, parents, and other teachers of raising “a gaggle of spoiled, pampered, enabled youth.” Notably, Carlos was also convinced that through practice, he had sharpened his senses to the point where he had developed extrasensory perception. He could “sense” others’ motives and feelings and felt justified in grading his students based on the feelings he got from them. He used his ESP to discover that other teachers and administrators were jealous of him and were motivated to “break him down” and get him fired. Initial Impressions Obdurate paranoids, like Carlos, are more pathological variants of the less structurally defective compulsive personality disorder, whose rule-bound and rigid characteristics typically mesh and unite with those of the paranoid (L. M. Horowitz, 2004). However, in contrast to his compulsive counterparts, who retain the hope of achieving gratification and protection through the good offices of others, Carlos had fully broken through his self–other conflict, renounced his dependency submission, and took on a stance of indignant self-assertion, all within the auspices of “the way things should be.” Despite his growing hostility and his repudiation of conformity (specifically, his conformity to the wishes of the administration, not others’ conformity to his viewpoint), he retained his basic rigidity and perfectionism; he remained humorless, tense, inflexible, and self-righteous. Though he found it necessary to discard others as his primary source of security, the remnants of his lifelong habits of overcontrol and faultlessness were not so readily abandoned; the basic personality style remained immutable. Carlos continued to seek the clarity of rules and regulations, but rather than adhering to the rules of society, as he may have done in the past, he imposed his clear view that it was his reading of societal rules that was important. Deprived of the customary guidelines he now spurned, he learned to rely increasingly on himself in search of order, power, and independence. With this perceived independence, he freed himself from the constraints of submission and propriety. He began to discharge the reservoir of hostility he previously had repressed and imposed his self-created standards on others, attacking them with the same demands and punitive attitudes to which he himself was earlier subjected. But Carlos could not free himself entirely of conflict and guilt: Despite efforts to justify his newly found hostility, he was unable to square these actions with his past beliefs. Furthermore, his arrogance reactivated past anxieties; he could not escape the memories of retaliation that his own hostile actions had provoked in the past. Deep within him, then, were the remnants of guilt and the fear of retribution; these two elements gave rise to persecutory delusions. As a result of anticipation, projection, and guilt, he began to believe that others were “after him,” seeking to condemn, punish, belittle, and undo him. These encapsulated and well-defined delusions, referred to in the past as cases of classic paranoia, often exist apart from the main body of a patient’s “normal” beliefs and tend to be found among these obdurate paranoid types. Carlos’s overly rigid and tightly controlled

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306 PERSONALIZED THERAPY FOR THE SUSPICIOUS/PARANOID PERSONALITY PATTERNS thought processes enabled him to segment his beliefs and to keep them as separate and compartmentalized units. Thus, he appeared to function much of the time in a normal manner; however, once a topic associated with the delusion was broached, his irrational but normally hidden and encapsulated belief became manifest. Owing to Carlos’s excessive pain orientation, early efforts in treatment would be limited to supportive strategies and efforts aimed at altering his irascible mood. Gradually, goal-oriented techniques would be introduced, in step with his ability to loosen his well-constructed defenses, which would concentrate on desensitization from fantasized hostilities in his environment. This would be followed by techniques to address self-perpetuations such as his beliefs that he could “keep the wolves at bay” by projecting anger, exhibiting extreme self-assertion, and positioning himself in a power role to maintain control (break from self–other conflict, as he had forsaken other and overemphasized self). As his defenses relaxed, other methods would serve to alleviate his feeling worthy of punishment and would explore less defensive social interactions. Domain Analysis Carlos refused to complete self-report measures, stating, “If therapy gets me in trouble, I can always argue that you’re a quack. I’m not going to have stuff down on paper that anyone can twist around and make it mean anything they want.” The only measure used, then, was the MG-PDC, which yielded the following: Temperamentally Irascible: Cold, callous, and nearly flat in affect, Carlos was humorless about everything. He maintained an air of unemotionality at every juncture; however, it seemed obvious that this masked a level of edginess and defensiveness. Cognitively Constricted/Suspicious: Rigid and immutable in his views, Carlos could not be swayed from the concrete, dichotomous structure of his views, which featured a series of beliefs framing the world around him as vile, overly permissive, and doomed to a great reckoning for refusing to live up to his standard. He further believed this world to be conspiring against him and the few like him. Interpersonally Provocative: Carlos was quarrelsome by nature and prone to throwing out inciting barbs that would highlight conflict; he appeared to have a mission to expose the decrepit world around him in order to retain his high and mighty stance and to ensure his own safety and security by insisting on others’ acquiescence and adherence to his worldview. Therapeutic Steps The initial major vehicle used with Carlos was short-term supportive therapy. Psychopharmacologic agents were also beneficial in the early periods of his difficulties

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to moderate anxieties giving rise to his edginess and sullen flatness (temperamental irascibility), but the level of dosage employed was not such as to cause significant decrements in his efficiency and alertness. Carlos’s notable symptoms included unanticipated attacks of anxiety, spells of immobilization, and excessive fatigue. Because symptoms such as these threatened his public style of efficiency and responsibility, it was especially useful to employ more focused humanistic treatment, such as the more directive motivational interviewing techniques. Also useful as part of a focused treatment approach were behavior modification techniques designed to desensitize him to currently discomforting or anxiety-provoking situations. Because he probably failed to recognize that his symptoms represented the outcropping of his inner psychological dynamics (e.g., ambivalence and repressed resentments), a less expressive and more concise approach was best. Certainly, for every piece of defensive armor removed, the therapist bolstered Carlos’s confidence twofold. Removing more defenses than he could tolerate may have prolonged the treatment plan extensively. Fortunately, he was so well guarded that careful inquiries by the therapist fostered growth without a problematic relapse. Caution was the byword with Carlos. Owing to his underlying fear of ridicule stemming from his cognitive suspiciousness, Carlos viewed therapy as a procedure that would expose his worst fears, represented by his feelings of inadequacy. Additionally, his constricted style led to the belief that “anyone who actually needs therapy must be weak,” a self-belief that would simply be intolerable. Tense, grim, and cheerless, he greatly preferred to maintain the status quo, regardless of what painful delusions that may give rise to, rather than confront any need to change. As noted earlier, his defensiveness had to be honored, and probing and insight proceeded at a careful pace. Once a measure of trust and confidence had developed in the therapeutic relationship, the therapist used cognitive methods to stabilize anxieties and foster change. Because Carlos preferred to restrict his actions and thoughts to those to which he was accustomed, therapeutic procedures could not confront more than he could tolerate. Goals of this nature focused on changing assumptions, noted by Beck and others, such as the fear that any shortcoming would result in a catastrophe or that not performing at the highest level would result in a humiliating failure. Furthermore, interpersonal skill building needed to accompany these methods, first, because Carlos needed to immediately have replacement strategies for his generally provocative interactions, and second, so that he could feel the benefit of his progressively changing strategies. Before his problematic beliefs were explicitly addressed, he voiced pseudo-insights, especially because he was well educated, but this was most frequently a fac¸ade to placate the therapist. His habitual defenses were so well constructed that general insight-based interpretations were temporary at best. Genuine progress necessitated brief, focused techniques to modify problematic self-statements and assumptions. Without these concrete techniques, he would tend to pay lip service to treatment goals, expressing guilt and self-condemnation for his past shortcomings but not readily relinquishing

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308 PERSONALIZED THERAPY FOR THE SUSPICIOUS/PARANOID PERSONALITY PATTERNS his defensive controls. Likewise, empathy alone was only modestly useful because of his evasiveness and his discomfort with emotion-laden materials. Owing to his need to follow a rigid and formalized lifestyle, he responded better to short-term cognitive and interpersonal methods that were specific in their procedures rather than to more expressive or nondirective techniques. To diminish the occurrence of setbacks, efforts were made to strengthen his will to give up maladaptive beliefs such as unrelenting self-criticism and the unyielding correctness of authority-based rules and regulations.

Case 8.4, Juliana M., 36 A Suspicious/Paranoid Personality: Insular Type (Paranoid with Avoidant Traits) Presenting Picture Juliana was an intense and uptight bookkeeper who was convinced her coworkers were trying to get her fired. Originally referred by her medical doctor after she sought antianxiety medication from her, Juliana was slightly bewildered by the therapeutic process. “I thought you wanted to know more specifically just about my symptoms. I didn’t know you were going to ask so many questions about me,” she remarked after a few questions in the initial interview. Juliana claimed to have great abilities to understand numbers and had the ability to see patterns in numbers that others did not understand; in this way, she said, she would be able to see trouble coming well before it happened, which usually worked. For her, numbers took on significance beyond the ordinary. Odd numbers were good, even numbers bad. For example, if her evening out started at 7:22, it was doomed from the start and could not be salvaged; contrarily, 7:21 was fine. If a word had six letters, it was divisible by three, which was good, but only twice (an even number), so ultimately, it was bad. Her superstitions about numbers interfered with every aspect of her life, including dictating the number of locks on her front door and how many hours a week she could work. She was convinced that her coworkers were slipping wrong numbers into her piles to throw off her patterns because they didn’t like her. From an early age, her mother had ingrained in her the idea that Juliana had to protect herself because others were out to take advantage and humiliate her. Her mother, whom Juliana described now as “a widow, ripe for picking,” was very concerned that others were out to get her money. Juliana had extremely limited contact with other people, never allowing others to visit or call because she did not like others entering her apartment and she was worried about her phone being bugged.

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Initial Impressions Juliana was notably hypervigilant. As an insular paranoid, she was extremely moody and apprehensive, overly reactive to criticism, particularly in response to judgments made of her status, beliefs, and achievements. In early stages of her pathology, she resembled an avoidant personality, frequently withdrawn from the world, increasingly reclusive and isolated. Extremely vulnerable, she sought solace in a variety of selffocused ways; for example, she engaged in abstruse intellectual activities to enhance her fantasized self-esteem. Many insular paranoids self-medicate with alcohol or drugs as a way of calming the frightening nature of troublesome fantasies; still others pursue promiscuous sexual escapades (generally with prostitutes), not only to provide a measure of physical relief from their insular state, but also to purchase a willing ear to listen to their fears and grandiosities. Juliana hid behind her “special skills” to protect herself from her surroundings, which she judged to be both threatening and destructive. In this way, she apparently spotted problems in their earliest stages, quickly anticipated what could be troubling, and defended herself against both real and imagined dangers. As evident in the preceding, self-protective insular types like Juliana share certain core features with the avoidant personality. Juliana was prone to coming to premature conclusions about rather incidental and trivial events, events that were given meaning largely by projecting her own anxieties and hostility. The natural complexities of her social world were narrowed to signify one or two persistent and all-embracing ideas; in this way, she could effectively deal with the problems she faced by “knowing” that everything represented basically one or two variants on the same theme. Part of the reason for insulating herself stemmed from her need to prevent anything or anyone from influencing her. Not only did she seek to divert or preclude external sources of influence, but there was a strong desire to remain autonomous, to keep to herself, and to rely solely on her own ideas and beliefs. Ultimately, this unwillingness to check her thoughts against reality resulted in her becoming removed from reality. With the only reality being her creation, she had no defense against the outside world. Hence, she not only had difficulty in accurately observing external reality, but there was no escape from the false reality that inhered within herself. Her intense feelings of insecurity and threat escalated as a consequence of her own defensive actions; the conspiracies and the persecution she perceived were self-created. To defend against these frightening feelings, she intentionally disrupted her own thoughts, seeking to distance herself from her own mind. Her inner world became a chaotic m´elange of incidental thoughts. Primary efforts with Juliana involved reducing her active-pain orientation toward avoiding a perceived harsh and cruel external world, and bolstering self and other to attain greater social abilities, thus also enhancing pleasure. It would be beneficial to address her mood and demeanor. Other explorations would include reorganization of thought patterns that led her to impulsively overemphasize trivial environmental concerns, as well as examine her fear of being controlled. To break perpetuating

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310 PERSONALIZED THERAPY FOR THE SUSPICIOUS/PARANOID PERSONALITY PATTERNS cycles, social realms would be explored to begin putting into motion those skills and actions consonant with her emotional spheres to achieve healthy interaction. Domain Analysis Juliana was intrigued by the domain analysis. Results of the Grossman Facet Scales of the MCMI-III and the MG-PDC were as follows: Temperamentally Anguished: Although she tried very hard to hide this, Juliana suffered from terribly confusing and vacillating tensions that would occasionally leak through to the surface, finding expression in her agonized face and bodily tightness, and acting out in her tenuous manner. Cognitively Distracted/Suspicious: Constantly alert to possible slights or other threats, Juliana was preoccupied with finding any sign that something might invade her otherwise manageable but worried existence; she retreated further and further into her own mind in an ill-fated attempt to manage her ever-increasing skepticism that kept her from enjoying any thought continuity (see “Fantasy Mechanism” of the avoidant personality, Chapter 3). Interpersonally Aversive: Retreating into her fantasy existence and blending the lines of reality and self-creation left Juliana ill equipped to effectively navigate what she saw as a threatening and malevolent world of others who could undermine her at any given moment, for no apparent reason. Her social skills reflected these beliefs in a tenuous interpersonal manner. Therapeutic Steps A major thrust of brief therapy for Juliana was to enhance her social interest and competence. With consultation from her medical doctor, her psychopharmacologic treatment was monitored and evaluated for effectiveness in helping resolve her anguished mood. Trial periods with several agents were explored to determine whether these effectively increased her energy and showed beneficial affective consequence. Such agents had to be used with caution, however, because they could activate feelings that Juliana was ill equipped to handle. Therapeutic inroads in the very first sessions took on more nondirective, supportive qualities, wherein she could explore some of her customary methods for dealing with stress and anxiety, bringing awareness to those coping mechanisms that were or were not effective. Early treatment efforts for this introversive and passive woman were best directed toward countering her withdrawal tendencies, thereby supporting those desires to be a more social person. Minimally introspective and evincing diminished affect and energy, she was prevented from becoming increasingly isolated from others, be they discomforting or benign. Energy was invested to enlarge her social world owing to her tendencies to pursue with diligence only those activities required by her job or by her family obligations.

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311

Although she could not be pushed beyond tolerable limits, careful and well-reasoned cognitive methods (e.g., Beck, Meichenbaum), employed as Juliana could begin tolerating more directive challenges to her status quo, fostered the development of less suspicious and distractible styles of thinking. Attempts to cognitively reorient her problematic attitudes were useful in motivating interpersonal confidence while decreasing her hypersensitivity. In addition to working toward the extinction of false beliefs about herself and the attitudes of others toward her, the therapist was alert to spheres of life in which Juliana possessed positive emotional inclinations and encouraged her, through interpersonal methods, to undertake less aversive activities consonant with these tendencies. By shrinking her interpersonal milieu, she precluded exposure to new experience. Of course, this was her preference, but such behavior only fostered her isolated and withdrawn existence. To prevent such backsliding and a relapse, the therapist ensured the continuation of all constructive social activities as well as potential new ones. Otherwise, Juliana may have become increasingly lost in asocial and fantasy preoccupations. Excessive social pressure, however, was avoided because her tolerance and competencies in this area were limited. Initial brief, focused treatment techniques aided her in developing more skills in this area. Working toward competency in social skills paid considerable dividends both in reframing uncomfortable cognitions and learning that she could handle interpersonal situations with a modicum of skill and competency. Although the success of short-term methods may have justified an optimistic outlook, Juliana’s initial receptivity created the misleading perception that further advances and progress would be rapid. Care had to be taken to prevent early treatment success from precipitating a resurfacing of her established ambivalence between wanting social acceptance and fearing that she was placing herself in a vulnerable position. Enabling her to give up her long-standing expectations of disappointment required booster sessions following initial, short-term success. Support was provided to ease her fears, particularly her feeling that her efforts were not sustainable and would inevitably result in social disapproval again.

Resistances and Risks Therapeutic work with paranoids is a touchy proposition at best. Few come willingly for treatment. Therapy to them signifies weakness and dependency, both of which are anathema. When they do come in, the therapeutic work may be complicated because paranoids’ suspicious and distrustful nature guards them against revealing emotional and interpersonal difficulties, making it extremely difficult to examine internal processes. Many therapists fall into the trap of disliking these patients because their suspicions and hostility readily provoke discomfort and resentment. Therapists must resist being

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intimidated by the arrogance and demeaning comments of these patients. Weakness is not a trait suspicious/paranoids can accept in someone in whom they have placed their trust. Other problems can complicate the therapeutic effort. Excessive friendliness and overt sympathies often connote deceit to these patients, a seductive prelude to humiliation and deprecation. As paranoids tend to view it, they have suffered pain at the hands of deceptively “kind” people. A comfortable distance must be maintained. Nor can therapists question these patients directly about their distorted attitudes and beliefs. This may drive them to concoct new rationalizations; it may intensify their distrust and destroy whatever rapport has been built; conceivably, it may unleash a barrage of defensive hostility or precipitate an open psychotic break. The beliefs, selfconfidence, and image of autonomy and strength of suspicious/paranoids should not be directly challenged. These illusions are too vital a part of their style; to question them is to attack the patient’s fragile equilibrium. Despite the risks involved and therapeutic modifications required in working with these personalities, it is possible to put them on the road to recovery, providing them with a glimpse of a positive, healthy way of relating that might ultimately draw them further into the process of therapy.

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INDEX Abraham, J., 235 Abraham, K., 160 Abramson, L. Y., 124 Abrasive interpersonal conduct, 23, 303 Abroms, E. M., 52 Abstinent expressive behavior, 21, 162–163, 181 Acting out intrapsychic mechanism, 31 Active-detached style (avoidant), 215 Admirable self-image, 26, 191 Affectless subtype, retiring/schizoid, 69, 77–80 Aggrieved personalities. See Masochistic (aggrieved/masochistic) personalities Ajchenbrenner, M., 86 Akiskal, H. S., 124, 125, 128, 132, 214, 227, 228 Akiskal, K. K., 125 Alden, L. E., 86 Alienated self-image, 26, 75, 89, 90, 92–93, 108, 118, 155, 181 Allen, C., 226 Allen, D. M., 250 Alloy, L. B., 124 Anderson, J. S., 249 Anderson, L. W., 160 Andover, M. S., 227 Anguished mood/affect, 28, 89, 90, 95–96, 108, 310 Antisocial (nonconforming/antisocial) personalities (Code I), 19, 21, 23, 25, 27, 29, 31, 33, 35 Antisocial features/traits: capricious/borderline, impulsive subtype, 255, 259–262 Apathetic mood/affect, 28, 56, 57, 60, 71 Appels, M. C. M., 200 Apter-Danon, G., 253 Arieti, S., 87 Arkowitz, H., 6, 7

Arntz, A., 86, 234, 247 Asberg, M., 231 Asceticism regulatory mechanism, 31, 126, 127, 131 Assertive/sadistic personalities (Code J), 19, 21, 23, 25, 27, 29, 31, 33, 35 Attachment, suspicious/paranoid personality, 274–276, 285 Attention-seeking interpersonal conduct, 22, 149 Auerbach, J. G., 87 Autistic cognitive style/content, 24, 82, 198, 199, 201, 221 Autonomous self-image, 27, 260 Aversive interpersonal conduct, 22, 89, 90, 91–92, 112, 115, 257, 310 Aviram, R. B., 247 Avoidant (shy/avoidant) personalities, 85–121 active-detached style, 215 clinical domains, prototype, 88–96 alienated self-image, 26, 89, 90, 92–93, 108, 118 anguished mood, 28, 89, 90, 95–96, 108 aversive interpersonal conduct, 22, 89, 90, 91–92, 112, 115 distracted cognitive style, 24, 89, 90, 92, 111–112 fantasy mechanisms, 30, 89, 90, 93–94, 118 fragile organization, 34, 89, 90, 94–95 fretful expressive behavior, 20, 89, 90, 91, 115 vexatious objects, 32, 89, 90, 93, 115 illustrative cases, 106–120 conflicted subtype (Case 3.1, Sharon B.), 107–110 hypersensitive subtype (Case 3.2, Malcolm S.), 110–113 phobic subtype (Case 3.3, Arlane A.), 113–117 self-deserting subtype (Case 3.4, Marialena P.), 117–120 interventional goals, 98–101

335

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336 INDEX Avoidant (shy/avoidant) personalities (Continued ) prototype definition: domain descriptors (code C), 19, 20, 22, 24, 26, 28, 30, 32, 34, 90 overview table, domain descriptors, 90 polarity dimensions, 88 salience diagram, 89 resistances and risks, 120–121 self-perpetuation processes, 96–98 subtypes (overview table), 106 synergistic arrangements, making, 105–106 therapeutic modalities, 101–106 behavioral techniques, 101–102 cognitive techniques, 103 interpersonal techniques, 102–103 intrapsychic techniques, 104 pharmacologic techniques, 104–105 self-image techniques, 104 Avoidant features/traits: capricious/borderline, discouraged subtype, 255–258 pessimistic/depressive, restive subtype, 144, 154–157 retiring/schizoid, remote subtype, 69, 73–77 suspicious/paranoid, insular subtype, 297, 308–311 Awakenings (Sacks), 39 Azorin, J.-M., 132 Badcock, J. C., 196 Bagby, R. M., 124 Barch, D. M., 202 Bateman, A. W., 244 Bates, T. C., 202 Battle, C. L., 86 Beck, A. T., 41, 64, 66, 72, 76, 80, 83, 103, 106, 109, 116, 176, 213, 222, 247, 249, 250, 268, 286, 289, 293, 311 Bedford, N., 202 Bedwell, J. S., 195 Beevers, C. G., 64 Behavioral techniques: aggrieved/masochistic, 175 capricious/borderline, 247–248 eccentric/schizotypal, 211 pessimistic/depressive, 139 retiring/schizoid, 64 shy/avoidant, 101–102 suspicious/paranoid, 291 Bemporad, J. R., 87, 142 Benazzi, F., 128 Bender, D. S., 101, 246, 287 Benjamin, L. S., 12, 15, 80, 101, 102, 103, 110, 112, 121, 147, 149, 153, 156, 212, 222, 247, 248, 261, 268, 292, 304

Bennett, D., 225 Ben-Porath, D. D., 227, 247, 248 Benvenuti, A., 227 Bergida, H., 200 Bergin, A. E., 45 Berlin, H. A., 235 Berliner, B., 177 Bernstein, D. P., 176, 271 Bertelli, M., 123 Bienvenu, O. J., 86, 226 Binienda, J., 124 Biondo, K. M., 52 Birkeland, S., 272 Birket-Smith, M., 295 Black, D. W., 253 Blackburn, R., 271 Blackwood, D. H., 227 Blanchard, J. J., 52 Bland, A. R., 247, 251 Blanke, O., 204 Bleiberg, K., 139, 251 Blizard, R. A., 165 Bloom, C., 13 Blum, N., 253 Bogenschutz, M. P., 253 Bohus, M., 237, 248 Borderline (capricious/borderline) personalities, 225–270 clinical domains, prototype, 229–238 capricious/vacillating cognitive style, 25, 230, 232, 234–235, 257, 260 incompatible objects, 33, 230, 232, 235–236 labile mood, 29, 230, 232, 238, 264 paradoxical interpersonal conduct, 23, 230, 232, 233–234, 257 regression mechanism, 31, 230, 232, 236–237 spasmodic expressive behavior, 21, 230, 231–233, 268 split organization, 36, 230, 232, 237 uncertain self-image, 27, 230, 232, 235, 257, 260, 264, 267 illustrative cases, 254–269 discouraged type (Case 7.1, Patty C.), 255–258 impulsive type (Case 7.2, Dwayne T.), 259–262 petulant type (Case 7.3, Shari W.), 262–265 self-destructive type (Case 7.4, Allison L.), 266–269 interventional goals, 242–246 prototype definition: domain descriptors (code N), 19, 21, 23, 25, 27, 29, 31, 33, 36, 232 overview table, domain descriptors, 232 polarity dimensions, 228 salience diagram, 230

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Index 337 resistances and risks, 269–270 self-perpetuation processes, 238–242 separation anxiety, 229–230, 238–240 subtypes (overview table), 255 synergistic arrangements, making, 253–254 therapeutic modalities, 246–253 behavioral techniques, 247–248 cognitive techniques, 249–251 interpersonal techniques, 248–249 intrapsychic techniques, 252 pharmacologic techniques, 253 self-image techniques, 251–252 vacillation, mood/behavior, 231 Borgogno, F., 67 Bos, E. H., 129, 132 Bowles, D. P., 86 Bradley, R., 104, 225, 226 Brandes, M., 86, 226 Braun, J. G., 203 Bremner, J. D., 238 Brendel, G. R., 229 Brenner, C., 177 Brook, J. S., 54, 86 Brown, G. K., 250 Brown, J., 271 Brown, M. Z., 226 Brugger, P., 204 Burkhardt, M., 234 Calkins, M. E., 200 Callahan, S., 235 Callous mood/affect, 29 Cameron, N., 272 Camisa, K. M., 53, 272 Candilis-Huisman, D., 253 Cantoni, A., 105 Capricious personalities. See Borderline (capricious/borderline) personalities Capricious/vacillating cognitive style, 25, 230, 232, 234–235, 257, 260 Carcione, A., 294 Carson, R. C., 103 Castro, D. D., 231 Catania, D., 294 Cellucci, T., 226 Chabrol, H., 231, 235 Chang, B. P., 207 Chaotic objects (intrapsychic content), 32, 198, 201, 203 Chapman, A. L., 226, 248, 250 Chapman, J. E., 250 Charlesworth, S. E., 250 Chatziandreou, M., 252

Cheavens, J. S., 250 Chelminski, I., 85 Chen, H., 54, 85 Chessick, R. D., 226 Chiaroni, P., 132 Chiesa, M., 242 Chilton, R., 235 Christensen, M. V., 124 Christos, P. J., 139 Clark, D. M., 103 Clark, L. A., 141 Clarkin, J. F., 5, 234 Cloninger, Robert, 12 Coccaro, E. F., 253 Coccossis, M., 252 Coen, S. J., 64 Cogan, R., 272 Cognitive style/content domain: in circulargram of functional domains, 14 trait descriptions checklist, 24–25 trait descriptions framework explained, 18–19 Cognitive techniques: aggrieved/masochistic, 176 capricious/borderline, 249–251 eccentric/schizotypal, 212–213 pessimistic/depressive, 140–141 retiring/schizoid, 65–66 shy/avoidant, 103 suspicious/paranoid, 293–294 Cohen, L. H., 235 Cohen, P., 54, 85, 86, 271 Coid, J. W., 271 Collins, L. M., 52, 196 Combative self-image, 27 Compartmentalized intrapsychic structure, 36 Complacent self-image, 26, 56, 57, 59, 82 Compulsive (conscientious/compulsive) personalities (Code O), 19, 21, 23, 25, 27, 29, 31, 33, 36 Compulsive features/traits: affectless subtype, schizoid personality, 69, 77–80 obdurate subtype, suspicious/paranoid, 297, 304–308 Concealed objects (intrapsychic content), 33, 79 Confident/narcissistic personalities (Code G), 19, 20, 22, 24, 26, 29, 30, 32, 35 Conklin, C. Z., 225, 226, 242 Conscientious/compulsive personalities (Code O), 19, 21, 23, 25, 27, 29, 31, 33, 36 Constricted cognitive style/content, 25, 79, 306 Contrary interpersonal conduct, 23, 109, 264 Contrived intrapsychic content, 32 Coolidge, F. L., 160, 272 Costa, 55

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338 INDEX Cowdry, R. W., 253 Coyle, J. P., 249 Craighead, L. W., 39 Craighead, W. E., 39 Craik, K. H., 276 Cramer, D., 85 Crits-Christoph, P., 250 Crowe, M., 226 Crump, D., 249 Cruz, J., 160 Curtis, C. E., 200 Cynical cognitive style/content, 25 Cyranowski, J. M., 139 Dance, D., 86 Davids, E., 231 Davis, D. D., 64 Davis, K. L., 195 Davis, R., 295 Davis, R. D., 13, 106 Debased intrapsychic content, 33 de Bruijn, E. R. A., 226 Defenseless interpersonal conduct, 23, 126, 127, 128–129, 146, 155, 268 Defensive expressive behavior, 21, 275, 278, 279 Deferential interpersonal conduct, 23, 162, 163, 164–165, 268 DenBoer, J. W., 272 Dependent (needy/dependent) personalities (Code D), 19, 20, 22, 24, 26, 28, 30, 32, 34 Dependent features/traits: aggrieved/masochistic, self-undoing subtype, 179–183 capricious/borderline, discouraged subtype, 255–258 eccentric/schizotypal, insipid subtype, 207, 216–219 pessimistic/depressive, self-derogating subtype, 144 shy/avoidant, phobic subtype, 106, 113–117 Depersonalization anxiety, 198–199 Depersonalized subtype, retiring/schizoid, 80–83 Depleted morphologic organization, 35, 126, 127, 131–132 Depressive (pessimistic/depressive) personalities, 123–158 clinical domains, prototype, 126–132 asceticism regulatory mechanism, 31, 126, 127, 131 defenseless interpersonal conduct, 23, 126, 127, 128–129, 146, 155 depleted morphologic organization, 35, 126, 127, 131–132 disconsolate expressive behavior, 21, 126, 127, 128, 155 forsaken object relations, 33, 126, 127, 130–131 melancholic/woeful mood, 29, 126, 127, 132, 152

pessimistic/fatalistic cognitive style, 25, 126, 127, 129, 149, 152 worthless self-image, 27, 126, 127, 129–130, 146, 149, 152 illustrative cases, 143–157 ill-humored type (Case 4.1, Nadia), 144–147 morbid type (Case 4.3, Travis R.), 150–153 restive type (Case 4.4, Lana P.), 154–157 voguish type (Case 4.2, Geoffrey S.), 147–150 interventional goals, 134–138 prototype definition: domain descriptors (code K), 19, 21, 23, 25, 27, 29, 31, 33, 35, 127 overview table, domain descriptors, 127 polarity dimensions, 125 salience diagram, 126 resistances and risks, 157–158 self-perpetuation processes, 132–134 subtypes (overview table), 144 synergistic arrangements, making, 143 therapeutic modalities, 138–143 behavioral techniques, 139 cognitive techniques, 140–141 interpersonal techniques, 139–140 intrapsychic techniques, 142 pharmacologic techniques, 142–143 self-image techniques, 141–142 Depressive features/traits: aggrieved/masochistic, oppressed subtype, 179, 187–190 aggrieved/masochistic, virtuous subtype, 179, 190–193 capricious/borderline, discouraged subtype, 255–258 capricious/borderline, self-destructive subtype, 255, 266–269 eccentric/schizotypal, insipid subtype, 207, 216–219 retiring/schizoid, languid subtype, 69–73 shy/avoidant, self-deserting subtype, 106, 117–120 Deviant cognitive style/content, 25 Dialectic behavior therapy, 247–248 Dick, D. M., 226 Diffident cognitive style/content, 25, 162, 163, 165, 181, 189 Dimaggio, G., 294 Dimic, S., 85 Dinn, W. M., 234 Disciplined expressive behavior, 21 Disconsolate expressive behavior, 21, 126, 127, 128, 155 Discontented self-image, 27, 264 Discouraged subtype, capricious/borderline, 255–258 Discredited objects (intrapsychic content), 33, 162, 163, 166, 192

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Index 339 Disjointed intrapsychic structure, 35 Disorganized cognitive style/content, 202–203 Displacement intrapsychic mechanism, 31 Dissociation intrapsychic mechanism, 30 Distracted cognitive style/content, 24, 89, 90, 92, 111–112, 257, 310 Distraught/insentient mood/affect, 28, 198, 201, 205, 218, 221 Divergent intrapsychic structure, 36 Dixon, J. K., 202 DNA, psychic, 4 Dogmatic cognitive style/content, 25 Domain checklists: cognitive style/content, 24–25 expressive behavior, 20–21 interpersonal conduct, 22–23 intrapsychic content, 32–33 intrapsychic mechanisms, 30–31 intrapsychic structure, 34–36 mood/affect, 28–29 self-image, 26–27 Donnelly, R. S., 195 Dorr, A., 67 Dougherty, L. R., 123 Dowson, J., 226 Dragovic, M., 196 Dramatic expressive behavior, 20 Dreessen, L., 86 Driver-Linn, E., 225 Dysphoric mood, 29, 162, 163, 168, 185, 188 Eccentric/peculiar expressive behavior, 20, 198, 200, 201 Eccentric personalities. See Schizotypal (eccentric/schizotypal) personalities Eclecticism, 7–8, 10, 12 Eggers, C., 291 Eisenbud, J., 178 Ekdahl, S., 231 Ekselius, L., 86 Eldridge, N., 43 Ellis, A., 41, 109, 156, 222, 268 Empirically oriented assessment instruments, 10 Endicott, J., 196 Energetic self-image, 26 Engel, G., 129 Eruptive intrapsychic structure, 35 Estranged self-image, 26, 198, 201 Ettinger, U., 196 Exaggeration regulatory mechanism, 31, 162, 163, 166–167, 185, 192

Expansive cognitive style/content, 24, 149, 299 Exploitive interpersonal conduct, 22 Expressive behavior domain: in circulargram of functional domains, 14 trait descriptions checklist, 20–21 trait descriptions framework explained, 18–19 Exuberant/hypomanic personalities (code E), 19, 20, 22, 24, 26, 28, 30, 32, 34, 36 Family/couples approaches: aggrieved/masochistic, 176 capricious/borderline, 249 pessimistic/depressive, 140 retiring/schizoid, 65 shy/avoidant, 103 suspicious/paranoid, 293 Fanatic subtype, suspicious/paranoid, 297–301 Fantasy intrapsychic mechanisms, 30, 89, 90, 93–94, 118, 221 Farmer, R. F., 86 Fatalistic/pessimistic cognitive style, 25, 119, 126, 127, 129, 149, 152 Feeney, J. A., 226 Fertuck, E. A., 226, 234 Fickle mood/affect, 28 Fiester, S. J., 159 Filippini, S., 160 Fine, M. A., 160, 161 Fischer-Kern, M., 64 Fisher-Irving, M., 226 Fleeting intrapsychic structure, 34 Flighty cognitive style/content, 24 Fluctuating intrapsychic content, 33 Folley, B. S., 206 Fonagy, P., 244 Fonto, S., 105 Forsaken objects (intrapsychic content), 33, 126, 127, 130–131 Fossati, A., 226 Fowler, D., 271 Fragile intrapsychic structure, 34, 89, 90, 94–95 Fragmented intrapsychic structure, 34, 198, 201, 204–205 Frances, A. J., 5 Francis-Raniere, E. L., 124 Frank, E., 246 Frankenburg, F. R., 227 Fredrikson, M., 86 Freeman, A., 64, 66, 83, 103, 106, 213, 247, 249, 250, 289, 293 Freeman, J. L., 271 Fretful expressive behavior, 20, 89, 90, 91, 115

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340 INDEX Fuchs, T., 272 Functional/structural domains: circulargrams, 14, 15 discussed, 17–18 overview tables, domain descriptors, 56, 90, 127, 163, 201, 232, 279 Furmark, T., 86 Gabbard, G. O., 67, 214, 294, 295 Gardner, C. O., 123 Gardner, D. L., 253 Garyfallos, G., 161 Gastpar, M., 231 Gavigan, C. A., 253 Genomic medicine, 4 Gerson, J., 247 Gestalt, two-chair, 7 Giannelli, M. R., 105 Gibb, B. E., 227 Gibbon, M., 196 Giesen-Bloo, J., 250, 252 Girardi, P., 226 Gladstone, G. L., 177 Glickauf-Hughes, C., 177 Goethe, J. W., 159 Goldberg, S. C., 214 Goldstein, Kurt, 39 Gooding, D. C., 203, 204 Gould, S., 43 Goulding, A., 202 Gouvernet, J., 132 Granholm, E., 196 Grant, B. F., 87 Gratz, K. L., 226, 252 Gray, N. S., 200 Gregarious self-image, 26 Gregory, R. J., 229, 246 Grilo, C. M., 86, 87, 129 Grinker, R. R., 53 Grootens, K. P., 253 Grossman, S. D., 3, 13, 15, 106 Group approaches: aggrieved/masochistic, 175–176 capricious/borderline, 249 pessimistic/depressive, 140 retiring/schizoid, 65 shy/avoidant, 103 suspicious/paranoid, 293 Grove, W. M., 200 Gunderson, J. G., 129, 227, 252 Gunthert, K. C., 235

Gutheil, T. G., 226, 229 Guzm´an, C. M., 250 Haaga, D. A. F., 176 Haigh, R., 271 Hale, N., 253 Haller, D. L., 86, 161 Handest, P., 195 Hans, S. L., 87, 200 Hantman, J. G., 67 Hantouche, E.-G., 132 Harper, D. J., 276 Harper, R. G., 271 Hartmann, A., 252 Harvey, P. D., 196 Haughty expressive behavior, 20 Hautzinger, M., 234 Hazlett, E. A., 237 Haznedar, M. M., 60, 204 Heim, A. K., 104 Heisler, L. K., 159 Hellerstein, D. J., 247 Hennen, J., 227 Herbert, J. D., 102 Hibbard, S., 272 High-spirited interpersonal conduct, 22 Histrionic (sociable/histrionic) personalities (code F), 19, 20, 22, 24, 26, 28, 30, 32, 35 Histrionic features/traits: aggrieved/masochistic, virtuous subtype, 179, 190–193 capricious/borderline, impulsive subtype, 255, 259–262 pessimistic/depressive, voguish subtype, 144, 147–150 Hoermann, S., 234 Hoffman, P. D., 249 Hollander, E., 253 Hollister, L. E., 53 Holmes, J., 226 Holographic metaphor, 52 Horney, K., 160, 164, 263 Horowitz, M. J., 249, 252 Hostile mood/affect, 29 Huprich, S. K., 86, 124, 125, 160, 161 Hyman, S. M., 100 Hypomanic (exuberant/hypomanic) personalities (code E), 19, 20, 22, 24, 26, 28, 30, 32, 34, 36 Iacono, W. G., 200 Ill-humored subtype, pessimistic/depressive, 144–147 Immature intrapsychic content, 32 Impassive expressive behavior, 20, 56, 57–58, 75 Impetuous expressive behavior, 20

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Index 341 Impoverished cognitive style/content, 24, 56, 57, 58–59, 218 Impulsive expressive behavior, 21 Impulsive subtype, capricious/borderline, 255, 259–262 Inchoate intrapsychic structure, 34 Incompatible objects (intrapsychic content), 33, 230, 232, 235–236 Incompetent expressive behavior, 20 Inelastic intrapsychic structure, 35, 275, 279, 283 Inept self-image, 26, 152 Insipid subtype, eccentric/schizotypal, 207, 216–219 Insouciant mood/affect, 29 Insular subtype, suspicious/paranoid, 297, 308–311 Intellectualization regulatory mechanism (intrapsychic mechanisms), 30, 56, 57, 60 Interpersonal conduct domain: in circulargram of functional domains, 14 trait descriptions checklist, 22–23 trait descriptions framework explained, 18–19 Interpersonal techniques: aggrieved/masochistic, 175–176 capricious/borderline, 248–249 eccentric/schizotypal, 211–212 pessimistic/depressive, 139–140 retiring/schizoid, 64–65 shy/avoidant, 102–103 suspicious/paranoid, 292–293 Interventional goals: aggrieved/masochistic, 171–174 capricious/borderline, 242–246 eccentric/schizotypal, 207–211 pessimistic/depressive personalities, 134–138 retiring/schizoid, 62–63 shy/avoidant, 98–101 suspicious/paranoid, 287–290 Intrapsychic content domain: in circulargram of structural domains, 15 trait descriptions checklist, 32–33 trait descriptions framework explained, 18–19 Intrapsychic mechanisms domain: in circulargram of functional domains, 14 trait descriptions checklist, 30–31 trait descriptions framework explained, 18–19 Intrapsychic structure domain: in circulargram of structural domains, 15 trait descriptions checklist, 34–36 trait descriptions framework explained, 18–19 Intrapsychic techniques: aggrieved/masochistic, 177–178 capricious/borderline, 252 eccentric/schizotypal, 214

pessimistic/depressive, 142 retiring/schizoid, 67 shy/avoidant, 104 suspicious/paranoid, 294–295 Introjection intrapsychic mechanism, 30 Inverted intrapsychic structure, 35, 162, 163, 167–168 Inviolable self-image, 27, 275, 279, 281, 299 Irle, E., 238 Irresponsible interpersonal conduct, 23, 260 Irritable mood/affect, 29 Isolation intrapsychic mechanism, 31 Isometsa, E., 123 Jackson, D. N., 16 Jackson, H. J., 86 Jang, K. L., 226 Janis, I. B., 225 Jankovic, J. G., 85 Jarrett, R. B., 141 Jiang, P., 253 Johnson, J. G., 54, 85, 86 Johnson, J. J., 271 Joseph, S., 214 Jovev, M., 86 Joyce, P. R., 226 Judd, P. H., 234 Kahn, R. S., 200 Kantor, M., 67, 292 Karana, D., 124 Karterud, S., 293 Kasen, S., 54, 86 Kawasaki, Y., 202 Kazdin, A. E., 39 Kellogg, S. H., 250 Kendler, K. S., 123 Kerns, J. G., 200 Keshavan, M., 215 Kessing, L. V., 124 Kiesler, D. J., 80, 103, 149, 153, 261, 300, 304 King, A. R., 85 King, R., 233 Klein, D. N., 123, 161 Klerman, G. L., 6, 110, 112, 147, 156, 300 Knight, R. G., 203 Kocsis, J. H., 139, 143 Koenigsberg, H. W., 203 Koo, M., 142, 205 Koons, C. R., 247 Kraepelin, E., 145, 148 Kremers, I. P., 235

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342 INDEX Kretschmer, E., 145 Kr¨oger, C., 250 Kulchycky, S., 253 Kullgren, G., 226 Kuo, J. R., 250 Kwitel, A., 226 Labile mood/affect, 29, 230, 232, 238, 264 Lacroce, D. M., 252 Laguerre, A., 197 Lambert, M. J., 45 Lamnidis, N., 252 Lange, C., 238 Languid subtype, retiring/schizoid, 69–73 Laposa, J. M., 86 Laptook, R. S., 123 Lebe, D., 170 Leboyer, M., 197 Lee, H., 280 Lee, K., 202 Lee, M. M., 141, 250 Leichsenring, F., 142, 227, 231, 252 Leithner, K., 64 Lejuez, C. W., 250 Lenzenweger, M. F., 200, 207, 231, 234 Leszcz, M., 65 Levy, K. N., 252 Lindeman, M. D., 66 Linehan, M. M., 247, 248, 250 Lingam, R., 235 Linscott, R. J., 203 Livesley, W. J., 16, 226, 246 Li-ying, W., 86 L¨offler-Stastka, H., 64 Lovell, P. G., 202 Luby, J. L., 140 Lynch, T. R., 250 Lyons, M. J., 159 MacKinnon, R. A., 141 Maggini, C., 105 Magnavita, J. J., 177 Magnification intrapsychic mechanism, 30 Mahoney, M. J., 39 Malignant subtype, suspicious/paranoid, 297, 301–304 Manning, S., 251 Marchesi, C., 105 Marcus, J., 87 Markovitz, P. J., 215, 253 Markowitz, J. C., 124, 139, 143, 251

Masochistic (aggrieved/masochistic) personalities, 159–194 clinical domains, prototype, 162–168 abstinent expressive behavior, 21, 162–163, 181 deferential interpersonal conduct, 23, 162, 163, 164–165 diffident cognitive style, 25, 162, 163, 165, 181, 189 discredited object representations, 33, 162, 163, 166, 192 dysphoric mood, 29, 162, 163, 168, 185, 188 exaggeration regulatory mechanism, 31, 162, 163, 166–167, 185, 192 inverted organization, 35, 162, 163, 167–168 undeserving self-image, 27, 165–166, 191 illustrative cases, 178–193 oppressed type (Case 5.3, Wanda K.), 187–190 possessive type (Case 5.2, Lourdes D.), 183–186 self-undoing type (Case 5.1, Randi P.), 179–183 virtuous type (Case 5.4, Helen M.), 190–193 interventional goals, 171–174 prototype definition: domain descriptors (code L), 19, 21, 23, 25, 27, 29, 31, 33, 35, 163 overview table, domain descriptors, 163 polarity dimensions, 161 salience diagram, 162 resistances and risks, 193–194 self-perpetuation processes, 168–172 subtypes (overview table), 179 synergistic arrangements, making, 178 therapeutic modalities, 174–178 behavioral techniques, 175 cognitive techniques, 176 interpersonal techniques, 175–176 intrapsychic techniques, 177–178 pharmacologic techniques, 178 self-image techniques, 176–177 Masochistic features/traits: capricious/borderline, self-destructive subtype, 255, 266–269 pessimistic/depressive, morbid subtype, 144, 150–153 Matts, C. W., 204 Mauchnik, J., 237 McCann, J. T., 177 McHoskey, J. W., 272 McKay, D., 176, 253 McWilliams, N., 52 Meager objects (intrapsychic content), 32, 56, 57, 59–60, 79 M´eary, A., 197

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Index 343 Meichenbaum, D., 72, 76, 116, 156, 251, 311 Meissner, W. W., 290 Melancholic/dysphoric mood/affect, 29, 162, 163, 168, 185, 188 Melancholic personalities. See Depressive (pessimistic/depressive) personalities Melancholic/woeful mood, 29, 126, 127, 132, 152, 188 Melartin, T., 123 Mercurial mood/affect, 28 Messer, S. B., 6, 7, 46 Meyer, B., 64, 86, 233 Michels, R., 141 Migo, E. M., 200 Miles, D. R., 86, 161 Miller, K. A., 226 Miller, T., 226 Millon, C., 106 Millon, T., 3, 4, 8, 10, 13, 15, 16, 37, 40, 42, 52, 55, 68, 69, 85, 87, 95, 106, 124, 196, 227, 254, 295 Millon Clinical Multiaxial Inventory (MCMI-III), 4, 14 Grossman Facet Scales, 4 Millon-Grossman Personality Domain Checklist (MG-PDC), 14–36 checklists, 20–36 codes (A–O) defined, 19 criteria for developing clinical domains listed in, 16–17 Minzenberg, J. J., 226 Minzenberg, M. J., 226 Mistrustful/suspicious cognitive style/content, 25, 275, 279, 280, 299, 306, 310 Mittal, V. A., 200 Modality-oriented therapy, 4, 9, 12 Mohr, C., 204 Mood-affect domain: in circulargram of structural domains, 15 trait descriptions checklist, 28–29 trait descriptions framework explained, 18–19 Morbid subtype, pessimistic/depressive, 144, 150–153 Morgan, C., 202 Morphologic organization. See Intrapsychic structure domain Muir, W. J., 227 Muller, J. E., 86 Munro, A., 271 Murray, E. J., 8 Nagata, T., 87 Naive cognitive style/content, 24 Nakamura, M., 207 Narcissistic (confident/narcissistic) personalities (Code G), 19, 20, 22, 24, 26, 29, 30, 32, 35

Narcissistic features/traits: aggrieved/masochistic, possessive subtype, 179, 183–186 capricious/borderline, petulant subtype, 255, 262–265 capricious/borderline, self-destructive subtype, 255, 266–269 pessimistic/depressive, ill-humored subtype, 144–147 pessimistic/depressive, voguish subtype, 144, 147–150 shy/avoidant, conflicted subtype, 106, 107–110 suspicious/paranoid, fanatic subtype, 297–301 suspicious/paranoid, querulous subtype, 297 Nash, H. M., 86 Needy/dependent personalities (Code D), 19, 20, 22, 24, 26, 28, 30, 32, 34 Negativistic (skeptical/negativistic) personalities (Code M), 19, 21, 23, 25, 27, 29, 31, 33, 36 Newman, C. F., 250 Neziroglu, F., 176 Nickel, M. K., 253 Nicolo, G., 294 Nigg, J. T., 226 Nonconforming/antisocial personalities (Code I), 19, 21, 23, 25, 27, 29, 31, 33, 35 Noonan, J. R., 272 Noyes, R., Jr., 176 Nurnberg, H. G., 253 Oades, R. D., 291 Oaksford, M., 200 Obdurate subtype, suspicious/paranoid, 297, 304–308 Object representations. See Intrapsychic content domain Oldham, J. M., 86, 226, 246, 253 O’Neill, S. C., 235 Ono, Y., 86 Oppressed subtype, aggrieved/masochistic, 179, 187–190 Orlinsky, D. E., 252 Orrico, E. G., 227 Overall, J. E., 53 Overholser, J. C., 141, 250 Pacific mood/affect, 28 Pagano, M. E., 86 Palermo. G. B., 272 Panagiotopoulou, V., 252 Paradoxical interpersonal conduct, 23, 230, 232, 233–234, 257 Paranoid (suspicious/paranoid) personalities, 271–312 attachment anxiety, 274–276 clinical domains, prototype, 274–284 defensive expressive behavior, 21, 275, 278, 279 inelastic organization, 35, 275, 279, 283

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344 INDEX Paranoid (suspicious/paranoid) personalities (Continued ) inviolable self-image, 27, 275, 279, 281, 299 irascible mood, 29, 275, 279, 283–284, 306 projection mechanism, 31, 275, 279, 282–283, 303 provocative interpersonal conduct, 23, 275, 278–280, 299, 303, 306 suspicious/mistrustful cognitive style, 25, 275, 279, 280, 299, 306, 310 unalterable objects, 33, 275, 279, 281–282 cognitive suspicions and delusions, 276–277 defensive vigilance and veiled hostility, 277–278 illustrative cases, 296–311 fanatic subtype (Case 8.1, Jacqueline M.), 297–301 insular type (Case 8.4, Juliana M.), 308–311 malignant subtype (Case 8.2, George S.), 301–304 obdurate subtype (Case 8.3, Carlos R.), 304–308 interventional goals, 287–290 prototype definition: domain descriptors (code H), 19, 21, 23, 25, 27, 29, 31, 33, 35, 279 overview table, domain descriptors, 279 polarity dimensions, 273 salience diagram, 275 resistances and risks, 311–312 self-perpetuation processes, 284–287 subtypes (overview table), 297 synergistic arrangements, making, 295–296 therapeutic modalities, 290–296 behavioral techniques, 291 cognitive techniques, 293–294 interpersonal techniques, 292–293 intrapsychic techniques, 294–295 pharmacologic techniques, 295 self-image techniques, 294 Paranoid features/traits: shy/avoidant, hypersensitive subtype, 106, 110–113 Paris, J., 225, 226, 227, 229 Park, S., 206 Parker, G., 167 Parnas, J., 195 Passive-detached style (schizoid), 215 Patient-based self-judgments, 16 Peculiar/eccentric expressive behavior, 20, 198, 200, 201 Pepper, C. M., 227 Pernicious intrapsychic content, 33 Perpetuating tendencies, countering. See Self-perpetuation processes Perry, S., 5 Perseius, K., 231 Personality-based evolutionary model, 12–38 checklists, descriptive trait choices: cognitive style/content, 24–25 expressive behavior, 20–21

interpersonal conduct, 22–23 intrapsychic content, 32–33 intrapsychic mechanisms, 30–31 intrapsychic structure, 34–36 mood/affect, 28–29 self-image, 26–27 circulargrams: functional personologic domains, 13–14 normal/abnormal personality patterns, 13 structural domains, 14, 15 Personalized psychotherapy: barriers to, 10 versus eclecticism, 7–8, 10, 12 potentiated pairings and catalytic sequences, 37–45 procedural caveats and considerations, 45–47 recapitulation of, 51–52 tactics/strategies, 41–45 about the term, 3–4, 5, 6 Personologic psychotherapy, 10 Pessimistic/fatalistic cognitive style/content, 25, 71, 126, 127, 129, 149, 152 Pessimistic personalities. See Depressive (pessimistic/depressive) personalities Peterson, G. A., 248 Petulant subtype, capricious/borderline, 255, 262–265 Pfohl, B., 253 Pharmacologic techniques: aggrieved/masochistic, 178 capricious/borderline, 253 eccentric/schizotypal, 214–215 pessimistic/depressive, 142–143 retiring/schizoid, 67 shy/avoidant, 104–105 suspicious/paranoid, 295 Phillips, W. A., 202 Pickup, G. J., 195 Piecemeal intrapsychic content, 32 Pilkonis, P. A., 64, 246 Polarity balances, reestablishing, 172 aggrieved/masochistic, 172 capricious/borderline, 243–244 eccentric/schizotypal, 208–209 pessimistic/depressive, 136 retiring/schizoid, 63 shy/avoidant, 99–100 suspicious/paranoid, 288 Polarity dimensions: aggrieved/masochistic, 161 capricious/borderline, 228 eccentric/schizotypal, 197 pessimistic/depressive, 125

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Index 345 retiring/schizoid, 54 shy/avoidant, 88 suspicious/paranoid, 273 Pompili, M., 226 Ponocny-Seliger, E., 64 Poole, J. H., 226 Porcerelli, J., 124, 272 Possessive subtype, aggrieved/masochistic, 179, 183–186 Precipitate expressive behavior, 21, 303 Prescott, C. A., 123 Proietti, J. M., 246 Projection intrapsychic mechanism, 31, 275, 279, 282–283, 303 Provocative interpersonal conduct, 23, 275, 278–280, 299, 303, 306 Psychic DNA, 4 Querulous subtype, suspicious/paranoid, 297 Raballo, A., 123 Raine, A., 196 Raja, M., 53 Ralevski, E., 86 Rasmussen, P. R., 39, 271 Rationalization intrapsychic mechanism, 30 Ravindran, A. V., 271 Rawlings, D., 271 Reaction formation intrapsychic mechanism, 31 Reality, reconstructing (suspicious/paranoid), 286–287 Regression intrapsychic mechanism, 31, 230, 232, 236–237 Regulatory action, modes of, 17 Regulatory mechanisms. See Intrapsychic mechanisms domain Reich, D. B., 227 Reich, W., 160 Reichenberg, A., 196 Reid, W. H., 272 Reliable self-image, 27 Remote subtype, retiring/schizoid, 69, 73–77 Renberg, E. S., 226 Resentful expressive behavior, 21, 185 Resistances and risks: aggrieved/masochistic, 193–194 capricious/borderline, 269–270 eccentric/schizotypal, 222–223 pessimistic/depressive, 157–158 retiring/schizoid, 83–84 shy/avoidant personalities, 120–121 suspicious/paranoid, 311–312 Respectful interpersonal conduct, 23

Restive subtype, pessimistic/depressive, 144, 154–157 Retarded depression, 53 Retiring personalities. See Schizoid (retiring/schizoid) personalities Robins, C. J., 248 Rogers, C., 104, 252 Rollmann, E. A., 204 Rolls, E. T., 235 Romero, M., 196 Rose, S., 123 Rosenthal, M. Z., 250 Rossell, S. L., 202 Rossen, E. K., 247 Rothschild, L., 85 Rousseau, A., 235 Ruberto, A., 226 Ruchsow, M., 234 Ruocco, A. C., 227, 253 Ryabchenko, K. A., 227 Ryder, A. G., 124 Ryle, A., 225 Sachsse, U., 238, 252 Sacks, M., 139 Sacks, Oliver, 39 Sadistic (assertive/sadistic) personalities (Code J), 19, 21, 23, 25, 27, 29, 31, 33, 35 Sadistic features/traits: suspicious/paranoid, malignant subtype, 297, 301–304 Salience diagrams: aggrieved/masochistic, 162 capricious/borderline, 230 eccentric/schizotypal, 198 pessimistic/depressive, 126 retiring/schizoid, 57 shy/avoidant, 89 suspicious/paranoid, 275 Salsman, N. L., 250 Salvatore, G., 294 Salzman, L., 295 Samuelsson, M., 231 Sansone, R. A., 226, 229 Scattered cognitive style/content, 24 Scharer, K., 251 Schatzberg, A. F., 142 Schizoid (retiring/schizoid) personalities: clinical domains, prototype, 55–60 apathetic mood/temperament, 28, 56, 57, 60, 71 complacent self-image, 26, 56, 57, 59, 82 impassive expressive behavior, 20, 56, 57–58, 75 impoverished cognitive style, 24, 56, 57, 58–59 intellectualization regulatory mechanism (intrapsychic mechanisms), 30, 56, 57, 60

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346 INDEX Schizoid (retiring/schizoid) personalities (Continued ) meager object representations (intrapsychic content), 32, 56, 57, 59–60, 79 undifferentiated/disjointed morphologic organization, 34, 56, 57, 60 unengaged interpersonal conduct, 22, 56, 57, 58, 71, 75, 79, 82 illustrative cases, 68–83 affectless type (Case 2.3, Patricia L.), 77–80 depersonalized type (Case 2.4, Marla D.), 80–83 languid type (Case 2.1, Josef W.), 69–73 remote type (Case 2.2, Doug G.), 73–77 interventional goals, 62–63 passive-detached style, 215 prototype definition: domain descriptors (code A), 19, 20, 22, 24, 26, 28, 30, 32, 34, 56 overview table, domain descriptors, 56 polarity dimensions, 54 salience diagram, 57 recapitulation of personalized idea, 51–52 resistances and risks, 83–84 self-perpetuation processes, 60–62 subtypes (overview table), 69 synergistic arrangements, 68 therapeutic modalities, 64–67 behavioral techniques, 64 cognitive techniques, 65–66 interpersonal techniques, 64–65 intrapsychic techniques, 67 pharmacologic techniques, 67 self-image techniques, 66–67 Schizoid features/traits: eccentric/schizotypal, insipid subtype, 207, 216–219 Schizotypal (eccentric/schizotypal) personalities, 195–223 clinical domains, prototype, 198–205 autistic cognitive style and disfunctiveness, 24, 198, 199, 201, 221 chaotic objects, 32, 198, 201, 203 distraught/insentient mood, 28, 198, 201, 205, 218, 221 eccentric/peculiar expressive behavior, 20, 198, 200, 201 estranged self-image, 26, 198, 201 fragmented organization, 34, 198, 201, 204–205 secretive interpersonal conduct, 22, 198, 200–202, 218 undoing mechanism, 30, 198, 201, 204 deficient social behaviors and impoverished affect, 199–200

depersonalization anxiety, 198–199 illustrative cases, 215–222 insipid type (Case 6.1, Kevin B.), 216–219 timorous type (Case 6.2, Drew S.), 219–222 interventional goals, 207–211 prototype definition: domain descriptors (code B), 19, 20, 22, 24, 26, 28, 30, 32, 34, 201 overview table, domain descriptors, 201 polarity dimensions, 197 salience diagram, 198 resistances and risks, 222–223 self-perpetuation processes, 205–207 subtypes (overview table), 216 synergistic arrangements, making, 215 therapeutic modalities, 211–215 behavioral techniques, 211 cognitive techniques, 212–213 interpersonal techniques, 211–212 intrapsychic techniques, 214 pharmacologic techniques, 214–215 self-image techniques, 213–214 Schizotypal features/traits: retiring/schizoid, depersonalized subtype, 69, 80–83 Schmahl, C., 237, 238 Schneider, K., 145, 148 Schneider B. A., 100 Schooler, N., 215 Schouten, E., 86 Schroeder, M. L., 16 Schuller, D. R., 124 Sch¨urhoff, F., 197 Schut, A. J., 104 Schwarz, J., 234 Scott, E. M., 272 Scott, J., 246 Scott, S., 105 Secretive interpersonal conduct, 22, 198, 200–202, 218 Seedat, S., 105 Segal, D. L., 272 Self-derogating subtype, pessimistic/depressive, 144 Self-destructive subtype, capricious/borderline, 255, 266–269 Self-image domain: in circulargram of structural domains, 15 trait descriptions checklist, 26–27 trait descriptions framework explained, 18–19 Self-image techniques: aggrieved/masochistic, 176–177 capricious/borderline, 251–252 eccentric/schizotypal, 213–214

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Index 347 pessimistic/depressive, 141–142 retiring/schizoid, 66–67 shy/avoidant, 104 suspicious/paranoid, 294 Self-perpetuation processes: aggrieved/masochistic, 168–172, 173 capricious/borderline, 238–242, 244–245 eccentric/schizotypal, 205–207, 209–210 pessimistic/depressive, 132–134, 136–137 retiring/schizoid, 60–62, 63 shy/avoidant, 96–98, 100 suspicious/paranoid, 284–287, 289 Self-undoing subtype, aggrieved/masochistic, 179–183 Sellen, J. L., 200 Separation anxiety, capricious/borderline, 229–230, 238–240 Serban, G., 214 Shad, M., 215 Shallow intrapsychic content, 32 Shankman, S. A., 123 Shapiro, D., 167 Shea, M. T., 85, 208 Shi-jie, Z., 231 Shopshire, M. S., 276 Shy personalities. See Avoidant (shy/avoidant) personalities Siegel, S., 214 Sieswerda, S., 234 Siever, L. J., 195, 196, 271 Silbersweig, D. A., 229 Silk, K. R., 226, 227, 252 Silverstein, S. M., 202 Simonsen, E., 295 Sinha, B. K., 271 Sitskoorn, M. M., 200 Skeptical/negativistic personalities (Code M), 19, 21, 23, 25, 27, 29, 31, 33, 36 Skodol, A. E., 86, 87, 124, 129, 251 Slater, L., 39 Slote, G., 177 Smailes, E. M., 271 Smee, J., 248 Smith, A., 52 Smith, D. J., 227 Smith, T. B., 253 Sociable/histrionic personalities (code F), 19, 20, 22, 24, 26, 28, 30, 32, 35 S¨oderberg, S., 226 Solemn mood/affect, 29 Soloff, P., 215, 253 Songer, D. A., 226 Spasmodic expressive behavior, 21, 230, 231–233, 268

Specht, M. W., 226 Spence, S. A., 202 Spinhoven, P., 235 Spitzer, R. L., 196 Split intrapsychic structure, 36, 230, 232, 237 Spurious intrapsychic structure, 35 Spurling, L., 246 Stanghellini, G., 123 Stanley, B., 226, 234, 247 Stanley, M. C., 226 Stavro, G., 226 Stein, D. J., 86 Stein, M. B., 105 Stern, E., 229 Stevens, A., 234 Stone, M. H., 215, 227, 247, 273, 292, 294 Strauss, J. L., 103 Structural domains. See Functional/structural domains Styr, B., 87 Submissive interpersonal conduct, 22, 115 Subtypes (overview tables): aggrieved/masochistic, 179 capricious/borderline, 255 eccentric/schizotypal, 216 pessimistic/depressive, 144 retiring/schizoid, 69 shy/avoidant, 106 suspicious/paranoid, 297 Sunseri, P. A., 248 Suspicious cognitive style, 111–112 Suspicious personalities. See Paranoid (suspicious/paranoid) personalities Swann, A. C., 253 Swartz, H. A., 246 Synergistic arrangements, making: aggrieved/masochistic, 178 capricious/borderline, 253–254 eccentric/schizotypal, 215 pessimistic/depressive, 143 retiring/schizoid, 68 shy/avoidant, 105–106 suspicious/paranoid, 295–296 Synodinou, C., 252 Sz¨oke, A., 197 Tajima, O., 86 Takahashi, T., 203, 204 Tao, L., 86 Tatarelli, R., 226 Taylor, C. T., 86 Terrance, C., 85

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348 INDEX Therapeutic modalities: aggrieved/masochistic, 174–178 capricious/borderline, 246–253 eccentric/schizotypal, 211–215 pessimistic/depressive, 138–143 retiring/schizoid, 64–67 shy/avoidant, 101–106 suspicious/paranoid, 290–296 Tillfors, M., 86 Timorous subtype, eccentric/schizotypal, 207, 216, 219–222 T´ızon Garc´ıa, J. L., 272 Todaro, J., 176 Tolpin, L. H., 235 Tosevski, D. L., 85 Travers, C., 233 Tringone, R., 16 Tritt, K., 253 Tsani, H., 252 Turkat, I. D., 248 Uhlhaas, P. J., 202 Unalterable objects (intrapsychic content), 33, 112, 275, 279, 281–282 Uncertain self-image, 27, 230, 232, 235, 257, 260, 264, 267 Unckel, C., 234 Undeserving self-image, 27, 165–166, 191 Undifferentiated intrapsychic structure, 34, 56, 57, 60 Undoing intrapsychic mechanism, 30, 198, 201, 204 Unengaged interpersonal conduct, 22, 56, 57, 58, 71, 75, 79, 82, 218 Unruly intrapsychic structure, 35 Useda, D., 271 Vacillating/capricious cognitive style/content, 25, 230, 232, 234–235, 257, 260 Van der Does, A. J. W., 235 Van Dyck, R., 235 Vaslamatzis, G., 252 Veague, H. B., 225 Verkes, R. J., 253 Vexatious objects (intrapsychic content), 32, 89, 90, 93, 115

Vinogradov, S., 226 Virtuous subtype, aggrieved/masochistic, 179, 190–193 Vittengl, J. R., 141 Vocisano, C., 161 Vogel, C., 252 Voglmaier, M. M., 203 Voguish subtype, pessimistic/depressive, 144, 147–150 Vollema, M. G., 200 Vuorilehto, M., 123 Warner, M. B., 85 Waska, R. T., 272 Watson, D. C., 271 Weertman, A., 86 Weinberger, J., 16 Wells, M,, 177 Wenzel, A., 250 Westen, D., 16, 104, 225, 226, 242 Whewell, P., 235 Whitson, S., 250 Widiger, T. A., 55, 159 Williams, C. A., 251 Williams, P., 271 Wilson, S. T., 226 Woeful/melancholic mood/affect, 29, 126, 127, 132, 152, 188 Wolf, H., 226 Wolfis, M., 234 Woodruff, P. W. R., 202 Worthless self-image, 27, 119, 126, 127, 129–130, 146, 149, 152, 188–189 Yalom, I. D., 65, 140, 293 Yaryura-Tobias, J. A., 176 Yatham, L. N., 271 Young, J. E., 64, 65, 66, 83, 250 Yun-ping, Y., 86 Zanarini, M. C., 227 Zeeck, A., 252 Zeigler-Hill, V., 235 Zervis, C., 252 Zimmerman, B., 291 Zimmerman, M., 85