Clarissa accuses Elliot because she cannot endure any accusation, blame, or responsibility directed at herself. Her experiences of frequent negative treatment along with repeated shaming and blaming create a toxically critical internalized parent. Clarissa is unable to fend off her own negative self-judgments and self soothe emotionally, psychologically, intellectually, or spiritually. The part of Clarissa that would validate and defend herself from shame is underdeveloped and unable to assert against her insecurities. The externalization or projections to Elliot and others in the outside world serve to blunt or block self-condemnation. "A feature of the self-narratives of patients suffering from paranoid personality disorder is dialogical impoverishment. By this we mean there is a restricted cast of characters in patients' self-narratives. PPD patients typically embody the inadequate and diffident aspects, while they see others as hostile and deceitful. Patients with PPD describe most of their relationships in this way, and these descriptions feature stereotyped dialogues. The patient described in our study exhibits similarities to patients described in the literature as having 'paranoia.' The dominant part of the self is weak and inadequate; she see others as hostile, wanting to make a fool of her and to take advantage of her. As a result, the self becomes diffident and reacts angrily to others if deceived or cheated. In other words, PPD patients concentrate on defending themselves from others' hostility and threats and on making vindictive counterattacks. This impoverishment of relationships is pathogenic because these patients do not construct alternative, more adaptive, pictures of the world" (Salvatore, et al., 2005, page 261).
Within someone such as Clarissa occurs a "stereotyped dialogical relationship between the 'I' and the 'Other.' The inadequate character feels attacked by a hostile other and as a result, becomes a victim and counterattacks or makes a preventive attack to avoid injury or to acquire supremacy (of a moral nature or in social standing) over the other. Such counterattack behaviours can be verbal or non-verbal and in reality provoke the reactions (attack or flight) in the other that the subject fears. This reinforces the inner pattern in the dialogical relationship; alternatively, paranoid individuals try to maintain a protective distance, but this causes a deep sense of social isolation (Nicolo & Nobile, 2003). These scenarios are typical of paranoid individuals inner and interpersonal dialogues; they create an obstacle to their imaginary life and harm the quality of relationships" (Salvatore, et al., 2005, page 254-55). The therapist will be drawn to attend to the conversation between Clarissa and Elliot, and engage in conversations individually with Clarissa and Elliot. Therapy may benefit if the therapist helps Clarissa verbalize her internal dialogue. The therapist identifies how the internal dialogue drives Clarissa's reactions and responses to Elliot. Elliot may or may not have some sense or idea that Clarissa has internal dialogue, but bringing it overtly into the relationship can significantly shift communication… and shift Elliot's compassion for Clarissa and her inner dialogue. The therapist may ask, "Clarissa, you need to protect yourself against being insulted, don't you? Is that what you're thinking… or feeling?" These are rhetorical questions that are more statements or observations offered to Clarissa to own as representative of her inner voice. The paranoid individual tends to focus on others' behavior and ill-intent with only cursory acknowledgement if prompted, of internal hurt along with more vehement ownership of righteous anger. This approach verbalizes and validates the deeper vulnerable feelings beneath the paranoia.
The person with paranoid personality disorder sees him or herself as fundamentally incapable of dealing with any assaults by enemies. Hypersensitivity causes an otherwise minor event to be a threat and an excessive defense response becomes necessary in his or her mind. "When faced with events which threaten one's personal safety, subcortical information processing systems (with related emotions and plans of conduct) are activated and take over from cortical information processing (Gilbert, 2002). When persons with PPD are faced with what they see as a threat to their self-image, they activate modules aimed at the preservation of self-image. These modules are based primarily on aggressive defence. This defence pattern proves to be effective in producing a state in which they are relatively certain about their representations of themselves. A particular characteristic of persons with PPD is the search for little signs that theirself-image is being threatened. They are in a permanent state of alarm and readiness to counterattack. This contributes to the perception of being threatened and is also likely to provoke the responses they fear—attack and flight—in others. These responses set up a vicious interpersonal circle" (Salvatore, et al., 2005, page 253). Clarissa anticipates being attacked because she fears her vulnerability, yet her self-image cannot tolerate feeling vulnerable. She anticipates that Elliot will harm her. Both being harmed and being vulnerable are intolerable, so she responds with an excessively aggressive counter-attack, which can be abusive. As Clarissa asserts her self-righteous counter-attack, it makes no sense to Elliot who cannot see or recall any original attack on his part. Any comments that characterize Clarissa as the instigator or Elliot as the non-instigator, further promote a sense of self that is intolerable to Clarissa. Thus, she rejects any such comments out of hand. This in turn causes Elliot to question or criticize Clarissa, which then proves again to her that he is against her.
Clarissa with her paranoid perspectives has difficulty making mature and accurate deductions of what another person may be thinking. In particular, she tends toward making negative assumptions about expressions that are not clearly positive. Elliot may have a firm, tired, or frustrated expression, which she may interpret as an angry threatening look. Family-of-origin work would likely find that assuming the worse and preparation for excessive reactions and punishments from her parents was the safer course to take versus a more balanced perspective. Expecting the worse and being wrong meant wasting energy with unnecessary self-defense. That waste however was more prudent versus not expecting the worse, being wrong, not being prepared, and then being annihilated. A "reason those with PPD get stuck in fantasies about being the target of aggression is that for them the subjective cost of being caught off guard is very high (Leahy, 2002). The strategy in their reasoning is the following: 'If I am always on the lookout for danger, there is less risk of getting harmed. If I underestimate even just one danger, and it then turns out to be real, I risk suffering irreparable harm.' This reasoning strategy is of the 'better-safe-then-sorry' type (Gilbert, 1998; 2002)… a) (Salvatore, et al., 2005, page 254).
Clients often want immediate solutions to enduring entrenched intrapsychic and interpersonal problems. This is often more pronounced in couple therapy since the relationship may be on the verge of termination. Couple therapy may be the one last and perhaps, begrudging attempt to eliminate core interactions, dynamics, and deep wounds. The therapist is often drawn to problem-solving or to meet expectations by clients or meet requirements of managed care organizations. The therapist may immediately begin teaching communication skills for example. With a couple with an individual with a paranoid personality disorder (or for the matter, any personality disorder or major disorder), communications therapy will not suffice by itself. Communication problems contribute to the core relationship problems but are often more the outcome of deeper problems. The first problem of therapy is often clearly identifying the problem for the clients. What to do is often not really an issue. The individuals often already know what to do or say, but cannot follow through consistently or will sabotage themselves.
The therapist needs to also gain a role or position of authority and trust for the clients to risk deferring to or considering his or her feedback and interventions. Immediate attention to problem-solving per client requests may be an attempt to build therapeutic rapport. However, it may backfire due to the inherent complexity of the partnership, which prevented simple solutions from working in the first place. Trust and rapport is loss as a result. Identifying the problem or problems include discovering, accepting, and understanding who and what each client is. For sound therapy and "To maintain a good therapeutic relationship at this early stage, a therapist needs to identify the characteristics of a patient's stereotyped internal dialogue. It is essential at this stage for the therapist to listen carefully to a client's verbal narrative and to observe the patient's nonverbal signals and one's own internal signals (i.e. thoughts and emotions)" (Salvatore, et al., 2005, page 256). Who and what is Clarissa? Who and what is Elliot? What is each person's inner emotional process? Clarissa and Elliot are not interchangeable individuals with other people and their partnership is not interchangeable with another couple. While each person's process and their joint process have similarities with other individuals and couples, the therapist needs to discover their unique composition of experiences, culture, emotions, thinking, and psychology.
Therapists "need to: (a) identify the dysfunctional relationship patterns dominating a client's transference; it is essential at this stage to listen carefully to a client's verbal narrative, observe his/her non-verbal signals, and pay attention to one's own internal signals, i.e., thoughts and emotions, thus accumulating awareness of the text that one is writing together with the client and of its potentially dysfunctional outcomes; (b) avoid embodying the hostile character or appearing too wary. One needs to modulate one's propensity to action, by adopting a critical distance towards one's inner states. It is essential to remember that clients' accusations, however unpleasant and apparently upsetting, can provide important insights about their inner states. To reinforce a therapeutic relationship it is also important to: (c) look for experiences one can share with a client and from these construct a new point of view on the world for him/her. It is easier to gain access to the healthy parts, that do exists in client with paranoid features, if the session atmosphere is good and negative emotions are kept to a minimum. The setting up of a shared context makes these processes easier. It is important, therefore, for client and therapist to talk about subjects of common interest and for any metaphors, ideas, and interpretations used to be drawn from this context. When therapists believe the transference relationship has become stable, they can: (d) help clients to gain awareness of their dysfunctional processes, distance themselves from them and adopt new I-positions. This stage also includes helping clients to interpret other people's behaviors and intentions more accurately" (DiMaggio, 2006, page 74).
FANTASY AND REALITY
"PPD patients have an underdeveloped ability to distinguish between fantasy and reality, that is an inability to differentiate between subjective fantasies and the outside world. They are, therefore, unlikely to assume that their impression of a threat is hypothetical. Not having this skill prevents those with PPD from escaping from the emotionally charged states of mind that are typical of them" (Salvatore, et al., 2005, page 254). When the individual is not at risk in an intimate relationship, he or she is often able to be more open-minded about alternative perspectives and intentions. Then the individual can use "other interpersonal schemas and to imagine that other persons are not hostile." The therapist may be able to activate this more dispassionate and less anxious process as the third person not personally involved in Clarissa's family-of-origin, and also not invested in either partner's outcomes. It is likely that Clarissa received parental indoctrination that denied her experiences and reality, including characterizing them as her imagination that they had been abusive or unfair or had incorrect recollection. The therapist can reference shared context either personally (in appropriate self-disclosure) or by referencing other clients or individuals with similar experiences. The therapist can tell Clarissa about how other individuals had been abused or harmed by their parents or significant others. And how they had been denied their experiences and realities. The therapist can tell her that Clarissa's parents followed the basic strategy of abusers in denying the victim's experiences and in any case, instilling blame for the abuse on the victim's behaviors. As a result, it becomes difficult for victims to know what is real or not.
The therapist can start from the reality of Clarissa's childhood experiences. He or she can evoke her memories and prompt her emotional realities and childhood experiences base on a conceptual framework of abuse and etiology of paranoid personality disorder origins. The psycho-educational approach drawing upon family-of-origin memories validates the hurt and scared child beneath the paranoia within Clarissa that is overly and aggressively reactive. The angry defiant self-righteous child-like or "immature" paranoid reactions are compulsive survival mechanisms. The therapist should emphasize that she had a right to try to survive and that the mechanisms she chose made sense given her developmental stage. The therapist is "speaking" to and nurturing the vulnerable inner child that Clarissa hides and protects. The therapist needs to address this deep vulnerability or otherwise, mature interventions assuming a mature rational adult response will continue to be frustrated. The more mature caring logical Clarissa persona gets waylaid whenever her victimized child self is threatened. The therapist should not expect a mature rational adult persona from the paranoid individual to stay present under the stress and triggers of couple therapy. A logical grown-up had up to now been unable to stay present under the stress of intimacy in the couple. Thus, another challenge of therapy is for the therapist to respectfully evoke, invoke, and work with the adult personas. Simultaneously, the therapist must also identify, nurture, and validate the child-like vulnerable personas to facilitate their maturation to mature proficiency.
The process of examining the family-of-origin from a distant place- the present sets up the possibility to attempt to have the partners- in particular, the paranoid partner take a third person perspective about the partnership. "Clarissa and Elliot, since I'm not married to either of you and won't be in the relationship long-term… and certainly not with the same potential risks or gains… and don't need either of you to be right… or me to be right, let me tell you what I see. And what makes and doesn't make sense to me. Then, you can try on this other perspective about your partner and yourself." The therapist is often struck by the individual's sometimes fantastic and negative interpretation of the partners' common experiences. Misinterpretation is often a major contributor to partnership dysfunction. Frequent reality checks are necessary to working partners through negative assumptions that wear down and eventually, destroy the relationship. However, the therapist must walk a delicate line offering or prompting another reality that will challenge the reality/fantasy that the paranoid individual holds. Nevertheless, the therapist must find a way to do so and eventually, teach the partner skills to do so as well. And most importantly, gain permission from the paranoid individual for this to happen. The therapist may introduce a beginning rudimentary model in the sessions. "This is what I see. If you weren't in this relationship, what would you say to yourself about what has been happening? For example, what would you say about how angry you often are? And how it affects the relationship?" Experiential inflexibility goes to the core of the paranoid personality disorder. Facilitating or introducing any flex in the individual's adamantly held paranoid sense of reality offers hope for change. The hope is important for the therapist, but highly needed for the partner such as Elliot.