Portrait of a Man Imprisoned in an Altered State of Consciousness: The Case of "Sean"

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.