Thanks for the reply, Jim. My previous post suggested that the interventions you began were problematic precisely because you did NOT have a formulation. I don't think that the patient was hiding things; it seems more likely that they were not investigated. I agree with the point you make about responsive formulation; this is, of course, the basis of functional analysis (c.f. Kanfer and Saslow). However, I repeat my earlier suggestion that CBT does not involve a superficial grab at a few problems followd by teaching relaxation; this can really distract from a proper formulation.The next question is; is the diagnosis of "paranoid personality disorder" useful, and does it contribute to the formulation. I was trained at a time when wise psychologists like Monte Shapiro and Jack Rachman suggested that the diagnosis of personality disorder was something made when the therapist did not like or agree with the patient, and was another way of blaming and disempowering the victim. I have been dismayed at the wholesale adoption of the personality disorder concept by otherwise sensible psychologists and psychiatrists with its reification in DSM IV. It can undermine normalising influences and disempower clients. It can also allow professional to distance themselves from the client; rather like in the emergency room when the doctor says "Oh, just another DOA, nothing important". I'm afraid to say that I've heard and seen many clinicians suggest that therapy hadn't worked because the patient was just another hopeless borderline. Usually, this happens when therapy has not been effective, and allows the therapist to discount their failures. I'm glad you have not shared your diagnosis with Gary; I believe that it would be harmful to suggest to him that he has a disordered personality. Why not instead consider his evidence for his beliefs? Maybe he is correct in some of them, and then making arbitrary inferences based on the correct ones? That kind of thing is a key part of the formulation in my book. Now consider the scientific basis for (i) the concept of paranoid personality disorder and (ii) CBT for the treatment of paranoid personality disorder. What do you get? (i) zilch (ii) zilch.
The developments which have occurred in this case are no surprise. The surprise lies in what you will do next. Good luck!