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The paranoid personality is a challenging psychotherapy case. Most paranoids resist serious delusions; they come into contact with psychological services only at the request of others, as in two of the case studies in this chapter. A spouse may insist on either therapy or divorce, or a boss may insist on either therapy or termination. Most paranoids are regarded as suspicious, testy, and emotionally closed. The greatest improvement is likely to occur in subjects who are fairly high functioning, where the expectation of sadistic treatment is not so deeply ingrained and the notions of persecution are more open to reality testing and falsification. In more severe cases, therapy may make particularly troublesome periods infrequent but cannot revamp the entire personality system.

As noted by Turkat (1990) and as with most pathological personality patterns, paranoids do not present stating, "I need help, I am paranoid," but instead present seeking symptom relief from the fallout of their own hostile vicious circles. One subject may complain of an inability to relax, another may want to become more assertive because others are so antagonizing, and another may complain of being passed over for a promotion. Because symptom-focused treatment misses the real problem, therapists should be sensitive to the possibility that these symptoms are driven by an underlying personality disorder and ask, "Why is this person having these problems?" (p. 47). Questions must be offered in a supportive context, however, for paranoids are naturally secretive and do not readily lay themselves open to scrutiny by others.

Therapeutic Traps

Perhaps more than with any other personality disorder, therapy with the paranoid subject is a battle to avoid numerous traps. Many ways to go wrong exist. Without a doubt, the most lethal is direct confrontation of semidelusional notions. Paranoid systems are not scientific hypotheses and cannot be disproved through supposedly objective evidence. First, paranoids' beliefs that others are attacking them are an empirical fact from their developmental history, one carried into inappropriate contexts in adulthood. Such beliefs are so core to the identity of the paranoid that success means a falsification of the self. Confrontation thus implies that something is wrong with who the subject is and, therefore, becomes just another attack. Even the most well-intentioned therapist may thus become the object of suspicion.

Just beginning therapy is highly stressful to most paranoids. Because fears of attack and blame drive the disorder, trust and the therapeutic alliance become a critical priority. Many therapists push for progress faster than trust can be established. Others may directly assert that they can be trusted, an effort that paranoids usually perceive as devious. Once an alliance is established, it remains fragile; one ambiguous slip can be interpreted as condescending and hurtful, destroying whatever foundation has been laid, and set therapy back months. Stone (1993) distinguishes between paranoids whose parents were abusive and those whose parents were both abusive and deceitful. The latter, he suggests, constantly fear that others are lying to them and sometimes require many months or years just to trust the therapist.

Moreover, because intimacy makes paranoids feel exposed and vulnerable, they often react against perceptions of closeness and warmth by retreating into the safe shell of emotional isolation. Some may even quit therapy. Unconditional warmth is a new experience for individuals perpetually mobilized for unexpected, vicious onslaughts. Overea-ger efforts to draw the paranoid back into the open usually intensify feelings of discomfort. During such times, patience is a virtue. Therapists should not require greater comfort in the transference than what the paranoid can give. Accordingly, time, consistency, and an "I'm okay, you're okay" attitude that respects the need for distance are probably the best course. Distance at least gives control back to the paranoid; any other path requires the subject to submit to someone not yet trusted, a contradiction.

Because paranoids are often blaming and abrasive, they naturally provoke the same countertransference reactions. Seldom are they the most rewarding clients. Nevertheless, progress requires that no defensiveness and counterhostility seep into the therapist's communications. Therapists must contain their own defensive and hostile feelings. Otherwise, a realistic basis for feelings of attack and vulnerability is created, and therapy just replays the same vicious circle that paranoids experience in real life. In response to provocation, some therapists naturally become more directive and take control of the session. This humiliates the paranoid, who senses the loss of control and feels that the therapist is trying to expose him or her to vulnerability and attack. Accordingly, directive interventions should be closely inspected for their underlying motives, especially when the therapist is male or has competitive issues or issues with authority.

Finally, offering interpretations and comments to paranoids is a fine art that develops only over time. Given their hypersensitivity to slights and their tendency to oversimplify, the most well-intentioned comment can be transformed into slander, laying the foundation for a grudge that sabotages further work. Some paranoids are sincere in their misperceptions; others enjoy the power of making the therapist squirm under the illusion of having offended them. During such tests, the subject is exquisitely interested in the therapist's reaction: Will the therapist blame the subject or simply set matters straight without the need to blame anyone? By containing his or her own negative counterreaction, the therapist passes the test and sets the groundwork for a very different kind of relationship. Therapy with paranoids always requires tact, the ability to phrase comments so that alternative, hostile interpretations are disallowed.

Therapeutic Strategies and Techniques

Writing from an interpersonal perspective, Benjamin (1996) suggests that paranoids naturally see the therapist as critical and judgmental and that when trust is finally established, treatment is already well underway. Because paranoids were taught to be loyal to the family, they are usually reluctant to explore connections between the developmental past and their behavior in the present. Confiding in the therapist amounts to betraying family secrets to a stranger.

Given their history, paranoids require what Benjamin (1996, p. 332) calls "noncoercive holding," basically, soothing empathy and affirmation as an antidote to early abuse. In addition, paranoids should eventually realize that their own feelings of vulnerability do not automatically mean that they have been attacked and that the expectation of attack follows directly from their experiences with caretakers. By realizing that their own hostility implicitly puts them in the role of their abusers, paranoids may find the will to explore alternative roles. By separating emotionally from caretakers, paranoids can purge themselves of vicious introjects that keep attacking night and day and must be projected, thus absolving themselves of hostility. Benjamin also suggests that countertransference feelings are best admitted honestly and constructively. This offsets a major childhood factor for most paranoids: the implicit attitude of condemnation felt from their families.

Writing in Beck et al. (1990), Pretzer notes that the paranoid personality is perpetuated by core beliefs that others cannot be trusted and will intentionally inflict hurt where possible. Interventions should modify this assumption, without being perceived as a personal attack. Because paranoids require safety, they are unable to relax their vigilance and defensiveness, core factors in perpetuating the disorder. Accordingly, a heightened sense of self-efficacy should function to reassure subjects that problems will not be overwhelming but can be handled effectively as they arise. Eventually, self-efficacy should lead to a measure of relaxation, thus making the paranoid accessible to traditional cognitive methods, such as the exploration of automatic thoughts. However, such techniques require disclosure, which makes the secretive paranoid uncomfortable.

Accordingly, Pretzer suggests therapy should begin behaviorally, by focusing on goals set by the subject and approaching the least threatening goals first. Because these problems are a consequence of the total personality system, issues that the therapist might select as a point of intervention are inevitably brought into play. There are two principal ways that self-efficacy can be increased. First, paranoids often overestimate the intensity of objective threats or underestimate their ability to solve the problem. Here, more realistic assessments lead to an improved sense of efficacy. Second, if skills appropriate to the situation are lacking, intervention can focus on teaching coping skills that might reduce the subject's sense of threat and anxiety.

Finally, Pretzer notes that cognitive style interventions can address the paranoid's black-and-white thinking and tendency to overgeneralize. Subjects can be asked to rate the extent to which others have followed through on particular requests, for example, or to rate their own competency in particular areas. Focusing on specifics breaks down totalizing cognitions, puts persons and events in a more realistic light, and brings a measure of complexity to a dichotomous worldview. By generalizing from the therapy session to real life, paranoids are able to assess situations more competently and with greater objectivity, defusing their need for projection. New perspectives on others can be gained by monitoring interpersonal experiences and the cognitions and emotions that accompany them. By gathering more information, paranoids fill in the gaps that exist in their fund of knowledge about the motives of others. Alternative explanations can then be explored.

From a behavioral perspective, Turkat (1990) discusses a variety of techniques that can be useful with paranoid personalities. Hypersensitivity to criticism produces anxiety and should, therefore, be accessible to behavioral techniques of anxiety reduction. Essentially, the subject first learns some antianxiety response, perhaps progressive muscle relaxation or cognitive modification. Next, a hierarchy of anxiety-provoking situations is constructed. As the subject moves upward, each situation in the hierarchy is paired with the antianxiety response. With repeated trials, subjects gradually learn to control the intensity of their anxiety, and the anxiety itself begins to be extinguished and is replaced by a relaxing alternative.

Because anxiety is only a surface manifestation of the disorder, however, Turkat (1990) recommends that the social behavior of the paranoid be modified. First, the breadth of social attention should be examined, perhaps by having subject and therapist watch videotapes of human interaction, perhaps a soap opera. Because paranoids miss a variety of social cues, the clinician can easily evaluate how their attention is distorted and provide corrective feedback that permits them a more realistic picture of human relationships. Social information processing can be modified by teaching the paranoid the correct interpretation of social cues, accomplished through role playing, videotaped feedback, and direct instruction. The hope is that subjects will eventually learn to take the observer role and become self-correcting.

The psychodynamic perspective emphasizes many aspects of these approaches but also draws on the theory of bipolar self-representations—that paranoid grandiosity compensates for underlying feelings of depression, including low self-esteem, vulnerability, inadequacy, powerlessness, and a sense of defectiveness or worthlessness. According to Kleinian object-relations theory, the paranoid-schizoid position is a primitive stage of development, during which the synthetic functions of the ego do not permit the good and bad characteristics of self and others to be integrated. In the paranoid personality, the "good me" and "bad me" are separate entities, with the "bad me" being projected out of the self and onto others, who become attackers and persecutors. Because the paranoidschizoid position resolves into the depressive position, treatments that can convert paranoid thinking into an acknowledged depression are more likely to be successful.

At this more advanced stage of object-relations development, ambivalent feelings and disappointments are tolerated and contained and, therefore, become amenable to conscious reflection. Moreover, by moving from paranoid projection to depression, the subject can be treated by more traditional methods. As stressed by Gabbard (1994), the ultimate purpose of therapy is an attributional shift, whereby paranoids come to see their problems as deriving from internal causes, not the external environment. Psycho-dynamic thinkers also stress the value of empathizing with the paranoid view of the world and of relationships, while also suggesting alternative interpretations. Therapists should acknowledge the possibility that some negative interpretation is correct but nevertheless seek to shift the weight of probability to a more adaptive or realistic hypothesis (Stone, 1993).

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