Contextual barriers as a source of problematic detachment

Contextual variables can have a profound impact on each of the three domains that underpin social attachment:

• motivation: the environment sets the contingencies of reward and punishment that drive motivation to attach or to detach;

• interpersonal safety appraisal: the optimal level of trust versus mistrust in any given interpersonal encounter is influenced by context – what is adaptive in one situation may be unsafe or may impede healthy relationships in another;

• communication: effective social communication is a bidirectional process – contingent on both the person who communicates and the messages that they are able to receive from others.

Hence, before diagnosing problematic detachment as primarily indicating individual-level psychopathology (whether personality-based or otherwise), it is essential to consider the environment in which the person finds themselves embedded.

Social contextual factors that may especially heighten the risk of detachment include (Mirowsky Reference Mirowsky and Ross1983; Haynes Reference Haynes1986):

• feeling different from the rest of a social group (such as in school, college or workplace) because of, for example, gender, race, level of experience;

• feeling under the evaluative scrutiny of others with more power, such as professional seniors;

• subjective uncertainty regarding social status, for example when new to a group;

• actual powerlessness, victimisation or bullying;

• acute disruption of social networks;

• environments in which previously learned social skills may be less useful, for example following imprisonment or emigration (especially in the early stages);

• environments involving sensory deprivation, for example prolonged darkness.

It has been suggested (Kramer Reference Kramer1998) that such situations promote ‘dysphoric self-consciousness’ and thence hypervigilance, rumination, mistrust, a reduced motivation to socialise and interpersonal detachment. Resulting behaviours, such as withdrawal and impaired communication, may in turn exacerbate self-consciousness, resulting in a vicious cycle.

Thus, a degree of detachment due to mistrust and/or communication challenges and/or reduced motivation to mix with others is normal in some contexts. The boundary between an understandable and ‘normal’ response to challenging situations versus diagnosable psychopathology is a contested and value-laden issue: false positives may stigmatise the individual and may endorse an iniquitous status quo that entrenches unfair power differentials; false negatives may mean that the opportunity to properly address an individual’s suffering is missed. Clearly, this is not an either/or proposition: frank mental illness can be generated by pathogenic environments and there may be an interaction between such environments and pre-existing personal vulnerabilities.

Personality spectrum pathology as a source of problematic detachment

A range of distinct but overlapping personality pathologies are associated with problematic detachment.

‘Avoidant’ refers to individuals with elevated sensitivity to interpersonal rejection and consequent avoidance of social interaction. Beneath the detached exterior may lie an anguished desire to relate to others, suffocated by fears for their own psychological safety: an anticipation of humiliation or rejection. It is not that they view others as malevolent, but rather that they view themselves as inadequate and hence likely to be negatively judged by others. Not surprisingly, negative affectivity, clinical depression, substance use and suicidal ideation are overrepresented in such individuals (Lampe Reference Lampe and Malhi2018). Early neglect and emotional abuse may be risk factors for avoidant pathology (Lampe Reference Lampe and Malhi2018), but it should not be assumed that all such individuals have suffered such childhood experiences.

‘Paranoid’ refers to individuals presenting with fear of harm that is attributed to purposeful malevolence on the part of others. Their appraisal of interpersonal safety is hypersensitive, manifest as suspiciousness and mistrust. Such individuals tend to also show elevated negative affectivity and may display pathological hostility: a tendency to react angrily to perceived attacks and to hold grudges. Paranoid traits have also been linked with deficits in cognitive empathy (Lee Reference Lee2017). Unsurprisingly, childhood emotional and physical abuse are associated with such traits (Triebwasser Reference Triebwasser, Chemerinski and Roussos2013). (Note that many patients use the word ‘paranoid’ to describe any fears that underpin their withdrawal from the world; it behoves the assessing clinician to clarify precisely what a given patient means by the word.)

‘Schizoid’ refers to individuals who are preoccupied with their own inner world, keeping their feelings inaccessible to others and presenting as asocial, reserved, without warmth or humour and sometimes frankly odd (Kretschmer Reference Kretschmer1936). It has long been recognised that some such individuals have a rich inner world (‘fantasy life’) in which they evidently prefer to dwell, to the neglect of their interpersonal milieu. Detachment results from the person simply not deriving usual levels of pleasure from interpersonal connections and thus lacking motivation to develop them. Individuals with schizoid personality pathology generally show such features from childhood onwards (Wolff Reference Wolff and Chick1980). As with paranoid traits, those with schizoid traits commonly show deficits in cognitive empathy (Booules-Katri Reference Booules-Katri, Pedreño and Navarro2019). Adverse childhood experiences (such as institutionalisation) are a risk factor (Yang Reference Yang, Ullrich and Roberts2007) and some have posited that emotionally cold early caregiving engenders such traits (Choi-Kain Reference Choi-Kain, Rodriguez-Villa, Ilagan, Walker, Schlozman and Alpert2021). However, the evidence is insufficient to make any assumptions about the developmental history of any given individual based purely on their presenting with schizoid features.

In certain other kinds of personality pathology, motivation to engage in interpersonal relationships may be overridden by competing motivations to engage in other sources of gratification:

• individuals with prominent anankastic features may value work and productivity at the expense of personal relationships;

• those with prominent narcissistic features may lack interest in others except insofar as they can bolster their own self-esteem; they may also be pathologically oblivious to others’ perspectives and/or hypervigilant about the possibility of being influenced by others.

Other psychopathology as a source of problematic detachment

Develop a shared understanding

The collaborative development of a shared understanding may be an especially slow process requiring patience and diligence. More often than not, even when co-occurring psychopathology is identified, some personality difficulties will form a core part of the formulation. Shared understandings, however, require shared language: clinicians must be mindful that terminology may alienate rather than engage. The public discourse around terminology relevant to mental health is fluid and at times turbulent: the term personality disorder remains heavily stigmatised (perhaps with the exception of borderline personality disorder). A useful approach is to tailor language sensitively and flexibly in a way that works for the individual patient, but to acknowledge that it may be ‘still necessary for medicolegal, technical and procedural reasons, to keep the term, personality disorder’ (Tyrer Reference Tyrer and Mulder2022a: p. 111).

When developing a shared understanding, discussing dimensional models of personality pathology that explicate its relationship to normal personality traits can be very helpful. A focus on traits (rather than diagnostic categories), along with the idea that such traits exist on a spectrum of severity and usually only become problematic in some circumstances (while perhaps being adaptive in other situations), can help to convince a hesitant patient that positive change is possible.

Furthermore, it can be helpful to conceptualise personality traits not as intrinsically maladaptive symptoms of disease, but as part of the person’s unique psychological make-up, to be worked with rather than eliminated. The distinction between basic tendencies (i.e. core personality traits) and characteristic adaptations (i.e. how traits manifest as thoughts, feelings and behaviours, sometimes in unhelpful ways, in certain contexts) can be therapeutic gold. Although basic tendencies underlying detachment may resist change, characteristic adaptations and related functional impairments and distress are amenable to therapeutic intervention (Tyrer Reference Tyrer and Mulder2022a: p. 85). Adaptations involving inflexible, unhelpful learned patterns of expressing core traits may be agreed on as a target for treatment, with a goal of discovering new, adaptive ways of being in the interpersonal world, in harmony with the underlying personality. Individuals presenting with detachment that is initially problematic may thus be helped to ‘create a way of living that is consistent with their basic stylistic traits and needs rather than attempting to become even mildly extroverted’ (Tyrer Reference Tyrer and Mulder2022a: p. 86). This strengths-based approach recognises that detachment (as with all traits) may be a relative strength in some contexts, for example when sustained focused work conducted in solitude is required. The clinician thus helps the patient to discover ‘a niche in society that provides some degree of involvement and social status’ (Paris Reference Paris2020: p. 86).

The extent to which exploration of putative historical antecedents of interpersonal detachment is a useful part of developing a shared understanding will vary. Where there is a clear, established history of trauma (with or without co-occurring personality pathology), this may be an important consideration when making sense of problematic detachment. However, it should not be assumed that significant past trauma is always part of the aetiological underpinnings of problematic detachment or that trauma-focused therapy is always an essential element of treatment.

Treat coexisting psychopathology

Depending on the formulation, in some individuals it will be essential to treat mental illness as a first step. In some, for example where a treatment-responsive major depressive episode drives social withdrawal, this may be all that is required. In others, there will be a significant residuum of problematic detachment, often due to co-occurring personality pathology.

As well as being part of the presenting problem, mental illness may later emerge as a new problem to be addressed during treatment. For example, depression and even suicidal thinking may emerge when previous rigid psychological defences are challenged in someone with avoidant or paranoid traits. This emergent psychopathology will then require treatment in its own right; this risk, of course, further highlights the need for an appropriately measured pace of therapy in such individuals.

Be very sensitive to the dynamics of the clinical relationship

Unsurprisingly, problematic detachment is likely to play out in the dynamics of the clinical encounter. When it is driven by the patient’s concerns about interpersonal safety, the power dynamics inherent in clinical encounters will require more than the usual degree of sensitivity and attention. A patient’s expectations of mistreatment and/or rejection may otherwise be readily confirmed by even a minor oversight or careless remark on the part of a well-intentioned clinician. Specific ways of managing issues of power dynamics include:

• conveying genuine desire to understand (curiosity) rather than judge;

• avoiding rushed or overly confrontative approaches;

• starting with ‘safe’ areas of conversation and not diving into the problem head-on;

• taking special care to avoid fomenting suspicion, for example by informing the patient if contact occurs with other clinicians involved in their care;

• documenting the source of any information in the clinical file;

• empowering the patient to maximise their sense of control over their treatment;

• being open, honest and firm when necessary, explaining why particular decisions have been made, particularly decisions that may be unwelcome.

The risks of an overly warm therapeutic style with patients with paranoid personality pathology are recognised: they may misunderstand acts of kindness or words of encouragement as a cover for malevolent intention; even overly close seating may be counterproductive. Conversely, patients with avoidant personality pathology may benefit from a warmer approach, with more in the way of supportive, explicit encouragement.

Promote change, but slowly

Notwithstanding the therapeutic pessimism often engendered by problematic detachment, the promotion of positive change by clarifying collaborative treatment aims and goals has been emphasised (Lampe Reference Lampe and Malhi2018). In keeping with the ICD-11 framework that prioritises severity rather than category of personality dysfunction, measurement of the functional impact of interpersonal detachment (for example by assessment on the DSM-5 Level of Personality Functioning Scale at suitably spaced intervals) may help to track slow but enduring therapeutic change over time.

Acknowledge and manage countertransference

The value of managing and making use of common countertransference reactions, such as frustration, irritability, impotence and despair, is recognised: it has been suggested (Stone Reference Stone and Gabbard2014: p. 1002) that ‘provided that the patient is not grossly delusional and that some working alliance has been formed, the therapist in becoming cognisant of these feelings may then suggest that the patient may also be saddled with these same feelings’: clearly, the timing of such interpretative suggestions will be a matter of careful clinical judgement.

Address behavioural cycles that maintain problematic detachment

Detachment, whether primarily attributable to challenges in motivation, interpersonal safety appraisal or reciprocal communication, can readily become a self-reinforcing problem. Whether at the level of social anxiety or frank paranoia, a downward spiral can develop, whereby psychological drivers underpinning detachment ‘group together because they mutually influence each other’ (Fonseca-Pedrero Reference Fonseca-Pedrero2017). Thus, withdrawal and isolation that has developed for any reason can promote:

• further deterioration in social skills;

• aggravation of interpersonal anxiety, as the individual never learns that the world is safer than they fear;

• further diminished motivation as withdrawal becomes an ingrained habit; and

• abandonment by previously important social attachment figures, who sense that they are no longer wanted as part of the person’s life.

The exploration of such behavioural cycles with the patient can provide a useful framework for individualised cognitive–behavioural work. There is also evidence that such maintaining cycles can even be ameliorated by self-help therapy (Freeman Reference Freeman, Freeman and Garety2016). I explored their role in paranoid thinking in more detail in an earlier article in this journal (Carroll Reference Carroll2009).

Manage risks

Notwithstanding what is often a calm and superficially ‘behaviourally settled’ veneer, individuals with problematic detachment – especially those with paranoid features – may ruminate on perceived slights and may have a low threshold for feeling deliberately provoked by others. As well as violence, risks of suicide, complaint and litigation, and stalking are hence relevant concerns in treatment (Carroll Reference Carroll2009). Therapeutic work needs to be undertaken with these concerns in mind and appropriate risk management implemented from the start: a collaborative crisis plan should be developed early on in therapeutic work; for those with prominent mistrust, clinical encounters should not take place in environments where emergency help cannot be summoned.

Consider judicious use of pharmacology

Clearly, co-occurring mental illnesses such as PTSD, psychosis or major depression may require pharmacotherapy. This may be a necessary step to clarify and thence to effectively address underlying, co-existing personality pathology.

The use of medication where personality pathology alone is diagnosed is much less straightforward. Although the evidence base for pharmacological treatment of personality disorder per se is not strong, at a pharmacological and neurobiological level, a clean line between personality pathology and mental illness pathology is unlikely (Goldberg Reference Goldberg, Stahl, Goldberg and Stahl2022).

Although low doses of potent antipsychotic agents have been recommended for individuals with prominent paranoid symptoms, those very symptoms may promote suspiciousness of pharmacotherapy and hence non-adherence (Stone Reference Stone and Gabbard2014). Certainly, it would be unwise to overemphasise the role of such treatment with such individuals, particularly early on in therapy before a trusting alliance of some degree has been established.

Where schizotypal disorder is diagnosed, the antipsychotic risperidone may improve global functioning; antipsychotics may also reduce the likelihood of transition to frank schizophrenia (Kirchner Reference Kirchner, Roeh and Nolden2018).

Importantly, clinicians should beware that an underlying personality trait of detachment may shape the outward manifestations of any mental illness, such that the illness may present in an atypical fashion. Where lowered mood is a feature therefore, even if many of the usual markers of major depressive disorder are absent, an empirical trial of antidepressant medication may be indicated.