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Summer 2010 Symposium: Two Views of Treating Paranoid Disorders

The Summer Symposium on the 'Two Views of Treating Paranoid Disorders' proved to be very intellectually stimulating indeed. Nancy McWilliams’ presentation focused on a diagnostic understanding of paranoid character and its implications for clinical practice. Her focus concerned the relationship between the therapist and the patient, and how paranoid patients might experience the therapist. Richard Reichbart’s presentation focused on the internal object relations carried by the paranoid patient in relation to the therapist.

Unfortunately, the DSM IV category for paranoia describes only the severe end of the continuum, lacking a category for the non-psychotic end of the spectrum which constitutes many of the patients we see in our private practices. As a result, clinicians need to become more adept at teasing out the nuances of paranoid dynamics that aren’t as flagrant at first glance.

Nancy described paranoia as the “pathology of trust.”. It’s a “defense against trust, not the obliteration of trust.” There is, typically, a history of parental humiliations where, owing to defensive operations of projection, denial, reaction formation, and disavowal, caregivers see the child as the problem. As a result, there is psychological fusion: a serious confusion of the boundary between self and others, between what’s inside and outside and whose insides are whose. The family fosters a deep suspicion of outsiders. As may well be imagined, emerging feelings of trust that begin to develop towards the analyst can be absolutely terrifying for the patient with a paranoid personality organization.

Nancy talked about the therapeutic implications of working with paranoid patients. She advises against the use of the couch because of the patient’s need to scrutinize the therapist’s face. One important clinical issue is the temptation these patients have to keep secrets. The therapist needs to avoid being too neutral or blank because the paranoid patient may think you’re keeping secrets or being evasive.

Because these patients were treated as a “repository of projected badness” rather than who they really were, the most critical attitude for the therapist is one of respect. Therapists convey this by showing a willingness to be taught by the patient, creating the sense of a level playing field which reduces the patient’s fears of humiliation. Normalizing these feelings is crucial. When paranoid patients believe the therapist understands their contradictory feelings about trust, they typically experience a sense of relief a greater willingness to relate to the therapist.

Richard Reichbart described paranoic patients as having a deep attachment to the parental figure, to the exclusion of others. The role of this attachment in the patient’s internal object relations results in a number of difficulties with real relationships, including a need to defend against emotional intimacy with the analyst. What is healing for these patients is to interpret and understand their deep-seated fears, that they were “enmeshed in a suffocating object relational embrace, refusing to loosen the too-tight attachment to the object.” In order to let go of the paranoia, the patient must separate from the internalized tie to the original love object. Since there’s a failure of the love object to comfort the patient as a child, paranoid patients can’t comfort themselves.

Overall, Richard and Nancy seemed to be more similar than different in their approaches to understanding paranoid patients. Each paper enhanced the other, and they responded in tandem to questions and comments from the audience during the discussion. Yet the difference in their focus was clear. Nancy put her emphasis on the relationship between patient and therapist, using her understanding of paranoid structure to listen for how these patients are experiencing her and then using that as the main focus of the work. From a different angle, Richard highlighted the internal object relations carried by his paranoid patients, using their fantasies, dreams and daily concerns to build an understanding of the internal dynamics and help his patients re-work their pathological internalized attachments. The complementarity of their two approaches created a valuable window on the troubled inner world of patients with paranoid experience.