Paranoid personality treatment planning

Most often found in males although female paranoid presentation is not all that uncommon. The paranoid personality type is primarily an anger based condition although there can be layering of feelings. Anger is used to defend self against attack from basically an untrustworthy world. Attack is seen as the best form of defence so the inborn temperament tends to be one of fight rather than flight or freeze. A focus of treatment can be about  anger management or developing ways of dealing with their anger such that it does not disrupt relationships too much. This can cause all sorts of difficulties in the workplace where they can been seen as difficult people two work with, which they may very well be.

One way to approach this therapeutically is to examine the thinking behind the anger. The paranoid will see self as justifiably angry. They will perceive self as being treated badly or unfairly which provides the intellectual basis for the anger at others. If they can develop a more Adult ego state assessment of their treatment by others they will find they are not being mistreated as much as they think they are. Hence there is less need to be angry in relationships.

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This however may be very difficult for the paranoid to achieve as there can be a basic distrust of others with a strong “Don’t trust” injunction. They are quick to see untrustworthy behaviour and motives in others and this can be a core life script belief. Some respond to empathy training where they start to see the world more through the other person’s eyes. One of the primary defence mechanisms in the paranoid is projection. He/she will project their basic sense of distrust onto others and believe others see the world the same way they do. With empathy training the paranoid can begin (probably slowly) to understand that most others see the world differently than they do. Most others do not have the same level of distrust they have. For them to understand when they are projecting and to trust that it is a projection is a good therapeutic goal. Hence bibliotherapy and cognitive work around the defence mechanism of projection can be a beneficial part of the overall treatment plan with the paranoid individual.

In the paranoid there can be a layering of anger, over anxiety, over shame or despair

Paranoid feeling layers

This provides another treatment option for the paranoid individual. To get through their anger to their anxiety or fear. To understand they have such feelings and to express and work through the anxiety. Again much easier said than done, as the paranoid may steadfastly resist such a suggestion about their anxiety. They see a world of no trust, where people are out to get you in some way rather than support you. If someone views life like this it seems a reasonable suggestion that they may experience some anxiety in life. The human psyche responds to perceived danger with the experience of anxiety.

If they can finally accept they do experience fear and then work through that, they have made a major psychotherapeutic advance. In addition the anger in one way is covering or defending the paranoid against their anxiety. If they accept it then the anger looses one of its purpose for being. Sometimes underneath the anxiety can be shame. If their primary fixation point is in the anal stage of development then it is more likely to be shame. However because trust is at the core of the paranoid personality style they can be mainly fixated in the oral stage of development where the issue of trust and mistrust is being considered by the young child. If this is so then there may not be shame so much as despair or a questioning of their existence. This does not mean a potential suicidality more a sense of gasping for air or for a psychologically potent life. This would mean an oral stage of fixation and hence one must always assess how much addictive behaviour the paranoid person is displaying. At first they may be reluctant to report any addictive behaviour as they see it is as quite personal thing to be defended. The therapist keeps an open mind to such behaviour even if the person initially reports no addictive behaviour.


One way to defend against anxiety


The paranoid can also be prone to sexualising human communication. They may see ulterior transactions of a sexualised or romantic nature that most often are not there. This can occur both in their communication with others and as they watch communication between two others. The therapist (or anyone else for that matter) needs to be careful in making any physical contact with the paranoid individual. For example the therapeutic tradition of hugging a client after a session needs to be much more carefully considered when the person has a paranoid personality structure as such physical contact can quite easily get sexualised in the paranoid’s mind. This also explains the male paranoid’s propensity for homophobia.


A suit of armour


The paranoid can be difficult to treat in that they are wearing a suit of armour, so they are hard to “get to” unlike, say the OC or schizoid. Their Child ego state in encased in the safety of an armoured suit. Part of their defence is to be highly defended unlike some other personality types. If one can get the paranoid to expose their Child and let you in past the armour then one has made a significant therapeutic advance and the prognosis looks much better. Getting allowed in, is the hard part and where the therapeutic relationship assumes most importance. The other difficulty with this particular personality type is they have the basic belief that one solves problems by thinking, (rather than doing or feeling). They often value and respect good thinking and many of them are good thinkers themselves. In some cases the therapist has to prove himself to the paranoid in this way. The paranoid wont respect the therapist (see them as having a potency) unless they prove themselves to be a good thinker, that can at least match the paranoid in this way.

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