Advanced Psychopathology

Saturday, April 01, 2006


Gillian: conceptualization of narcissism

According to Bromber’s conceptualization, narcissistic presentations of grandiosity and a lack of genuine relatedness are in place to protect the fragile, poorly diffentiated self from the threat of annhiation from internal and external experience. Narcissistic pathology may stem from a trauma at 7-8 months, when development of stranger anxiety and the first capacity for an outside and an inside to be created in the mind of the infant has its origin. This is when an autonomous self can emerge that is separate from the fusion with the all-powerful other. Development of individuated self and object representation is dependent on the presence of an emotionally available mother. If this good object experience is missing, and particularly if there is a trauma at this stage, external reality may seem too different from the experience of self-contained gratification, and the infant will prefer fusion with the internalized idealized object and a retention of the resulting magical omnipotence. The infant will feel the need to control rather than internalize reality, and this may continue into adulthood manifesting as difficulty with full immersion in life, and a constant sense of shame, rage, and self-consciousness. The grandiose self may be seen as an attempt to retain the all-powerful nature of the internalized object with whom the patient is fused.

Kohut’s conceptualization of narcissisim is similar, in that traumatic parental disappointment can shock the child’s system and force her to let go of the idealized view of the all-powerful object before she is ready. In response to this, she may just interject her entire idealized parent and use this as a makeshift self. She has no time to integrate the good and bad aspects of the object, and no time to create a differentiated self in the accpeting and present environment of a real object. The idealized object is seen as part of the self, and rage and grandiosity are both conjured; rage at the disappointing object, and grandiosity to protect against a fragile fossilized infantile self, and infantile view of the object and the world. Kohut disagrees with Bromberg’s position that narcissism develops pre-psychologically, before the creation of an ego. Instead, Kohut puts narcissism in the category of those pathologies that occur after some sort of cohesive self has developed, albeit a feeble one. While in Bromberg’s conception the major injury predisposing one to narcissism occurs around 7-8 months, Kohut’s conception suggests that normal, necessary narcissism in the development of the child is still underway well into the second year, and that in normal maturation healthy grandiosity does not change into ambition with the help of appropriate mirroring and gentle parental disappointments until the ages of 2-4. Thus in Kohut’s conception, narcissism is an important developmental stage that only when interrupted with a trauma gets fixated, and those traumas which lead to narcissistic pathology may occur well into toddlerhood, rather than in the first year as posited by Bromberg. Bromberg recognizes that narcissism to some degree is present in most people, but does not see total grandiosity as an essential step in development, as does Kohut.


Kelly: Bromberg and Kohut

Although Bromberg stresses the importance of empathy in the therapeutic stance with narcissism, his conceptualization of therapeutic action differs in several ways from Kohut (although, admittedly I’m struggling to clearly identify them). Bromberg maintains the active agents of therapy with the narcissist are both interpretation and internalization. In this way, treatment of the narcissist does not require a different set of therapeutic techniques; rather certain facets are relied on more heavily than others and at different phases in the treatment. Bromberg believes that in the initial stages of analysis, the narcissist actively wards off direct experience of the transference neurosis (therapist as an object of value). This transference, he believes is too threatening to the narcissist’s weak self structure or “mask” of grandiosity. Instead, the narcissistic transferences serve to maintain the patients mask allowing him to perform for the analyst. Bromberg warns against the analyst too hastily dismantling the narcissistic transference. However, for the patient to develop a more accurate observing ego and genuine sense of an autonomous self the patient must be able to internalize the analyst. So for Bromberg, a main aim of the therapy is to lessen the over-reliance on narcissistic transferences and replace these with a more reality based transference neurosis in which interpretation plays a more central role.

For Kohut, in the right therapeutic environment – “optimal responsiveness”- the narcissism will resolve and transform into healthy self assertiveness. Rather than focusing on the “target of the instinctual investments”, Kohut is more concerned with the “quality of the instinctual charge” (grandiose and exhibitionistic). In this way, Kohut believes the therapeutic action takes place within the narcissistic transference and the analyst as a selfobject. Here this is unlike Bromberg’s view that it is primarily as a defensive maneuver that walls off the potential for growth.

Tuesday, March 28, 2006


Relational Theory on psychopathology, diagnosis and treatment

Relational theory has made a significant contribution to the evolution of psychoanalysis, particularly in North America. It has provided a distinctive view towards the diagnosis of mental illness, and established a revolutionary method of therapy. An obstacle for relational theory, however, is that it does not provide a coherent theory for distinctive disorders and is in a way, naïve in its assumption regarding the development of various pathology.
The assumption in relational theory, in regards to psychopathology, is that it is the result of considerable disturbance in a significant relationship. It is also assumed that when an infant’s relational needs are disrupted, this results in anxiety. This anxiety is specified to indicate the need for security. The individual will attempt to protect the self from the anxiety, by performing various security operations. However, in some cases, the individual is unsuccessful in his attempt to stymie the anxiety. This brings about negative feelings towards the self, preventing the integration the thoughts or memories of other relationships or interactions that did satisfy the needs of the individual. This splitting off or relationship memories, causes the individual to assume that all relationships will have the same, negative consequences. The individual develops an “illusory personification” in which all future relationships will be filtered through a relational template, causing the perception of present relationships to be impacted by, and comparable to the past, anxiety provoking relationships. This distorted view towards relationships and the maladaptive pattern of interaction that ensue, along with the rigidity of this pattern, essentially impairs relational and personality functioning. The relational pattern is said to be responsible for the development of the self. However, impairment in this area and disruptive relationships that follow, will cause parts of the self to be hidden and expressed, instead as various forms of neurosis.
The relational theory provides a distinctive approach to psychopathology, in that mental illness is essentially due to a disruption of needs, or provoked anxiety, from a significant relationship within a person’s life. Because the focus is on interpersonal patterns, there are no real diagnostic labels or criteria of symptoms that can be used as a guide to diagnose, and provide treatment based on that diagnosis. Instead, the relational assumption regarding the interpersonal pattern provides the information on development and course of pathology. This approach does have its holes, in that this particular theory does not account for individuals that have traumatic relationships, yet do not develop pathology. There is evidence of biological and genetic pre-determinants of mental illness, as well as biological motivation behind certain behaviors, thoughts and feelings towards relationships. The inability to assimilate these factors of human development into the theory causes some loss of credibility, although the contributions to the therapeutic process have been quite noteworthy.
An objective of treatment is to uncover the maladaptive relational pattern and improve interpersonal functioning, as well as increase the flexibility in the perception of relationships. The therapist is much more engaged in the therapeutic process, providing an authentic and collaborative interaction with the patient. Instead of interpretations of the analytic data, the relational model suggests the patient and analyst work together to infer the patient’s interpersonal reality. There are many variations on the general approach to treatment, but a significant feature is the analysis of the relationship with the analyst and its correlation with interpersonal patterns that would most likely occur with others in the individual’s social life. As the patient is made more aware of their relational patterns, and as the analyst provides an authentic form of interaction, the patient can experience his authentic self. Since there was once a rigid perception on relationships, the patient must be made aware that not all relationships will be as traumatic as was the original initiator of the anxiety. Through the authenticity of the analyst and the freedom to work through interpersonal relations in a safe setting, the patient gains confidence in his ability to interact with others

Monday, March 27, 2006


James's reaction # 6

McWilliams discusses, at length, the defensive adaptations of the paranoid person. Essentially, unwanted personal traits and inferiorities are difficult to tolerate, or even sublimate for this type of person. Disowning and projecting these unwanted traits onto another object becomes the dominant way of protecting the ego. Thus, the paranoid person can easily invent explanations for persecution. The inferiorities can become distorted as dangerous in the projected object, depending on the level of paranoia in the individual. Sullivan conceptualizes this developmentally by looking at the failure to establish meaningful interpersonal intimacy during infancy and childhood. He views the projection as a defense against the ‘persecutory parent’.
From a relational standpoint, Sullivan’s theory makes sense. McWilliams addresses the need, as a therapist, to accept the hostile transference of the paranoid patient and to create an environment of safety and acceptance. If Sullivan is correct, the internalized persecutory parent is a barrier that needs to be overcome and can be through the therapeutic relationship. Traditional analytic therapy could easily interfere with the progress of a paranoid patient, according to McWilliams, as the analysis can irrationally confirm inferiorities. Instead, she advocates devoting the most attention to the development of a strong and trusting working alliance. That way an environment can be created which allows the paranoid patient to feel comfortable enough to express raw hostility. The therapist’s job then becomes “unflustered acceptance of powerful degrees of hostility”(pg. 217) so that the patient can overcome his irrational view of the meanings and implications of his inferiorities.


Relational Theory and the Diagnosis and Treatment of Paranoia

Jay Kosegarten
Professor Papouchis

Relational Theory and the Diagnosis and Treatment of Paranoia

At the heart of the relational approach to paranoia is the belief that the early formative experiences of the child who later has a paranoid character organization had an anxious and critical mother/caregiver along with the absence of another significant relational presence who could compensate for this experiential pattern.
As Fonagy and Target write about Mitchell’s theory, “…individuals cling to pathological patterns because these are the only relationships they know,” a dependence on the external environment, especially the mother, for cues about the subjective, internal experience becomes the organizing factor of the personality. This paradigm results in a particular type of enmeshment with the internal and external worlds of the individual- a unique brand of poor differentiation. In terms of Mitchell’s theory, the major relational disturbance is in “affect permeability,” what Fonagy and Target define as “the shared experience of intense affect across permeable boundaries.” In therapy, which would be emblematic of the paranoid’s other relationships, this pathological disruption in relational mode would become manifest in projective identification, that is “the analysts own emotional experiences are seen as reflections of the patient’s own emotional turmoil.”
Unlike many post-Freudian analytical theorists, Mitchell wisely has a great deal of respect for fantasy, developing subtle, complex notions of the interaction that occurs between fantasy and reality. For Mitchell, fantasy functions as both the inevitable projection of wishes onto others and, in other ways, a reaction to intrapsychic and interpersonal anxiety. Depending on circumstance and character make-up, fantasy can be the impetus causing problematic distortions in relationships (and object relations), whereas at other times, fantasy is secondary, a defensive reaction to intrapsychic and interpersonal anxiety. Fantasy in the former only becomes problematic when the distortions are maladaptive, and this is the case of the paranoid’s projective operations. The defining feature of the paranoid character, projection takes on the unique, multilayered function of disavowal, that is, projecting the parts of the self which are intolerable and highly anxiety-provoking onto others. In the paranoid, the projections are infused with the defensive characteristics of denial and reaction formation.
Therapeutically, goals of treatment would revolve around Sullivanian and Kohutian approaches, including corrective emotional experiences and an emphasis on the subjective experience of the paranoid.


Relational understanding of paranoia

The interpersonal approach distinguishes itself from other psychological theories by emphasizing collaborative investigation of a patient’s problems. It differs from Classical theory by stressing intersubjectivity instead of intrapsychic phenomena; pragmatic explanations not descriptions of fantasy; and observation of the analytic process not analytic interpretations. Thus, instead of analyzing drives, defense mechanisms, and conflicts between id, ego, and superego relational analysts try to understand a patient through insight into the therapeutic relationship. Accordingly, their notion of pathology stems from Fairbairn’s concept of internalized ‘bad’ objects, attachment, and transference. Information gathered in analysis is thus used to mediate the anxiety (and psychopathology) caused by unsatisfactory relationships.

One significant consequence of the relational perspective is the de-emphasis of the therapist as a blank slate and expert interpreter of unconscious issues. It is understood that the analyst’s reactions to a patient can be prompted both by the material presented (actual countertransference) or the analyst’s own struggles (subjective countertransference).

Interpersonalists believe that stressful relationships bring about rigid relational patterns that then lead to psychopathology. From this perspective, paranoia is seen as a reasonable reaction to anxiety created by difficult relationships with primary caregivers / significant others. According to Sullivan, the core conflict of the paranoid individual is transference of blame stemming from awareness of one’s own inferiority and an inability to tolerate this awareness. Thus, in order to defend against unpleasant feelings about the self, the paranoid individual projects the insecurity outward, inventing explanations for persecution. Sullivan attributes the etiology of paranoia to incomplete development occurring in the preadolescent and adolescent phases.


Interpersonal/relational take on paranoia

The commonalities of interpersonal and relational theorists point toward a therapeutic approach that seems useful for paranoid clients.

First, the interpersonal/relational belief in relationships as the central aspect of subjective experience dovetails well with the paranoid’s defensive structure – the paranoid individual desperately needs other people, if only to serve as targets for projection. The interpersonal/relational therapist and the paranoid patient already share the belief that one’s experience is a product of one’s relationships to others. It is the therapist’s job to get the paranoid client to see that this relatedness is a good thing; to move the client towards understanding which relationships are salient (as opposed to imagined, as in the case of conspiracies), benign, and even benevolent. This movement is effected via the therapeutic relationship and unusual, sensitive interventions -- McWilliams, for example, suggests humor.

Second, the interpersonal/relational technique of staying in the “here and now” and experiencing the therapeutic moment with the paranoid client is more likely to disarm the client’s defenses than interpretations, which the paranoid individual is likely to find threatening. In addition, by removing the therapist from the role of expert interpreter, this therapeutic stance may diminish the analyst/analysand power differential, which in turn may engender in the client a feeling of trust and even closeness. According to Sullivan, it is such experiences of warmth, trust, and intimacy that are frequently lacking in paranoid clients’ histories. (Presumably, interpersonal/relational therapy is meant as a corrective emotional experience to the emotionally arid upbringing common to paranoid clients; I don’t think Sullivan says this directly, however.) Privileging the interpersonal/transferential content of the client’s associations over their manifest content also gives the therapist a meaningful focal point – rather than having to parse the client’s latest elaborate plot, the therapist may look instead to the emotional content in the room as the patient spells out his theories.


The Interpersonal-Relational Approach and Paranoid Personalities

Reaction Paper
The Interpersonal-Relational Approach and Paranoid Personalities
Sullivan views psychopathology as originating when the satisfaction of interpersonal or relational needs is upset by anxiety. In contrast to classical Freudian therapy, anxiety does not arise when the ego is met with a potential threat (from some demand of the id or the superego) but arises in relation to the primary caregiver. When an infant senses that her tension has produced anxiety in her caretaker, the infant internalizes this perception of anxiety. A sense of self is constructed in which those behaviors that create a sense of warmth and approval from the caregiver are attributed to the “good self” and the infant has succeeded in avoiding creating anxiety in her mother. To the “bad self” are attributed those behaviors that create anxiety in the caregiver. A third dimension of the self, the “not me,” arises to handle behaviors that are perceived to be so straining for the mother that the infant dissociates from them. Psychopathology, then, results when early anxiety is so intense that the dissociative aspect of the self, the “not me” could not be contained. Such a view is not incompatible with McWilliams’ formulation of the paranoid personality. According to McWilliams, children who are temperamentally aggressive or irritable may find it difficult to incorporate this aspect of their self with a more positive self-image. Caretakers who respond negatively to such a demanding and exacting child would then reinforce the divide between the child’s “good self” and “bad self.” In an attempt to integrate the two parts of the self, or simply as an effort to accept the “good self” the child may begin to view the outside world and others as being persecutory. In more extreme cases, the negative reaction and anxiety created may be so intense that the “not me” is personified. The dissociative aspect of the “not me” is compatible with the use of projection at the psychotic level, where upsetting aspect of the self are completely projected onto another object. The psychotic, without an observing ego and intact reality testing, projects regardless of whether or not there is a fit with the external experience. Such indifference could be attributed to a dissociative process.

Sunday, March 26, 2006


Matt: Interpersonal/Relational Psych & Paranoia

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.


The Relational Model: Implications for Diagnosis & Treatment

Relational theorists contend that psychopathology results when individuals become wedded to dysfunctional relational patterns that originate in childhood. These patterns are so rigidly held that they color social interactions well into adulthood. Stephen Mitchell, a significant contributor to the interpersonal-relational school, contends that children learn from a young age just how to interact with parental figures in a way that minimizes anxiety. These patterns then become pathological templates, maintained simply because the child knows no other way of interacting. If tension between particular relational patterns and the main “self-shaping” patterns occurs, they will find ways of expressing themselves covertly and give rise to neurosis. It could be suggested that paranoia, for example, is the product of parental failure to confirm reality and a child’s normal reactions. Instead of feeling validation, the child is filled with shame, fear and confusion that he or she carries into adulthood.

The process of relational psychotherapy is entirely different than that of classical psychoanalysis, particularly because of the very active role in which the therapist is cast. The task for the relational therapist is to understand the subjective world of the patient and to assist in broadening his or her interpersonal interactions despite the limits imposed by childhood experiences. The patient is also encouraged to examine why the chosen manner of relating is seen as the only way to forge a bond with the therapist. In contrast with classical analysis, the emphasis of the relational style is on current social relationships as well as the interactions occurring within the therapeutic context. The connection between therapist and patient is socially constructed by the two parties, neither of whom is the “expert”. Self-disclosure is not limited to the patient and transference is understood not as a simple projection but as an authentic social reaction to the therapist. Grand interpretations are unnecessary; the vehicle through which change occurs is therapist participation. Progress and healing take place through the shared experience, which teaches the patient that his modes of relating need not be so restricted. In other words, successful relational therapy results in the patient’s ability to understand and experience a range of relationships in a variety of ways.


Relational Persective on Paranoia: Lucy's Reaction

For a supposedly Freudian analyst, McWilliams does an excellent job of laying out the diagnostic and treatment issues that would be relevant to a more ‘relational’ analyst. As usual, not only does McWilliams describe what the patient experiences internally and behaves like outwardly, but she describes the patient in terms of the interpersonal dynamics their illness invokes and what they feel like to be with in the room. She places patterns of countertransference and transference at the center of her understanding of the patient and treatment, much like a relational analyst would do. She provides a nice two-person view of the paranoid experience, which was a welcome complement to Shapiro’s more cognitive-intrapsychic presentation.

In McWilliams’ view, the struggle of the paranoid is essentially a relational one, in the sense that the paranoid is primarily guarding against potential shaming, humiliation and harm by the other (as opposed to some internally-located discomfort, like guilt, although the paranoid does experience diffuse guilt). The paranoid accomplishes this largely via projection, and McWilliams describes in great detail the interpersonal (relational) dynamics involved in the use of this defense. She argues that the paranoid engages in a complex form of projection -- projective identification -- in which he empties himself of his disavowed fear and overwhelming weakness by projecting it into the other person, and then recognizes it in the other. The other person thus becomes the container for the paranoid’s most frightening feelings.

Although McWilliams doesn’t say this outright, one can infer from her writing that analyst’s countertransference can confirm the paranoid diagnosis, since the feelings evoked by the paranoid are quite distinct. For example, she reports that the analyst often reacts with vulnerability, anxiety and certain defensiveness and these reactions are much stronger and come to the fore more quickly than with other patients with personality disorders.

In terms of treatment, McWilliams argues that it’s very important for the analyst to resist temptations to “set the record straight” with the patient about the accuracy of their perceptions or the benevolence of the analyst’s own motivations. For her, the working alliance is the central part of the treatment with the paranoid, and in fact, she claims that when the paranoid trusts his analyst, the treatment is essentially over. This focus on the development between the relationship between the patient and analyst as curative is totally congruent with the relational position on therapeutic action.


Relational Approach to Diagnosis & Treatment of Paranoia

The main constructs of the interpersonal-relational approach relate to the notion of the analyst and analysand participating in an interrelational, interactive shared activity. Interpersonalists place considerably less emphasis on analytic interpretations and instead see the interplay of the here-and-now transference and countertransference interactions as providing the greatest source of information to be observed by the analyst for defining the progress of therapy. Development of psychopathology as dictated by relational theorists centers on the child’s negative relational experiences with “bad” objects that cause the child to develop maladaptive behavior patterns involving defense mechanisms. These negative relational experiences become deeply embedded within the psyche of the child and set the foundation for the manner in which the individual will handle and utilize these methods of engagement in future relationships. The goal of therapy from the relational viewpoint seems to be for the analyst to challenge the patient’s negative relational patterns by entering into the patient’s subjective world and helping him/her to see for themselves the reasons for which these maladaptive behavior patterns have developed. Also, an additional goal of therapy would be for the patient to identify what he/she can do in accordance with the analyst to create a more adaptive way of relating to others in spite of the difficulties encountered in childhood relations.

McWilliam’s postulates that many paranoid individuals have negative experiences with object relations during critical phases of development. They tend to have suffered instances of severe humiliation and overpowerment in relation to encounters with primary care givers. In addition, many paranoid individuals have had experiences with parents who modeled suspicious or overly anxious behavior which therefore imbued the child with a sense of fear and suspiciousness towards others who fell outside of the protective and trustful family realm. It seems that from the relational perspective, therapeutic treatment with paranoid individuals would center around the therapist joining with the patient and helping them to see how the patient has come to see others as dangerous and persecutory. Engaging the patient’s intense suspicion and mistrust of the analyst while simultaneously exploring why this appears to be the main interactional pattern the patient has for relating to others seems to be one of the necessary components of the therapeutic intervention. The therapist’s ability to accept the high level of hostility and mistrust coming from the patient will serve to foster a sense of safety for the patient, in turn helping him/her to experience a more adaptive way of relating to others. In addition, this technique would aim to allow the patient to gain insight into their problematic manner of relating to others and to develop more adaptive methods of interaction.


Sara's Response: Relational Conceptualization of Paranoid Personalities

According to Sullivan, the failure to establish meaningful, interpersonal intimacy during infancy and childhood is the source of paranoid personality development. Of course there are different levels of paranoia: psychotic, borderline, and neurotic, but the crucial common denominator among these levels of functioning is a fundamental feeling of inferiority that stems from deficient or punitive early object relationships. People with paranoid personality organization typically have affects that exude a palpable sense of hostility and anger. However, this is not to say that the paranoid is incapable of love. According to Nancy McWilliams, in fact, it is the paranoid person’s capacity to love that distinguishes him from the psychopath. Aside from their manifest hostility, their unconscious affective state is plagued by fear, shame, and guilt: such feelings are, in part, a consequence of disconfirming and humiliating treatment by parents. Furthermore, these unbearable feelings of guilt and shame are disowned, projected, and transformed into externalized threats.

Sullivan views this projective defense (that serves to target the ‘persecutory parent’) as the primary barrier that prohibits the paranoid from repairing and reestablishing interpersonal intimacy. In actuality, the paranoid person deeply desires human connectedness, but because he is so suspicious of other people’s true feelings and intentions, he will likely reject the person’s (or even his own) good faith effort at establishing intimacy, and instead become more vigilant and fearful. His very need for intimacy is a threat in and of itself. Often times, this need for human connection gets misperceived as being homosexual in nature. Consequently, he comes to perceive homosexuality as an extremely menacing threat. What this illustrates is that the paranoid has an overwhelming inability to preserve his self-worth in connection with other people.

The relational outlook on treatment for paranoid patients requires the therapist to accept the hostile transference of the patient in an effort to instill in him some degree of safety (which was so utterly lacking in childhood), thereby planting the seed for trust. McWilliams believes that typical psychoanalytic methods (e.g., analyzing defenses and unconscious processes) will inevitably backfire with the paranoid patient. Instead, the therapist should: focus more on the patient’s affective cues and reactions, lend interpretations in a non-definitive and good-humored way, and maintain confidence and power so that the patient will not perceive his destructive fantasies/tendencies as having the capacity to sabotage yet another relationship.


Gillian's interpersonal/paranoid response

Classical Freudian models of the psyche indicated an internal turmoil between id ego and superego, as biological imperatives acted on psychodynamic functioning. Freudian theories took drive reduction as the main behavioral motivator and as the basis of psychological material. According to this model all interpersonal relationships were secondary to, and mainly relevant to the drives only as they provided a conduit for the discharge of aggressive or sexual impulses. The role of the Freudian analyst was that of a neutral party, who simply provided a space in which the repressed unconscious of the patient could eventually come to light. The interpersonal school of psychotherapy, on the other hand, taught that the analyst should take an active role in therapy and that the therapeutic currency was not in the patient admitting to their repressed impulses, but rather in the relational dynamics that were played out between patient and therapist. The interpersonal school drew from object relations theories the idea that human relationships, rather than discharge of libidinal energy, were the main “drives”, and components of psychological material. Rather than focusing on the internal struggle of an independent individual, the interpersonal school focused on the relationships in a person’s life, with the idea that there could be no independence without interdependence, and that humans were defined by their relationships.

The interpersonal school viewed development as a process through which the child sorts his own impulses and behaviors through the filter of reactions elicited from caregivers. In this way, the child groups all interactions with the caregiver into either “good mother” or “bad mother” interactions, and also classifies all of his or her own actions and impulses as “good me” or “bad me” depending on the type of anxiety evoked in the caregiver, and in the amount of anxiety then experienced by the child. Those with a paranoid style may experience themselves as intrinsically bad. Guilt and shame are prevalent in those with this style, and they may be imbued with a sense that they are constantly at risk, either through an internal giving-in and relinquishment of hypervigilance, or through external domination and aggression that they must defend against and keep watch for. According to the relational school, this style may have been learned through an environment in which most organic parts of the child elicited anxiety in the caregiver, and were relinquished to “bad me” status. This sort of environment would likely be unfavorable and perhaps even dangerous for the young child, thus adding real external threat to the internal perception of badness. These early relationships and the internal expectancies created by them may produce a person who has given up most organic and spontaneous responsiveness, trading authenticity and spontanaeity for a carefully constructed act to evade those who are perceived as threatening. The internal “badness” may be projected onto others, manifesting as a paranoid style requiring the constant search for and overblowing of clues that suggest external threat.


Kelly: Interpersonal and Paranoid Personality (Uhg)

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.


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