From the perspective of the paranoid process, the symptoms of the patient with paranoid personality disorder can be seen as expressing attitudes and feelings derived from the patient’s pathological sense of self. Consequently, the emphasis in therapy falls on inner attitudes and feelings toward the self rather than on the projective system. This internal focus serves as the basis for certain principles that can serve to set priorities and provide a sense of direction for the therapeutic work.

The following recommendations pertain primarily to patients who are seeking therapy and in whom paranoid defenses have weakened to an extent that would allow the possibility of effective therapeutic intervention. For the most part, successful paranoid personalities do not seek treatment and do not respond well to therapeutic intervention, for the reasons noted earlier. Patients who seek treatment usually have some degree of anxiety or depression resulting from failure of paranoid defenses; such patients are deserving of therapeutic effort. However, some will respond, whereas others will be able to do little more than reclaim their paranoid stance. To the extent that coming to therapy is motivated by distress caused by symptoms and little else, prospects for effective therapy are dim. Patients seeking change in themselves and their pathological feelings have better prospects.

Therapeutic Alliance
The first principle in treatable cases of personality disorder concerns establishing and maintaining a meaningful therapeutic alliance. The therapeutic alliance is a major part of any meaningful therapy and provides the framework and the basis on which therapeutic work proceeds for all patients, but in paranoid patients it is a major concern and the most critical area of therapeutic work. The therapeutic alliance requires at a minimum that the patient have a certain degree of trust in the therapist, but it is precisely this aspect of the relationship that gives rise to the greatest difficulties for paranoid patients. Their inherent suspiciousness and guardedness run counter to any capacity for a trusting relationship.

Basic therapeutic issues center on questions of trust and autonomy. The alliance is stabilized to the degree that the patient can develop a meaningful trust in the therapist and is also increasingly able to build and sustain a sense of autonomy within the therapeutic relationship. Important contributions on the therapist’s part include empathic responsiveness to the idiosyncratic needs (largely narcissistic), anxieties, and inner tensions felt by the patient, so that the therapist responds to the patient in terms of the latter’s own individuality rather than in terms of the therapist’s needs or in terms of some preexisting therapeutic or theoretical stereotype.

Conversion of Paranoia to Depression
A second principle concerns conversion of the paranoid stance into depression. As therapy progresses, projective and externalizing defenses are gradually eroded, so that the patient comes more directly and immediately in touch with the form and content of feelings of vulnerability, weakness, inferiority, and inadequacy connected with a defective sense of self. These feelings will find expression because they are so much a part of the patient’s sense of self, but useful therapeutic work with them is facilitated by the therapist’s consistent empathy with, tolerance for, and nonjudgmental acceptance of these feelings as part of the patient’s self-experience. The therapeutic focus remains on accepting the validity of these feelings and understanding their meaning. The patient begins to experience more immediately those hidden elements of himself or herself against which the paranoid system has served as an elaborate defense.

The paranoid defense rides on an underlying personality structure, often related to early traumatic fantasies or actual emotional, physical, or sexual abuse, usually transformed into fears of attack and counterattack. Through the previous defensive effort, the patient sought to avoid taking responsibility for these fears and to shift the blame for them elsewhere. For the patient to tolerate these feelings of inner pain and humiliation is one of the most difficult and shame-ridden aspects of the therapy. This part of the process also can be facilitated by the maintenance of the therapeutic alliance and by a nonjudgmental acceptance of such feelings as human and universal.

If and when the patient becomes depressed, he or she must come to terms with, understand, work through, and resolve the depressive elements contained in his or her pathological sense of self as victim. The therapeutic effort is directed toward focusing on, understanding, and resolving elements of weakness, vulnerability, and impotence embedded in the sense of victimhood, along with the feelings of worthlessness, inferiority, and shamefulness reflecting the underlying narcissistically inferior aspect of the patient’s sense of self. The sense of vulnerability, victimization, and fear of injury may have developmental links to early experiences in which the roles of victimizer and victim were directly enacted with parental or other significant figures or in which these unconscious schemata were experienced and internalized by introjections from parental or other figures.

Failures in development can impair the patient’s capacity to function autonomously and to maintain consistent mental representations of self and others. This impairment can result in increased vulnerability to issues of control, domination, submission, self-esteem regulation, and possession of or by a threatening, destructive, or persecutory object. The blend of masochism and narcissistic rage reflects the disturbance of narcissistic equilibrium, giving rise to both grandiose and inferior self-images. The helpless, victimized, and devalued self seeks to revenge the fantasied injury by construction of a projected persecutory object and hypervigilant sensitivity to external hostility. When this defense is undone, the result is depression.

Issues of Autonomy
A third principle in the treatment of paranoid patients involves respect for the patient’s autonomy and efforts to build and reinforce it in the therapeutic relationship. The patient’s sense of autonomy is fragile and threatened, so that issues related to establishing and maintaining it permeate all aspects of the therapy. This fragile autonomy is associated with fantasies of magical connection and even merger with the projective object, so that weakening of boundaries in projection may be an inherent intent of the projective process rather than an unfortunate side effect. The paranoid cognitive style of environmental scanning may serve as more than an early warning system of attack; it may also reflect the need for connectedness and the intolerance of indifference from the object. The therapist directs his or her effort to fostering and maintaining the patient’s autonomy at all points possible within the therapeutic work. Complete openness, honesty, and confidentiality are essential in all dealings with the patient. Any decisions that need to be made must be explored with the patient, and insofar as possible, the ultimate choice should be left in the patient’s hands - even decisions about taking medications, if their use seems indicated. In the context of the patient’s desperate need to know, nothing is done or said without his or her being completely informed.

Therapeutic Techniques
Working with the patient’s projective defenses calls for special techniques. Confrontation, challenge, or even reality testing of projective defenses can create a situation of opposition and run the risk of turning the therapist into an enemy or persecutor. More progress can be made through empathically eliciting details of the patient’s projective system, bringing into focus the patient’s feelings, particularly those of doubt, insecurity, vulnerability, weakness, inadequacy, or inferiority, that lie behind the paranoid facade. An additional technique is so-called counterprojection, which involves acknowledging and accepting the patient’s feelings and perceptions, without disputing or reinforcing them. Temporarily accepting the patient’s perceptions avoids confrontation and allows access to underlying feelings of vulnerability and powerlessness.

Countertransference Issues
Countertransference, reflecting the therapist’s unconsciously derived and motivated reactions to the patient, is an area of special concern in therapy with paranoid patients, who are often highly sensitive to such innuendoes. These patients can often be difficult, resistant, provocative, and contentious. Not only are paranoid defenses usually rigid and unyielding, but the patient may resort to argumentative or contemptuously demeaning attacks on the therapist. Reacting to an inner sense of vulnerability and powerlessness, the patient will often see the therapist in transferential terms as hostile, attacking, sadistic, and persecuting. Although these provocations can elicit consciously hostile or defensive responses from the therapist, these are more readily processed in the therapeutic interaction, as long as they do not erode the alliance, but unconscious countertransference reactions can be more subtle and damaging to the therapy and must be monitored and contained.

Behind the defensive attitudes of self-sufficiency and arrogance there may lurk exquisite narcissistic vulnerability and passive dependency longings. Such dependency needs are associated with a sense of shameful vulnerability and fears of humiliation. The paranoid patient often tries to counter these anxieties by turning the tables and making the therapist feel helpless, vulnerable, and humiliated in turn. These feelings of vulnerability and humiliation were classically attributed to homosexual inclinations, an association that may arise in some cases but not in others.

Each of these projective dimensions can involve the therapist in an emotional countertransference pull to respond in terms that satisfy the projective demand and reinforce the patient’s victimized and embattled position. The therapist may find himself or herself reacting with annoyance or impatience. In the face of the patient’s insistent argumentativeness, the therapist may unwittingly come to play the aggressor to the patient’s victim, becoming more forceful, argumentative, or confrontational. In other instances, the therapist may become frustrated and discouraged, feeling inadequate, helpless, and worthless, thus playing out the role of victim to the patient’s aggressor.

These reactions must be carefully monitored and their effect on and implications for the therapy analyzed. The therapist’s task in such circumstances is to bring the therapeutic interaction back to some more effective therapeutic balance in which real therapeutic work takes precedence over the acting out of transference and countertransference (i.e., to reestablish the interaction in alliance rather than transferential terms).

Litigiousness
An additional matter of concern is the threat of legal action by litigious patients. Given the hostile, defended, suspicious, and overly sensitive disposition of paranoid patients, legal threats against the therapist are not uncommon. A litigious stance generally can be avoided by careful attention to the therapeutic alliance and the arrangements for dealing with matters of privacy and confidentiality. If threats of legal action arise, they reflect a disruption of the alliance and should be worked with accordingly. If restitution of the alliance fails and the patient moves toward legal action, the therapy probably should be terminated. Appropriate arrangements should be made for referral of the patient to other treatment resources, if indicated, and the therapist should take steps to protect his or her own legal interest. This is a course of last resort, implemented only when efforts to deal therapeutically with the patient’s threatening attitude have failed. Psychotherapy cannot be conducted under conditions of threat.