10

Paranoid Personalities

Most of us have a clear mental image of a paranoid person and recognize the type when it is portrayed fictionally. Peter Sellers’s brilliant performance in the classic movie Doctor Strangelove, for example, captures the suspiciousness, humorlessness, and grandiosity that strike familiar chords in any of us who have paranoid acquaintances, or who recognize the comic elaboration of the paranoid streak we can all find in ourselves. Identifying less flagrant paranoid presentations requires a more disciplined sensibility. The essence of paranoid personality organization is the habit of dealing with one’s felt negative qualities by disavowing and projecting them; the disowned attributes then feel like external threats. The projective process may or may not be accompanied by a consciously megalomanic sense of self.

The diagnosis of paranoid personality structure implies to many people a serious disturbance in mental health, yet as with other dynamics that infuse personality, this type of organization exists on a continuum of severity from psychotic to normal (Freud, 1911; Meissner, 1978; D. Shapiro, 1965). As with the personality types in the preceding chapters, the defense that defines paranoia may derive from a time before the child had clarity about internal versus external events, where self and object were thus confused. Paranoia intrinsically involves experiencing what is inside as if it were outside the self. It may be that “healthier” paranoid people are rarer than “sicker” ones, but someone can have a paranoid character at any level of ego strength, identity integration, reality testing, and object relations.

The trait-based descriptions of paranoid personality disorder in DSM-IV are from a clinician’s perspective rather superficial, but the manual is accurate in noting that our knowledge of this personality type may be limited. A paranoid person has to be in fairly deep trouble before he or she seeks (or is brought for) psychological help. In contrast to depressive, hysterical, or masochistic people, for example, higher-functioning paranoid individuals tend to avoid psychotherapy unless they are in severe emotional pain or are causing significant upset to others. Because they are not disposed to trust strangers, paranoid people are also unlikely to volunteer to be research subjects.

People with normal-level paranoid characters often seek out political roles, where their disposition to oppose themselves to forces they see as evil or threatening can find ready expression. Reporters and satirists have often portrayed Dick Cheney as paranoid, but even if they hate his politics, they have seldom questioned his capacity to cope efficaciously in the world. At the other end of the continuum, some serial murderers who killed their victims out of the conviction that the victims were trying to murder them exemplify the destructiveness of projection gone mad; that is, paranoia operating without the moderating effects of more mature ego processes and without a solid grounding in reality. Several recent notorious murders seem to have had a paranoid basis.

I want to emphasize again as I did in Chapter 5 that attributions of paranoia should not be made on the basis of an interviewer’s belief that a person seeking help is wrong about the danger he or she is in. Some people who look paranoid are actually being stalked or persecuted—by members of a cult they have left, for example, or by a rejected lover or a disaffected relative. (Some people who are diagnosably paranoid are also realistically imperiled; in fact, the off-putting qualities of many paranoid people make them natural magnets for mistreatment.) Some people who are not characterologically paranoid become temporarily so in paranoiagenic situations that are humiliating and entrapping. When interviewing for diagnostic purposes, one should not reject out of hand the possibility that the interviewee is legitimately frightened, or that those who are urging him or her to seek therapy have a personal stake in making the client look crazy.

Contrastingly, some individuals who are in fact paranoid do not appear to be. Nonparanoid associates in their social group—and the interviewer for that matter—may share their beliefs about the dangers of certain people, forces, or institutions (terrorists, capitalists, religious authorities, pornographers, the media, the government, patriarchy, racists—whatever is seen as the obstacle to the triumph of good) and may therefore fail to discern that there is something internally generated and driven about their preoccupations (Cameron, 1959). If Congressman Allard Lowenstein had fathomed the paranoid character of Dennis Sweeney, one of his protégés in the student movements of the 1960s and the man who later assassinated him in the grip of a delusion, he might have known better than to behave in a way that was interpretable as sexually seductive, and he might still be alive (see D. Harris, 1982). But Lowenstein and Sweeney had similar beliefs about what social evils required confrontation, and where Lowenstein’s were not primarily projections, Sweeney’s were.

There are also people whose perceptions turn out to be prescient, who are nevertheless paranoid. Howard Hughes had a consuming terror of the consequences of atomic testing in Nevada at a time when few others were concerned with nuclear contamination of the environment. Years later, as the toll exacted by radiation became clearer, he looked a lot less crazy. But the eventual vindications of his point of view do not make his psychology less paranoid; the events of his later life speak for the extent to which his own projections were the source of his suffering (Maheu & Hack, 1992). My aim in bringing up all these possibilities is to stress the importance of making informed, reflective diagnostic judgments instead of automatic, a priori assumptions—especially with clients whose grim, suspicious qualities may make them hard to warm up to.

DRIVE, AFFECT, AND TEMPERAMENT IN PARANOIA

Because they see the sources of their suffering as outside themselves, paranoid people in the more disturbed range are likely to be more dangerous to others than to themselves. They are much less suicidal than equally disturbed depressives, although they have been known to kill themselves to preempt someone else’s expected destruction of them. The angry, threatening qualities of many paranoid people have prompted speculations that one contributant to a paranoid psychology is a high degree of innate aggression or irritability. It stands to reason that high levels of aggressive energy would be hard for a young child to manage and integrate into a positively valued sense of self, and that the negative responses of caregivers to an obstreperous, demanding infant or toddler would reinforce the child’s sense that outsiders are persecutory. There has not been much recent research relating paranoia to temperament; in 1978 Meissner marshalled empirical evidence connecting it with an “active” symptomatic style in infancy (irregularity, nonadaptability, intensity of reaction, and negative mood) and with a thin stimulus barrier and consequent hyperexcitability.

Affectively, paranoid people struggle not only with anger, resentment, vindictiveness, and other visibly hostile feelings, they also suffer overwhelmingly from fear. Silvan Tomkins (e.g., 1963) regarded the paranoid stance as a combination of fear and shame. The downward-left eye movements common in paranoid people (the “shifty” quality that even nonprofessionals notice) are physically a compromise between the horizontal-left direction specific to the affect of pure fear and the straight-down direction of uncontaminated shame (S. Tomkins, personal communication, 1972). Even the most grandiose paranoid person lives with the terror of harm from others and monitors each human interaction with extreme vigilance.

Analysts have long referred to the kind of fear suffered by paranoid clients as “annihilation anxiety” (Hurvich, 2003); that is, the terror of falling apart, being destroyed, disappearing from the earth. Anyone who has experienced this level of dread knows how terrifying it is. The research of Jaak Panksepp (1998) into mammalian affect has identified this kind of anxiety as part of the FEAR system that evolved evolutionarily to cope with the possibility of predation. Panksepp differentiates it from attachment/separation anxiety that belongs neurobiologically to the PANIC system and is mediated by serotonin. Paranoid anxiety tends not to be quelled by serotonin reuptake inhibitors, but is instead responsive to benzodiazepines, alcohol, and other “downer” drugs, which may be why paranoid patients often struggle with addiction to those chemical agents.

As for shame, that affect is as great a menace to paranoid people as to narcissistic ones, but paranoid people experience the danger differently. Narcissistic individuals, even arrogant ones, suffer conscious feelings of shame if they feel unmasked. Their energies go into efforts to impress others so that the devalued self will not be exposed. Paranoid people, contrastingly, may use denial and projection so powerfully that no sense of shame remains accessible within the self. The energies of the paranoid person are therefore spent on foiling the efforts of those who are seen as bent on shaming and humiliating them. People with narcissistic character structures are afraid of revealing their inadequacies; those with paranoid personalities are afraid of other people’s malevolence. This focus on the assumed motives of others rather than on what is happening internally can be, as anyone experienced with paranoid patients can testify, a formidable obstacle to therapy.

Also like narcissistic people, paranoid individuals are vulnerable to envy. Unlike them, they handle it projectively. The degree of anger and intensity they have to manage may account for some of the difference. Resentment and jealousy, sometimes of delusional proportions, darken their lives. These attitudes may be directly projected (the conviction that “others are out to get me because of the things about me that they envy”); more often, they are ancillary to the denial and projection of other affects and impulses, as when a paranoid husband, oblivious to his own normal fantasies of infidelity, becomes convinced his wife is dangerously attracted to other men. Frequently involved in this kind of jealousy is an unconscious yearning for closeness with a person of the same sex. Because such longings may be unconsciously confused with erotic homosexuality (Karon, 1989), which can frighten heterosexual males, the wishes are abhorred and denied. These desires for care from a man then resurface as the conviction that it is, for example, one’s girlfriend rather than oneself who wants to be more intimate with a mutual male friend.

Finally, paranoid people are profoundly burdened with guilt, a feeling that may be unacknowledged and projected in the same way that shame is. Some reasons for their deep sense of badness will be suggested below, along with ways of trying to relieve it therapeutically. Their unbearable burden of unconscious guilt is another feature of their psychology that makes paranoid clients so hard to help: They live in terror that when the therapist really gets to know them, he or she will be shocked by all their sins and depravities, and will reject or punish them for their crimes. They are chronically warding off this humiliation, transforming any sense of culpability in the self into dangers that threaten from outside. They unconsciously expect to be found out, and they transform this fear into constant, exhausting efforts to discern the “real” evil intent behind anyone else’s behavior toward them.

DEFENSIVE AND ADAPTIVE PROCESSES IN PARANOIA

Projection, and disavowal of what is projected, dominate the psychology of the paranoid person. Depending on the patient’s ego strength and degree of stress, the paranoid process may be at a psychotic, borderline, or neurotic level. Let me first review those differences. In a frankly psychotic person, upsetting parts of the self are projected and fully believed to be “out there,” no matter how crazy the projections may seem to others. The paranoid schizophrenic who believes that homosexual Bulgarian agents have poisoned his water is projecting his aggression, his wish for same-sex closeness, his ethnocentrism, and his fantasies of power. He does not find ways of making his beliefs fit with conventional notions of reality; he may be quite convinced that he is the only one in the world who sees the threat.

Because reality testing is not lost in people at a borderline level of personality organization, paranoid patients in the borderline range project in such a way that those on whom disowned attitudes are projected are subtly provoked to feel those attitudes. This is projective identification: The person tries to get rid of certain feelings, yet retains empathy with them and needs to reassure the self that they are justified. The borderline paranoid person works to make what is projected “fit” the target. Thus the woman who disowns her hatred and envy announces to her therapist in an antagonistic manner that she can tell that the therapist is jealous of her accomplishments; comments made in a sympathetic spirit are reinterpreted by the client as evidence of envy-driven wishes to undermine and control, and soon the therapist, worn down by being steadily misunderstood, is hating the patient and envying her freedom to vent her spleen (Searles, 1959). This remarkable process torments therapists, who do not choose our profession expecting to have to endure such powerful negative feelings toward those we hope to help; it accounts for the general intolerance among many mental health professionals toward both borderline and paranoid patients.

In paranoid people at the neurotic level, internal issues are projected in a potentially ego-alien way. That is, the patient projects yet has some observing part of the self that eventually will be capable, in the context of a reliable relationship, of acknowledging the externalized contents of the mind as projection. People who, in an intake interview, describe themselves as paranoid are often in this category (though borderline and psychotic paranoid clients may sometimes talk this way also, in an effort to show that they know the jargon but without any real internal appreciation that their fears constitute projections). I knew one of my patients was getting better when he came in announcing that he was having fantasies that I was critical, even though he couldn’t find any evidence of my critical attitude. Sensitive to the possible grain of truth in a projection, I said something like, “Well, let me think about whether there is some way in which I may have been critical,” and he responded, “Can’t you sometimes just let it be my crazy paranoia?!”

A talented and healthy but characterologically paranoid client of mine was subject to profound fears that I would sell him out in the service of my need to look good to others. If a professional in the community who knew both of us were to criticize him to me, he was sure that I would somehow convey agreement. (Meanwhile, when he felt hurt by me, he had no reluctance to complain about me in ways that made some of my colleagues quite critical of my treatment of him.) Even before he was able to understand this fear as the projection of his own—unnecessarily hated—needs for acceptance and admiration, plus the projection and acting out of his defensive criticism, he was willing to consider that he might be putting on me something that I did not deserve.

The need of the paranoid person to handle upsetting feelings projectively entails the use of an unusual degree of denial and its close relative, reaction formation. All of us project; indeed, the universal disposition toward projection is the basis for transference, the process that makes analytic therapy possible. But paranoid people do it in the context of such a great need to disavow upsetting attitudes that it feels like a whole different process from projective operations in which denial is not so integral. Freud (1911) accounted for paranoia, at least of the psychotic variety, by the successive unconscious operations of reaction formation (“I don’t love you; I hate you”) and projection (“I don’t hate you; you hate me”). Implicit in this formulation is the paranoid person’s terror of experiencing normal loving feelings, presumably because prior attachment relationships were toxic. Freud thought same-sex longing was particularly implicated in paranoia, but my own experience suggests that any kind of longing feels unbearably dangerous to a paranoid person.

Freud’s paradigm shows only one of several possible routes by which a paranoid person may emerge at a psychological place very far from the original, more humanly comprehensible attitudes that initiated the paranoid process (Salzman, 1960). Karon (1989) summarizes the ways in which a delusional paranoid person can handle wishes for same-sex closeness:

If one considers the different ways in which one could contradict the feeling “I love him,” one derives many typical delusions. “I do not love him, I love me (megalomania).” “I do not love him, I love her (erotomania).” “I do not love him, she loves him (delusional jealousy).” “I do not love him, he loves me (projecting the same-sex longing, producing a delusional homosexual threat).” “I do not love him, I hate him (reaction formation).” And, finally, most common, projecting the delusional hatred as “He hates me, hence, it is alright for me to hate him (and if I hate him, I do not love him).” (p. 176)

Again, a significant difficulty in working with paranoid people concerns how long and convoluted is the distance between their basic affects and their defensive handling of them.

RELATIONAL PATTERNS IN PARANOID PSYCHOLOGY

Clinical experience suggests that children who grow up paranoid have suffered severe insults to their sense of efficacy; they have repeatedly felt overpowered and humiliated (MacKinnon et al., 2006; Tomkins, 1963; Will, 1961). The father of Daniel Paul Schreber, from whose report of a paranoid psychosis Freud (1911) extracted a theory of paranoia, was reportedly a domineering patriarch who advocated, and insisted on his son’s adopting, arduous physical regimes intended to toughen up children (Niederland, 1959). Then Schreber suffered humiliation by authorities he had trusted and by the legal system of his era (Lothane, 1992).

Criticism, capricious punishment, adults who cannot be pleased, and utter mortification are common in the backgrounds of paranoid people. Those who rear children who become paranoid also frequently teach by example. A child may observe suspicious, condemnatory attitudes in parents, who emphasize—paradoxically, in view of their abusive qualities and the objectively kinder worlds of school and community—that family members are the only people one can trust. Paranoid people in the borderline and psychotic ranges may come from homes where criticism and ridicule dominated familial relationships, or where one child, the future sufferer of paranoia, was the scapegoat—the target of the family members’ hated and projected attributes, especially those in the general category of “weakness.” In my experience, those in the neurotic-to-healthy range tend to come from families in which warmth and stability were combined with teasing and sarcasm.

Another source of paranoid personality organization is unmanageable anxiety in a primary caregiver. A paranoid patient of mine came from a family in which the mother was so chronically nervous that she took a thermos of water with her everywhere she went (for her dry mouth) and described her body as having “turned into a cement block” from accumulated tension. Whenever her daughter would come to her with a problem, the mother would either deny it, because she could not bear any additional worries, or catastrophize about it, because she could not contain her anxiety. The mother was also confused about the line between fantasy and behavior and hence conveyed to her child that thoughts equaled deeds. The daughter got the message that her private feelings, whether loving or hateful, had a dangerous power.

For example, when once as an adult my patient told her mother that in reaction to her husband’s arbitrariness she had challenged him, her mother first contended she was misreading him: He was a devoted husband, and she must be imagining anything objectionable coming from him. When my patient persisted with an account of the argument, her mother urged her to be careful, as he might beat her up or abandon her if provoked (she herself had been battered and then divorced by her husband). And when my patient went on to vent anger at how he had acted, she was begged to think about something else so that her negative thoughts would not make things worse. An adolescent prototype for this interaction was her telling her mother of her father’s effort to molest her. The mother managed both to insist that it had not happened and to blame it on her daughter’s sexuality.

This well-meaning but very disturbed mother, who had had no comfort as a youngster, was incapable of comforting. In her daughter’s formative years, her anxiety-soaked advice and dire predictions compounded the girl’s fears. My client thus grew up being able to console herself only by drastic transformations of her feelings. When I began working with her, she had already seen several therapists who had been defeated by her bottomless need and relentless hostility. All of them had seen her as paranoid in either the psychotic or low-level borderline range. Her capacity to report transactions like the preceding to me, and to comprehend how destructive similar ones had been all her life, came only after many years of therapy.

One can detect in the preceding example of distorted maternal responsiveness several different seeds of paranoia. First, both reality and the patient’s normal emotional reactions to it were disconfirmed, instilling fear and shame rather than a sense of being understood. Second, denial and projection were modeled. Third, primitive omnipotent fantasies were reinforced, laying the foundation for a diffuse and overwhelming guilt. Finally, the interaction created additional anger while resolving none of the original distress, thus magnifying the patient’s confusion about basic feelings and perceptions. In situations like this, in which a person has been implicitly insulted (in this case, seen as unappreciative, incapable of managing feelings, dangerous), he or she must at some level feel even more aggravated than originally. But such a reaction may be judged as either incomprehensible or evil because the insulting party was only trying to help.

Such mind-muddling transactions get replicated repeatedly in the adult relationships of paranoid people. Their internalized objects keep undermining both the paranoid person and those to whom he or she relates. If a child’s primary source of knowledge is a caregiver who is deeply confused and primitively defended, who—in desperate attempts to feel safe or important—uses words not to express honest feeling but to manipulate, the child’s subsequent human relations cannot be unaffected. The struggle of the paranoid person to understand what is “really” going on (D. Shapiro, 1965) is comprehensible in this light, as is the bewilderment, helplessness, and estrangement that beset people dealing with paranoid friends, acquaintances, and relatives.

The mother’s anxiety was not the only influence on this woman’s psychology, of course. If she had had any significant caregiver capable of relating in a confirmatory way, her personality would probably not have developed in a paranoid direction. But her father, prior to abandoning his family when she was an older teenager, was frighteningly critical, explosive, and disrespectful of boundaries. The tendency of paranoid people to lash out rather than endure the anxiety of passively awaiting inevitable mistreatment (“I’ll hit you before you hit me”) is another well-known and unfortunate cost of this kind of parenting (Nydes, 1963). The presence of a frightening parent and the absence of people who can help the child process the resulting feelings (except by making them worse) is, according to many therapists who have successfully mitigated the condition, a common breeding ground for paranoia (MacKinnon et al., 2006).

Because of their orientation toward issues of power and their tendency to act out, paranoid people have some qualities in common with psychopathic ones. But a critical difference lies in their capacity to love. Even though they may be terrified by their own dependent needs and wracked with suspicion about the motives and intentions of those they care about, paranoid individuals are capable of deep attachment and protracted loyalty. However persecutory or inappropriate their childhood caregivers were, paranoid clients apparently had enough availability and consistency in their early lives to be able to attach, albeit anxiously or ambivalently. Their capacity to love is what makes therapy possible in spite of all their hyperreactivity, antagonisms, and terrors.

THE PARANOID SELF

The main polarity in the self-representations of paranoid people is an impotent, humiliated, and despised image of the self versus an omnipotent, vindicated, triumphant one. A tension between these two images suffuses their subjective world. Cruelly, neither position affords any solace: A terror of abuse and contempt goes with the weak side of the polarity, whereas the strong side brings with it the inevitable side effect of psychological power, a crushing guilt.

The weak side of this polarity is evident in the degree of fear with which paranoid people chronically live. They never feel fully safe and spend inordinate energy scanning the environment for dangers. The grandiose side is evident in their “ideas of reference”: Everything that happens has something to do with them personally. This is most obvious in psychotic levels of paranoia, instances in which a patient believes, say, that he or she is the personal target of an international spy ring or is receiving covert messages during TV commercials about the incipient end of the world. But I have also heard high-achieving, reality-oriented clients ruminate about whether the fact that someone sat in their usual chair revealed a plot to harass and humiliate them. Incidentally, such clients often do not come across as paranoid in the intake interview, and it can be startling to hear, after several sessions, the emergence of the organizing conviction that everything that happens to them reflects the significance to other people of their personal existence.

The megalomania of paranoid people, whether unconscious or overt, burdens them with unbearable guilt. If I am omnipotent, then all kinds of terrible things are my fault. The intimate connection between guilt and paranoia can be intuitively comprehended by any of us who have felt culpable and then worried about being exposed and punished. I notice that when one of my students is late turning in a paper, he or she avoids me whenever possible, as if the only thing on my mind is that transgression and my planned retribution. A woman I was treating who was having an extramarital affair reported with amusement that while she was on a drive with her lover, holding hands in the car, she noticed a police vehicle ahead and pulled her hand away.

When an unbearable attitude is denied and projected, the consequences can be grave. A connection between paranoia and disavowed homosexual preoccupations has been noted for some time by clinicians (e.g., Searles, 1961) and was confirmed by some empirical studies (e.g., Aronson, 1964) several decades ago. More recently, Adams, Wright, and Lohr (1996) did a series of experiments that showed that the more a man was aroused by homosexual imagery, the more homophobic he tested. Paranoid people, even the minority of them who have acted on homoerotic feelings, may regard the idea of same-sex attraction as upsetting to a degree that is scarcely imaginable to the nonparanoid. To gay and lesbian people, who find it hard to see why their sexual orientation is perceived as so threatening, the homophobia of some paranoid groups is truly menacing.

As the brief triumph of Nazism demonstrates (and Nazism targeted gay people, mentally disabled people, and the Roma, as well as the Jews), when paranoid trends are shared by a whole culture or subculture, the most horrific possibilities arise. Students of the rise of Nazism (e.g., Gay, 1968; Rhodes, 1980; F. Stern, 1961) locate its psychological origins in the same kinds of events that clinicians have found in the childhoods of paranoid individuals. The crushing humiliation of Germany in World War I and the subsequent punitive measures that created runaway inflation, starvation, and panic, with little responsiveness from the international community, laid the groundwork for the appeal of a paranoid leader and the organized paranoia that is Nazism (for a description of the role of paranoia in recent American politics, see Welch, 2008).

At the core of the self-experience of paranoid people is a profound emotional isolation and need for what Sullivan (1953) called “consensual validation” from a “chum” or what Benjamin (1988) later called “recognition.” The main way in which paranoid people try to enhance their self-esteem is through exerting effective power against authorities and other people of importance. Experiences of vindication and triumph give them a relieving (although fleeting) sense of both safety and moral rectitude. The dreaded litigiousness of paranoid individuals derives from this need to challenge and defeat the persecutory parent. Some people with paranoid personalities provide devoted service to victims of oppression and mistreatment, because their disposition to battle unjust authorities and vindicate underdogs keeps them on the barricades far longer than other well-meaning social activists whose psychodynamics do not similarly protect them against burnout.

TRANSFERENCE AND COUNTERTRANSFERENCE
WITH PARANOID PATIENTS

Transference in most paranoid patients is swift, intense, and often negative. Occasionally, the therapist is the recipient of projected savior images, but more commonly he or she is seen as potentially disconfirming and humiliating. Paranoid clients approach a psychological evaluation with the expectation that the interviewer is out to feel superior by exposing their badness, or is pursuing some similar agenda that has nothing to do with their well-being. They tend to strike clinicians as grim, humorless, and poised to criticize. They may fix their eyes relentlessly on the therapist in what has been called the “paranoid stare.”

Not surprisingly, interviewers respond with a sense of vulnerability and general defensiveness. Countertransference is usually either anxious or hostile; in the less common instance of being regarded as a savior, it may be benevolently grandiose. In any case, the therapist is usually aware of strong reactions, in contrast to the often subtler countertransferences that arise with narcissistic and schizoid patients. Because of the combination of denial and projection that constitute paranoia, causing the repudiated parts of the self to be extruded, therapists of paranoid patients often find themselves consciously feeling the aspect of an emotional reaction that the client has exiled from consciousness. For example, the patient may be full of hostility, whereas the therapist feels the fear against which the hostility is a defense. Or the patient may feel vulnerable and helpless, while the therapist feels sadistic and powerful.

Because of the weight of these internal reactions in the therapist, and the extent to which they betray to a sensitive person the degree of suffering that a paranoid client is trying to manage, there is a countertransference tendency in most therapists to try to “set the patient straight” about the unrealistic nature of whatever danger the patient believes he or she is in. Most of us who have practiced for any length of time have had at least one client who seemed to be crying out for reassurance and yet, upon receiving it, became convinced that we were part of the conspiracy to divert him or her from a terrible threat. The therapist’s powerlessness to give much immediate help to a person who is so unhappy and suspicious is probably the earliest and most intimidating barrier to establishing the kind of relationship that can eventually offer relief.

THERAPEUTIC IMPLICATIONS OF THE DIAGNOSIS
OF PARANOID PERSONALITY

The first challenge a therapist faces with a paranoid patient is creating a solid working alliance. Although establishing such a relationship is necessary (and sometimes challenging) for the successful treatment of any client, it is particularly important in work with paranoid people because of their difficulty trusting. A beginning student of mine, asked about his plan for working with a very paranoid woman, commented, “First I’ll get her to trust me. Then I’ll work on assertiveness skills.” Wrong. When a paranoid person truly trusts the therapist, many years may have passed, and the treatment has been a huge success. But the student was right in one sense: There has to be some initial embrace by the client of the possibility that the therapist is well intentioned and competent. This takes not only considerable forbearance from the therapist, it takes some capacity for comfort talking about the negative transference and conveying that the degree of hatred and suspicion aimed at the clinician is to be expected. The therapist’s unflustered acceptance of intense hostility fosters the patient’s sense of safety from retribution, mitigates fear that hatred destroys, and exemplifies how aspects of the self that the patient has regarded as evil are simply ordinary human qualities.

This section will be longer than in other chapters because effective work with paranoid clients differs substantially from “standard” psychoanalytic practice. Although it has in common the goals of understanding at the deepest level, bringing into consciousness the unknown aspects of the self, and promoting the most thoroughgoing possible acceptance of one’s full humanity, it accomplishes these ends differently. For example, interpretation “from surface to depth” is usually impossible with paranoid clients because so many radical transformations of their original feelings have preceded their manifest preoccupations. A man who longs for support from someone of his gender, who has unconsciously misread that yearning as sexual desire, denied that, projected it on to someone else, displaced it, and become overwhelmed with fears that his wife is having an affair with his friend will not have his real concerns addressed if the therapist simply encourages him to associate freely to the idea of his wife’s infidelity.

“Analyzing resistance before content” can be similarly ill fated. Commenting on actions or statements made by a paranoid client only makes that client feel judged or scrutinized like a laboratory guinea pig (Hammer, 1990). Analysis of the defenses of denial and projection elicits only more Byzantine uses of the same defenses. The conventional aspects of psychoanalytic technique—such as exploring rather than answering questions, bringing up aspects of a patient’s behavior that may be expressing an unconscious or withheld feeling, calling attention to slips, and so forth—were designed to increase patients’ access to internal material and to support their courage to talk more openly about it (Greenson, 1967). With paranoid people, such practices boomerang. If the standard ways of helping clients to open up elicit only further elaborations of a paranoid sensibility, how can one help?

First, one can call on a sense of humor. Many of my teachers advised against joking with paranoid patients lest they feel teased and ridiculed. This caution is warranted, but it does not rule out the therapist’s modeling an attitude of self-mockery, amusement at the world’s irrationalities, and other nonbelittling forms of wit. Humor is indispensable in therapy—perhaps especially with paranoid clients—because jokes are a time-honored way to discharge aggression safely. Nothing relieves both patient and therapist more than glimpses of light behind the gloomy stormcloud that surrounds a paranoid person. The best way to set the stage for mutual enjoyment of humor is to laugh at one’s own foibles, pretensions, and mistakes. Paranoid people miss nothing; no defect in the therapist is safe from their scrutiny. A friend of mine claims to have perfected the “nose yawn,” a priceless asset to the conduct of psychotherapy, but I would bet my couch that even he could not fool a good paranoid.

The woman whose history I described earlier in this chapter has never failed to notice my yawning, no matter how immobile my face. I reacted to her initial confrontations about this with apologetic admissions that she had found me out again, and with whining self-pity about not being able to get away with anything in her presence. This kind of reaction, rather than the heavy, humorless exploration of what her fantasy was when she thought I was yawning, has deepened our work together. Naturally, one stands ready to apologize if one’s wit is mistaken for ridicule, but the idea that work with hypersensitive patients must be conducted in an atmosphere of oppressive seriousness seems to me unnecessarily fussy and somewhat patronizing. Especially after a reliable alliance has been established, something that may take months or years, judicious teasing, in an effort to make omnipotent fantasies ego alien, can be helpful to a paranoid person. Jule Nydes (1963), who had a gift for working with difficult clients, cites the following interventions:

Hammer (1990), who stresses the importance of indirect, face-saving ways of sharing insights with paranoid patients, recommends the following joke as a way to interpret the drawbacks of projection:

A man goes toward his neighbor’s house to borrow a lawnmower, thinking how nice his friend is to extend him such favors. As he walks along, however, doubts concerning the loan begin to gnaw at him. Maybe the neighbor would rather not lend it. By the time he arrives, the doubts have given way to rage, and as the friend appears at the door the man shouts, “You know what you can do with your damn lawnmower; shove it!” (p. 142)

Humor, especially willingness to laugh at oneself, is probably therapeutic in that to the patient it represents being “real,” rather than playing a role and pursuing a secret game plan. The histories of paranoid people may be so bereft of basic authenticity that the therapist’s direct emotional honesty comes as a revelation about how people can relate to each other. With some reservations cited below, having to do with maintaining clear boundaries, I recommend being quite forthcoming with paranoid clients. This means responding to their questions honestly rather than withholding answers and investigating the thoughts behind the inquiry; it is my experience that when the manifest content of a paranoid person’s concern is respectfully addressed, he or she becomes more rather than less willing to look at the latent concerns represented in it.

Second, one can “go under” or “sidestep” or “do an end run around” (depending on one’s favored metaphor) the complex paranoid defense and into the affects against which it has been erected. In the case of the man consumed with ruminations about his wife’s possible infidelity, one could be helpful by commenting on how lonely and unsupported he seems to feel. It is startling to see how fast a paranoid rant can disappear if the therapist simply lets it run its course, avoiding all temptations to deconstruct a convoluted defensive process, and then engages empathically with the disowned, projected feelings from which the angry preoccupation originally sprang.

Often the best clue to the feeling being defended against is one’s countertransference; paranoid people are usefully imagined as actually projecting their unacknowledged attitudes physically into the therapist. Thus, when the patient is in an unrelenting, righteous, powerful rage, and the therapist feels resultingly threatened and helpless, it may be deeply affirming for the client to be told, “I know that what you’re in touch with is how angry you are, but I sense that in addition to that anger, you’re coping with profound feelings of fear and helplessness.” Even if one is wrong, the client hears that the therapist wants to understand what is creating such severe upset.

Third, one can frequently help patients suffering from an increase in paranoid reactions by identifying what has happened in their recent experience to upset them. Such triggers often involve separation (a child has started school, a friend has moved away, a parent has not answered a letter), failure, or—paradoxically—success (failures are humiliating; successes involve omnipotent guilt and fears of envious attack). One of my patients tends to go on long paranoid tirades, during which I can usually figure out what he is reacting to only after 20 or 30 minutes. If I assiduously avoid confronting his paranoid operations and instead comment on how he may be underestimating how bothered he is by something that he mentioned in passing, his paranoia tends to lift without any analysis of that process at all. Educating people to notice their states of arousal and to look for triggers often preempts the paranoid process altogether. And I have found that especially if one can tap into underlying grief and bear gentle witness to the client’s pain, paranoia may evaporate.

One should usually avoid direct confrontation of the content of a paranoid idea. Paranoid people are acutely perceptive about emotion and attitude; where they get mixed up is on the level of interpretation of the meaning of these manifestations (Josephs & Josephs, 1986; Meissner, 1978; D. Shapiro, 1965; Sullivan, 1953). When one challenges their interpretations, they tend to believe that one is telling them they are crazy for having seen what they saw, rather than suggesting that they have misconstrued its implications. Hence, although it is tempting to offer alternative interpretations, if one does this too readily, the patient feels dismissed, disparaged, and robbed of the astute perceptions that stimulated the paranoid interpretation.

When a paranoid client is brave enough to ask outright whether the clinician agrees with his or her understanding of something, the therapist can offer other interpretive possibilities with suitable tentativeness (“I can see why you thought the man intended to cut you off, but another possibility is that he’d had a fight with his boss and would have been driving like a maniac no matter who was on the road”). Note that the therapist in this example has not substituted a more benevolent motive for the paranoid person’s self-referential one (“perhaps he was swerving to avoid hitting an animal”) because if paranoid people think one is trying to pretty up intentions that they know are debased, they will get more anxious. Note also that the comment is made in the tone of a throwaway line, so that the patient can either take it or leave it. With paranoid patients one should avoid asking them to explicitly accept or reject the therapist’s ideas. From their perspective, acceptance may equal a humiliating submission, and rejection may invite retribution.

Fourth, one can make repeated distinctions between thoughts and actions, holding up the most heinous fantasies as examples of the remarkable, admirable, creative perversity of human nature. The therapist’s capacity to feel pleasure in hostility, greed, lust, and similar less-than-stellar tendencies without acting them out helps the patient to reduce fears of an out-of-control, evil core. Lloyd Silverman (1984) stressed the general value of going beyond interpretation of feelings and fantasies to the recommendation that one enjoy them, a particularly important dimension of work with paranoid people. Sometimes without this aspect of treatment, patients get the idea that the purpose of therapy is to get them to expose such feelings and be humiliated, or to help them purge themselves of them, rather than to embrace them together as part of the human condition.

When my older daughter was about 3, a nursery school teacher promulgated the idea that virtue involves “thinking good thoughts and doing good deeds.” This troubled her. She was relieved when I commented that I disagreed with her teacher and felt that thinking bad thoughts is a lot of fun, especially when one can do good deeds in spite of those thoughts. For months afterward, especially when she was trying not to abuse her infant sister, she would get a mischievous expression on her face and announce, “I’m doing good deeds and thinking very bad thoughts!” Although she was a much quicker study than a person with a lifetime of confusion about fantasy and reality, what I was trying to teach her is the same message that is healing to paranoid clients.

Fifth, one must be hyperattentive to boundaries. Whereas one might sometimes lend a book or spontaneously admire a new hairstyle with another kind of patient, such behaviors are rife with complication when enacted with a paranoid person. Paranoid clients are perpetually worried that the therapist will step out of role and use them for some end unrelated to their psychological needs. Even those who develop intensely idealizing transferences and insist that they want a “real” friendship with the therapist—perhaps especially these clients—may react with terror if one acts in a way that seems uncharacteristically self-extending.

Consistency is critical to a paranoid person’s sense of security; inconsistency stimulates fantasies that wishes have too much power. Exactly what the individual therapist’s boundaries are (e.g., how missed sessions or phone calls to the therapist’s home are handled) matters less than how reliably they are observed. It is much more therapeutic for a paranoid person to rage and grieve about the limits of the relationship than to worry that the therapist can actually be seduced or frightened out of his or her customary stance. While a surprising deviation that speaks for the therapist’s caring can light a spark of hope for a depressive person, it may ignite a blaze of anxiety in a paranoid patient.

On this topic, I should mention the risk of pseudoerotic transference storms in paranoid clients. Same-sex therapists may have to be even more carefully professional than opposite-sex ones, on account of the vulnerability of many paranoid people to homosexual panic, but both may find themselves suddenly the target of an intense sexualized hunger or rage. The combination of extreme psychological deprivation and cognitive confusion (affection with sex, thoughts with action, inside with outside) often produces erotized misunderstandings and fears. The best the therapist can do is to restore the therapeutic frame, tolerate the outburst, normalize the feelings behind the eruption, and differentiate between those feelings and the behavioral limits that make psychotherapy possible.

Finally, it is critical that one convey both personal strength and unequivocal frankness to paranoid clients. Because they are so full of hostile and aggressive strivings, so confused about where thoughts leave off and actions begin, and so plagued with feelings of destructive omnipotence, their greatest worry in a therapy relationship is that their evil inner processes will injure or destroy the therapist. They need to know that the person treating them is stronger than their fantasies. Sometimes what matters more than what is said to a paranoid person is how confidently, forthrightly, and fearlessly the therapist delivers the message.

Most people who have written about the actual experience of treating paranoid people (as opposed to the much larger literature theorizing about the origins of paranoid processes) have stressed respect, integrity, tact, and patience (Arieti, 1961; Fromm-Reichmann, 1950; Hammer, 1990; Karon, 1989; MacKinnon et al., 2006; Searles, 1965). Some, especially those who have worked with psychotic clients, have recommended joining in the patient’s view of reality, in order to create enough affirmation that the patient can start shedding the paranoid constructions that therapist and client now seem to share (Lindner, 1955; Spotnitz, 1969). Most writers, however, feel one can convey respect for the client’s view of the world without going that far.

Because of their excruciating sensitivity to insult and threat, it is not possible to treat paranoid patients without some debacles. Periodically, the therapist will be made into a monster (Reichbart, 2010), as the client makes what Sullivan (1953) called “malevolent transformations” and suddenly experiences the therapist as dangerous or corrupt. Sometimes the therapy work seems like an endless exercise in damage control. In the short run, one has to tolerate a protracted feeling of standing alone, since people with paranoid psychologies are not inclined to confirm, by verbal acknowledgment or visible appreciation, one’s exertions in the service of understanding. But a devoted, reasonably humble, honest practitioner can make a radical difference over the years with a paranoid person, and will find beneath all the client’s rage and indignation a deep well of warmth and gratitude.

DIFFERENTIAL DIAGNOSIS

The diagnosis of paranoid personality structure is usually easy to make, except, as noted previously, in instances in which a person is high functioning and trying to keep the extent of his or her paranoia hidden from the interviewer. As with schizoid clients, attention to the possibility of psychotic processes in a manifestly paranoid patient is warranted.

Paranoid versus Psychopathic Personality

In Chapter 7 I commented on the differential importance of guilt as a central dynamic in the respective psychologies of paranoid and antisocial people. I should also mention love. If a paranoid person feels that you and he or she share basic values, and that you can be counted upon in adversity, there is virtually no limit to the loyalty and generosity of which the person may be capable. Projective processes are common in antisocial people, but where psychopaths are fundamentally unempathic, paranoid people are deeply object related. The main threat to long-term attachment in paranoid people is not lack of feeling for others but rather experiences of betrayal; in fact, they are capable of cutting off a relationship of 30-years’ duration when they feel wronged. Because they connect with others on the basis of similar moral sensibilities and hence feel that they and their love objects are united in an appreciation of what is good and right, any perceived moral failing by the person with whom they are identified feels like a flaw in the self that must be eradicated by banishing the offending object. But a history of aborted relationships is not the same thing as an inability to love.

Paranoid versus Obsessive Personality

Obsessive people share with paranoid individuals a sensitivity to issues of justice and rules, a rigidity and denial around the “softer” emotions, a preoccupation with issues of control, a vulnerability to shame, and a penchant for righteous indignation. They also scrutinize details and may misunderstand the big picture because of their fixation on minutia. Further, obsessional people in the process of decompensating into psychosis may slide gradually from irrational obsessions into paranoid delusions. Many people have both paranoid and obsessional features.

People in these respective diagnostic categories differ, however, in the role of humiliation in their histories and sensitivities; the obsessive person is afraid of being controlled but lacks the paranoid person’s fear of physical harm and emotional mortification. Obsessive patients are more likely to try to cooperate with the interviewer despite their oppositional qualities, and therapists working with them do not suffer the degree of anxiety that paranoid patients induce. Standard psychoanalytic technique is usually helpful to obsessive clients; rage reactions to conventional clarifications and interpretations in a patient one has believed to be obsessional may be the first sign that his or her paranoid qualities predominate.

Paranoid versus Dissociative Psychology

Many people with dissociative identity disorder have an alter personality that carries the paranoia for the personality system and may impress an interviewer as representative of the whole person. Because emotional mistreatment is implicated in the etiologies of both paranoia and dissociation, the coexistence in individual people of these processes is common. In Chapter 15 I discuss the diagnosis of dissociative disorders thoroughly enough that it will be clear how to discriminate an individual with a paranoid personality from a dissociative person with a paranoid alter personality or paranoid tendencies.

SUMMARY

I have described the manifest and latent qualities of people whose personalities are predominantly paranoid, stressing their reliance on projection. Possible etiological variables include innate aggressiveness or irritability, and consequent susceptibilities to fear, shame, envy, and guilt. I considered the role of formative experiences of threat, humiliation, and projective processes in the family system, and anxiety-ridden, contradictory messages in the development of this type of personality organization, and I described the paranoid person’s sense of self as alternately helplessly vulnerable and omnipotently destructive, with ancillary preoccupations resulting from a core fragility in identity and self-esteem. Finally, I discussed the intensity of transference and countertransference processes, especially those involving rage.

I recommended that therapists of paranoid patients demonstrate a good-humored acceptance of self and an amused appreciation of human foibles; work with affect and process rather than defense and content; identify specific precipitants of symptomatic upset, avoiding frontal assaults on paranoid interpretations of experience; distinguish between ideas and actions; preserve boundaries; and convey attitudes of personal power, authenticity, and respect. Finally, I differentiated people with predominantly paranoid psychologies from those with psychopathic, obsessive, and dissociative types of personality organization.

SUGGESTIONS FOR FURTHER READING

The most comprehensive book on paranoia may be Meissner’s The Paranoid Process (1978). But D. Shapiro’s (1965) chapter on the paranoid style is better written, shorter, and livelier. Much recent psychoanalytic writing on paranoia has addressed social justice issues or commented on political phenomena, as paranoia is central to the process by which groups achieve cohesion by exploiting fears of other groups. The journal Psychoanalytic Review recently devoted an interesting issue (2010, vol. 97[2]) to this topic, in which I have an essay.