Pragmatic Case Studies in Psychotherapy

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October 12, 2020 -- From the Editor 


Portrait of a Man Imprisoned in an Altered State of ConsciousnessThe Case of "Sean"

*** Michael Garrett, SUNY Downstate Medical Center, Brooklyn, NY 


*** Louis Sass & Jamie Walkup, Graduate School of Applied and Professional Psychology, Rutgers-New Brunswick, NJ

*** Paul Wachtel, Doctoral Program in Clinical Psychology, City College, NY  

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From the target article abstract by the author, Michael Garrett 

        “This case study describes the first 18 months of weekly psychotherapy with a man suffering from a debilitating chronic psychosis that centers around his conviction that a group of four older men that he refers to as the Council of Four (CoF) operate a machine that can monitor his thoughts to determine if he is having disrespectful thoughts toward them. 

          The patient lives in an altered state of consciousness in which the privacy of mind that people generally take for granted has dissolved.  Every Monday the CoF sends him a Morse-code-like message conveyed by automobile horns.  It is his belief that if he can meet the standards of the CoF they will reward him with a lucrative book deal and movie contract, which will allow him to approach a female movie star of whom he is much enamored.  

           This case study describes a treatment approach that integrates cognitive-behavioral therapy (CBT) and psychodynamic technique, where CBT techniques are used to consider the literal falsity of the CoF idea while a psychodynamic approach is used to examine the figurative truth of the delusion by exploring the meaning of his subjugation to the CoF.” 


          The first commentary, by Louis Sass and Jamie Walkup, explores a number of questions raised by the case, including diagnostic and functional issues, the nature of Garrett’s rich therapeutic relationship with Sean, Sean’s attitudes towards his delusions, and, in some depth and more generally, the phenomenology and related epistemological status of delusions and implications for treatment.  

         The second commentary, by Paul Wachtel, explores additional themes, such as “the boundaries of self and other in subjective experience;” “the cyclical nature of the dynamics that maintain Sean’s guilt and his problematic life patterns;” and “the creative tactics through which Garrett integrates psychodynamic and cognitive-behavioral perspectives in his efforts to help Sean escape from the repetitive pattern in which he is caught.” 

          The issue ends with an extended response to the commentaries by Garrett.     


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1. Case Context and Method
2. The Client
3. Guiding Conception with Research and Clinical Experience Support
4. Assessment of the Client's Problems, Goals, Strengths, and History.
5. Formulation and Treatment Plan
6. Course of Therapy
7. Therapy Monitoring and Use of Feedback Information
8. Concluding Evaluation of the Therapy's Process and Outcome
9. References
10. Tables (optional)
11. Figures (optional)
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Vol 16, No 2 (2020)

Table of Contents

Case Study

Michael Garrett
Louis Sass, Jamie Walkup
Paul L. Wachtel
Michael Garrett