This programme is a treatment manual for mental health professionals. It assumes clinical training, experience with personality disorders, and a supervision framework. It replaces neither your clinical judgement nor your professional responsibility. Diagnostic criteria are reworded here in our own words, never reproduced. Two warnings specific to this indication. A preference for solitude is not in itself a disorder: this manual applies only to a way of functioning that causes distress or impairment, and it never aims at sociability for its own sake. And the level of evidence is almost non-existent: no controlled trial has studied this disorder, as section 11 states plainly.
1. The programme at a glance
Indication. Schizoid personality in adults, in outpatient settings, with distress or impairment that the patient acknowledges, after autism spectrum disorder and psychotic disorder have been ruled out.
Reference model. A cognitive behavioural therapy adapted to personality disorders, centred on the costs of detachment as the patient defines them, enriched by three borrowings: values-based behavioural activation, work on recognising emotions, and particular attention to the alliance and to distance.
Format. Treatment lasting about a year, that is, some thirty to forty sessions; this manual describes sixteen key sessions, organised in five phases, with extension points indicated. Sessions of 45 to 50 minutes, weekly or fortnightly depending on what the patient can tolerate. Written communication between sessions is accepted if it helps.
Targeted mechanism. Reducing what detachment costs without touching what it protects: treating the depression that sets in with withdrawal, making unavoidable social demands bearable, learning to recognise one's own needs and emotions, building a practical network for everyday necessities, and allowing the patient to decide freely how much room they want to give to other people.
| Phase |
Session |
Topic |
Session output |
| I. Alliance |
1 |
Meeting without intruding |
Reason formulated, distance respected |
|
2 |
What I want to change, and what I keep |
Goals chosen, things not to be touched written down |
|
3 |
Assessment |
Autism and psychosis ruled out or referred, mood and risk assessed |
| II. Understanding |
4 |
The map of contacts |
Contacts listed with their cost and benefit |
|
5 |
Chosen solitude, unwanted isolation |
Two columns distinguished |
|
6 |
Recognising what one feels |
A body-emotion record kept |
| III. Acting on what costs |
7 |
Activation based on one's values |
Three activities chosen and scheduled |
|
8 |
The social demands of work |
Two scripts prepared and tried |
|
9 |
Asking and refusing |
One request and one refusal formulated |
|
10 |
Midpoint review |
Measures repeated, plan revised |
| IV. Chosen connections |
11 |
The practical network |
Three practical contacts identified |
|
12 |
A connection at the right distance |
One contact chosen, at a chosen intensity |
|
13 |
Pressure from others |
A written position for the family |
| V. Consolidation |
14 |
What lies underneath |
Beliefs and history linked, if the patient wishes |
|
15 |
Transitions ahead |
Plan for a loss, health, ageing |
|
16 |
Review, relapse, next steps |
Plan written, measures repeated |
What sets this programme apart from the other manuals on this site. Three things. A treatment whose explicit target is not the most visible symptom. A therapist who measures success by what they do not impose. And a diagnostic category that the manual acknowledges is debated.
2. Before you begin
Who this programme is for
Psychologists, psychiatrists and psychotherapists familiar with cognitive behavioural therapy, with experience of personality disorders and of autism in adults, who can rely on supervision. This work tests the therapist's patience in a particular way: little feedback, little visible emotion, few signs of alliance. A place to talk about what this stirs up is needed.
The four preliminary decisions
1. Is this autism spectrum disorder? The overlap is considerable, and the developmental history decides. Section 7.
2. Is this anxious avoidance? Does the patient want relationships they fear, or do they not feel the desire for them? Section 7.
3. Is there depression, and suicide risk? In a patient who expresses little, they must be actively looked for. Section 9.
4. What is the patient asking for, and who is asking? Often someone else: an employer, a parent, a partner. The patient's own request, if they have one, is the only one that can be worked on.
What this programme does not treat
Autism spectrum disorder, which calls for specialist assessment and specific support, even though some tools from this manual may be useful.
Schizophrenia and its negative symptoms, and prodromal states.
Schizotypal personality, which has its own manual.
Social withdrawal due to depression without a personality disorder, which calls for treatment of the depression.
What this programme is not
It is not a socialisation programme. It is not training in becoming warm. Nor is it a therapy that assumes the patient is repressing a desire for connection that needs to be released. In some patients such a desire exists; in others it does not, and the treatment must work in both cases.
How to use it
Read sections 3 to 14 first: they ground the choices made in the sessions. The sessions described are key sessions, not a timed programme; each may take two or three, and phases IV and V are optional for patients who do not ask for them. Sections 31 to 36 detail what the sessions introduce. Section 39 says what must not be dropped.
3. The clinical picture
What defines the disorder
A lasting detachment from social relationships and a restricted range of emotional expression in interactions with others, present since early adulthood and in a variety of contexts.
What characterises the disorder is not solitude, which many people enjoy, but the constancy of the detachment, its pervasiveness — including towards family and sexuality —, and its impact.
The forms it takes
Little desire for close relationships, and little pleasure in having them, including within the family.
An almost constant choice of solitary activities.
Little interest in shared sexuality.
Few activities that bring pleasure, or pleasure that comes through intellectual, technical or contemplative activities pursued alone.
No close friends or confidants, apart, sometimes, from a first-degree relative.
Apparent indifference to praise and criticism alike.
Coldness, detachment or blunted affect as perceived by others.
What patients describe
Often, none of this as a problem. They describe a life organised around work, an interest, a routine, and other people as sources of fatigue, intrusion or misunderstanding. They also sometimes describe boredom, emptiness, a feeling of living behind glass.
When they seek help, it is for something else: an employer who criticises their distance, a parent who is worried, a partner who leaves, a mood that collapses, the death of the only person they had a connection with.
Two presentations to distinguish
The contented loner. Detachment is experienced as a choice. The patient does not wish to change their relational life; they come for a specific problem or under pressure from others. Treatment focuses on that problem, and it is short.
The sensitive loner. Beneath the apparent coldness, a rich inner life, sensitivity to intrusion, sometimes a desire for connection experienced as dangerous. Older clinical descriptions spoke of a "secret" schizoid personality; they have not been validated empirically, but they describe a profile that clinicians recognise. It partly overlaps with avoidant personality, and treatment can go further.
The therapist does not decide at the outset which category the patient falls into. It is discovered, and not forced.
What is seen in the consulting room
A polite, reserved presence. Brief, precise answers, sometimes detailed on topics of interest. Little eye contact, few facial expressions. Few questions about the therapist. Silences that do not bother the patient. Difficulty saying what they feel, which does not mean they feel nothing.
What is not part of it
Ideas of reference, odd beliefs, unusual perceptions, odd speech: these point towards schizotypal personality or a psychotic disorder. Fear of rejection with a desire for connection: this points towards avoidant personality. Communication difficulties and restricted interests present since childhood: these point towards autism.
Epidemiology, briefly
Estimates in the general population vary widely with the method and remain uncertain. The disorder is very rarely seen in clinical settings in its own right. It is associated with social and occupational impairment, and with a risk of depression and isolation in later life.
4. The cost of withdrawal: a cautious model
The model that guides this programme is deliberately modest. It does not claim to explain the origin of detachment; it describes how detachment can become costly, and where it is possible to act without fighting it.
The starting point
Relationships are experienced as unrewarding, tiring or intrusive. The reasons vary from one patient to another and are not always knowable: a temperament with little sensitivity to social reward, sensitivity to intrusion, a history of cold or intrusive relationships. Nothing is assumed.
The loops that can be costly
The mood loop. Withdrawal reduces opportunities for pleasure and meaning. In some people, the range of activities narrows to an empty routine; mood drops, which further reduces activities. This is the depression loop, and it is the most common reason for seeking help.
The demands loop. Work, administrative bodies and health care require interactions. The less they are practised, the more they cost; the more they cost, the more they are avoided, until the consequences arrive: a job lost, care postponed.
The perception loop. Others read reserve as coldness or contempt. They withdraw or insist. The patient, pressured or excluded, withdraws further.
The unrecognised needs loop. Difficulty identifying one's emotions and bodily signals means that fatigue, sadness, pain and unwanted loneliness go unnoticed. They only become visible at the point of crisis.
What treatment does
It acts on each loop without aiming at sociability: it broadens the range of activities that the patient values, including solitary ones; it makes unavoidable interactions less costly; it helps the patient recognise their own signals; and it offers, to those who want it, connections at a bearable distance.
What the model explains to the patient
That no one is trying to change who they are. That their way of living has its own logic and advantages. And that certain things cost them without their having chosen them — and that it is on those, and those alone, that the work will focus.
5. Solitude is not an illness
Why this section exists
Because a therapist's natural inclination is to assume that everyone needs relationships, and that solitude is a lack. This conviction, applied to these patients, produces goals they do not have, sessions they experience as intrusive, and dropout.
What needs to be distinguished
Introversion, a normal trait, without impairment.
Chosen solitude, experienced without distress and compatible with a satisfying life.
Unwanted isolation, where the person is alone without having wanted to be — because they do not know how to do otherwise, because they fear others, because they have lost everything.
Loneliness, which is a subjective experience and can be present among other people just as it can be absent in isolation.
What research says, and how to use it
Social isolation and loneliness are associated with poorer health and higher mortality in large population studies. These findings concern averages, and loneliness plays its own role. They justify taking an interest in the practical consequences of isolation — health, safety, help when needed —; they do not justify imposing relationships on someone who does not suffer from their absence.
Cultural and gender differences
Norms of sociability vary widely. Reserve that seems pathological in one setting may be ordinary in another. Detached men are more readily seen as "loners", detached women as "cold" or "depressed". These readings need to be checked.
What you do
You simply ask the patient whether they suffer from being alone. You take the answer seriously. And you come back to the question later, without insisting, because the answer can change — with trust, with age, with a loss.