Phenomenological, Epistemological, and Integrative Perspectives on the Case of "Sean"
Keywords:psychotherapy for schizophrenia, psychosis, delusion, therapeutic alliance, case study, clinical case study
This article presents my response to commentaries on my case of "Sean" (Garrett, 2020) by Louis Sass and Jamie Walkup (2020), and by Paul Wachtel (2020). In my response to the Sass and Walkup commentary, I underscore what I consider their very astute observation that Sean seems to be aware that he himself can place Megan in a mental space where he relates to her, in which case she is an object of his subjectivity closely allied with his imagination, while he does not have the same experience of placing the CoF in an imagined scene because they are expressions of his own subjectivity rather than being objects of his subjectivity. Elsewhere in their commentary Sass and Walkup argue that delusions are not simply mistaken "truth statements" about the world (a view I share), which they believe might not be expected to respond to CBT techniques that examine beliefs. However, I think their emphasis of this point may have led them to a less than fully accurate account of my approach to and use of CBT, which I attempt to correct in my response. I also show why I believe some the Sean’s awareness of his situation was a hard-won result of his treatment rather than a precursor to his psychotherapy. And I respond to their speculation that Sean might more properly be diagnosed as having a delusional disorder, a sentiment I do not share. I also question the validity of the diagnosis of schizophrenia and say why I prefer the more open-ended descriptor "psychosis."
Wachtel's commentary reflects the observations of an experienced clinician thinking about psychotherapy process. He understands what I am trying to do, and at times articulates the clinical process with Sean with greater clarity and in a wider context than would occur to me in my own words. His observations allow me to expand upon several points here. Specifically, (a) I acknowledge the lack of more information about Sean’s family as an important limitation in the therapy; (b) I expand my description of the way in which I try to listen to patients and conduct psychotherapy; (c) I underscore Wachtel's observation that the primary conflict that appears in psychotic symptoms may be Oedipal (although this is not always so); (d) I agree with and elaborate Wachtel’s idea that the past is not discovered in psychotherapy like a "woolly mammoth" unearthed in frozen tundra, but rather the past speaks through a living host that shapes its voice; and (e) I describe in more detail how the therapy process allowed me to over time to find a common language in the phrases "guilt loop" and "guilt work" in a way that advanced the therapy.
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