Patients with schizoid personality disorders (SPD) often challenge clinicians because of their seemingly detached and restricted affective behaviour, which may be interpreted as lack of motivation for treatment and lifestyle changes. However, Bleuler indicated the intrapsychic dynamics of ambivalence in schizoid disorder, and it has been discussed in later literature on psychopathology. Schizoid ambivalence refers to contrasting feelings in patients of a seemingly emotionally detached appearance that may curtain an inner, heightened sensitivity and longing for closeness. This article introduces different diagnostic and theoretical descriptions of the ambivalence construct in the schizoid personality disorder. The discussion is elaborated by means of a case example, presenting both the patient's and professionals' points of view on the treatment process. We use the concepts of treatment alliance and countertransference as explanatory models in the discussion of how the schizoid ambivalence may affect the treatment relationship.
KEYWORDS: schizoid personality disorder; ambivalence; treatment relations; case example
In our work with patients with substance use disorders, we have frequently noted that over the years some patients tend to be "forgotten" by their therapists and caseworkers. These patients initially present as awkward, yet friendly and compliant. As the patient is not very problematic, he (usually, it is a male patient) does not come up in regular supervision; little or no progress is noted by the caseworker or therapist, and as time goes by, the therapist tends to lose "interest" in the patient, directing focus and attention to other more challenging or engaged patients. When we teach psychopathology at workshops for caseworkers and therapists, we suggest that often this pattern emerges when patients suffer from schizoid personality disorder. We suggest that this pattern emerges because the patients are unable to communicate their difficult feelings and inner worlds, but we also stress that a substantial proportion of patients with this disorder may experience more benefit from treatment than they are able to communicate. Most participants in such workshops tend to react with a mixture of relief and shame to these descriptions: They recognize that one of their patients might have a schizoid disorder, and they have indeed either lost interest or distanced themselves from him, reasoning that he was friendly, maybe strange, and probably lonely, but because he did not complain or cause ruptures in the treatment setting, he was also a patient with whom they did not feel very involved.
The American Psychiatric Association (2000) reports that the prevalence in the general population of schizoid personality disorder (SPD) in the general population is less than 1%. Other studies have found a community prevalence of 3.1% in the United States (Grant et al., 2004) and a higher prevalence in substance abusing and primary care and medical samples (Kosson et al., 2008). In surveys with a more general focus on personality disorders, schizoid personality disorder is associated with a childhood history that includes a lack of positive parenting (Cohen, Brown, & Smailes, 2001), and is associated with alcohol and drug dependence, but not abuse, and with depression and anxiety disorders (Grant, Hasin et al., 2005; Grant, Stinson, Dawson, Chou, & Rúan, 2005). Prototypic cases of SPD are rare and often blended with avoidant or schizotypal disorders (APA, 2000).
The literature is rich with descriptions of SPD. Eugen Bleuler coined the term schizoid in 1908, describing persons with schizoid features as shut-in, suspicious, and comfortably dull, while simultaneously sensitive and in pursuit of vague purposes, frequently occurring in the prepsychotic personality of schizophrenic illness (Bleuler, 1976). Bleuler argued that ambivalence was a consequence of the schizophrenic association disturbance, representing a tendency to experience contrasting feelings (affective ambivalence), intentions (ambivalence of the will), and thoughts (intellectual ambivalence) to situations, objects or people, for example, experiencing love and hatred for the same person (Bleuler, 1976). …