Journal of Social Work Practice

Psychotherapeutic Approaches in Health, Welfare and the Community

ISSN: 0265-0533 (Print) 1465-3885 (Online) Journal homepage: http://www.tandfonline.com/loi/cjsw20

Schizotypal Personality Disorder: A Clinical Social

Work Perspective

Joseph Walsh

To cite this article: Joseph Walsh (2016): Schizotypal Personality Disorder: A Clinical Social
Work Perspective, Journal of Social Work Practice, DOI: 10.1080/02650533.2015.1132686

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 Journal of Social Work Practice, 2016
http:/dx.doi.org/10.1080/02650533.2015.1132686

Joseph Walsh

SCHIZOTYPAL PERSONALITY DISORDER: A

CLINICAL SOCIAL WORK PERSPECTIVE

Schizotypal personality disorder (SPD) is considered to be a “schizophrenia spectrum disorder”

as evidenced in part by its cross-listing in that chapter of the DSM-5. SPD is considered to be
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a condition with limited potential for positive change because one of its major features is the
presence of a biologically based cognitive deficit. This assumption, however, is an example of
the medical model’s creating a bias against psychosocial features that are always involved in
character development. The social work profession’s bio-psycho-social perspectives focus more
comprehensively on all features of the condition and promote a more optimistic view of clients’
change potentials.The purposes of this paper are to examine SPD from a social work perspective
and to demonstrate, with a case example, how effective intervention can be organized and
delivered.

Keywords  schizotypal personality disorder; clinical social work;

mental illness

Schizotypal personality disorder: a clinical social work perspective

The newest edition of the Diagnostic and Statistical Manual of Mental Disorders contin-
ues to promote a medical model in conceptualizing mental, emotional, and behavioral
disorders (American Psychiatric Association [APA], 2013). This reductionist lens has
always been at odds with the social work profession’s bio-psycho-social perspective on
human functioning. Emerging evidence does suggest that some diagnostic conditions
have significant biological etiologies, but social workers must resist forgoing their psy-
chosocial assessment and intervention perspectives on the basis of claims that some
clients are limited in their ability to experience holistic growth. One such condition of
concern is schizotypal personality disorder (SPD), an uncommonly treated condition
on the schizophrenia spectrum that presumes a strong biological predisposition. The
purposes of this paper are to review what is known about the etiology and course of
this condition, and to demonstrate how social work’s bio-psycho-social perspective can
ensure that those clients receive comprehensive mental health care.

Schizotypal personality disorder

SPD is defined as a pervasive pattern of interpersonal deficits characterized by acute
discomfort with, and a reduced capacity for, close relationships, as well as by perceptual
distortions and behavioral eccentricities. With a prevalence of 0.6–4%, its symptoms

© 2016 GAPS
 2 JOURNAL OF SOCIAL WORK PRACTICE

include ideas of reference; odd beliefs, thinking, speech, behavior or appearance; magi-
cal thinking; unusual perceptual experiences; suspiciousness or paranoia; inappropriate
or constricted affect; and excessive social anxiety (APA, 2013). Edmundson and Kwapil
(2013) utilize the five-factor model of personality (Widiger & Costa 2013) to illustrate
its major features in the context of those factors, as follows:

• neuroticism (emotional instability) – anxiety and self-consciousness;

• extraversion (positive affectivity) – low warmth and gregariousness; few positive emotions;
• agreeableness (versus antagonism) – lacking a capability for trust;
• openness (intellect vs. unconventionality) – an interest in fantasy and unconventional ideas.
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The authors add that the person with SPD is unremarkable with regard to the fifth
factor, conscientiousness.
SPD is believed to have a genetic or biological link with schizophrenia, as 17–40% of
schizotypal adolescents eventually qualify for that diagnosis (Chemerinski et al. 2013). It
differs from schizophrenia, however, in that the person experiences less severe cognitive
deterioration, fewer social deficits, and less vulnerability to psychotic episodes (Popovici
et al. 2012). Some argue that the disorder exists in several forms; one in which positive
symptoms predominate (most often in females), and another in which negative symptoms
are more evident (most often in males). Ryan et al. (2015) further note that SPD may
have two developmental trajectories; one with adolescent onset (70% of those persons
retain the diagnosis at age 25) and another with adult onset (30% of cases), which appears
to involve more psychosocial risk factors. SPD shares overlapping symptoms with other
personality disorders, especially the paranoid, schizoid, and avoidant types. From a com-
parative perspective, some persons with SPD have a lesser fear of social humiliation and
possess a measure of emotional capacity characteristic of avoidant persons, while others
maintain a well-developed fantasy life and prefer the solitary existence of schizoid persons
(Millon & Davis 1999). However conceptualized, a majority of persons with SPD lack a
clear life plan, sense of accomplishment, strong interests, and close relationships.
In spite of its association with schizophrenia by the APA, there is no clear indication
that SPD should be considered a medical condition. The present author does not con-
sider it to be such, but rather that it represents a group of behaviors and characteristics
that result from a particular set of etiological factors, knowledge of which can provide
the practitioner with useful guidelines for intervention. Its biological influences, while
speculative, do not point to disordered neurological functioning but merely suggest
characteristics that influence perceptual processes in certain ways. Persons who meet
criteria for the diagnosis should not be viewed as disordered, but as people who expe-
rience certain types of stress for which they seek relief.

The Etiology of SPD

The precise causes of SPD are not known, but the following biological, psychological,
and social factors have been postulated.
Biological
The onset of SPD seems to require the presence, in varying degrees, of genetic and neu-
rological risk factors (Chemerinski et al. 2013). It must be emphasized, however, that
 S C H I Z O T Y PA L P E R S O N A L I T Y D I S O R D E R 3

these factors are characteristics, not deficits, a distinction that, when ignored, supports
the notion of SPD as a “disorder”. Distinguishing between “normal” and “abnormal”
biology is often an arbitrary strategy in psychiatry. Several candidate genes have been
hypothesized to play a role in the condition, although more research needs to be done
on their potential influences. The person appears to experience relative deficits in spe-
cific areas of the frontal and medial temporal lobes of the cerebral cortex. The frontal
lobes include a majority of one’s dopamine transmitters, an excess of which is believed
to create difficulties in the ability to utilize working memory and engage in abstract
thought and executive functioning (planning). These features of the temporal lobes are
associated with difficulties in selective attention and the screening of external stimuli.
All of these features, while problematic for a person’s functioning, are hypothesized
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as being more circumscribed that in persons with schizophrenia, which accounts for
the greater coping capacity in persons with SPD (Tendon 2013). A systematic review
by Ferhava and Remington (2013), in fact, concludes that such persons possess larg-
er-than-normal prefrontal structures, which may facilitate compensatory strengths.
Psychological
While certain neurological conditions seem to be a prerequisite for the development of
SPD, psychosocial experiences contribute to the nature and severity of its symptoms.
One useful psychological etiology has been postulated by Benjamin (1996). According
to her perspective, the schizotypal child typically grows up in a household characterized
by parental neglect, abuse, and a modeling of illogical thinking. The parent punishes the
child for any movement towards autonomy in ways that are confusing to the child. For
example, a parent who spends much time away from home might punish the child for
not staying at home. As a substitute for in-person parenting the adult implies that he or
she can monitor the child’s behavior even when not present. (“I know what you’re doing
when I’m away! You’d better be careful!”). The child internalizes this pattern of mag-
ical observation and develops beliefs that people may have special means of acquiring
knowledge about, and the ability to influence, others. The person has ample opportu-
nities to practice this telepathic sense throughout life as a means of interpreting his or
her own unclear internal states, which emerge because the person cannot coherently
organize his or her thoughts. Ongoing parental injunctions against peer play, and the
realization that being alone provides a safe haven from confusing interactions, further
encourage the child’s development of fantasy. The negative effects of abuse or neglect
further encourage the child’s paranoid withdrawal from most interactions.
Another characteristic of the client’s background that contributes to the develop-
ment of SPD is an inappropriate parental dependence on the child. Because the child is
usually at home he or she is often given major responsibility for such tasks as cleaning,
cooking, and laundry while the parent is away or otherwise occupied. Such a child may
come to believe (correctly) that his or her presence, while a source of evident stress for
the parent, is also essential for maintaining the household. The client has major influ-
ence on family functioning while lacking emotional connections.
Social
It has been noted that young persons with the potential to develop SPD are discour-
aged from developing relationships outside the home, and perhaps within the home.
They are oblivious to normal codes of conduct and, by responding to social situations
 4 JOURNAL OF SOCIAL WORK PRACTICE

in unconventional ways, fail to acquire an ability to comfortably engage in social en-

counters. Their resulting tendencies to find comfort in isolation set off a cycle that may
persist throughout life. Unable to grasp the everyday elements of human interaction,
they misinterpret interpersonal communication and impose suspicious frames of refer-
ence onto those situations. The preference for isolation leads persons with SPD toward
secretive activities. Social influences of SPD also include the tendency to withdraw as a
means of managing stress that is related living in urban areas (Ryan et al. 2015).
To summarize, early learning shapes the form of the client’s biologically based
thought patterns. There is a fear of being controlled and a wish that others would leave
the person alone. The individual’s natural position is one of withdrawal with a capac-
ity for magical influence. The person is comfortable with autonomy and unlikely to
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demonstrate help-coercing behaviors. The capacity to consolidate a coherent sense of

self, world, and others is lacking. The person must retreat or risk suffering psychotic
disorganization when over-stimulated by the demands of social life.

Intervention
Persons with SPD are unlikely to seek treatment on their own and are more likely than
other client populations to drop out, largely because of their difficulties forming com-
fortable relationships with providers (Ryan et al. 2015). They may have motivation to
persist with intervention, however, because of discomfort with certain symptoms, most
often related to depression, anxiety, and substance abuse (Chemerinski et al. 2013).
There may also be an external incentive for the person’s seeking intervention, such as
the possibility of losing a job. Symptom remission correlates positively with functional
outcomes, so the practitioner’s focus on sources of distress rather than the larger task
of personality reorganization can be constructive (Schennach-Wolff et al. 2009).
Utilizing the five-factor model of personality can be helpful in this regard, as it keeps
the social worker’s focus on psychosocial factors and provides a range of possible trait
targets for intervention (Lanier et al. 2013).
Regarding goals, persons with SPD can be helped to develop more normal patterns
of interpersonal relationships, enhance any sources of pleasure in their lives, and learn
to recognize when they are distorting reality. To help clients achieve these goals, the
social worker can utilize interventions derived from person centered theory, with its
emphasis on empathy and unconditional positive regard (Rogers 1951; Walsh 2013),
and cognitive-behavioral theory, which modifies dysfunctional beliefs by helping clients
understand links between perceptions, beliefs, and emotional and behavioral reactions
(Lecomte et al. 2014). The social worker can provide clients with a comfortable,
validating environment and help them acquire knowledge of social conventions, positive
coping techniques, social and anxiety management skills, and corrective cognitions
in the context of their stressful experiences. If intervention is successful, clients will
experience less distress, improvements in attention and memory (which is impaired by
fantasy), and a diminished strength of fantasy (Nathanson & Jamison 2011).
The potential utility of medications to treat SPD is not a focus of this article,
although such clients are sometimes prescribed antipsychotic drugs such as risperidone
and olanzapine, and other drugs that are targeted at certain symptoms (Ettinger et al.
2014). Many studies note that medications alleviate troublesome symptoms, but there
 S C H I Z O T Y PA L P E R S O N A L I T Y D I S O R D E R 5

is no summary evidence yet available on their long-term effectiveness (Volim, et al.,

2011).
The worker–client relationship
Clients with SPD do not understand relationships. Through a positive worker/client
relationship, however, with steady support and empathy, a client can experience a cor-
rective interpersonal experience. Because the client’s unstable core makes him or her
feel confused and threatened by outside input the social worker’s intervention should
feature a clear structure, including concrete, consistent, positive statements. The client
has trouble sorting out the relevant and irrelevant aspects of relationships so the social
worker must be prepared to spend much time helping the client test reality and gain
new perspectives on the kinds of behaviors that can promote a sense of security. The
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client may internalize the practitioner’s caring and become able to move on to tasks
involved in learning about normal socialization.
The worker-client relationship must survive the client’s extreme social anxiety and
suspiciousness. Initially the client will likely see the therapist as critical and try to main-
tain distance for safety. The client may further believe that he or she can read the thera-
pist’s mind and act on those misperceptions, which will have negative consequences for
the relationship. In the best of circumstances the client with SPD will retreat when anx-
ious, so the social worker must be patient, allowing for silences and emotional distanc-
ing. To avoid alienating the client, the social worker should attempt no more than one or
two efforts at inquiry about sensitive topics before relenting. The client’s rambling (if it
occurs) can be countered by the social worker’s requests for summary statements, and
a client’s global statements can be countered by asking for elaboration. The practitioner
must also be willing to defer to the client’s sensibilities by terminating sessions early
(when requested) and tolerating no-shows. Once the client feels accepted, he or she
may begin to disclose previously hidden aspects of the self. The client’s revelations may
include reports of an abuse history, so the practitioner must be mindful of any negative
transferences related to that.
The following interventions should not occur until later in therapy when client’s
stronger sense of self allows for a better response potential.
Cognitive / behavioral interventions
Once a relationship of mutual acceptance has been established, a number of struc-
tured cognitive interventions can be provided that have been shown to be useful in
helping people with SPD enhance their social functioning and reduce their inter-
personal anxiety. Social skills training (sometimes called cognitive remediation) has
been supported in two recent literature reviews as having positive effects when its
focus is on task learning and repeated practice (Saperstein & Kurtz 2013, Lecomte
et al. 2014). Kern et al. (2005) stress the usefulness of a hierarchical form of social
skills training, in which tasks to be learned are partialized and addressed from their
easiest steps upward. Ottavi et al. (2014) describe a kind of social skills training that
utilizes elements of social cognition training (described below) to promote change by
helping the client’s reflect on real-life episodes of concern, better understand other’s
minds by watching and commenting on prepared scenarios, and role-playing for skills
acquisition and retention.
 6 JOURNAL OF SOCIAL WORK PRACTICE

Social cognition refers to the mental operations that underlie one’s social interac-
tions, including the abilities to perceive, interpret, and generate appropriate responses
to the messages, dispositions, and behaviors of others (Green & Horan 2010, Mazza
et al. 2010). Appropriate social cognition requires that a person be able to perceive and
use emotions adaptively (identifying, understanding, and managing them) and main-
tain accurate social perceptions (awareness of social contexts, rules, and roles) and
attributions (the causes of social events as being internal or external). While these pro-
cesses are impeded by the cognitive deficits found in SPD, they can be remediated to
a significant degree with education, reflection, role-playing, task practice, and repeat-
ed rehearsal. Interventions can improve basic cognition, interpersonal comfort, and
empathy (which is in fact often preserved in persons with SPD) (Corbera et al. 2013)
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as well as attribution style (Roberts et al. 2014).

The following vignette provides an example of a person diagnosed with SPD and
the ways in which the above interventions facilitated a successful outcome for the client.
While the course of the intervention included three phases, these were not anticipated
in advance by the social worker.
The bison lover
Inola Ridgeway (a pseudonym) was a 29-year-old single Native American woman who
worked as a research assistant in a large public organization. She came to the agency
at the behest of her employer, stating that she wanted to become “more like a person”.
Soft-spoken and anxious in demeanor, Inola explained that she had a hard time getting
along with co-workers, whom she believed always made fun of and gossiped about her.
She added that she didn’t really want to change, but wanted to become able to minimally
fit in with co-workers so they would leave her alone. During the first appointment, and
for months to come (the intervention lasted two years), Inola apologized repeatedly for
having trouble putting her thoughts into words. She was clear from the outset, however,
that she would not take any medications, saying “they’re poison”.
Inola’s social worker was a 40-year-old Caucasian male named John. He had
a difficult time conducting an assessment because she was extremely guarded. She
wouldn’t say where she worked, because “it’s not important for you to know that”, but
she described herself as a member of a work force that applied statistical methods to
research data. All she wanted was to be able to go to work, go to her desk (in a shared
open space), carry out her assignments in peace, and go home at the end of the day
without interacting with anyone.
To Inola, “The only reason people talk to each other is to get something out of
them.” She interpreted all efforts to engage her in conversation as malicious; ploys
for others to learn how they could take advantage of her. Of course, her standoff-ish
attitude did bring on ridicule from others who saw her as “weird”. She mentioned that
when stressed she often “spaced out”, losing track of periods of time (10–20 min) and
she had a habit of mumbling to herself as a way of “keeping going”. Her supervisors
“think I’m weird, too”, although since she got her work done they tolerated her behav-
ior. The one pleasure Inola enjoyed was taking short breaks at work and going outdoors
to observe the small herd of bison kept on the company’s extensive grounds. She said it
“felt peaceful” to do this.
In her personal life Inola stuck to a rigid daily routine. She usually stayed in her
apartment, feeling anxious and unsafe. She said, “I don’t have any interests. Everything
 S C H I Z O T Y PA L P E R S O N A L I T Y D I S O R D E R 7

I do is for diversion, so I won’t feel anxious”. Inola engaged in craft activities at times
(making jewelry) and owned a cat. She slept poorly, waking up with frequent night-
mares. When her neighbors made overtures to get to know her she felt certain that they
were “out to get something”.
Inola eventually shared some details of her personal history. The social worker
learned that Inola grew up in an isolated, tumultuous household, feeling frightened
and vulnerable. She was the older of two children (a brother was two years young-
er) born to a Caucasian mother and Native-American (Cherokee) father. The family
had no involvement with her father’s culture, but Inola had a distinct Native American
appearance, which brought her unwelcome attention. She said, “People are always ask-
ing, ‘What are you?’ So you see, they know I’m not a real person.” Her father abandoned
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the family when she was two years old. She recalls a childhood of abuse and neglect
from her mother, brother, and extended family. Inola recalled much illicit drug use by
visitors to the apartment. Her mother often left the children at home alone for days at
a time. Inola was forbidden to have friends, in order (she suspected) to keep the fam-
ily secrets safe. Inola said that between the ages of ten and twelve she was a victim of
occasional sexual abuse from several older male relatives. At age 13 she called the local
Department of Human Services to report her mother for neglect but an investigation
could not establish whether this was occurring. She reported that her brother was “out
of control” and now in jail. She described her entire extended family as “deranged”.
Incredibly, Inola not only finished high school (where she was made fun of because
of her clothing and withdrawn manner) but she took out loans to attend college in an
effort to get out of the house. She was eventually successful in getting a degree in public
administration, although the experience was painful. She lived alone and remembers
her mother calling her frequently to “come home”. Inola was a poor student (“I couldn’t
concentrate”) and she failed as many courses as she passed. Still, she persisted, graduat-
ing in eight years after stops and starts at four institutions. Afterward she began a series
of administrative assistant jobs, which she liked because of their solitude. She had been
fired from two of these jobs in the past four years, however, for “unprofessional behav-
ior”, being told that she was making the other staff uncomfortable.
Inola had been in one significant relationship outside the family, with a young man
she met in high school and spent time with so she “wouldn’t have to be at home”. Dur-
ing her college years she moved in with the man but “hated every minute of it”. She
described the man as immature and physically abusive. They never had a sexual rela-
tionship, partly because Inola hated to be touched. She added that living with a man was
protective in that she could tell other people she “had someone”. Inola had recently left
him after thinking about doing so for a full year.
Diagnostic assessment
Inola was highly anxiety and experienced cognitive distortions. John decided after their
fourth visit that she most clearly met the criteria for SPD. Inola met six of the nine
criteria including ideas of reference (activities going on around her all pertained to
her), paranoid ideation, constricted affect, lack of friends, excessive social anxiety, and
odd behaviors (mumbling and giggling inappropriately, the loss of time). On the other
hand, she demonstrated appropriate grooming and dress and did not appear to engage
in magical thinking. These latter two characteristics made John feel that her personality
 8 JOURNAL OF SOCIAL WORK PRACTICE

disorder was the result of severe social and developmental deficits and relatively mild
biological influences.
Intervention
Phase 1
Inola agreed to bi-weekly sessions. She had little awareness of basic social conventions,
so John suggested that they work on developing a set of appropriate social responses
that she could utilize at her job. Inola agreed, so over the course of several months John
offered a repertoire of simple responses that Inola could use when approached by oth-
ers, such as, “Hello, how are you?”  “I’m fine”  “No, thank you, I’m busy”  “Sorry, have
to get to work.”  They practiced these social skills in role-plays and John suggested that
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she write the responses on index cards to keep at her desk so she could review them
each morning. Inola, after trying to use these prompts, would usually report that she
remained confused about when to use each one, and she expressed fears of not knowing
how to respond if a co-worker followed up her comments with additional questions or
statements. The process moved slowly.
Phase 2
A turning point came a few months later when John asked how the intervention was
going for Inola. She surprised John by stating that she was often angry with him, believ-
ing he did not understand and was often critical of her. Having been invited to share her
impressions of the process she often came to subsequent sessions and complained about
John’s “attitudes” the previous week, using examples. She said that she never knew how
to respond to John’s demeaning comments at the time but reflected on them on her
way home. It appeared to be helpful to Inola that John accepted her critical feedback
non-defensively and repeated his desire to understand and be of help to her. As one
example, he mentioned his lack of knowledge about Cherokee culture and eagerness
to understand it. She offered no information in this regard but accepted his interest as
“possibly” genuine. Inola’s comments made John aware that he was moving too fast with
his client, being too directive and agenda-driven. He was aware, too, that the client did
not always respond well to his affirmations of her strengths (tenacity, good work per-
formance, intelligence, and sensitivity) but accused him of patronizing her. John made a
point of inviting her feedback at the end of each session, and Inola eventually acknowl-
edged that John was trying to be supportive. At the many times when John wondered
if Inola was benefitting from the intervention, he considered her perfect attendance as
evidence that it was meeting some of her needs.
John reduced his structuring of sessions around social skills development and
focused more on listening to and empathizing with the client. He continued to try
to help her problem-solve but was more intent on her need to be understood. Inola
responded positively, becoming more verbal and disclosive. John was able to maintain a
focus on enhancing the client’s social cognition, speculating about what might be on the
minds of her co-workers in various situations while validating Inola’s own perspectives.
He helped her to consider alternative interpretations of the motivations of others.
He also asked her to speculate about what might be on his own mind during their
interactions and she became more open in her responses.
It was at this time that Inola disclosed general information about her history of
neglect and sexual abuse. John wondered what kind of transference she might be having
 S C H I Z O T Y PA L P E R S O N A L I T Y D I S O R D E R 9

toward him since was a male who could be perceived as having a controlling position
in her life. He raised this issue with her directly, and Inola appeared to give it careful
thought before responding that she had been abused in various ways by both men and
women, and so she evaluated each person individually with regard to threat potential.
John said then, and at other times during their meetings, that he understood her fears
of abuse and hoped she would point out if he seemed to be a threat to her in any way.
Inola agreed to this and, while never raising the point herself, always processed her
feelings when John brought up the topic. It seems that she slowly developed a sense of
comfort with him.
Phase 3
After more than a year John observed another turning point in their work when Inola
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surprised him with a new kind of sharing. She reported, with a smile on her face, that she
had noticed a newborn bison calf on the company’s grounds. This was the first time that
Inola had ever shared something without being asked, and she obviously enjoying the
retelling of the event. They had a long conversation about the bison and about animals
in general. This was a spontaneous sharing of an event that had no direct pertinence to
Inola’s presenting issues. John realized that Inola was more at ease with him and able
to know that another person might enjoy hearing about one of her experiences. He
took this as evidence that she was experiencing growth in her ability to interact with
reciprocity.
Inola also demonstrated change in her reports that she was making occasional efforts
to spend time with a few co-workers or training seminar classmates in social settings.
She had accepted invitations to join people for lunch or to participate in “safe” activities
such as a local 5 K walking event. When John asked if she enjoyed these outings, Inola
responded, “It’s a way to practice being a person. I still don’t know what I’m supposed
to do. I just try to keep quiet and fit in.” Inola added that she didn’t know what her
peers thought of her at these times, but she focused on her efforts to “be there” and left
it at that. Still, she could tolerate being with others, if only peripherally, and her fear of
being judged had diminished.
After two years of therapy, Inola accepted a transfer to a branch of her organization
located in another state, for more money. During their final meetings John helped Inola
plan for the changes that awaited her. The client didn’t think that her life would be any
different after the move. “I still just have to get my work done”, she said.
Intervention summary
John was confident that Inola had benefitted from her two years of bi-weekly
intervention that included modeling, relationship development, social skills training,
and social cognition training. She had remained in therapy, kept her job and qualified
for a higher-paying re-assignment, and increased her ability to tolerate interaction with
others. At the same time, Inola could not say for certain that the intervention had done
her any good (“I still don’t feel like a real person.”) On reflection John was pleased with
his intervention approach, especially his decision to focus as much on their relationship
as the skills-development strategies. He recognized a major mistake in their first six
months together when he “pushed” those cognitive interventions in a way that seemed
to feed into her sensitivity to being negatively judged. It is possible that, had her desire
to maintain employment not played a major role in her ongoing participation, she may
have dropped out of treatment at that time. John concluded that Inola, who had never
 10 JOURNAL OF SOCIAL WORK PRACTICE

before had an affirming, supportive relationship, internalized some feelings of self-

worth and developed confidence that she could indeed become “more of a person”.

Summary

Persons with SPD experience some cognitive deficits but they also possess capacities to
compensate for those limitations. Most research on the disorder emphasizes its biolog-
ical rather than psychological and social factors, but the disorder can be viewed more
holistically as a bio-psycho-social rather than a medical condition. It is best to consider
the diagnostic criteria as a summary of characteristics and behaviors to address rather
than evidence of an internal disorder. With a positive clinical relationship persons with
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SPD may be receptive to psychosocial interventions that can help to improve their qual-
ity of life even if many of their “odd” behaviors persist.

Disclosure statement

No potential conflict of interest was reported by the author.

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 12 JOURNAL OF SOCIAL WORK PRACTICE

Joseph Walsh is a Professor of social work at Virginia Commonwealth University in Richmond,

VA. He has a longstanding interest in clinical social work practice, particularly with persons who
have serious mental illnesses, and he has written widely on those topics. School of Social Work,
Virginia Commonwealth University, 1000 Floyd Avenue, Richmond, VA 23284-2027, USA. [email:
[email protected]].
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