Many aspects of the borderline personality or the narcissistic personality can be seen in the paranoid personality: the intense anger and sense of being betrayed over seemingly incidental and minor transgressions, extreme righteousness of the position held, and the brutal lashing out in vengeance for harm experienced. As in other developmental disorders, the origins of the paranoid personality disorder lay deep within the individuals formative childhood experiences and may not be accessible in the present to him or herself or the therapist. Similar to the narcissistic personality, the paranoid personality experiences his or her world perspective as ego syntonic -- it all makes sense to him or her. However, whereas the narcissist in a narcissistic rage tends to go to an ostensively cool nonemotional place that justifies every cruel act of revenge to him or her as logical, the paranoid tends to go to an intensely emotional place of rage. Similar to the borderline personality, the paranoid personality is deeply hurt by others acts. However, whereas the borderline, once the pain has subsided has deep regret for what he or she then recognizes as inappropriate and abusive behavior, the paranoid stays in the pain and does not ever have either regret nor awareness of his or her behavior having been inappropriate (or the regret or awareness is only momentary or superficial). While the borderline can move from the anger and the narcissist will deny his or her anger, the paranoid stays in the anger. Individuals with stimulant abuse and dependency issues such as methamphetamines ("crank," "speed," "crystal"), crack or cocaine and alcohol will often present in the same manner as the paranoid personality.
In couples counseling, the underlying and overriding thrust and goal of the paranoid personality is to prove the righteousness of his or her perspective, and to prove the corrupt and evil intent and behavior of his or her partner. Any discussion about an incident or an interaction always goes to how the partner maliciously and purposefully violated the paranoid. To engage in such a discussion about what happened, when it happened, what one person did or the other person did, what precedents and history are involved, and whatever details that are supposedly relevant is essentially fruitless. The paranoid's goal is not to get clarity about what happened, to understand what the underlying motivation or intent may have been (it was obviously "evil" intent!), to achieve resolution or compromise, to improve communication, or to heal or to achieve greater intimacy. There is often little or no insight as to how vicious his or her behavior is or has been nor how damaging it has been to the partner or to the relationship.
The thrust of couples therapy in this situation include (similar to working with a couple with a borderline), the therapist clearly asserting that no member of the couple has the right or the permission to be abusive no matter how righteous or entitled they feel. The paranoid will not like this boundary, nor be readily able to follow it. In this case, this boundary is more for the partner to hear and feel reinforced and validated. It would serve the partner and the therapy for the therapist to name the paranoid's dynamic to prove the partner's corruption and to label it unacceptable.
Jesse and Jane, 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. Jesse is flabbergasted as to the vehemence that Jane attacks him with continually. She is relentless. Not only does she bring up transgressions in the present, but she has a whole history from the last 10 years. Rather than just list the things that she feels he has done to her, she spices the narrative with frequent vulgarities and what is obviously intense hatred. When I challenge her that she seems to hate Jesse, she snaps back with another list of justifications to hate him. When I asked Jesse if he feels the hatred, he acknowledges it. When I asked him how it feels, he says it beats him down but he has gotten to the point where he shuts her out because it is too overwhelming. Jane jumps in here to condemn him again that he emotionally abandons her and shuts her out. Her jaw is set, her face is red, the veins bulge out in her neck, and fire darts out of her eyes. She is fuming. Jesse sighs and states rhetorically, "So, I guess I am the biggest ass hole in the whole world!" I challenge her that much if not all of her comments in the therapy have been to prove that Jesse is the "biggest ass hole in the whole world!" Her response is to give further proof that he is the biggest ass hole in the whole world. I prompt her as to what positives she has experienced with Jesse. She begins with some experiences early in their relationship and then quickly and determinedly moves to show how he subsequently betrayed her. I prompt her as to why she does or has stayed with Jesse. She responds about how he can be caring and then gives more examples of how he hurts her. I feed back to her again, that her responses seem to always go to proving that he is the "biggest ass hole in the whole world!" This is where Jesse jumps in and exclaims, "That's why I don't try to talk to her anymore. It's always about me being the big ass hole!" He goes on to describe walking on egg shells around her but still failing and get ripped over and over. I asked her again why she stays with him. She becomes sullen and says she does not know. I asked her if she could stop abusing him (it is important to clearly label this process as abuse). She responded with further justification for her abuse, "If he didn't..., then I wouldn’t..." I commented that it sounds like she was unable to stop abusing him. I asked her how her anger and attacks have been affecting Jesse. She initially says he must not like it, and then moves immediately into justifying why she does it and how he deserves the anger.
This seemingly futile therapeutic process is actually clarifying to me as the therapist that she 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 can gain clarity from this process, is the paranoid's partner -- in this case Jesse.
I prompted Jesse, "It seems that any so-called discussion between you and Jane ends up being Jane trying to get you to confess to being the biggest ass hole in the whole world. Is that right?" Jesse acknowledged that it was. "Are you the biggest ass hole in the whole world?" Jesse acknowledged his faults and his mistakes, and he also acknowledged how he sometimes strikes back at Jane when her attacks were relentless or particularly nasty. And, he acknowledged that he was wrong and it was abusive. However, he asserted, "But, I am not the biggest ass hole in the whole world." I challenged him, that if he wasn't the biggest ass hole in the whole world and the totality of the process with Jane was consistently about proving him to be the biggest ass hole in the whole world, that his continued participation in such a series of discussions seemed to be masochistic. He acknowledged this. I challenged both of them, that Jane seemed to be unable to stop trying to prove that Jesse was the biggest ass hole in the whole world and that Jesse seemed to be willing to have Jane continue to try to prove it to him forever. At this point (in response to the paradoxical intervention), Jesse's body rose out of its defeated slumped position and he 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, the therapeutic process is essentially and even totally about setting boundaries. The direction of couples therapy when there is a paranoid personality is toward getting the partner to set the boundary that abuse is unacceptable. That continued participation in the relationship will not happen if abuse continues. 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 gives guidance to working with the paranoid personality. Much of that 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 which will then facilitate or prompt change in behavior (from dysfunctional to functional behavior and life). Many substance abuse and dependence treatment models have a reverse therapeutic process -- change the behavior and there will be eventual change in insight, awareness, thinking, emotions, spirituality and so forth. Much of the direction of the change in behavior is about asserting and establishing clear boundaries of acceptable and unacceptable behavior. The maintenance of the treatment is focused on those boundaries.
For Jesse and Jane, the assertion of the boundary by Jesse removed permission for Jane to continue to abuse him. The logical consequence of this if Jane is unable to change, is that Jesse will remove himself from the relationship (or, possibly decide to keep letting himself be abused -- if not accepting that he is the biggest ass hole in the whole world, then that he is the biggest idiot or biggest masochistic 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. Only if Jane is finally able to acknowledge and accept that she cannot be abusive and keep this relationship, will she even begin considering changing his or her behavior. And, some people continue to drink, lose everything until they eventually die. And Jane can do likewise.