The therapist notices that in many interchanges, Clarissa verbalizes from a defeated and worried stance. Moreover, in her body language, facial expressions, and other non-verbal communication, Clarissa seems excessively sensitive and vigilant that Elliot will say something accusatory. She expresses much more aggressively and with hostility that seems uncalled for. Although she verbally is deferential and even insecure, Clarissa's interactions with Elliot as well, as with the therapist are tense. When Elliot attempts to lighten the atmosphere with a joke or irony, Clarissa becomes annoyed. She interrupts him with an impatiently expressed challenge to "get to the point!" When the therapist gives an interpretation about Elliot's process to relieve tension, she leans back and crosses her arms. It is a clear communication that she thinks the therapist is full of it. After a couple of sessions, the therapist suggests that the partners take some personality tests and go through a process for establishing therapeutic goals. Clarissa reacts angrily and with disappointment when the therapist explains how shared goals help therapy as the therapist, the partners, and the couple work more cooperatively. When Elliot agrees that he is willing, Clarissa declares that she does not like to be analyzed by some "bullshit test" that will label her and give Elliot and the therapist excuses to screw with her.
Clarissa gets more animated and her face contorts in rage, her neck bulges, and her voice gets loud. She accuses Elliot and the therapist of a conspiracy against her, stands up suddenly, and declares icily that she has had enough. Before exiting however, Clarissa says "Same time, next week" confirming another appointment. Elliot, alone for a moment with the therapist says it is as if Clarissa shifts from one persona to another. Sometimes, Clarissa does not have the desire or energy to deal with any close examination. Another time, she feels guilty that she takes advantage of him. Clarissa becomes depressed, realizing that her parent had taken advantage of her previously. However, her most problematic and consistent stance arises out of feeling threatened and distrusting Elliot, or as happens in the session distrusting the therapist. Clarissa reacts as if Elliot or the therapist is purposely abusing her for their enjoyment or using her in some manipulative exercise.
Clarissa becomes infuriated and accuses Elliot of being the perpetrator. She twists any corrections, attempts to divert the hostility, and reason into further proof of unfounded accusations. These hostile reactions often confound Elliot and potentially, the therapist as well. Unlike emotionally charged interactions between many partners that erupt and recede, Clarissa's unapologetic and consistent vitriol is pervasive in their interactions. Assertive language and actions are more frequently aggressive than not. Aggressive words and behavior readily become abusive attacks clearly intended to hurt Elliot. Much of her behavior fits within definitions of emotional abuse and may readily be considered domestic violence short of physical harm. The therapist should investigate if she crosses the physical boundary and intimidates or strikes Elliot. She seems to be simultaneously very much in control and out of control. Her hurt and anger get triggered suddenly and intensely over often very trivial issues. And then, she goes off without any possibility of restraint. Yet when triggered, she can be very purposeful in blasting Elliot or quite calculating in going after his most vulnerable sensitive wounds. Unjustly and continually accused of crimes that he did not commit, and then, slammed or skewered, Elliot get angry and becomes liable to give up in therapy... and in the relationship. The therapist is likewise vulnerable to becoming offended and inclined to quit. Elliot and the therapist's experience of Clarissa is no surprise once they recognize that Clarissa has paranoid personality disorder.
Review of paranoid personality disorder finds Clarissa's behavior not just with Elliot, but also with the therapist fitting an identifiable pattern. "The Treatment Protocol Project (1997) lists paranoid behaviours that may be recognized, including: inability to confide in others, hostility if it is perceived they are being schemed against, reluctance to sign documents, excessive concern about confidentiality, and a history of repeated termination of employment. Pathological jealously concerning faithfulness of partners is also common (Carrasco & Lecic-Tosevski 2000). Beck and Freeman (1990) also describe possible symptoms of paranoid personality disorder: tendency to attribute blame to others, difficulties considering alternative explanations, searching intensely and narrowly for evidence, inability to see humour in situations, strong need for independence, and inability to relax and close his or her eyes. Self-protective behaviours may be evident such as locking doors, closing windows and curtains, hiding papers, not forming close relationships, isolating themselves (Carrasco & Lecic-Tosevski 2000), as well as hypervigilance (Beck & Freeman 1990; Bernstein et al. 1993; Meissner 1996)" (Hayward, 2007, page 17).
The therapist interacts with both partners in therapy. Nothing however that occurs between the therapist and Elliot is benign to Clarissa. She often infers meaning- negative meaning to their interactions and words, as she frequently infers disreputable meaning in Elliot's actions and words at home and with others. "Paranoid personalities find causal connections everywhere; nothing is coincidental. They think that others are taking special notice of them and see references to themselves in innocuous behavior and irrelevant events. They are constantly on guard, searching for hidden motives and meetings. Once they fix on an idea or explanation, they look for evidence to validate their prejudices, and it is almost impossible to change their minds. When something goes wrong in their lives, they believe that another person is to blame. Some are arrogant, but others may be secretive because they fear that anything they say or do will be used against them. That can be a self-fulfilling prophecy because apparent coldness and arrogance make others uneasy, and mistrust provokes mistrust. According to the familiar saying, even paranoids have enemies. In fact, it is especially paranoids who have enemies because their attitudes and behavior provoke real hostility, further feeding their suspicions." (Harvard Mental Health Letter, 2004, page 1).
The therapist may assume the commitment of the individual and particularly, both partners in a couple to therapy. If entry into couple therapy appears to be volitional, assumptions of partners' investment and trust may cause the therapist not to fully consider this diagnosis. Or, the individual may hide his or her paranoid attitudes well, particularly in the early stages of therapy. "The diagnosis is rare in inpatient populations (Fulton & Winokur 1993; The Quality Assurance Project 1990), which may be a result of clinicians having a too low threshold and therefore underdiagnosing the disorder (Beck & Freeman 1990; The Quality Assurance Project 1990). When the diagnosis is made, it is more common in men (Bernstein et al. 1993; Fulton & Winokur 1993), prisoners, refugees and immigrants, the elderly, and the hearing impaired (Bernstein et al. 1993). It has a prevalence of 0.5–2.5% in the general population, 10–30% among those in inpatient psychiatric settings, and 2–10% among those in outpatient settings (American Psychiatric Association 2000)" (Hayward, 2007, page 16).
As women, Clarissa or Madeline's behavior may be interpreted as female sensitivity or hypersensitivity- perhaps, as borderline issues. In men such as Elliot or Dirk, the same behavior may be more readily considered paranoia. Individuals can be assessed along a continuum of hypo-sensitivity, sensitivity, hypersensitivity, and paranoid sensitivity. Is Clarissa's experience of Elliot and the therapist's words and behaviors appropriately sensitive- that is, in proportion to intent and motivation? Or, is she hypersensitive or paranoid? With Madeline and Dirk, the therapist would be correct in noting that at times both partners became hypersensitive and occasionally paranoid. When an individual is aroused from feeling hurt from the words or actions of the partner, his or her sensitivity would be sure to increase. A key differentiation would be whether their hypersensitive and paranoid states were transitory or characterological. If positive experiences of reconnection, intimacy, and good will occur, then ones sensitivity to further hurt should lessen. This appears to be relevant with Madeline and Dirk. The individual can also range along a spectrum in terms of hypo-vigilance, vigilance, hypervigilance, and paranoid vigilance. Vigilance scans and assessing others and the environment for potential dangers before they arise and difficult to deal with. Vigilance should increase with identifiable people and in identifiable situations of unpredictability and risk. And should decrease with identifiable people and in identifiable situations of relative predictability, safety, and security.
Do Clarissa's experiences of Elliot lead to appropriate vigilant? Is he relatively "safe" to be around? Or, has he said or done negative things to her that would cause her to be highly vigilant to paranoid that he might harm her again? Increased vigilance becomes logical and necessary when there have been frequent and painful transgression against oneself. And, more relaxed awareness and observation of the other person and circumstances become normal. Elliot asserted that he does not purposefully do hurtful things to her. He complained that Clarissa stays angry and accusatory when he has done nothing harmful to her. In fact, he gets no credit when he is attentive and supportive. If his characterization of their relationship is accurate, Clarissa should have been reassured by his behavior, unless there are other compelling reasons for her to feel highly vulnerable. Such reasons include trauma and personality disorders, which must become the object of therapeutic exploration. With both couples, the therapist needs to assess the level and intensity of sensitivity and vigilance between partners. Further assessment may be needed to determine if Madeline and Dirk's excessive sensitivity and vigilance is transitory or characterological. Therapy changes if it is largely transitional. Clarissa, on the other hand, fundamentally remains in an aroused sensitive and vigilant paranoid state whether or not there are current problematic episodes. In addition, it is arguable that her litany of Elliot's transgressions is about legitimate abuse or a product of her paranoia. Therapy with an individual with paranoid personality disorder and couple therapy with one such partner becomes more complex and difficult. Conflict, control, and getting out of control have increased intensity and become less amenable to therapeutic strategies and interventions ordinarily effective with non-paranoid partners in couple therapy.
PARANOID PERSONALITY DISORDER SUBTYPES
Paranoid personality disorder can be split into two subtypes. "Schneider, Hamilton, and Shapiro propose two subtypes: one weaker, passive, secretive, and cynically brooding and the other stronger, actively defiant, openly angry, and litigious. The former appears to have a kinship with schizoid personality and the later with narcissistic personality. Such nosological linkages within the severe-character-pathology spectrum do make phenomenological and theoretical sense. It may, however, not be a matter of subtypes but of a varying level of social functioning manifested by individual paranoid patients" (Akhtar, 1990, page 21). It may be that some individuals are able to function more adequate, perhaps for example, in less social settings and behave more overtly aggressively and defiantly. On the other hand, some individuals with less strong ego structures are "passive, secretive, and unable to translate their inner programs into real action." The therapist may have greater difficulty recognizing the more passive type, while noting the more overtly aggressive and expressive type. It is also possible that there may be a difference in the likelihood of which type opting to submit him or herself in therapy. The more passive type would be more likely to come to therapy but sabotage it through not showing up and lack of participation, while the more defiant type less likely to come to therapy. If in therapy, the defiant type would be angry and aggressive in sabotaging or terminating the process.
Another consideration is that the two paranoid personality subtypes are related to socialized gender differences. "The silently resentful outcome may be more frequent among women and the blatantly defiant picture seen more often in men" (Akhtar, 1990, page 21). Clarissa would not fit this stereotype when she is overtly aggressive and negative. She does however exhibit more sullen behavior at times. The therapist should consider how "society's demands and expectations, personal experiences, cultural values, and life conditions greatly affect the inclination to express one type of yearning or the other. Research by Richman, Bornstein et al. and Dickstein (1987) and analysis by Freud demonstrate the impact of these factors. Richman's (1988) study finds that men experience distress when they express strong interpersonal dependency needs whereas women experience distress when they conceal such needs. An extreme example of this distress is evident in Freud's (1911, 1963) analysis of several male patients with severe paranoia. Freud concluded that the patients' paranoia was a defense against the intolerable homoerotic fantasies the patients generated in the context of their dependent relationship on the male analyst. A study by Bornstein et al. (1993) concludes that men and women have similar dependency needs but that women are more willing than men to acknowledge their dependent feelings, attitudes and behaviors. Dickstein (1987) notes a trend in some men to deny the existence of their dependency needs and to seek therapy when the relationship satisfying those needs collapses" (Berk and Rhodes, 2005, page 191). Therapeutic inquiry based on these hypotheses may improve assessment and treatment. While paranoid personality disorder can strongly impact individual functioning and the couple dynamics, the therapist should keep in mind paranoid characteristics are not limited to paranoid personality disorder. "Paranoid characteristics are also found in antisocial personality (belligerence, arrogance, blaming others); in compulsive personality (small-mindedness, stubbornness, rigidity, and self-righteousness); and in narcissistic personality (arrogance, self-importance, self-centeredness)." (Harvard Mental Health Letter, 2004, page 1). Stimulant drug abuse or dependence can also create paranoid attitudes and behaviors. The therapist should do due clinical diligence to identify differential causes of paranoid behavior.
As opposed to certain other disorders or characterological styles, how the individual with paranoid personality experiences self versus others may be diametrically different from how others see him or her and themselves. "Individuals with paranoid personality disorder view others as devious, deceptive, and covertly manipulative. They view themselves as righteous and mistreated by others and vulnerable and open to the possibility of being exploited and therefore need to be on guard. They fear being controlled, demeaned, and discriminated against. As a result, they are wary, suspicious, and looking for cues. The main affect is anger over presumed abuse and they may experience anxiety over perceived threats (Beck & Freeman 1990) because of heightened sense of fear and vulnerability (Ward 2004). Others frequently perceive these individuals as argumentative, stubborn, defensive, and uncompromising (Beck & Freeman 1990)." (Hayward, 2007, page 16-17). Although he or she self-define as innocent, others see the paranoid individual as self-serving emotionally, verbally, and behaviorally aggressive. While other people may see themselves as unjustly accused of devious intentions and behaviors, the paranoid individual sees them as potential abusers. The discrepancy between someone such as Clarissa's self-image and how Elliot sees and describes her is a key diagnostic clue. Further and compelling diagnostic indications are the therapist's observations of Clarissa's paranoid interpretations and assumptions in the process or therapy, and the counter-transference experience of being accused of ill will and negative motivations.
There is also a major dichotomy between the paranoid individual's social presentation and his or her internal experience. A key insight for the therapist that should affect the process of therapy is that there is a "discrepancy between the outer persona and the inner world of such individuals. The split is pervasive and involves self-concept, object relations, affects, morality, sexuality, and cognitive style. Outwardly, paranoid and acutely vigilant towards the external environment. Internally, however, they are frightened, timid, self-doubting, gullible, inconsiderate, vulnerable to erotomania, and cognitively unable to grasp the totality of actual events" (Akhtar, 1990, page 21-22). This may be a critical diagnostic distinction when considering Clarissa versus Elliot, Madeline, or Dirk. While Clarissa appears to fit this dichotomy between inner and outer personas, the inner and outer personas of her husband Elliott and the other two are more consistent. The therapist and others are often attentive and triggered by the external negative presentation and may fail to note or attend to the frightened inner experience of the individual with paranoid personality disorder. Clarissa as are many others with paranoid personality disorders is terrified to hurt again by people who become close to them. Failure to recognize or ignorance of the inner experience may cause a third party to dismiss the individual as unworthy of any effort to build a relationship with. Friends, family, and the therapist may label the partner such as Elliot as foolish or worse to have chosen or remain in a relationship. The partner of this individual however may see and be drawn to care for his or her vulnerability, while also being hurt by his or her self-righteous aggressive behavior. Elliot experienced and valued the sweeter side of Clarissa, although that part of her was often submerged or hidden. He felt rewarded when Clarissa could be intimate and supportive, but now was contemplating if it was enough and whether it was worth the abuse anymore.
Freudian theory postulates "that paranoia is a psychological defense that arises when repressed childhood impulses reemerge in an adult crisis, converted into suspicions and delusions by projection — the process of attributing one's own unacknowledged wishes to another person. For example, a man who feels violently angry at someone may deny his own rage but insist that the other person is going to attack him. Projection is still considered central to paranoia. Paranoid persons cannot acknowledge that they feel unworthy, so they say others are criticizing them. Feeling guilty, they decide that others are making false accusations. Feeling helpless, they say that others are trying to entrap them. They are constantly thinking about their alleged persecutors, so the persecutors must be constantly thinking about them" (Harvard Mental Health Letter, 2004, page 3). This theory directs the therapist investigate psychodynamic, cultural, and family-of-origin experiences of the individual. In couple therapy, often the partner has heard stories about childhood experiences from the individual. The paranoid individual such as Clarissa is likely to eagerly tell his or her history of experiencing repeated injustices to the therapist as he or she has probably told his or her partner. The therapist should listen to the tone of self-righteous outrage to unfair treatment. The paranoid individual is likely to present him or herself as a victim, but not in a sad dismissed state. The presentation is more likely to be animated, activated, and angry. The partner is also likely to contribute additional stories of injustice that the individual has told him or her previously. From her stories, Elliot knows of Clarissa's horrible previous boyfriends, two-faced former friends, and unstable mean family members. The partner may also have observed current manifestations of negating interactions with the individual's siblings and parents.
The individual's paranoia may cause him or her to over note and overstate current experiences as additional attacks. However, as the saying goes… just because someone is paranoid, doesn't mean someone isn't after him or her. Or as the case of the individual with paranoid personality disorder, it does not mean that he or she has not suffered frequent and egregious unjustified emotional ambushes- particularly in childhood. And that Clarissa does not, for example get mistreated in current toxic relationships. It is questionable if these toxic relationships are not some form of self-fulfilling prophecy fueled by her paranoid treatment of others (including Elliot). A pattern of assault or abuse that the individual has been unable to prevent or protect him or herself from can create enduring characterological consequences. His or her sense of self becomes negatively compromised. His or her sense of potency- that is, impotency may become embedded. Clarissa feels fundamentally out of control and vulnerable.
Admitting this vulnerability however may be intolerable. "...if a person experiences a failure event, this should activate underlying negative self-schemas, that will increase the probability of an internal attribution for any subsequent negative experience. However, if an external attribution is made for a negative experience (because an underlying negative self-schema is not sufficiently activated at that particular moment or because situational factors suggest that an internal attribution is inappropriate), this should further reduce the accessibility of negative self-schemas, thereby decreasing the probability of an internal attribution for future negative events. One implication of this analysis is that both attributional style and self-esteem should be highly unstable in paranoid patients. Consistent with this prediction, Bentall and Kaney (2005) recently observed that paranoid patients showed a marked internalizing shift for negative events when their attributional style was measured following a contrived failure experience" (Melo et.al., 2006, page 272). The more the individual has experienced failure, the more he or she may feel it may be due to some personal inadequacy- especially, if told by a parent in childhood that it was his or her fault or failure. In attempting to avoid this psychic self-condemnation, cause of negative experiences may become habitually projected onto others. Since it is intolerable for any vulnerability or problem to mean anything negative about herself, Clarissa has to make it about Elliot being horrible.