The Case of Gary IV: Conclusion

Less than a month after Gary “terminated” therapy, he called to schedule another appointment. He explained that he was doing well in general but had started worrying about an upcoming vacation which was more adventurous than usual for him. After we spent most of the session addressing his concerns, it became clear that he had been afraid that his increase in worry was an early sign of relapse. After we discussed how to differentiate between normal episodes of anxiety and an impending relapse he seemed much relieved.

We met monthly for four months and focused both on maintaining the gains he had made and on his concerns regarding moving into his own apartment, getting engaged, and handling conflicts with his girlfriend. As he was increasingly comfortable handling problems on his own, we switched to meeting on an “as needed” basis. I didn’t hear from Gary for six months then he resumed therapy as he and his girlfriend were experiencing increasing conflict and he was increasingly ambivalent about their relationship.

As we worked on Gary’s relationship difficulties, it became clear that some of his problems occurred because he had little ability to grasp the other person’s point of view. Work on “empathy induction” was helpful. This involved asking questions which required Gary to anticipate the impact of his actions on others, to consider how he would feel if the roles were reversed, or to infer the thoughts and feelings of the other person from their actions and then to examine the correspondence between his conclusions and the available data. Initially Gary found these types of questions difficult to answer, but as he received feedback from me and from subsequent interactions with the individuals in question, his ability to grasp the other person's perspective increased steadily. As this happened he began to find the actions of others less aggravating and he was more able to deal effectively with interpersonal conflicts. We again switched to meeting “as needed” when things were going well.

At the close of this round of therapy, Gary was noticeably more relaxed than he had been at first and was only bothered by symptoms of stress and anxiety at times when it is common to experience mild symptoms, such as immediately before major examinations. He reported being much more comfortable with friends and colleagues, was socializing more actively, and seemed to feel no particular need to be vigilant. When he and his girlfriend began having difficulties, due in part to her discomfort with the increasing closeness in their relationship, he was able to suspend his initial feelings of rejection and his desire to retaliate long enough to consider her point of view. He then was able to take a major role in resolving their difficulties by communicating his understanding of her concerns ("I know that after all you've been through it's pretty scary when we start talking about marriage"), acknowledging his own fears and doubts ("I get pretty nervous about this too "), and expressing his commitment to their relationship ("I don't want this to tear us apart"). Thus this approach to intervention resulted both in substantial improvement in his presenting problems and in substantial changes in the way in which he related to others.

When I see someone in real-life private practice, I usually don’t have any long-term follow-up data and therefore I usually don’t know how well the improvements persist. However, in Gary’s case, after a break of nearly three years, he resumed therapy after breaking off his relationship with his girlfriend. He had weathered the three years without his paranoid thinking returning and without having significant problems with his IBS. His primary problems when he resumed therapy were ambivalence about ending his relationship with his girlfriend, uncertainty about a career change, and an exacerbation of a problem with compulsive checking which we had addressed early in treatment.

With both Gary’s ambivalence about ending his relationship with his girlfriend due to her excessive drinking and his uncertainty about a career change, therapy consisted primarily of my supporting him and helping him face his conflicting thoughts and feelings. Gary’s compulsive checking had been treated successfully early in treatment but had returned, apparently due to the stress resulting from his relationship problems. Since an “Exposure and Response-Prevention” approach had been effective in the past, we used this approach again. It required some persistence but worked well. At the close of treatment he decided to change jobs and, since this involved his moving to another city, our work together ended for good.

All in all, therapy with Gary involved a total of 31 sessions spread over four and a half years. I know that he sought additional treatment elsewhere three years after he terminated with me, and again five years after that, because I received requests for information from the therapists he consulted; however, I’ve had no further contact with him.

• Understand and Using the Transference by Jessica Broitman:Faculty, 12/13/97