If the therapist is clear and conceptually sound, he or she can anticipate the paranoid personality disorder instincts, triggers, behaviors, and underlying etiology. He or she can adjust building rapport generally with an individual to building rapport with an individual who basically distrusts everyone as a consequence of mild to severe paranoid instincts and behaviors. Over the course of therapy, the therapist may be able to build a significantly strong rapport with the paranoid partner, but not by being "nice" and supportive as may be effective otherwise therapeutically. Attachment theory may be a guide to build trust and rapport. Paradoxical interventions may be useful strategies to predict negative behavior and interrupt them. If rapport is strong enough- while this may be difficult or problematic with paranoid personality disorder, the individual may be able to withstand his or her partner's boundary setting and the therapist's confrontation. Or, the hypersensitivity and hyper-vigilance of the individual may not as extreme as the paranoia of others with paranoid personality disorder. Or, somehow the love or the need for intimacy is strong enough for the individual to transcend, perhaps tentatively his or her fears. Only the clinical instincts of the therapist can make the assessment of rapport and degree of paranoia. And, the therapist's skills in the heat of therapy affect the quality of his or her interventions and strategies. If… and it is a huge if… given the nature of individuals with paranoid personality disorder, the individual can trust and invest in the therapeutic relationship sufficiently to have a stable relationship, the therapist can use the therapist-client relationship as a model for the partners' relationship.
When the therapeutic relationship has enough stability or strength, the therapist can "search for traces of new characters as the foundations for new narratives. The first observable signs often are poorly expressed emotions, vague sensations, or fragments of speech not acknowledged as being the patient's own. In general, when dialogical relationships are impoverished, therapy needs to encourage the emergence and expression of those new emotions or traces of thoughts required for the construction of narratives (Dimaggio et al, 2003 a)" (Salvatore et al., 2005, page 258). This approach assumes nascent but undeveloped or hidden ability to risk vulnerability in the paranoid individual. He or she may want the nurturing and validation of significant others but his or her defensive habits have often precluded the risk. Personal growth and gradual alleviation of paranoid tendencies may have made risk a possibility. Impending termination of the relationship may trigger further paranoid acting out, but for some individuals the threat may have made the risk worthwhile... or made taking the risk compelling. The therapist needs to recognize and honor the individual's vulnerability and the inherent danger to attempt intimacy, rather than expect to be trusted. The partner who has struggled with mistreatment but tried over the years to build or heal the relationship may have sensed or seen the vulnerability as well. It was what motivated the partner to continue to try despite repeated frustration. The paranoid individual in his or her own inefficient and off-putting manner has sought for someone to met his or her needs.
A reparative approach revisits early developmental deficits and traumas that created the paranoid personality defensive style. These recommendations are as much for a progressive stage of therapy as they are building elements to build the rapport that allows progression. The therapist may simultaneously review formative family-of-origin experience, identify logical resulting survival mechanisms, and the individual's current attitudes and functioning in the couple. "It is only when the therapeutic relationship is inhabited by these adaptive characters that a therapist can help a patient to self-reflect on his/her dysfunctional processes, distance him/herself from them, and adopt a metaposition. This stage also includes helping patients to interpret other people's behaviours and intentions in a less egocentric way"(Salvatore et al., 2005, page 259). When the therapist is able to get the paranoid individual to risk introspection, there are hopefully three requirements that are simultaneously outcomes. The foundation is the development of the therapist-individual relationship. Next, the partner of the paranoid individual begins to understand that the individual's behaviors are not solely about the partner, but have ancient causes. And third the partners experience through the therapist-individual interactions a model for their relationship. From these three requirements and outcomes, the partners begin to create and practice their own model for interactions.
Standard couple therapy often starts with the therapist trying to promote change in the relationship and with partners. The partners may agree that there are clearly dysfunctional patterns of communication and behavior between them. They ask and the therapist complies with attempts to alter these patterns. While this is often what the couple request, it clearly misdirects the process of therapy when there is a partner with paranoid personality disorder. "PPD psychotherapy, and that of the PDs in general, has only a limited pattern-breaking value, involving the disproving of dysfunctional convictions (Beck, Freeman et al., 1990). What is problematic for these clients is, in fact, their view of the world and it is not possible to change it without having first set up new ways of ascribing meaning to events. Moreover, a therapist pushing for change is likely to be construed as tyrannical, dominating or threatening by persons diagnosed with PPD. There is always a fragile therapeutic alliance with these clients and it is probably inevitable that one has to continuously concentrate on the working through and repairing of ruptures in it (Safran & Muran, 2000)" (DiMaggio, 2006, page 83). When the therapist prompts change, the individual with paranoid personality disorder may experience the prompt as more criticism and become triggered.
Many theories of therapy and many therapists set the foundation of therapy in the rapport between the therapist and client. The challenge of working with someone with paranoid personality disorder is that the individual is characterological predisposed to avoid trusting anyone. What brings him or her to therapy or what causes his or her life problems essentially also preclude easy development of therapeutic rapport. If the therapist is not aware of the paranoia, therapy almost inevitably breaks down. Even if fully cognizant of the paranoia or the paranoid personality disorder, the therapist still faces extremely difficult therapy. His or her frustration and impotence establishing a strong therapeutic alliance basically mirrors the experience of the partner. The therapist is vulnerable to being triggered by paranoid hostility- especially, if ambushed because of his or her clinical ignorance. Any annoyance or even mildly retaliation confirms the paranoid individual's worldview of the conspiracy against him or her. The therapist fails the individual as his or her partner has failed, and as original caregivers had failed him or her. Nevertheless, the therapist must strive to build a sound relationship with the paranoid individual. Just as the therapist should be aware of the underlying emotional and psychological wounds characteristic of and distinguishing among borderline, narcissistic, dependent, or histrionic vulnerabilities, he or she must be aware of the existential needs of an individual with paranoid personality disorder.
The therapist should not expect to be trusted. He or she should expect to be mistrusted. The therapist should not expect to be liked. He or she should not expect that any trust, respect, or affection to be stable, but instead anticipate fluctuations in the individual's attitudes, moods, and perceptions. There is significant personal work, growth, and ego-strength required for the therapist to ride the paranoid roller coaster with the individual and the couple. There will be ups and downs, and gut wrenching twists that feel on the precipice of doom. The therapist will experience essentially what the individual is experiencing and has experienced- devastating betrayal, profound hurt, and self-righteous desire for vengeance. And perhaps, a desire to give up. The therapist needs to be accepting and understanding of underlying issues creating paranoia in order to validate the individual's personal process, in particular the survival instincts to protect deep injuries. In doing so, the therapist must also educate the individual about him or her origins and subsequent instincts and now dysfunctional behaviors. This will ignite the individual as more criticism. The therapist must challenge the individual by setting boundaries for therapist-client and partner interactions. These will inevitably create new ruptures in relationships: in the therapeutic relationship and in the couple's relationship when experimenting new behaviors. The therapist should present the therapeutic contract as a process to ignite old stresses and trigger new disruptions. Rather than proposing relief from or avoidance of triggers, therapy proposes dealing with inevitable triggers. The therapist and partner while refraining from purposeful assaults are to function as genuinely as possible. The paranoid individual is expected to be triggered and respond differently. The therapist primarily models this new contractual relationship. He or she engages the partners to accept a comparable contract for relating as well.
BOUNDARY AND CONSEQUENCE
The therapist challenged both of them that Zane seemed to be unable to stop trying to prove that Jessica was the biggest bitch in the whole world. And that Jessica had seemed to be willing to have Zane continue to try to prove it to her forever. At this point (in response to the paradoxical intervention), Jessica's body rose out of its defeated slumped position. She stated emphatically but calmly, "I'm done. I don't deserve this and I am not taking it anymore." The therapeutic process can be about improving communication, insight or awareness, or healing. Improvement and progress in these areas lead to growth and change hopefully. Sometimes, however the therapeutic process is essentially and even totally about setting boundaries. The direction of couple therapy when there is a paranoid personality may of necessity move toward getting the non-paranoid partner to set the boundary that abuse is unacceptable. An appropriate therapeutic goal can be about setting the boundary that further participation in the relationship will not continue if abuse continues. Whether or not setting this boundary is an appropriate goal in couple therapy, when a partner such as Jessica asserts his or her unwillingness to stay in a partnership to continues to be abusive, therapy and the relationship fundamentally changes. The change may be that both couple therapy and the relationship may terminate. The therapist must be willing to accept either or both possibilities to maintain the integrity of the process.
As noted earlier, the paranoid personality disorder individual functions essentially in the same manner as certain individuals with substance abuse and dependence issues. Substance abuse and dependence treatment can give guidance to working with the paranoid personality. Much of substance abuse and dependence treatment is based on a behavioral model with very clear and very firm boundaries. In many therapeutic models, the therapist tries to facilitate or prompt change in insight, in awareness, in thinking, in emotions (emotional reactivity), in spirituality, and so forth. Changes in these elements will then facilitate or prompt change in behavior from dysfunctional to functional behavior and life. Many substance abuse and dependence treatment models have a therapeutic process that operates in reverse to these models. They promote change in behavior primarily. There may or will be eventual change in insight, awareness, thinking, emotions, spirituality and so forth, although these may not be expressed goals. Much of the direction of the change in behavior is about asserting and establishing clear boundaries of acceptable and unacceptable behavior. Maintenance of the treatment is focused on those boundaries.
For Jessica and Zane, Jessica's the assertion of the boundary (with prompting and support from the therapist) removed permission for Zane to continue to abuse her. The logical consequence of this if Zane is unable to change, is that Jessica will remove herself from the relationship. The other possibility, which had been the default setting was to keep letting herself be abused. Effectively, if not accepting that she is the biggest bitch in the whole world, then that she is the biggest idiot or most masochistic person in the whole world! On the other hand, only when the drinker is finally able to acknowledge and accept that he or she is unable to drink and be functional, will the drinker even begin considering changing his or her behavior. Comparably, only if Zane is finally able to acknowledge and accept that he cannot be abusive and keep this relationship, will he even begin considering changing his or her behavior. Up until Jessica asserts this boundary, Zane had not been held against this ultimatum. Jessica gave permission for the status quo. With the status quo deemed unacceptable, Zane as well as other individuals with paranoid personality disorder in other couples could be compelled to change. And, some people continue to drink, lose everything until they eventually die. And Zane might do likewise.
If Jessica leaves the relationship, it is arguable that the therapist in this situation failed. That is correct if keeping the partners together is the sole goal of therapy. While that may be the expressed goal of the partners, the therapist should in the initial stages qualify the goal as beyond his or her skills or right to assert. An alternate and more nuanced goal would be to do their best to stay together, be healthy and happy together. Further, for them to find out in the process if they can stay together, be healthy and happy together. On the other hand, they may discover if they need to separate in order to not be unhealthy and not unhappy… or if they go their separate ways in order to seek health and happiness. With such an adjusted goal, the therapist may pursue helping the partners discover if they can be healthy and happy together. As the therapist does his or her best, whatever the partners discover directs their subsequent decisions, including separation, continuing, or other attempts at change. In this situation, if Jessica is clear about her decision without significant ambiguity, she would also be more resigned as opposed to agitated. Resignation would be an indication of Jessica beginning a loss/grief process whereas agitation would be indicative of still being unsettled about the viability of the relationship. Someone such as Jessica is more likely find therapy to have been productive because of it having satisfied her need to try to repair the relationship and her acquired clarity that she had gained.
On the other hand, an individual with paranoid personality disorder such as Zane would tend to follow his or her characterological pattern and condemn the therapist as another member of the pantheon of antagonistic conspiracy making his or her life miserable. The therapist is normally conscious or semi-conscious of the paranoid response throughout the course of therapy. He or she may have instinctively know that the individual would, could, and probably will turn on him or her as soon as paranoid personality disorder began to manifest in the sessions. If not sufficiently aware, he or she can be intimidated from following through with therapeutic integrity. This may be particularly difficult for the therapist who normally builds strong rapport with clients… who gets individuals to like and trust him deeply. Since the individual with paranoid personality disorder is highly prone to intense arousal, termination of the relationship can be highly triggering. The therapist and the partner need to be aware of further and intensified paranoid acting out. That may mean further and intensified verbal, emotional, and psychological abuse, passive-aggressive behavior, financial or social aggression, and domestic violence. The pain or desperation the paranoid process seeks to avoid may be ignited by loss of the relationship- another abuse by intimate others.
The therapist should be aware of three principles when separation stress is triggered. First, they should be aware that an individual under stress tends to follow his or her pattern of problematic behavior. When stressed or triggered if he or she tends to self-medicate with alcohol or drugs or shut down or become passive-aggressive or verbally abusive or physically aggressive or assaultive or has other characteristic behavior, then the individual may be likely to duplicate such behavior upon relationship termination. The second somewhat contradictory principle is that separation may be so severely distressing that the probability of extreme and uncharacteristic behavior increases. The third principle is that in the immediate period following separation is the most volatile period and therefore, holds the greatest risk for violence against the partner and/or to him or herself- that is, self-harming or suicidal behavior by the person being left.
The therapist should be wary of these principles for all couples terminating their relationship. However, the therapist should be especially concerned about critical interactions these principles have with paranoid characteristics. The pattern of the individual with paranoid personality disorder includes compulsive rage and rageful behavior, and thus, is likely to be activated under the stress of separation. The individual's lifelong accumulation of suffered injustices can intensify the immediate painful loss exponentially in comparison to a non-paranoid person. This increases the possibility of dangerously extreme or uncharacteristic reactions. Despite forewarnings and abundant cues of the relationship's imminent demise, and anticipation of further atrocity, the individual normally has no healthy way to manage the finality. It will hurt and hurt deeply, but rage- perhaps, uncontrollable rage will be the immediate reaction. This can cause the paranoid individual to target the partner as the evil perpetrator deserving his or her vengeance. All the principles of separation stress combine with paranoid characteristics combine to warn the therapist and the partner to take extra caution. In terms of safety, the therapist and partner should take steps to ensure the safety of the partner from violent acts by the paranoid individual and the stability and safety of the paranoid individual.
In terminating the relationship, the partner such as Jessica should be guided by the therapist to emphasize that she did not and cannot meet Zane's needs. Blaming the individual with paranoid personality disorder may be tempting. There may be some theoretical justification to hold the paranoia primarily responsible for the failure of the relationship. However, verbalizing this would further ignite paranoid hypersensitivity against this further insult and attack. This is true on a theoretical level. A partner such as Jessica has tried and failed to meet the paranoid person's needs. The partner has some pathology theoretically that he or she somehow had accepted the individual's impossible demands to never trigger paranoid sensitivities. On a practical level, the partner has failed and the relationship has failed. The priority and urgency for the partner needs to be to exit without unnecessary difficulties, acrimony, and unnecessary drama. More specifically, it behooves the partner to leave as peacefully as possible. The focus should be to avoid triggering paranoid arousal as much as possible and thus, reduce the risk of further toxicity, and specifically, further abuse and potential violence.
While the partner may want to hold onto his or her self-righteousness and blame the paranoid partner for the demise of the relationship, doing so may not be worth the risk of paranoid acting out. Acquiescing and confirming the individual's basic paranoid assertions of the partner's inadequacies in meeting the individual's needs is a practical strategy. The partner may avoid admitting to accusations of evil intent, manipulation, and corruption, but can and should own failure to satisfy the individual. The partner who insists on trying to convince the paranoid individual of the partner's assignment of responsibility for relationship's termination is replicating his or her historical dysfunctionality in the relationship as he or she is trying to exit the relationship. Throughout their relationship, the partner had failed to convince the paranoid individual of innumerable things, and yet continued to try... and still is compelled to try again. The partner and individual fought continually over who was right or wrong. At the end of the relationship, the battle for the mountaintop continues. And it continues to incite further paranoid wrath. The therapist should strongly structure and guide the partner's communication in separation.
The therapist also should attend directly to the paranoid individual's deep pain, probable anger, and instincts to lash out. Validation of the individual's distress should be balanced with directions for appropriate behavior to self-care and prohibitions against self or other harming behaviors. Someone such as Zane may sullenly withdraw from interaction with others, from the relationship, and from therapy and the therapist. He may add this betrayal, rejection, and abuse to his list of injustices done to him, and add Jessica and possibly the therapist to his list of conspirators against him. He may or may not lash out physically (or financially, socially, or otherwise). Some individuals with paranoid personality disorder hold their grievances and resentments for years and decades without striking out. However, no one can be sure if, when, and how such individuals reach a critical mass of self-righteous bitterness that culminates in a violent assault on another or others. Stewing internally and/or finally striking out are in lieu of allowing him or herself to feel the desperation of intimacy loss... again.
The therapist needs to remember that paranoid behaviors including angry projections and accusations are survival alternatives to feeling. The therapist should evoke and honor the deeper vulnerable feelings with respect and care. The paranoid individual is less likely to own or express his or her emotional pain or ask for nurturing from another. Yet, his or her behavior is such an expression. Soothing and support from intimate others is what the individual has always been seeking however dysfunctionally. At the point of another loss relationship, caring attention attends to him at his deepest level, and has the practical potential benefit of mitigating paranoid acting out, including violence. Hard hard work. Working at all stages and all circumstances of couple therapy with an individual with paranoid personality disorder is extremely challenging and often very delicate and nuanced. Working with such a couple may be among the most difficult therapeutic challenges for the therapist. Sometimes the ordinary goal of healing and sustaining the relationship cannot be achieved, and therapeutic focus turns to managing boundaries and safety.