Chapter 10 McWilliams Paranoid Organization

Things to keep in mind:

Dont immediately think that a patient is not in severe danger
Some may be stalked
In peril
Others may have a personal stake in them looking crazy
You may share a paranoids beliefs, such as threats of terrorism, governmental control,
pornographers, but it is the
Paranoid beliefs that come true or may be warrant but only after the fact
Over all, making informed, reflective diagnostic judgments instead of automatic, a priori
assumptions-especially with clients whose grim, suspicious qualities may make them hard to
warm up to.
What is paranoid organization?
The essence of paranoid personality organization is the habit of dealing with one's felt negative
qualities by disavowing and projecting them; the disowned attributes then feel like externa!
threats. The projective process may or may not be accompanied by a consciously megalomanic
sense of self.
The Continuum
Neurotic
Families are warm and stable, but combined with teasing and sarcasm
Likely to be politicians
Internal issues are projected in a ego-alien way
Borderline
Reality testing is not lost
Psychotic
Severely paranoid can be serial murders; they kill to protect themselves due to immature
ego processing without grounding in reality
Lowenstein and Sweeney
Does not need their beliefs to be conventional
The childhood precursors to paranoid organization
The organization may develop before the child has clarity about internal versus external events,
where the self and object were thus confused.
Temperament
In 1978 Meissner marshalled empirical evidence connecting temperament with an
"active" symptomatic style in infancy (rregularity, nonadaptabiliry, intensity of reaction, and
negative mood) and with a thin stimulus bar.
McWilliams clinical experience suggests that children who grow up paranoid have suffered
severe insults to their sense of efficacy; they have repeatedly felt overwhelmed and humiliated
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(MacKinnon et al., 2006; Tomkins, 1963;Will, 1961) Criticsm, capricous punishmcnt, adults
who cannot be pleased, and mortification are common in the backgrounds of paranoid people.
Child rearing is usually done by teaching through examples. It is stressed that the family is the
only people one can trust, however borderline and psychotic comes from homes where criticism
and ridicule dominate familial relationships or when the child is the scape goat.
Parents may have an unmanaged anxiety in a primary caregiver. The tendency of paranoid
people to lash out rather than endure the anxiety of passively awaiting inevitablele mistreatment
{"I'll hit you before you hit me") is another well known and unfortunate cost of this kind of
Parenting (Nydes, 1963).
The presence of a frightening parent and the absence of people who can help the child process
the these feelings (except by making them worse) is, according to many therapist who have
successfully mitigated the condition, a common breeding ground for paranoia (MacKinnon et
al., 2006).
Paranoid people enhance their self-esteem by exerting power against authorities or those of
importance, which provides a relieving, but fleeting, sense of safety and rectitude. This is derived
from the need to challenge and defeat the persecutory parent.
Drive Affect and Temperament
Because they see the sources of their suffering as outside themselvcs, paranoid people in the
more disturbed range are likely to be more dangerous to others than to themselves.
They are much less suicidal than equally disturbed depressives, although they have been
known to kill themselves to preempt someone elsc's expected destruction of them.
High degree of innate aggression or irritability
Hard for a young child to manage and integrate into a positively valued sense of self, and
that the negative responses of caregivers to an obstreperous, demanding infant or toddler
would reinforce the child's sense that outsiders are persecutory.
Its postulated that the paranoid lives in a state of fear and shame. (Tomkins 1972)
Fear by paranoids is called annihilation anxiety (hurvich 2003)
The terror of falling apart, being destroyed, disappearing from the earth
This type of fear has been tends not to be quelled by serotonn reuptake inhibitors,
but is instead responsive to benzodiazepines, alcohol, and other "downer" drugs,
which may be why paranoid patients often struggle with addiction to those
chemical agents

Freud (1911) argued that paranoids have unconscious operations of reaction formation and
projection, which implies that the person has a fear of experiencing normal loving feelings,
presumably because prior attachment relationships were toxic
Delusional paranoid person handles wishes for same sex closeness
"I love him,"
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"l do not love him, I love me (mcgalomania)." "

I do not love him, I love her (erotomania)."
I do not love him, shc loves him (delusional jealousy)."
I do not love him, he loves me (projecting thc samc-sex longing, producing a delusional
homosexual threat)."
I do not love him, I hate him (reacton formation)."
Most common is "He hates me, hence, it is alright for me to hate him (projecting the delusional
hatred).
Envy
They will project envy by believing people are out to get them because of the things about them
that others envy.
The paranoid self
The main polarity in the self-representations of paranoid people is an versus an. A tcnsion
bctween these two images is the inevitable side effect of psychological powcr and guilt.
The weak: impotent, humiliated, and dcspiscd image of the self; degree of fear they chronically
live in, never feel safe, spend most energy scanning for danger.
The grandiose: omnipotent, vindicated, triumphant image of the self; is evident in the ideas of
reference: Everything that happens has something to do with them. Because I am omnipotent, all
things that are terrible are my fault, guilt and paranoia can be understood by any of us who have
handed in a paper late.
Differentiate
Narcissist vs Paranoid
Narcissistic individuals, evcn arrogant oncs, suffer conscious feelings of shame if they feel
unmasked. However, the narcissists energies go into efforts to impress others so that the
devalued self will not be exposed, whereas the paranoid may use denial and projection in order
to foil the efforts of thosc who are seen as bent on shaming and humiliating them.
Psychopath vs Paranoid
Both have issues of power and their tendencies to act out, but the paranoid maintains a capacity
to love. Even though they may be terrified by their own dependent needs and wracked with
suspicion about the motives and intentions of those they care about, paranoid individuals are
capable of decp attachment, love, and protracted loyalty.
However persecutory or inappropriate their childhood caregivers wcre, paranoid clients
apparently had enough available affection consistency in thcrc early livcs to be able to attach,
albeit anxiously or ambivalently. Their capacity to love is what makes therapy possible in
spite of all their hyperreactivity, antagonisms, and terrors.
Issues in therapy

They fear the therapists rejection or punishment for their sins.

The focus is primarily on the assumed motives of others rather than internal conflict,
which can be an obstacle to therapy.
They are chronically warding off this humiliation by transforming any sensc of
culpability in the self into danger that is threaten from outside.
Likely to experience projective identification
Person tries to get rid of certain feelings, yet retains empathy with them and
needs to reassure the self that they are justified
Ex. Accuse you of being jealous of them, over time you start to hate them
and resent how much freedom they have to express themselves compared
to you

Transference and Countertransference with Paranoid Patients

Transference
o Transference in most paranoids patients is swift, intense, and often negative
o Occasionally the therapist is the recipient of projected savior images but more
commonly he/she is seen as potentially disconfirming and humiliating
o Paranoid clients approach a psychological evaluation with the expectation that the
interviewer is out to feel superior by exposing their badness or a similar agenda
that has nothing to do with their well being
Countertransference
o Interviewers respond with a sense of vulnerability and general defensiveness
o Countertransference is either hostile or anxious
o In the occasional instance when the therapist is regarded as a savior,
countertransference may be benevolently grandiose
o Therapist is usually aware of the strong reactions
o Therapists often find themselves consciously feeling the aspect of an emotional
reaction that the client has exiled from consciousness
Ex. The patient may feel vulnerable and helpless, while the therapist feels
sadistic and powerful.
o Most therapists try to set the patient straight about the unrealistic nature of the
danger the patient believes he/she is in. The therapist may feel like the patient
wants reassurance but when the patient receives it they then become convinced
that the therapist is part of the conspiracy to divert him/her from a terrible threat.
o This powerlessness of the therapist to give much immediate help to a person who
is so unhappy and suspicious is probably the earliest and most intimidating barrier
to establishing the kind of relationship that can eventually offer help.
Therapeutic implications
1st challenge the therapist faces is creating a solid working alliance.
o This alliance is particularly important when working with paranoid individuals
because they have such difficulty trusting others.
o It is not necessary to gain full trust from the patient before taking next steps in
treatment, especially since this may take years. Instead, it is important to have the
patient embrace the possibility that the therapist is well intentioned and competent
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o In order to do what is suggested above, the therapist must be patient and be

comfortable talking about the negative transference and convey to the patient that
the hatred and suspicion aimed at the clinician is to be expected. Acceptance of
intense hostility makes the patient feel safe and makes the patient feel like the
aspects of the self the patient regards as evil are ordinary human qualities
Effective work with paranoid clients differs substantially from standard psychoanalytic
work
o Interpretation from surface to depth is usually impossible with paranoid clients
because there have typically been so many radical transformations of their
original feelings before their preoccupations manifested
Ex. a man who longs for support from someone of his gender,
unconsciously misread this yearning as sexual desire, denied this, then
projected it onto someone else, and became overwhelmed with fears that
his wife is having an affair with his friend. The real concerns will not be
addressed if the therapist encourages him to associate freely to the idea of
his wifes infidelity.
o Analyzing resistance before content usually will be unsuccessful with paranoid
clients. Analyzing the defenses of denial and projection will make the client feel
judged and scrutinized and likely the client will continue to use these defenses.
The standard ways of helping clients open up will likely be unsuccessful with paranoid
individuals. Thus, how do we help them access internal material?
o 1. Use of humor
Be cautious that the humor does not make the paranoid patient feel teased
and ridiculed
Best way to set the stage for mutual enjoyment of humor is to laugh at
ones own weaknesses and mistakes.
Humor can help make omnipotent fantasies ego alien
Ex. a patient was convinced that his plane would crash en route to his
vacation in Europe. He was startled and relieved when the therapist said
do you think God is so merciless that He would sacrifice the lives of a
hundred other people simply to get at you?
Humor, especially the willingness to laugh at oneself, is probably
therapeutic in that to the patient it represents being real rather than
playing a role or pursuing a secret game plan.
Be forthcoming with paranoid clients. Respond to their questions honestly.
When the manifest content of a paranoid persons concern is addressed,
he/she becomes more willing to look at the latent concerns represented in
it.
o 2. Sidestep the paranoid defense and instead identify the feelings that may have
triggered it
It can be helpful to allow the paranoid clients rant to run its course and
then empathically talk about the feelings behind it
Countertransfernce can help the therapist identify the clients feeling being
defended against.
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Ex. when the patient is in an unrelenting powerful rage the

therapist may feel threatened and helpless. The therapist may say
I know that what youre in touch with is how angry you are, but I
sense that in addition to that anger, youre coping with profound
feelings of fear and helplessness.
o 3. Identify what has happened in the clients recent experience to upset them
Triggers often involve separation (a child started school, a friend moved
away) or success (success involves guilt and fears of envious attack)
Educating people to notice their states of arousal and to look for triggers
often preempts the paranoid process altogether
One should be careful when offering alternative interpretations of a
paranoid clients idea since it can make the patient feel crazy for what they
saw and feel dismissed. If a paranoid client asks the therapist if he/she
agrees with a paranoid idea the therapist can offer interpretive possibilities
but tentatively. The therapist should avoid asking the client explicitly if
they accept or reject the alternative interpretations. Acceptance may equal
humiliating submission and rejection may invite retribution.
o 4. Make repeated distinctions between thoughts and actions
Sometimes patients may get the idea that the purpose of therapy is to get
them to expose feelings such as hostility, lust, greed and to help them
purse these feelings rather than embrace them
It can reduce the patients fears of an out of control, evil core if the
therapist helps the patient identify that it is okay to feel these feelings and
there is a difference between feelings these feelings and acting on them.
o 5. Be hyperattentive to boundaries
Paranoid clients are perpetually worried that the therapist will step out of
role and use them for some end unrelated to their psychological needs
Consistency is critical thus maintain the therapeutic frame
Differential Diagnosis
Paranoid versus psychopathic personality
o Guilt: Both antisocial and paranoid people are highly concerned with issues of
power but unlike psychopaths, paranoid individuals have profound guilt.
o Love: paranoid people are deeply object related and psychopaths are
fundamentally unempathic
The main threat to long-term attachment in paranoid people is not lack of
feeling for others but rather experiences of betrayal
Paranoid versus obsessive personality
o They share a sensitivity to issues of justice and rules, a rigidity and denial around
the softer emotions, a preoccupation with issues of control, a vulnerability to
shame
o Differ in the role of humiliation in their histories and sensitivities. The obsessive
person is afraid of being controlled but lacks the paranoid persons fear of
physical harm and emotional mortification.
o Thus the obsessive clients more likely to cooperate with the interviewer and the
therapist does not suffer the degree of anxiety that paranoid patients induce.
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