McWilliams describes the paranoid style as predominantly relying on projection to disavow one of negative qualities. These negative self attributes are disowned and projected outward such that the external environment is viewed as threatening and harmful. As a result, the paranoid is disposed to mistrust relationships and may only seek help as a last resort. The paranoid may present along the psychotic – borderline – neurotic range, depending on intactness of reality testing. At the extreme end, the paranoid in a psychotic state may exhibit extreme delusions of persecutions (for example). McWilliams however, cautions the therapist not to discount the possibility that the paranoid’s fear regardless of how delusional may actual have a basis in reality – here she points to Howard Hughes as an apt example.
Developmentally, McWilliams cites speculations that paranoids may be temperamentally endowed with higher levels of aggressive energy and suffered severe insults to their sense of self efficacy. Difficulty managing and integrating aggressive impulses may have strained early interpersonal relations and these interactions biased the paranoid’s view of the external world as rejecting and hostile (here, an interpersonal/relational view). The paranoid stance is dominated by a combination of fear, shame and guilt – all of which are denied and projected outwards. McWilliams differentiates the paranoid from the narcissist in that the paranoid chiefly defends against malevolence of others whereas the narcissist against injury to the self (revealing inadequacies).
Taking an interpersonal/relational perspective will inform how one conceptualizes the paranoid organization and intervenes in the therapeutic situation. The interpersonal/relational therapist would pay attention to the subjective experience of the patient and therapist in relation to patient to decipher the patient’s ways of handling current anxieties and experience. This organization is then considered as a strategy adopted by the patient enabling him to interact with others. The therapist would focus on focus on how this strategy played out in the context of the current relationship.
McWilliams highlights distortion in the sexual identity as common in the paranoid (also emphasized by Klein’s paranoid-schizoid). Namely, the paranoid exhibits a tendency to misinterpret the need for same-sex intimacy and connectedness with sexual orientation spurring homophobic anxieties and fears. Here, the interpersonal/relation view posits that “sexual difficulties are sexualized expressions of relational conflicts.” The paranoid’s misattribution of same sex intimacy needs to homosexuality would be conceptualized as indicative of prior formative relations. The interpersonal/relational therapist would explore ways in which this relational pattern is playing out in the patient's current interpersonal relations and analytic relationship.