Jungian analysts have called it the “swampland of the soul”. Other psychotherapy writers have observed how it originally served to keep us safe; the tendency to shame has been a universal one in which our desire to hide our flaws from others has saved us from being kicked out of the group (the society), which evolutionarily would have meant death (Sholl, 2013). So which is it? Is shame totally pathological, or is it ever helpful to us? And how shall we deal with it in the therapy session, especially when we are faced with a highly self-critical or otherwise shame-prone client?

In a recent blog post we defined shame and provided examples of it, differentiating it from similar emotions. In this follow-up article, we identify the signs and symptoms that a client is experiencing shame, review the dynamics and states of mind relevant to it, and explore ways to build shame resilience – a capacity to deal with potentially shame-triggering incidents – in clients.

How you can identify it in the therapy room

First, let’s make sure that you are, indeed, able to spot this elusive and dark emotion. As we noted in the earlier piece, the salient characteristic of shame is that, paradoxically, it is hidden. People can experience a deep-seated shame for years that even close associates do not recognise. So how, on perhaps only a few minutes of therapeutic association, do we? The first complication of many on this topic is that shame is ubiquitous in the therapy room. This is true for three reasons: (1) nearly all clients will be experiencing some form of it; (2) clients are also likely to feel shamed merely because of the stigma associated with seeking mental health help; and (3) finally, we as therapists must acknowledge that we have our own places of shame, which in the exchange of transferences that is psychotherapy, inevitably manifest in our interactions with clients.

Physical and emotional symptoms of shame

Dearing and Tangney (2011), in drawing together the threads of multiple master clinicians’ observations on the topic, noted that therapists consistently commented on the physical and/or emotional withdrawal of clients experiencing shame. This could be seen in decreased eye contact, slumped or rigid posture, avoidance of “here and now” material, freezing, stammering, tightened voice, self-deprecating comments possibly expanding into hilarious monologues, and a micro-flash of irritation before apology for missing a session or failing to do an assigned homework. Downcast eyes, squirming in the seat, laughter covering embarrassment, and indications that a topic is somehow degrading were all nominated as signs of shame. Some therapists noted that their shamed clients tended to go blank; manifest submissive, crouched body postures; avoid topics (as in talking “around” them); become anxious or angry; or directly refuse to divulge relevant clinical material (Dearing & Tangney, 2011).

The “hidden” demonstrations of shame

As obvious as the above signs would seem to be, a common observation is that shame is easily overlooked in the therapy room. It is an emotion that clients wish to hide because they feel ashamed of having shame, and we as therapists may collude with that, partly because of our own areas of felt shame. Beyond that, though, client shame is frequently disguised by other emotions: anger and rage, envy, contempt, and expressions of grandiosity, as clients “wear” several subtypes of narcissism in order to hide their vulnerable, shamed self. Paralinguistic cues can include confusion of thought, hesitation, soft speech, mumbling, silence, long pauses, rapid speech, or tensely laughed words. Therapists not trained to recognise it can easily miss these many, more hidden, faces of shame (Dearing & Tangney, 2011).

Shame-related states of mind in session

When in a typical shameful state of mind, an individual has a sense of an exposed, vulnerable, devalued self being scrutinised and found wanting in the eyes of a devaluing other. Acute shame may be experienced as an overwhelming pang of secret discomfort associated with communication that explicitly or implicitly conveys themes of inferiority. Extremely shame-prone clients suffer from persistent, oppressive appraisal processes in which all interactions (including those with you in session) are rigidly assessed in accord with the degree of perceived criticism, judgment, or humiliation experienced. This has been likened to a computer application program which, whether running inconspicuously in the background or more saliently in the foreground, is nevertheless always present at any given moment, never completely disengaged. It can be triggered into the foreground (primary operation) by myriad interpersonal events or by internal processes such as memories, fantasies, and reactions to internal states of arousal, such as sexual excitement, rage, or even exhibitionistic urges (Zaslav, 1998).

The defences a client chooses to engage as a result of the shame may vary widely. Narcissistic clients, for example, may ward off shameful schemas about self through grandiose, inflated self-regard in the (imagined) presence of an admiring audience. But upon perceiving a lack of sufficient support or attention from the psychotherapist, the same narcissist may experience other shame-related states, such as painful emptiness or of being a “nothing”. Volatile expressions of anger can result for shame-prone clients experiencing bitter, resentful feelings of being unappreciated or even humiliated; these the client may perceive as “self-righteous rage”. Others defend against shame through paranoid states in which others are seen as tormenting or accusing the self. For still other clients, envious states or episodes of blaming self or others manifest. How can you as therapist discern these states of mind? Zaslav (1998) suggests that psychotherapists are apt to enter complementary states of mind in which shame-related themes dominate. Thus, tapping into your own feelings in the moment will provide important clues to the client’s state of mind. Note that the client may present their guilty self (guilt being an often adaptive emotion in which we experience doing something bad rather than being bad), but a shamed self is not likely to appear directly, as clients go to frantic lengths to avoid experiencing it; by its nature, it is hidden even from the client (Zaslav, 1998).

Finally, upon entering a shameful state, many clients experience a transient inability to think, referred to as “cognitive shock” (Zaslav, 1998). Thus, while a psychotherapy session may work well for guilt, which can be expressed, processed, and expiated, the sense of vulnerability and exposure that goes with shame is almost always accompanied by a direct avoidance of communication about it, and this is compounded by states including disruptive imagery, cognitive disorganisation, and emotional dysregulation (Zaslav, 1998). All of this can trigger behaviour which conflicts with any prosocial, adaptive functions of shame (such as helping an individual to find his or her place in society), and instead leads the person to cut empathic ties to others.

Shame is rich in transferences

Along with all of this comes the challenge that shame – especially because it is so difficult for people to confront directly in themselves – is often repressed and thus projected outward, to the therapist and others. Much has been written about this aspect which is beyond the scope of this article, but note that, given the painful split between the devalued self and a devaluing other, defensive operations within the client are likely to result in the shame experience being projected onto or into the therapist (in projection and projective identification, respectively). This means that you as therapist may be made to feel about yourself as the client feels about him/herself. How do you know this is happening? Again, the information is located conveniently in your own body/emotions, when you begin to notice shifts in your own self-evaluation. You become, in essence, the “spokesperson” for the client’s poor self-esteem. The client may project inadequacy onto you, systematically and unconsciously undermining and devaluing your efforts, until you begin to doubt your own adequacy as a therapist. Feelings of weakness or deficiency are common in shame-based projections. Similarly, the client may reveal contemptuous or devaluing attitudes toward the therapist that can be linked in treatment to a disowned weak or defective self superimposed upon the psychotherapist. If this happens to you and you are able to tolerate the projections openly – without corresponding shameful retreat, you provide a powerful message to the client that it is safe to examine his or her internalisation of a devalued, incompetent self (Zaslav, 1998).

Finally, we note that a different form of transference/countertransference can occur when the client unconsciously pressures you as therapist to accept a disapproving stance toward him/her. In this case you function as a spokesperson for the client’s self-contempt. Once you understand this, it is easier to maintain a supportive stance, while encouraging exploration of those self-critical attitudes that the client generally puts onto him/herself (Zaslav, 1998).

Enhancing shame resilience in the therapy room

Dearing and Tangney (2011) integrate their master clinicians’ suggestions for how to work with shame in the therapy room through a framework with four aspects: accessing and acknowledging shame, relational validation, shame regulation, and transformation of shame. We look through that framework into suggestions we have unearthed for building shame resilience.

Accessing and acknowledging shame

Numerous authors make the point that shame draws much of its power from the shadows; when we bring it into the light of shared discussion, we disempower it. The saying is apt here that emotions (and shame is one of the darkest and most intense of emotions) are like breathing: they only cause trouble when obstructed (Sack, 2015). Thus, getting beyond shame means being able to share experiences of shame with trusted others. It means exposure to shame. We have emphasised throughout this article and the earlier one that people acting from shame-based instincts uniformly want to avoid looking at it, let alone talking about it. But deal with it they must; exposure to it can be like the graded exposure techniques used with individuals experiencing panic attacks and other forms of anxiety: first a little exposure to it, then gradually increasing amounts (LeJeune, 2016).

It is useful for clients to be able to recognise their triggers. Shame is sneaky; it attacks us where we are most vulnerable, or in other words, our insecurities “prime” us to feel shame in particular areas. The aspiring writer with the freshly-minted novel is more apt to feel shamed when someone points out how compelling another novelist is than when comments are made about someone else’s car. The overweight person who hears how beautiful another (very slender) person is may take that as a hint that he or she should lose the excess weight. Research suggests that a chief shame trigger for women is physical appearance, whereas for men it is the fear of being perceived as weak (Sack, 2015).

In therapy, the mere process of naming shame helps to differentiate it from similar emotions (such as humiliation, guilt, or embarrassment) and also can help the client to normalise it (i.e., pointing out that it is a universal human experience; we all have it at one time or another). The point is to “titrate the dose” of shame-naming so that the client is not overwhelmed, but confronts it little by little as he or she is ready to accept it. As this process occurs, the client comes to see that few, if any, experiences warrant the global “smearing” of the whole personality with the tar-brush that created the global negative self-attributions. Rather, in the logical light of day, most genuine flaws, setbacks, and transgressions are limited to particular areas – and the client can either resolve them or choose to view them more kindly (Dearing & Tangney, 2011; LeJeune, 2016).

Relational validation

Talking about the shame, as above – or rather, being heard around it – is a form of relational validation as well as a way of accessing shame. Empathy is the antidote to shame, so receiving it when telling a shame-generating story can help dissolve it. Especially because of the hidden nature of shame, we can tend to feel isolated in it. Authentic sharing – with vulnerability, to someone who responds empathetically – can build the therapeutic alliance in a therapy session, or strengthen a relationship outside of it. Yes, it can be anxiety-inducing to do this with high shame. As a therapist, note that many psychotherapy writers suggest that you actually use the term “shame”, but you may wish to wait until some relationship is built before using that word (Sholl, 2013; Dearing & Tangney, 2011).

Shame regulation

Along these lines, whatever you can do to help build self-compassion in the client makes it easier for the person to self-soothe, self-validate and regulate the shame. Thus, not only your words, but the timbre, pacing, and tone of your voice – how you say what you say – may influence clients cued to experience threat or disapproval. LeJeune’s research (2016) suggests that even engendering a sense of physical warmth in the therapy room (via a cup of tea, a blanket, or a cosy office) may induce a client to greater compassion for self and therefore greater capacity to self-regulate the shame.

Certainly, psychoeducation and guiding clients in experiences of loving-kindness (Metta) meditation and practices of mindful non-judgment are shown to positively impact a whole host of difficulties related to shame. One technique is to locate where the sensation of shame manifests in the body; let’s say it’s in the pit of the client’s stomach. The client then places a hand over that area (or alternatively, over the heart) and directs comforting, affirming energy to that part of the body. When a client has enhanced self-compassion, it makes it easier to be vulnerable and engage the world from a place of worthiness, thus regulating shame, so it is a full feedback loop (Sholl, 2013).
Tied to helping the client regulate his or her shame is the capacity in us as therapists to be able to recognise and then normalise our own places of shame. Let us say this strongly: it is normal to feel shame as a therapist! We spoke before about shame being put onto or into us by the client via projection or projective identification. Beyond that, we are human, too, and may experience shame from previous experiences completely unrelated to the client. LeJeune’s Number One scientifically-based recommendation for dealing with shame is to “Love your own self-doubt; it makes you a better therapist” (2016). At least, being aware of our own shame and learning about it can help us to model self-compassion and eventual shame regulation for our clients (LeJeune, 2016; Dearing & Tangney, 2011).

Transformation of shame

Finally, we come to the question of how we can change a problematic emotional experience – that of shame – into a more adaptive, empowering, and meaningful emotion that can serve as a resource. One powerful way is to transform shame into guilt. We have differentiated between shame (“I am bad”) and guilt (“I have done something bad”). If we are inherently wrong or bad, there is no hope. But if we have done something wrong, we have the opportunity to make reparation: to apologise, to compensate, to redress whatever wrong we have somehow done. Sometimes it is only necessary to educate clients as to the difference between “being bad” and “doing bad”. Some forms of treatment already support this transformation. Alcoholics Anonymous, for example, encourages members to separate character flaws from their core selves (Step 4) and make amends for what they have done wrong during their addictions (Steps 8 and 9), thus moving from shame to guilt. Taking this step is at least implicit, if not explicit, in therapies such as CBT and REBT. Many success-oriented therapies, such as narrative therapy and solution-focused therapy, ask clients to look for exceptions, so shame-based perfectionists have the opportunity to challenge excessively high standards and others’ evaluations of the self.

In some cases, such as with sexual abuse, the client had no responsibility for the shame-engendering experience and so the therapeutic goal is not the change of focus from shame to guilt. Rather, it is about appropriately externalising the blame back onto the abuser: putting where it belongs. As such clients construct new meaning for long-standing wounds, their shame may shift to anger or sadness. These emotions can be growth-producing in that they point to adaptive actions appropriate to the situation: for example, reaching out to connect to others in sadness and using anger to assert one’s right to life one’s own life without shame (Dearing & Tangney, 2011).

Summary

Much can be written about this intensely painful, complex, and often misunderstood topic of shame. In this article we have looked into how you can identify it in your therapy room, what the typical shame-related states of mind tend to be, and the kinds of transferences that typically pop up in session. We have suggested a four-component framework for treating it which includes accessing and acknowledging it, deepening relational validation, helping the client to regulate the shame, and eventually transforming the shame into other, more adaptive emotions. Paradoxically, the ultimate arbiter of your effectiveness in dealing with client shame is your willingness to be with your own shame.

References

• Dearing, R.L., & Tangney, J.P., Eds. (2011). Working with shame in the therapy hour: Summary and integration. Shame in the therapy hour. Washington, D.C.: APA Books.
• LeJeune, J. (2016). 20 science-based recommendations for therapy with highly self-critical or shame-prone clients. ACT with compassion. Retrieved on 17 May, 2018, from: Hyperlink.
• Sack, D. (2015). 5 ways to silence shame. Psychology Today. Retrieved on 17 May, 2018, from: Hyperlink.
• Sholl, J. (2013). Shutting shame down. Experience Life. Retrieved on 17 May, 2018, from: Hyperlink.
• Zaslav, M. R. (1998). Shame-related states of mind in psychotherapy. J Psychother Pract Res. 1998 Spring; 7(2), 154-166.

Retrieved from Issue 346 of Institute Inbrief 20/01/2021

Paranoia: Definition and levels

When a person believes that others are “out to get them”, trying to stalk or harm them, or paying excessive attention to them for no reason, they may be experiencing paranoia. Occurring in many mental health conditions, paranoia is most often present in psychotic disorders. It involves intense anxious or fearful feelings and thoughts, most often related to persecution, threat, or conspiracy (Mental Health America, n.d.). It can be a symptom of illnesses such as schizophrenia, brief psychosis, paranoid personality, psychotic depression, mania with psychotic features, delusional disorders, or substance abuse (chronic or momentary) (Barron, 2016).

Mental health experts have identified three levels of paranoia:

1. Paranoid personality disorder (PPD): Characterised by odd or eccentric ways of thinking, PPD involves an unrelenting mistrust and suspicion of others when there is no reason to be suspicious. It is one of the personality disorders in the DSM-5’s Cluster A, along with schizoid and schizotypal personality disorders. Thought to be the mildest form of paranoia, a person with PPD may still be able to function in relationships, employment, and social activities. The onset is typically in early adulthood and is more common in men than in women.
    
2. Delusional (paranoid) disorder: Found in the DSM-5 chapter, “Schizophrenia spectrum and other psychotic disorders”, this is a condition in which an individual holds one major false belief or delusion; it will often be an implausible but not bizarre delusion. A delusional disorder typically occurs without any other signs of mental illness. So a person might think that others are talking behind their back if they have a persecutory delusion, or believe that they need immediate medical attention for a (non-existent) medical problem if they have a somatic delusion. This condition is slightly more common in women than men.
    
3. Schizophrenia with bizarre delusions: People with this condition do not function well in society and need consistent treatment (Sunrise House, 2018; WebMD, 2018).This is the most severe form of paranoia, involving bizarre delusions without basis, such as that aliens are trying to abduct them, or that an unseen enemy is removing their internal organs and replacing them with others’ organs.

This article is about Levels (1) and (2), the paranoid personality disorder (PPD) and delusional disorder, which you may encounter more commonly, either in your client or the client’s partner.

Identifying paranoia

We have several options for finding out what characteristics should be called “paranoid”: we can assess how we experience the person — how we describe them and what they evoke in us — and/or we can run with DSM-5 descriptions, which outline the clinical symptoms we can observe specifically with the paranoid personality disorder and delusional disorder. Let’s do both.

Descriptions of the paranoid person

Joe Navarro, who has written extensively about mental disorders, asked those who had either lived with or been victimised by paranoid personality types to describe this personality type from their experiences. Here is the list of some of their words:

“Angry, anxious, apprehensive, combative, complainer, contrarian, critical, delusional, demanding, difficult, distrustful, disturbed, eccentric, fanatic, fearful, fixated, fussy, guarded, hard-headed, inhospitable, intense, irrational, know-it-all, menacing, mentally rigid, moralistic, obsessed, odd, offensive, opinionated, sensitive, peculiar, pedantic, quarrelsome, questioning, rigid, scary, strict, stubborn, suspicious, tense, threatening, tightly-wound, touchy, unforgiving, unhappy, vindictive, wary, watchful, withdrawn” (Navarro, 2016).

What they evoke in us:

Experiencing a relationship with someone described by such intense words as those above cannot fail to bring forth a reaction in us. Laurel Nowak (2018) outlines the common feelings evoked by paranoid individuals in those with whom they are in relationship. She talks about: “feeling weighed down, negative, stressed, isolated from the people and activities you used to enjoy, and like you’re walking on eggshells”. Some have noted that it can feel to the other person like they are not being seen — ever — for who they truly are. The exaggerated negative spin on events or in response to statements occurs in the context of relating which lacks tenderness, humour, or comfort (Navarro, 2016). While these authors are describing feelings evoked in intimate relationships with paranoid individuals, they could have been talking about how therapists feel when faced with a client with this condition. Dealing with such a person eats away at the most robust sense of happiness and self-esteem. Here are the DSM-5 symptoms.

Paranoid Personality Disorder: DSM-5 symptoms description

According to the DSM-5, there are two primary diagnostic criteria for Paranoid Personality Disorder, of which Criterion A has seven sub-features. Four of these must be present to warrant a diagnosis of PPD:

Criterion A is: Global mistrust and suspicion of others’ motives which commences in adulthood. The seven sub-features of Criterion A are:

1. Belief others are using, lying to, or harming them, without apparent evidence thereof
2. Doubts about the loyalty and trustworthiness of friends and associates
3. Inability to confide in others due to the belief that their confidence will be betrayed
4. Interpretation of ambiguous or benign remarks as hurtful or threatening
5. Holding grudges (being unforgiving of insults, injuries, or slights)
6. In the absence of objective evidence, belief that their reputation or character are being assailed by others; retaliation in some manner
7. Being jealous and suspicious without cause that intimate partners are being unfaithful.

Criterion B is that the above symptoms will not be during a psychotic episode in schizophrenia, bipolar disorder, or depressive disorder with psychotic features (American Psychiatric Association, 2013).

Delusional Disorder: DSM-5 definition and types

According to the DSM-5, this condition is characterised by at least one month of delusions but no other psychotic symptoms. Delusions are false beliefs based on incorrect inference about external reality that persist despite the evidence to the contrary; these beliefs are not ordinarily accepted by other members of the person’s culture or subculture. In delusional disorder (a moderate level of paranoia), a person experiences non-schizophrenic (i.e., not bizarre) delusions, such as that they are that they are being spied on. Because only thoughts are affected, a person with a delusional disorder can act normal and function in everyday life, although they may display paranoia or other symptoms related to their delusion. The five types of delusions people with this disorder have are:

1. Erotomanic, where there is a belief that a person with higher social or financial standing (such as the president or a movie star) is in love with them; it can lead to stalking and obsession.
    
2. Grandiose, involving the false belief that the person has a special power or ability not shared by anyone else (such as that they are extremely lucky and will always win at the casino).
    
3. Jealous: a mistaken belief that a current or former loved one is unfaithful or even harmful. Paranoia about the loved one’s words or actions can be a symptom of these delusions.
    
4. Persecutory, in which the common sense of the paranoia is that someone is out to get the individual, because the person believes they are being threatened, mistreated, or that they will be harmed in the future.
    
5. Somatic: a delusion in which the individual believes that they have an illness, disability or physical defect (Sunrise House, 2018; Mental Health America, n.d.; Bourgeois, 2017).

Treating and coping with paranoia

For the therapist

First, we must note the common advice: a person suffering from either PPD or a delusional disorder needs to seek professional help, although most such individuals do not believe that they are paranoid; rather, they think they are perceptive, noticing things that no one else sees. In this sense, it can be difficult to get such a person to therapy, as the condition tends to be ego syntonic. If such an individual turns up in your therapy rooms, however, note that a referral to a medical doctor is in order to determine if medication is needed.

Medication generally is not a major focus of treatment for PPD; therapy is. However, medications, such as anti-anxiety, antidepressant, or anti-psychotic drugs, might be prescribed if the person’s symptoms are extreme, or if he or she also suffers from an associated psychological problem, such as anxiety or depression (WebMD, 2018).

With delusional disorders, the diagnosed individual begins a combination of medication and psychotherapy. The anti-psychotic medication helps the individual improve enough to be able to understand reality and the need for therapeutic help. In milder cases, the individual may receive anti-anxiety medications or anti-depressants, which allows them to undergo therapy, where they learn coping skills, how to recognise delusions as false, and how to manage stress or difficult feelings. Hospitalisation may sometimes be indicated to stop the person from harming themselves or others during violent delusions (Sunrise House, 2018).

As the condition affects the client’s thought patterns and beliefs, it can be worked with effectively using cognitive behavioural therapy, which transforms the unrealistic, maladaptive thoughts by replacing them with more helpful, realistic adaptive thoughts. In addition, some therapists have observed that psychodynamic work, such as object relations, can help paranoid clients look into reasons for becoming mistrustful and suspicious which arise from early childhood relationships (Everyday Health, n.d.).

You might be asking, “Wait a minute; chief symptoms are a tendency to be suspicious and an inability to trust. How, then, can a therapist make any reasonable headway with such a client, given that trust is the basis for any solid therapeutic alliance?” If you twigged to this issue, congratulations; you have nailed the problem: how to keep the paranoid client in therapy long enough for enough trust to be built so that real progress can be made. Building trust is where the challenge is, no matter what modality is being used with the client.

To help a client in relationship with a person living with paranoia

You are likely to see the partner of a person acting paranoid. Once it is established that some form of paranoia is indeed the diagnosis, some clear guidelines exist for helping the partner. Some of the following tips also hold true for therapists working with this client population.

Setting boundaries. The paranoid person needs compassion and understanding, true, but that does not equate to acceptance of poor treatment on the grounds that the person has a disorder and is frustrated. Clear lines of what is acceptable and what is not must be drawn; those expectations for decent treatment must be communicated clearly, including around the issue of refusing to collude with delusional thinking (compromising one’s own needs) because of the person’s paranoia or fear.

Practicing self-care. For therapists and partners alike, this one is paramount! Dealing with this disorder is exhausting and sometimes heart-breaking. Those in close relationships (whether intimate or therapeutic) with paranoid individuals must have regular, solid habits of self-care. All the usual practices go into this category: relaxation/meditation, exercise, decent diet, support systems activated, and perhaps journalling or creative work to vent frustrations. Particularly for partners of those with PPD or a delusional disorder, maintaining a healthy social life — not allowing oneself to become isolated — is important.

Don’t abandon own stance, but empathise with their fear. If either the partner of the paranoid person or you, as therapist, hear an accusation that seems really “off” — totally unfounded — you can employ the tactic of empathising with the feeling, but not necessarily agreeing with the facts (though outright disagreeing doesn’t work, either). Carrie Baron, M.D., and Director of the Resilience Program at Dell Medical School in Texas, explains that consoling the person and refuting what they have said will not likely alter any paranoid convictions or delusions. What works better is “observation, reflection, curiosity and openness without judgment”, which lead to better understanding (Barron, 2016). Thus, the partner could say to the paranoid person, “I can imagine you’re worried if you think that the inheritance you counted on for your retirement might be taken away through your dad marrying. Have you observed any behaviour that made you question her motives?” (curiosity). However they do it, partners of people with any form of paranoia must look beneath the surface before getting swept up in the partner’s claims (Barron, 2016).

Recognise that the paranoid person can still contribute to life. Because of the fact that mild or moderate forms of paranoia are circumscribed, showing up only in particular thoughts and delusions, only those involved or accused may be aware of the psychopathology of the condition. The person can thus contribute to family life, work, and aspects of social life in positive ways, which you as therapist can help highlight for the partner.

Having either a client or a client’s partner who is paranoid is not easy, but the worst heartbreak and chaos can be avoided if the person can engage treatment, including medication when necessary.

References:

1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders.(5th Edition). Washington, DC.: APA.
2. Barron, C. (2016). 7 Tips for coping with a paranoid partner. Psychology Today. Retrieved on 4 December, 2018, from: Website.
3. Bourgeois, J. (2017). Delusional disorder. Medscape. Retrieved on 9 December, 2018, from: Website.
4. Everyday Health. (n.d.) Coping with paranoia in a loved one. Everyday Health. Retrieved on 4 December, 2018, from: Website.
5. Mental Health America. (n.d.). Paranoia and delusional disorders. Mental Health America. Retrieved on 6 December, 2018, from: Website.
6. Navarrro, J. (2016). The paranoid partner: Identifying the paranoid personality in relationships. Psychology Today. Retrieved on 4 December, 2018, from: Website.
7. Nowak, L. (2018). Paranoid personality disorder and relationships: Moving past fear, together. Bridges to Recovery. Retrieved on 4 December, 2018, from: Website.
8. Sunrise House. (2018). Is there a difference between paranoia and delusional disorders? American Addiction Centers. Retrieved on 9 December, 2018, from: Website.
9. WebMD. (2018). Paranoid personality disorder. WebMD LLC. Retrieved on 9 December, 2018, from: Website.

There have been various theories and models proposed over time to help us understand why individuals use alcohol and other drugs, and why some people become dependent or ‘addicted’ but not others. The following are several models or theories of addiction. They reflect the political, medical, spiritual, and social forces of those times in history.

The Moral Model

Alcohol and tobacco was introduced in the Western countries during the 1500’s. The widespread use and misuse of chemical substances resulted in a range of social problems and it was thought by some that substance use was “problematic” and “morally wrong” (Lassiter & Spivey, 2018). The moral model viewed AOD dependency as a moral and personal weakness that involved a lack of self-control, and was often viewed as a potential danger to society (Stevens & Smith, 2014).

The moral model considered addiction a “sin” and a result of free, yet irresponsible, choice. Therefore, many politically conservative groups, religious groups, and legal systems tended to punish the individual who uses AOD. The moral model or attitude towards addiction can still be seen today in certain cultures. Those who still believe addiction is morally “wrong” tend to perceive the most appropriate way to treat the individuals who use AOD are through legal sanctions, such as imprisonment and fines. For example, in many countries, drivers who are caught under the influence of alcohol or other drugs are not considered for treatment programs but instead receive court sentences as punishments (Fisher & Harrison, 2017).

This model has been rejected by alcohol and other drugs professionals as unscientific and contributes to the stigma surrounding addiction and substance use (White, 1991, cited in Fisher & Harrison, 2017).

The Disease Model

This model takes up the medical viewpoint and proposes addiction as a disease or illness that an individual has. It proposed that addiction is a disease that is progressive and chronic whereby the individual holds no control as long as the substance use continues. In other words, their addiction will continue to deteriorate with the continuous AOD (Thombs & Osborn, 2019). It also proposes that individuals who uses AOD can never be cured from addiction, though it can be readily treated through sustained abstinence such as self-help fellowships and treatment community. 

In the 1940s, Jellinek proposed a disease model in relation to alcoholism, arguing that it is a disease caused by a physiological deficit in an individual, making the person permanently unable to tolerate the effects of alcohol (Stevens & Smith, 2014). Jellinek identified signs and symptoms and clustered them into stages of alcoholism, as well as progression of the disease, which form the basis of 12-step or Anon-type programs (e.g., Alcoholics Anonymous and Narcotics Anonymous; Stevens & Smith, 2014). 

Under the disease model, treatment requires complete abstinence. Once an individual has accepted the reality of their addiction and ceased substance use, they are labelled as being in recovery, but are never ‘cured’ (e.g., “Once an alcoholic, always an alcoholic”; Thombs & Osborn, 2019). Whilst originally applied to alcohol dependency, it has now been generalised to other substances and many traditional substance use treatment models are based on this model (Capuzzi & Stauffer, 2020; Stevens & Smith, 2014).

The disease model offered an alternative to the moral theory, helping to remove the moral stigma attached to addiction and replacing it with an emphasis on treatment of an illness (Capuzzi & Stauffer, 2020). Disease theory helped to explain how some people experience the physiological effects of addiction such as dependence, tolerance, and withdrawal more than others, and how these mechanisms are caused by a biochemical abnormality in an individual which increases their likelihood of developing a dependency (DiClemente, 2018). 

While the disease model was well received by a range of professionals, many criticised it because research did not find that the progressive, irreversible progression of addiction through stages always occurs as predicted (Capuzzi & Stauffer, 2020). Additionally, many in the AOD field argued that the model did not address the complex interrelated factors that accompany dependency (Stevens & Smith, 2014). Finally, some professionals argued that the concept of addiction being a disease may also convey the impression to some individuals that they are powerless over their dependency and/or not responsible for the consequences of destructive addictive behaviours, which can be counteractive to treatment (Capuzzi & Stauffer, 2020).

Genetic and Neurobiological Theories

These theories suggest that some people may be genetically predisposed to develop drug dependency. For example, individuals usually begin substance use on an experimental basis. They then continue using because there is some reinforcement for doing so (e.g., a reduction of pain, experience of euphoria, social recognition, and/or acceptance, etc.). Some people may continue to use substances in a controlled or recreational manner with limited consequences while others progress to non-medical use and eventually develop a dependency. Why? Genetic and neurobiological theories propose that this is the result of a genetic predisposition to drug dependency (Fisher & Harrison, 2017). 

Factors being considered by researchers in the genetic transmission of dependency on alcohol include neurobiological features such as an imbalance in the brain’s production of ‘feel good’ neurotransmitters or in the metabolism of ethanol, which is the key component of alcohol (Stevens & Smith, 2014). Other researchers explored genetic differences in temperament and personality traits which they argued may lead to certain individuals becoming more vulnerable in the face of challenging environmental circumstances, leading to AOD use (Stevens & Smith, 2014). Genetic predispositions such as these may explain why some individuals develop dependency on AOD while others in similar situations do not.

The Psycho-dynamic Model

This model proposes that substance use may be due to an unintentional response to some difficulties that an individual experienced in their childhood. This explanation is based on the theory that was put forward by Sigmund Freud, whereby the problems of whether we are able to cope with difficulties as adults are linked to our childhood experience. Many counselling approaches today are based on this theory which aim to seek understanding of people’s unconscious motivations and to enhance how they view themselves (Capuzzi & Stauffer, 2020).

The Psycho-dynamtic model also believes that AOD use is often secondary to a primary psychological issue. In other words, alcohol and other drugs is a symptom rather than a disorder, and AOD use is a means to temporarily relieve or numb emotional pain. For example, an individual suffering from depression might self-medicate with stimulants to relieve the enervating effects of depression or manage their anxiety by using benzodiazepines (Fisher & Harrison, 2017). 

There is evidence to support this model, whereby childhood traumatic events are associated with mental health problems and substance use disorders. Wu et al. (2010) conducted a study among 402 adults who were receiving substance use disorder treatments. They revealed that almost all (95%) of the participants experienced one or more childhood traumatic events, and 65.9% of them experienced emotional abuse and neglect from their childhood. The authors also reported that the higher the number of childhood traumatic events experienced, the higher the risk of substance use disorders and mental health problems such as post-traumatic stress disorder. 

Personality Traits

Some theorists suggest that certain individuals have certain personality traits that are linked to AOD dependency. For example, dependency on alcohol has been associated with traits such as developmental immaturity, impulsivity, high reactivity and emotionality, impatience, intolerance, and inability to express emotions (Capuzzi & Stauffer, 2020).

Social Learning Model

This model suggests that social learning processes such as observing other peoples behaviours (i.e., modelling) and cultural norms are important in the process of learning behaviours. Albert Bandura proposed Social Learning Theory which would argue that substance use is initiated by environmental stressors or modelling people around you with “perceived status”. For example, a child observes their parents use alcohol in social situations and the child is therefore more likely to perceive that AOD use for social situations is appropriate (Harrison & Fisher, 2017); the association between socialisation and alcohol has been established.

The social learning model also recognises the influence of cognitive processes such as coping, self-efficacy, and outcome expectancies. Some researchers are currently focusing on how an individuals expectation of the effects of drugs influence the pattern of AOD use and resulting dependency. Russell (1976, cited in Wise & Koob, 2013) suggested that dependency on substance is not only chemical (biological) but also behavioural and social in nature. 

It has also been suggested that substance use occurs when an individual thinks substance use is a coping mechanism. This can be learned from television and film, social medial, peer influence, or messages from caregivers during childhood. The individual hopes the AOD use will relieve from them from stress (Stevens & Smith, 2014). 

Socio-cultural Model

Different from the previous models, the socio-cultural model perceives substance use as an issue of society as a whole instead of focusing only on the individual. People tend to overestimate the influence of internal and psychological factors while underestimating the external and environmental factors, even among some alcohol and other drugs workers (Gladwell, 2000, cited in Lewis, Dana, & Blevins, 2015). Thus, this model highlights the importance of how society shapes substance use behaviours, such as cultural attitudes, peer pressures, family structures, economic factors, and more (Bobo & Husten, 2000). For example, Coffelt et al. (2006) found that parents’ alcohol use are associated with their children’s drinking behaviour, whereby when the adult’s alcohol problems increased, the likelihood of their adolescent child’s alcohol use increased. 

The Biopsychosocial Model

Substance use behaviour cannot be explained or understood scientifically or spiritually based on a single variable, antecedent, or “cause”. Biological, psychological, learning, social and cultural context all contributes to explaining why addiction develops and maintains. The interactions between these factors are presented in The Biopsychosocial Model – arguably the most commonly used model to explain addiction today. The model suggests that substance use and the progression of substance dependency can be explained by recognising that the body and mind are connected within a social and cultural context (Skewes & Gonzalez, 2013).

The model allows any combination of biological, psychological, social and cultural factors to contribute to AOD misuse and dependency, rather than a single dominating factor. This is much more holistic and integrative when attempting to understand the determinant of addiction (Stevens & Smith, 2014).

References:

1. Bobo, J. K., & Husten, C. (2000). Sociocultural influences on smoking and drinking. Alcohol Research and Health, 24(4), 225-232. 
2. Capuzzi, D., & Stauffer, M. D., Sharpe, C. W. (2020). History and etiological models of addiction. In D. Capuzzi, & M. D. Stauffer (Eds.), Foundations of addictions counseling (pp. 1-22). Pearson Education.
3. Coffelt, N. L., Forehand, R., Olson, A. L., Jones, D. J., Gaffney, C. A., Zens, M. S. (2006). A longitudinal examination of the link between parent alcohol problems and youth drinking: The moderating roles of parent and child gender. Addictive Behaviours, 31, 4, 593-605. https://doi.org/10.1016/j.addbeh.2005.05.034 
4. DiClemente, C. C. (2018). Addiction and change: How addictions develop and addicted people recover. The Guilford Press.
5. Fisher, G. L., & Harrison, T. C. (2017). Substance abuse: Information for school counsellors, social workers, therapists, and counsellors. Pearson Education. 
6. Lassiter, P. S., & Spivey, M. S. (2018). Historical perspectives and the moral model. In P. S. Lassiter, & J. R. Culbreth (Eds.), Theory and practice of addiction counselling. (pp. 27-46). Sage Publications. 
7. Lewis, J. A., Dana, R. Q., & Blevins, G. A. (2015). Substance abuse counselling. Cengage Learning.
8. Skewes, M. C., & Gonzalez, V. M. (2013). The biopsychosocial model of addiction. In P. M. Miller, A. W. Blume, D. J. Kavanagh, K. M. Kampman, M. E. Bates, M. E. Larimer, N. M. Petry, P. D. Witte, S. A. Ball (Eds.), Principles of addiction: Comprehensive addictive behaviours and disorders (pp. 61-70). Academic Press.
9. Stevens, P., & Smith, R. L. (2014). Substance abuse counselling: Theory and practice. Pearson Education. 
10. Teesson, M., Hall, W., Proudfoot, & Degenhardt, L. (2012). Addictions. Taylor & Francis Group.
11. Thombs, D. L., & Osborn, C. J. (2019). Introduction to addictive behaviours. The Guilford Press. 
12. Wise, R. A., & Koob, G. F. (2013). The development and maintainance of drug addiction. Neuropsychopharmacology, 39, 254-262.
13. Wu, N. S., Schairer. L. C., Dellor, E., & Grella, C. (2010). Childhood trauma and health outcomes in adults with comorbid substance abuse and mental health disorders. Addictive Behaviors, 35(1). 68-71. https://doi.org/10.1016/j.addbeh.2009.09.003