Jessica and Zane, a couple in their early fifties present for therapy after 10 years of a very difficult marriage. It is a second marriage for both of them. There are issues about their adult children and how they affect their relationship. Jessica is flabbergasted at the vehemence that Zane attacks her with continually. She describes him as relentlessly attacking her. In session, Zane is relentless despite the therapist's attempts to slow him down and to offer alternative tacks. Not only does he bring up transgressions in the present, but he has a whole history from the last 10 years. Rather than just list the things that he feels she has done to him, Zane spices the narrative with frequent vulgarities and what is obviously intense hatred. When the therapist challenges him that he seems to hate Jessica, he snaps back with another list of justifications to hate her. Zane brushes aside feedback that hatred seems to indicate that the relationship has gone beyond repair and the question of whether there is still affection and hope. When directly asked what the point of therapy is given his adamantly held picture of Jessica, he glares at her and sneers, "So, she can get her crap together and start treating me right!" When the therapist asks Jessica if she feels Zane's hatred, she acknowledges it. When asked how it feels, she says it beats her down but she has gotten to the point where she shuts him out because it is too overwhelming. "And he can't stand my family, our neighbors, his boss... I'm just the #A1 on the list!" This further inflames Zane. Zane jumps in here to condemn her again that she emotionally abandons him and shuts him out. His jaw is set, his face is red, the veins bulge out in his neck, and fire darts out of his eyes.
He is fuming. Jessica sighs and states rhetorically, "So, I guess I am the biggest bitch in the whole world! I've tried and tried not to provoke him. I've tried to do things… and be what he wants, but it doesn't matter. It's always my fault to him. At first I believed him when he told me all I had to do was not do the crap or say the things that hurt him or he didn't like. But he always finds something else… something new… something innocent to prove me evil!" The therapist comments that much if not all of his comments in the therapy have been to prove that Jessica is the "biggest bitch in the whole world!" His response is to give further proof that she is the biggest bitch in the whole world. When this is pointed out, he snaps, "That's hardly the whole of it. There's been shit she's been doing to me for years. You don't have the time to hear it all." The therapist prompts him as to what positives he has experienced with Jessica. He begins with some experiences early in their relationship and then quickly and determinedly moves to show how she subsequently betrayed him. "First, she's all nice and caring and then after she gets me into her, she doesn't care anymore." The therapist asks him as to why he does or has stayed with Jessica given all the horrible things he says he had done. He responds about how she can be caring, especially with the kids... but then gives more examples of how she hurts him.
When the therapist feeds back again that his responses seem to always go to proving that she is the "biggest bitch in the whole world!" Jessica jumps in and exclaims, "That's why I don't try to talk to him anymore. It's always about me being the nasty bitch!" She goes on to describe walking on egg shells around him but still failing and get ripped over and over. "You don't know how hard it is, trying to be 'good" but knowing that sooner or later you're going to get crucified again." When the therapist asks Zane again why he stays with her, Zane becomes sullen and says he does not know. The therapist asks him if he could stop abusing Jessica. The therapist deems it important to clearly label his process as abuse. Zane retorts with further justification for his behavior, "If she didn't..., then I wouldn't..." The therapist commented that it sounds like he was unable to stop abusing her. The therapist asks him how his anger and attacks have been affecting Jessica. He initially says she must not like it, and then moves immediately into justifying why he does it and how Jessica deserves the anger.
This seemingly futile therapeutic process is actually revealing to the therapist that Zane has major paranoid issues and possible paranoid personality disorder (or a substance abuse issue that creates paranoia). A borderline can acknowledge the other person's pain as he or she can step away from his or her own pain in a calmer moment. The inability to have empathy is a characteristic of paranoid personalities. Such people are so immersed in their own pain that they cannot empathize with someone else's pain. They experience the request to connect with someone else's pain as a denial of their right to have their own pain, and will resist empathizing and deny the other person's pain. The narcissist also is unable to acknowledge or empathize with the other person's pain, but his or her rage is deeply buried out of his or her own consciousness. In fact, whereas the paranoid will be in rage but also in pain (owning and acknowledging his or her own pain), the narcissist not only denies the other person's pain but his or her own pain and rage. The other person, who Zane reveals himself to in this therapeutic process is the paranoid's partner- in this case, Jessica. If the paranoid individual's intransigence completely resists therapeutic challenges, the therapist may shift therapy away from bringing partners to some compromise or consensus to further clarifying for the partner the depth of the individual's paranoid rigidity.
ALTERING THE GOAL
This would be very significant change and probably instigate a major shift in therapy. Zane for example may have wanted couple therapy to focus on getting Jessica as the bad partner to stop triggering him. Zane actively made his case to the therapist that Jessica was the villain in the couple. Jessica had already said it was impossible to not trigger Zane. Zane being triggered had less to do with what she or anyone did, but him being in a negative vulnerable (paranoid) mood. Normal (non-personality disordered) couple therapy often includes focusing on identifying and avoiding interpersonal triggers. However with the individual with paranoid personality disorder, such a strategy would be distorted to perpetuate his or her holding the partner solely to blame for dysfunction. Therapy thus may perpetuate the relationship dysfunction. Strategic work- interrupting dysfunctional behavior patterns along with communications therapy seeks to heal or improve the couple's dynamics. The therapist may be considered to be fundamentally altering the goal of couple therapy from healing and reaching mutual satisfaction if he or she decides to side with and promote the case of one partner (the non-paranoid individual) over the other.
Another interpretation is that the goal of therapy is always to promote the greatest clarity for every client, including one or both clients in a couple. Offering to the partners that the process in therapy had duplicated the dysfunctional process of the couple in life follows the goal of clarity. The therapist emphasizes that their dynamic does not work and helps the partners recognize the elements of perspective and behavior that block functionality. The therapist confirms to the paranoid partner (Zane, in this case) that he or she absolutely holds that it is solely or essentially his or her partner's (Jessica's) attitude and behavior that causes their problems. The therapist points out that the firm stance is that his or her partner (Jessica) refuses to take responsibility and change. This then means healthy relationship growth is impossible. The therapist further confirms to the paranoid partner that he or she is both entitled and compelled to respond negatively against the non-paranoid partner. This validates the paranoid individual's reality without judging it. The non-paranoid partner often nods in agreement, while the paranoid partner offers a non-committal expression but no overt contradiction to the characterization.
Simultaneously, the therapist confirms to the non-paranoid partner (Jessica) that the other partner (Zane) absolutely holds that it is solely or essentially his or her (Jessica's) attitude and behavior that causes their problems. The therapist further reminds the non-paranoid partner that the paranoid partner is adamant that his or her partner's attempts to take responsibility and change are insincere and manipulative. The paranoid partner's does not see a need to change and thus, does not try change since he or she holds the other partner solely to blame. Without any of these resolute stances changing, then healthy relationship growth is impossible. The therapist points out to the non-paranoid partner that it will not matter how much he or she cares or tries if the paranoid partner will not change. One cannot begin to try to change or grow without first owning one has a problem. One cannot own a problem without being first able to be aware. The direction or goal of therapy may include or be fundamentally tied to one (preferably, both) partners becoming aware, owning, and only then attempting to problem-solve growth and change. Recognition that paranoid personality disorder or some other characterological issue precludes personal introspection and insight becomes essential to therapy being realistic and successful- albeit limited success. On the other hand, ignoring or ignorance of paranoid personality disorder will allow therapy to remain idealistic and doomed to failure- absolutely.
Communicating or facilitating both partners' or as may be the case, the non-paranoid partner's awareness of the inflexible story held by the paranoid partner challenges the therapist's clinical skills. Getting the non-paranoid partner to be aware of how blocked his or her partner is and will or may remain is also very delicate therapeutically, especially with the paranoid person's hypersensitivity and hyper-vigilance against insult. The story of the couple has replicated within their relationship- often painfully year after year. It will duplicate again in the couple therapy. The therapist needs to adjust or alter the story. This may mean the therapist will to enter the story or relationship so the same old doom does not regenerate. The therapist needs to be aware of he or she may be activated by the story and/or the personality of clients, or risk entering the story ineffectively or in some problematic non-therapeutic manner. This is a particular relevant caution when working with someone with paranoid personality disorder. The individual's paranoia and subsequent hostile distrust is at best off putting and at worst instigate reciprocal hostility.
"When clients tell their stories to their therapists, and to themselves, a dialogical space is created that promotes the retelling of the story in such a way that new meanings are generated (Angus & McLeod, 2004; Hermans, 1996). It is the client that starts a dialogue, with the many and various voices he/she possesses doing the talking, but the outcome of the dialogue depends on how the therapist enters it and on the counter-positions he/she adopts, i.e. one therapist might reply with hostility to clients' protests and thus confirm their conviction that if they express dissent, they will get attacked. Another therapist, with a personal history in which his/her aggressiveness gets expressed less readily, might respond in a more modulated fashion making it easier for patients to access a metaposition from which they can ponder their protests. Therapists are successful when they manage to take the role of an understanding listener, able to attune with a client, and become witnesses of the client's formerly unspoken discourse (Neimeyer,2000; Orange, 1995). Another valid form of positioning for a therapist is to bring new characters into a story (Dimaggio, Salvatore & Catania, 2004; Livesley, 2003)" (DiMaggio, 2006, page 71).
The therapist prompted Jessica, "It seems that any so-called discussion between you and Zane ends up being Zane trying to get you to confess to being the biggest bitch in the whole world. Is that right?" Jessica acknowledged that it was. "Are you the biggest bitch in the whole world?" Jessica acknowledged her faults and her mistakes. In addition, she acknowledged how she sometimes strikes back at Zane when his attacks were relentless or particularly nasty. And, she acknowledged that she was wrong, has been wrong, can be wrong, and she can become abusive too. However, Jessica asserted, "But, I am NOT the biggest bitch in the whole world." I challenged her, that if she wasn't the biggest bitch in the whole world about her participation with Zane's goals. If the totality of the process with Zane was consistently about him proving her to be the biggest bitch in the whole world, then her continued participation in such a series of discussions seemed to be masochistic. She acknowledged this. "That's why I'm keep wondering… thinking more and more that I can't… won't do this anymore. What's the point if all Zane seems to want is to prove me the bitch? I don't need to prove him to be the asshole. He doesn't want to find some mutual ground… or to problem-solve. I'm the problem as far as he's concerned. He hammers me that I'm the problem all the time. I can take that I'm part of the problem, but damn… what about him? Maybe the problem is that I was stupid enough to keep taking it for years. Maybe I'm not the biggest bitch in the world… maybe I am! But you know, for sure I have been the biggest fool in the world… up to now! Maybe I'm getting smart enough to see what's been going on… and will keep going on… what Zane will keep on doing, no matter what I do."