An Interpersonal/Relational Approach to Paranoia
The DSM definition of paranoia (i.e. paranoid personality disorder) is fundamentally at odds with the core concepts of the interpersonal and (especially) the relational schools of thought. The central tenet of these theories is the concept that the therapeutic relationship is necessarily created out of the meeting of two equal subjectivities, and that there is no basis for privileging the therapist’s perspective. The therapist has no greater claim on reality than the patient. The DSM, in contrast, defines paranoia in terms that make the clinician’s subjective view the last word on the reality of the patient’s position. The diagnosis can only be given if the patient’s fears and suspicions are judged to be unrealistic, and the criteria use words like “without sufficient basis,” “unjustified,” and “unwarranted.” Even aside from the fact that the relationalists reject the notion of diagnostic labels altogether, clinician’s role here is undeniably privileged.
The relational argument specifically highlights the weaknesses of the DSM version of paranoia, with implications for both diagnosis and treatment. First, there is the very sensitive and essentially untenable position of the DSM-guided therapist. To be forced to judge the realities of another person’s life in this way places therapists in a role that many probably never wanted to be in. If we have chosen the therapy trade it is likely out of an affinity for empathy and a tendency to withhold judgment. Who but a therapist should know better than to believe in the fallacy that one can know the facts of patient’s life better than the patient? Second, there is the not-unlikely possibility that the therapist may judge incorrectly, applying the labels “unjustified” and “unwarranted” to fears that are actually realistic. Third, there is the possibility that a patient facing obviously real dangers may still be under the influence of a paranoid dynamic. Just because you’re paranoid doesn’t mean they aren’t following you, as the saying goes.
McWilliams, as is her wont, occupies a sort of middle ground in this conflict. While she is quite ready to apply the paranoia label, she is careful to emphasize that the clinician’s judgment of the realism of the paranoid’s fears is not the crucial criterion. Instead, it is the use of projection of disowned feelings and thoughts, which then take on the appearance (to the patient) of external threats. Of course, the relational people would take issue with this formulation too, noting that it has only shifted the object of the clinician’s judgments, from what is external to the patient to what is internal. Still, McWilliams’ formulation has implications for treatment that I think these critics would applaud. Namely, she eschews interpretation and direct confrontation and instead emphasizes humor, frankness, and as much genuineness as possible while simultaneously upholding the boundaries of the therapeutic relationship.