The Case of Gary II: Things become more complex.

The Results of the Initial Interventions

Gary responded fairly positively to the initial homework assignment. He started the next session by saying that it had been a rough week because his girlfriend had made a comment that left him concerned that their careers might interfer with their relationship and that he might end up losing her. However, he reported that despite this concern he had practiced the progressive relaxation exercises regularly. He found that the relaxation exercises worked well and helped with his difficulty getting to sleep. He also reported that he was better able to cope with his irritable bowel.

After two more weeks of working on relaxation techniques, controlling his worries, and using cognitive restructuring techniques to challenge his view of himself as incompetent, Gary reported that he was feeling pretty good about myself and began to plan a move into his own apartment despite anxiety about living on his own. It appeared that continued work towards helping him to cope with stress effectively, to deal actively with problem situations rather than worrying about them, and to face his fears would proceed straightforwardly.

However, after six sessions of apparently successful treatment, Gary reported that the relaxation techniques (which had been quite effective) now had quit working. In describing situations where relaxation didn1t work Gary described himself as being unwilling to relax becuase he felt vigilance was necessary. As we explored this further, I discovered that Gary had a persistent view of others as hostile and malicious, anticipated mistreatment at the hands of others, and was quick to interpret mundane actions by others as being motivated by malicious intentions. It turned out that in addition to the Generalized Anxiety Disorder which initially brought him to treatment, Gary met DSM-III-R criteria for Paranoid Personality Disorder (and Dysthymic Disorder as well).

A Brief Excursion Into Theory

How can Cognitive Therapy understand Paranoid Personality Disorder? Well, when Gary and I examined one of the situations in which the progressive relaxation exercises didn't work, Gary reported remembering that his immediate reaction as a colleague approached was "He'll catch up with me and see what I'm doing. I don't want him stealing my idea." Given that he perceived the situation as one in which he needed to be vigilant in order to prevent a rival at work from "stealing" his ideas, it isn't surprising that he was unable to relax. Unfortunately for Gary, he tended to think that he had to be vigilant and on guard in a wide range of situations where vigilance was actually unnecessary and where the resulting tension and anxiety was seriously maladaptive.

Gary, had operated on a long-standing conviction that other persons were malicious, deceptive, and hostile and would take advantage of him or attack him if given a chance. These assumptions had important effects on the way in which Gary interpreted experiences. First, since he anticipated that others would be malicious and deceptive, he was alert for signs of deceit, deception, and malicious intentions. This selective attention resulted in his being quick to recognize those occasions when others were being dishonest or untrustworthy. In addition, many interpersonal interactions are ambiguous enough to be open to a variety of interpretations. Given his hypervigilance, Gary was quick to respond to ambiguous situations on the assumption that others had malicious intentions without pausing to consider other possibilities. Thus, his world-view resulted in his being vigilant for signs of maliciousness and deception in a way that tended to result in his perceiving many of his experiences in a way which was congruent with his world-view. Furthermore, when he did have an experience of someone's proving trustworthy or benevolent, his assumption that others are deceptive led to his concluding that the other person was trying to "set him up" rather than his concluding that the person was genuinely being trustworthy. In short, Gary's vigilance for experiences which appeared to confirm his preconceptions and his tendency to discount experiences which appeared to be inconsistent with his world-view tended to confirm and perpetuate his assumptions about others.

In addition to their beliefs and assumptions about "the way things are", individuals also hold beliefs and assumptions about what one should do about this which can be termed "interpersonal strategies". For example, in addition to his assuming that others were malicious and deceptive, Gary believed that the way to be safe was to be vigilant, on guard, and to be quick to react to any offense. This reaction had a major impact on his interpersonal relationships. He tended to be quite guarded and defensive in interpersonal interactions, to avoid closeness, and to react quickly and strongly to any perceived mistreatment. He also assumed that assertion would prove ineffective or counter-productive, so instead of speaking up for himself when he felt mistreated, he often overreacted dramatically.

A third aspect of cognition which can contribute to persistent misperceptions of situations are systematic errors in reasoning, termed "cognitive distortions". Humans are prone to a variety of errors in logic which can contribute to misinterpretations of events and which can amplify the impact of schemas. Gary viewed trustworthiness in a dichotomous manner. As he saw it, one is either trustworthy or untrustworthy, with no gradation in between. As he approached interpersonal interactions he was vigilant for signs of deceit, deception, or malicious intentions, and once he observed any indication that the individual was not perfectly trustworthy, Gary automatically classified the other person as untrustworthy. Because of Gary's dichotomous view, intermediate categories such as "not very trustworthy" or "usually reliable" were not considered. Individuals were seen as trustworthy only if they had proven to be completely trustworthy and were considered to be untrustworthy as soon as a single apparent lapse in trustworthiness was observed. This, of course, contributed to Gary's view that people in general were untrustworthy since very few of the people he knew managed to prove perfectly trustworthy for long.

For example, Gary's assumptions led him to interpret mundane interpersonal interactions as presenting a risk of malicious treatment and to interpret unremarkable interpersonal interactions as thinly disguised abuse. As a result, he experienced recurrent feelings of anxiety and resentment. On those occasions when he happened to be feeling relatively calm and peaceful, Gary showed only mild vigilance for interpersonal threats and only mild hypersensitivity to mistreatment. However, as soon as some event or spontaneous thought elicited feelings of anxiety and resentment, his vigilance for interpersonal danger and his sensitivity to mistreatment immediately increased substantially. This increased the likelihood of his interpreting subsequent events in a way which would elicit additional anxiety and resentment and thus his moods tended to "snowball" quite quickly. Once Gary's anxiety and resentment built to clinical levels, they tended to be persistent.

Affect can play an important role in an individual's functioning in another way as well. Individuals may fear certain emotions and may strive to avoid the emotion itself, may seek to escape from experiencing the emotion as quickly as possible, or may attempt to avoid thoughts, memories, or situations which they expect to elicit the emotion. Gary was unwilling to tolerate a number of emotions which he perceived as "weak" including feelings of sadness, loneliness, and vulnerability. Consequently he avoided situations which he perceived as likely to elicit these feelings, was quick to intentionally focus his attention on perceived mistreatment by others in order to feel angry rather than sad, and refused to acknowledge or express these "weak" feelings. This further complicated commonplace interpersonal situations such as coping with periods of estrangement from his girlfriend.

Gary believed that people in general were malicious and deceptive, that they would attack him if they got a chance, and that the way to be safe was to be vigilant, on guard, and ready to defend himself. How did he come to hold these views? According to Gary's descriptions, he grew up in a family where a suspicious, vigilant approach to the outside world was explicitly taught by his parents both through their words and their example. In addition, family members had been physically and verbally abusive of him and each other throughout his childhood, and had frequently taken advantage of him from childhood through the present. In short, he reported growing up in a family environment where his world-view and interpersonal strategies were explicitly taught and were strongly reinforced by repeated experiences. Of course, we cannot be certain regarding the accuracy of Gary's perception and recall of interactions in his family of origin. However, it was his subjective experience rather than objective reality which, over time, gave rise to generalized beliefs about his world and his role in it.

A New Treatment Strategy

Just as in Cognitive Therapy with other problems, the basic strategy in Cognitive Therapy with personality disorders is to develop an initial conceptualization based on the initial evaluation and then to intervene strategically, focusing both on alleviating the individual's current distress and on accomplishing lasting changes. In the case of Gary, the cognitive understanding of his problems summarized above may seem to provide little chance for effective intervention. One goal of therapy would be to modify Gary's basic assumptions since these are the foundation of the disorder. However, how can one hope to challenge Gary's conviction that others are malicious and deceptive effectively while his vigilance and guardedness constantly produce experiences which seem to confirm his assumptions? If it were possible to induce Gary to relax his vigilance and defensiveness, this would simplify the task of modifying his assumptions. But how can we hope to do this as long as he is convinced that people have malicious intentions? Fortunately, the client's sense of self-efficacy plays an important role in the model as well and provides a promising point for intervention.

The paranoid individual's intense vigilance and defensiveness is a product of the belief that constant vigilance and defensiveness is necessary in order to stay safe. If it is possible to increase the client's sense of self-efficacy regarding problem situations to the point that he or she is confident of being able to handle problems as they arise, then the intense vigilance and defensiveness seems less necessary and it may be possible for the client to relax both to some extent. This can reduce the intensity of the client's symptomatology substantially, make it much easier to address the client's cognitions through conventional Cognitive Therapy techniques, and make it more possible to persuade the client to try alternative ways of handling interpersonal conflicts. Therefore, the initial strategy in the Cognitive treatment of paranoid personality disorder is to work to increase the client's sense of self-efficacy. This is followed by attempts to modify other aspects of the client's automatic thoughts, interpersonal behavior, and basic assumptions.

Self-efficacy can be increased in two basic ways. Since it is essentially a subjective evaluation of the demands inherent in a situation and the individual's ability to successfully meet those demands, an unrealistically low sense of self-efficacy can result if individuals overestimate the demands of the situation or underestimate their ability to handle the situation. When this is the case, cognitive interventions which result in a more realistic evaluation of the situation can increase self-efficacy. A low sense of self-efficacy can also result when individuals realistically conclude that they do not have the skills or capabilities needed to handle the situation effectively. In that case, self-efficacy can be increased through interventions which increase the client's coping skills. This can be a matter of helping them master new coping skills, helping them muster the needed resources, helping them plan how to best use the skills and resources they have, etc.

Therapy Proceeds

With Gary, his paranoid personality disorder was not recognized until the seventh therapy session, and the stress-management interventions which began therapy had already raised his sense of self-efficacy substantially. However, he still felt that vigilance was necessary in many innocuous situations because he doubted his ability to cope if he was not constantly vigilant. This stemmed from his persistently labeling himself as "incompetent" despite his skills and accomplishments. When this was explored in therapy, it became clear that he had very strict idiosyncratic standards for competence and viewed competence dichotomously. He believed that one was either fully competent or totally incompetent. Since he manifested a dichotomous view of competence, the "continuum technique", a cognitive technique used specifically to counteract dichotomous thinking was used:

Therapist: It sounds like a lot of your tension and your spending so much time double-checking your work is because you see yourself as basically incompetent and think "I've got to be careful or I'll really screw up."

Gary: Sure. But it's not just screwing up something little, someone's life could depend on what I do.

Therapist: Hmm. We've talked your competence in terms of how you were evaluated while you were in training and how well you've done since then without making much headway. It occurs to me that I'm not sure exactly what "competence" means for you. What does it take for somebody to really qualify as competent? For example, if a martian came down knowing nothing of humans and he wanted to know how to tell who was truly competent, what would you tell him to look for?

Gary: It's someone who does a good job at whatever he's doing.

Therapist: Does it matter what the person is doing? If someone does well at something easy, do they qualify as competent in your eyes?

Gary: No, to really be competent they can't be doing something easy.

Therapist: So it sounds like they've got to be doing something hard and getting good results to qualify as competent.

Gary: Yeah.

Therapist: Is that all there is to it? You've been doing something hard and doing well at it, but you don't feel competent.

Gary: But I'm tense all the time and I worry about work.

Therapist: Are you saying that a truly competent person isn't tense and doesn't worry?

Gary: Yeah. They're confident. They relax while they're doing it and they don't worry about it afterward.

Therapist: So a competent person is someone who takes on difficult tasks and does them well, is relaxed while he's doing them, and doesn't worry about it afterwards. Does that cover it or is there more to competence?

Gary: Well, he doesn't have to be perfect as long as he catches his mistakes and knows his limits.

Therapist: What I've gotten down so far [the therapist has been taking notes] is that a truly competent person is doing hard tasks well and getting good results, he's relaxed while he does this and doesn't worry about it afterward, he catches any mistakes he makes and corrects them, and he knows his limits. Does that capture what you have in mind when you use the word competent?

Gary: Yeah, I guess it does.

Therapist: From the way you've talked before, I've gotten the impression that you see competence as pretty black and white, either you're competent or you aren't.

Gary: Of course. That's the way it is.

Therapist: What would be a good label for the people who aren't competent? Does incompetent capture it?

Gary: Yeah, that's fine.

Therapist: What would characterize incompetent people? What would you look for to spot them?

Gary: They screw everything up. They don't do things right. They don't even care whether it's right or how they look or feel. You can't expect results from them.

Therapist: Does that cover it?

Gary: Yeah, I think so.

Therapist: Well, let's look at how you measure up to these standards. One characteristic of an incompetent person is that he screws everything up. Do you screw everything up?

Gary: Well, no. Most things I do come out ok but I'm real tense while I do them.

Therapist: And you said that an incompetent person doesn't care whether it comes out right or how they look to others, so your being tense and worrying doesn't fit with the idea that you're incompetent. If you don't qualify as incompetent, does that mean that you're completely competent?

Gary: I don't feel competent.

Therapist: And by these standards you aren't. You do well with a difficult job and you've been successful at catching the mistakes you do make, but you aren't relaxed and you do worry. By these standards you don't qualify as completely incompetent or totally competent. How does that fit with the idea that a person's either competent or incompetent?

Gary: I guess maybe it's not just one or the other.

Therapist: While you were describing how you saw competence and incompetence I wrote the criteria here in my notes. Suppose we draw a scale from zero to ten here where zero is absolutely, completely incompetent and ten is completely competent, all the time . How would you rate your competence in grad school?

Gary: At first I was going to say three but, as I think about it, I'd say a seven or eight except for my writing, and I've never worked at that until now.

Therapist: How would you rate your competence on the job?

Gary: I guess it would be an eight or nine in terms of results, but I'm not relaxed, that would be about a three. I do a good job of catching my mistakes as long as I'm not worrying too much, so that would be an eight, and I'd say a nine or ten on knowing my limits.

Therapist: How would you rate your skeet shooting?

Gary: That would be a six but it doesn't matter, I just do it for fun.

Therapist: So I hear several important points. First, when you think it over, competence turns out not to be all or nothing. Someone who's not perfect isn't necessarily incompetent. Second, the characteristics you see as being signs of competence don't necessarily hang together real well. You rate an eight or nine in terms of the quality of your work but a three in being relaxed and not worrying. Finally, there are times, such as when you're at work, when being competent is very important to you and other times, like skeet shooting, when its not very important.

Gary: Yeah, I guess I don't have to be at my peak all the time.

Therapist: What do you think of this idea that if a person's competent they'll be relaxed and if they're tense that means they're not competent?

Gary: I don't know.

Therapist: It certainly seems that if a person's sure they can handle the situation they're likely to be less tense about it. But I don't know about the flip side, the idea that if you're tense, that proves you're incompetent. When you're tense and worried does that make it easier for you to do well or harder for you to do well?

Gary: It makes it a lot harder for me to do well. I have trouble concentrating and keep forgetting things.

Therapist: So if someone does well despite being tense and worried, they're overcoming an obstacle.

Gary: Yeah, they are.

Therapist: Some people would argue that doing well despite having to overcome obstacles shows greater capabilities than doing well when things are easy. What do you think of that idea?

Gary: It makes sense to me.

Therapist: Now, you've been doing a good job at work despite being real tense and worried. Up to this point you've been taking your tenseness as proof that you're really incompetent and have just been getting by because you're real careful. This other way of looking at it would say that being able to do well despite being anxious shows that you really are competent, not that you're incompetent. Which do you think is closer to the truth?

Gary: I guess maybe I'm pretty capable after all, but I still hate being so tense.

Therapist: Of course, and we'll keep working on that, but the key point is that being tense doesn't necessarily mean you're incompetent. Now, another place where you feel tense and think you're incompetent is in social situations. Let's see if you're as incompetent as you feel there.....

Once Gary accepted the idea that his ability to handle stressful situations well despite his stress and anxiety was actually a sign of his capabilities rather than being a sign of incompetence, his sense of self-efficacy increased substantially. Following this increase in self-efficacy, he was substantially less defensive and was more willing to disclose his thoughts and feelings in therapy. He also was more willing to look critically at his beliefs and assumptions and to test new approaches to problem situations. This made it possible to use standard Cognitive techniques with greater effectiveness.

• Formulation and therapy by Paul Salkovskis, 9/15/97
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            • What Therapist Would You Want If You Had A Personality Disorder? by Chuck Giles, Ph.D., 9/20/97
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      • Can Scientist-Practitioners deal with Personality Disorders? by Jim Pretzer, 9/20/97
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