As Gary was more able to see himself as capable and competent, and as we continued working to improve his ability to cope with stress, his concerns about coping with grad school and his IBS became less of a problem. However, his distrust of others and his expectation that others would be jealous, hostile, resentful, and malicious was a major source of stress and contributed to a variety of interpersonal problems.
We focused first on getting his view of others clearly spelled out clearly (i.e. Every little thing you say is used to attack you.) Once this was done, we could frame his views as predictions about how others would act and then test whether the predictions were accurate or not. Was it actually true that everything he said was used to attack him or was this not true? Gary initially was certain that his view was accurate but when we chose several specific interactions at work and reviewed them, Gary was surprised to discover that most of the things he said were not used to attack him and that most of his co-workers showed little maliciousness or hostility towards him. Actually several co-workers were kind or generous towards him.
We ran out of time at that point so I proposed to Gary that he observe how people responded to him during the week and tally the number of times people seemed malevolent towards him and the number of times they were benevolent. At the beginning of the next session, he reported that he was surprised todiscover that most of the people he dealt with during the week were neither malevolent nor benevelent. They were indifferent! He also found that the times when people were benevolent clearly outnumbered the times when people were malevolent.
As Gary continued to pay attention to the actual behavior of the people he interacted with rather than automatically responding on the basis of his preconceptions, he came to the conclusion that most members of his immediate family were malicious and deceptive but that the world at large was much less malevolent than he had assumed. He had been living his life as though people in general were going to treat him the way his parents and siblings did.
These cognitive interventions did not automatically result in changes in his interperonal behavior. Instead we needed to work explicitly on handling interpersonal conflict more effectively. This required focusing on specific problem situations as they arose and identifying and addressing the cognitions which blocked appropriate assertion. These included, "It won't do any good.", "They'll just get mad.", and "If they know what I want, they'll use that against me." It was also necessary to work to improve Gary's skills in assertion and clear communication through assertion training. When this resulted in improvements in his relationships with colleagues and in his relationship with his girlfriend, it was fairly easy to use guided discovery to help him recognize the ways in which his previous interaction style was counter productive.
Therapist: So it sounds like speaking up for yourself directly has been working out pretty well. How do the other people seem to feel about it?
Gary: Pretty good I guess. Sue and I have been getting along fine and things have been less tense at work.
Therapist: That's interesting. I remember that one of your concerns was that people might get mad if you spoke up for yourself. It sounds as though it might be helping things go better instead.
Gary: Well, I've had a few run-ins but they've blown over pretty quickly.
Therapist: That's a change from the way things used to be right there. Before, if you had a run-in with somebody it would bug you for a long time. Do you have any idea what's made the difference?
Gary: Not really. It just doesn't seem to stay on my mind as long.
Therapist: Could you fill me in on one of the run-ins you had this week?
[discussed a disagreement with his boss in detail]
Therapist: It sounds like two things were different from the old way of handling this sort of situation, you stuck with the discussion rather than leaving angry and you let him know what was bugging you. Do you think that had anything to do with it blowing over more quickly than usual?
Gary: It might.
Therapist: It works that way for a lot of people. If it turns out to work that way for you that would be another payoff to speaking up directly. If they go along with what you want there's no problem and if they don't, at least it blows over more quickly. Do you remember how you used to feel after leaving a disagreement unresolved?.
Gary: I'd think about it for days. I'd be tense and jumpy and little things would bug me a lot.
Therapist: How do you think it was for the people at work?
Gary: They'd be pretty tense and jumpy too. Nobody'd want to talk to each other for a while.
Therapist: That makes it sound like it would be easy for a little mistake or misunderstanding to set off another disagreement.
Gary: I think you're right.
Therapist: You know, it seems pretty reasonable for a person to assume that the way to have as little conflict and tension as possible is to avoid speaking up about things that bug him and to try not to let his aggravation show but it doesn't seem to work that way for you. So far it sounds like when you speak up about things that bug you, there are fewer conflicts and and the conflicts that happen blow over more quickly.
Therapist: Do you think that your attempts to keep from aggravating people may have actually made things more tense?
Gary: It sounds like it.
For several sessions we continued to work on assertion, on handling anger more appropriately, on coping with anxiety, and on his relationship with his girlfriend and Gary reported steady improvement. His IBS was not being much of a problem, he was handling conflicts without either submitting to mistreatment or becoming agressive, and he reported that he was feeling generally happy. He was able to tell his parents that he was planning to change his name (ostensibly to avoid the prejudice which resulted from having a clearly ethnic name). When his father reacted with intense anger and threatened to disinherit him, Gary was able to stand his ground without getting into a fight.
Gary expressed satisfaction with what we had accomplished and proposed that he terminate therapy. We reviewed the extent to which he had achieved his goals for therapy and what he would need to do to maintain his progress. I agreed to terminate therapy with the option of his resuming therapy in the future if he wished to. (This is not the last of Gary)