Impoverished Dialogical Relationship Patterns in Paranoid Personality Disorder

By Salvatore, Giampaolo; Nicolò, Giuseppe et al. | American Journal of Psychotherapy, July 1, 2005 | Go to article overview

Impoverished Dialogical Relationship Patterns in Paranoid Personality Disorder


Salvatore, Giampaolo, Nicolò, Giuseppe, Dimaggio, Giancarlo, American Journal of Psychotherapy


In the opinion of many experts, the self is made up of numerous different, independent facets interacting with each other in an ongoing inner dialogue. The meaning of events depends on the form this dialogue takes. The hypothesis we discuss in this article is that patients suffering from paranoid personality disorder (PPD) present impoverished dialogical relationship patterns. By this we mean that: a) The characters operating on their mental stage are few and repetitive. The character identified as self is insufficient-inadequate or diffident-mistmsting-hostile. The characters embodied by other persons are hostile, humiliating, and threatening, b) The inner dialogue the characters set up is stereotyped and always has the same outcome-the inadequate part of self feels under attack by a hostile other. This pattern has an influence on patients' behaviour and the course of psychotherapy.

Our discussion of this hypothesis will be based on an analysis of extracts from diaries written by a patient with PPD during therapy. We shall give a number of strategies as to how a therapist may avoid patient drop-outs and provide effective treatment.

INTRODUCTION

It is the first session and Sabrina, a 29 year old, is talking about her previous therapist:

He wasn't to be trusted. The first thing he asked me, after I said to him that " I needed help but didn't know whether I'd manage to pay for the therapy, was 'If you don't mind me asking, how much can you afford?' I realised immediately that he wanted to make me look a fool. I talked for a bit, and then at the end I got up feeling convinced that I wouldn't be going there again..

Her present therapist imagines at first that his predecessor was only concerned with how much the patient could pay. He then imagines that Sabrina's life themes are distrust and diffidence, and the therapist finds himself fantasising about a scene in which the previous therapist, with whom he now identifies, waits in vain for Sabrina to return. The present therapist feels disappointed, has doubts about his ability, and feels guilty about being unable to help her.

The new therapist tries not to repeat any errors the other might have made. He becomes very attentive and takes heed of any sign of irritation by the patient; when he tells her how much his fees are, he lowers his voice and looks away. After the session he realises that he feels hostile towards toward the patient and considers her ungrateful for the tact with which he has treated her. He now embodies a mistrusting and diffident character, like her. If he were to continue to enact this negative attitude, he would end up being ill-disposed to treat Sabrina, like the previous therapist. A negative cognitive-interpersonal cycle would get started up during the sessions (Safran & Muran, 2000): The position taken by the patient would evoke verbal and emotional responses in the therapist that would reinforce the former's initial conviction that "others take advantage of me." The outcome would be a quick patient drop-out.

Let us analyse the clinical sketch we have been outlining. When Sabrina and her new therapist meet, there is a dialogue with various characters. The self is the diffident and angry victim and is being taken advantage of by an other, who is dishonest and selfish. Sabrina and her therapist both represent the same scene to themselves: Self is a distrusting victim and other is bad.

The hypothesis we shall discuss in this article is that impoverished dialogical relationship patterns are typical of the self-narratives-the way in which individuals organise their internal experiences in the form of stories (Angus &McLeod, 2004a; Bruner, 1990; Hermans, 1996; Salvatore, Dimaggio & Semerari, 2004)-of patients suffering from paranoid personality disorder (PPD). By this we mean that: a) The characters inhabiting their narratives are few in number and the thought themes, emotions and somatic states on which their stories concentrate are repetitive, b) The inner and interpersonal dialogues by which the characters relate to each other are stereotyped and always have the same outcome (Dimaggio, Salvatore, Azzara, Catania, Semerari & Hermans, 2003a; Dimaggio, Salvatore & Catania, 2004). …

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