The primary and preferred approach to the treatment of the paranoid personality is long-term, relatively intensive (two or more sessions weekly) individual psychotherapy. If this level of intensity proves too threatening, the scheduling can be modified to meet the patient’s needs. The patient’s pathology is embedded in his or her character structure and yields to therapeutic influence only gradually over an extended time. In specific cases, however, adjunctive therapeutic interventions may prove useful and productive.
Paranoid patients do not willingly or easily involve themselves in the therapeutic process, but at certain points they may experience a failure of characterological defenses, and as their paranoid defensive systems weaken, they may begin to experience acute anxiety or depression. At such points, they may find themselves forced into short-term therapy, which can serve to sustain them through the crisis and may open the way to a more extensive therapeutic endeavor.
Some therapists have undertaken short-term psychotherapy with paranoid patients. For many paranoid patients, this may be the preferred modality because they may not be able to tolerate much more. Rapid relief of symptoms and a return to their prior defensive status are preferred to longer-term and difficult treatment. Balint et al. described treatment in a patient with acute paranoid difficulties. Similarly, Malan described patients with acute paranoid reactions who could be helped by brief psychotherapy, but only if their personality organization manifested a strong, healthy part struggling against paranoid feelings. The pathology in paranoid personalities is usually more deeply embedded and enduring than reactive, so that patients with paranoid personalities tend to have relatively poor prospects for more definitive change in brief psychotherapy.
In the long-term treatment of a patient with paranoid personality, occasion may arise for combining individual psychotherapy with other therapeutic modalities, such as family therapy. Family therapy may be indicated particularly for adolescent patients whose family dynamics and patterns of interaction may be contributing to the patient’s difficulties. The reported experience in this area deals with other diagnostic entities, particularly borderline personality, but similar dynamics apply in paranoid patients. Such approaches, however, should remain secondary to the primary psychotherapeutic approach. Because of the paranoid patient’s hypersensitivity and vulnerability, there is always a risk that family work can undermine individual therapy. A paranoid adolescent patient, for example, may see the therapist as joining forces with the family against him or her. The therapist must determine whether such adjunctive modalities facilitate or hinder the therapeutic process.
Group therapy also may be considered as an adjunctive modality in selected cases. The resources of a group situation may enable a relatively healthy paranoid patient to sort out and resolve difficulties in socialization, thereby facilitating the course of therapeutic improvement. But paranoid patients generally do not do well in group settings of any kind because of their hypersensitivity, suspiciousness, and tendency to misinterpret comments or contributions from other group members. If group approaches are used, the therapist must be alert to possible paranoid reactions.
Behavior therapies have little demonstrable role in the treatment of paranoid personality, although at times secondary symptoms (e.g., phobic anxiety) may be modified by behavioral techniques. Usually the patient’s suspiciousness, guardedness, distrust, and easily threatened autonomy contraindicate a behavioral approach.
Revision date: June 20, 2011
Last revised: by Andrew G. Epstein, M.D.