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CASE STUDY
"Father Smith" •  Psychosis

Andrew Martin, Psy.D., is a therapist at Saint Luke Institute.

Fr. Smith is the oldest of three children. He described his childhood as difficult because his life was dominated by his mother's demands. She also relied on him excessively for emotional support, effectively substituting him for his alcoholic father. While he was living at home, his mother was repeatedly treated for depression and anxiety. During these early years, he also suffered from extreme anxiety, which required medication to help him function. His anxiety and the lack of encouragement by his parents to relate to individuals his own age, including his siblings, complicated his ability to make friends with peers and led to a profound sense of loneliness during his childhood and adolescence. It was at this time that Fr. Smith also found himself excessively worrying about some common tasks, e.g., he would return home to make sure that he had locked the front door. As a result of these early experiences, he avoided contact with his peers, did not date, and coped by developing his intellectual gifts and by engaging in fantasy. Later in high school and college, his intellectual gifts provided him with some foundation for a social network, especially through academic clubs.

Fr. Smith continued to experience anxiety and depression in college, in part related to the uncertainty he felt about his future. During college, he also began thinking about priesthood. Although he acknowledged feeling ambivalent about a priestly vocation, he decided to enter seminary directly after college. While in the seminary, he was moderately successful and at times even enjoyed his seminary experience.

During his first assignment, he experienced significant conflict with others, some of which was related to his excessive worrying and his insistence that things (doors/windows) be checked and rechecked. Excessive hand washing, another sign of his persistent anxiety, also began at this time.

Because of his recurring depression, and his increasing inability to function in his parish, Fr. Smith sought help and came for an evaluation. His superiors were concerned not only about his depression but also about recent reports of escalating anxiety and some bizarre behaviors. In the past few months, Fr. Smith often secluded himself in his room in the rectory, rarely emerging except for the few important meetings that were scheduled for him. Co-workers reported that he was not showering regularly and that his clothes were often unkempt and dirty. Although he was often silent during the clinical interviews, Fr. Smith gradually revealed that he believed he was being followed by parishioners who were angry with him and that he frequently heard threatening messages about himself coming from the radio. During the assessment and later in treatment, these paranoid symptoms persisted. Not only was Fr. Smith suspicious of others within the treatment community, he was also suspicious of the clinical staff.

Treatment of Psychosis
As a result of the assessment, it became clear that Fr. Smith was dealing with much more than depression; namely, he was experiencing psychosis. Efforts to assist Fr. Smith were two-fold: first, stabilize him on an appropriate antipsychotic medication, and then attempt to talk with him about his perceptions in the context of his emotional world. Working collaboratively with the consulting psychiatrist, Fr. Smith was prescribed an antipsychotic that helped him to distance from his suspicious and paranoid thoughts, while also easing some of his emotional distress. The medication allowed him to be more receptive and more comfortable in some individual and group psychotherapy settings. With some "wiggle room" between Fr. Smith's thoughts and his conviction about the reality of those thoughts, he was able to begin to question his distorted thinking and understand some of the emotional underpinnings of his perceptions. Through therapy, he also realized that there was a history of psychiatric disorders in his family. This realization helped him to understand the genetic and biological nature of his illness, which lessened the shame he felt about his diagnosis.

In the course of working with Father Smith in therapy, clinicians learned that it was counter productive to confront his paranoid thoughts directly, since this approach usually led to non-cooperation. Rather, the clinical team attempted to connect with him and understand what he might be feeling within his view of the world. This approach allowed him to talk more directly about his anxiety, fear, sadness, and alienation from others, a common experience of the severely mentally ill. As Fr. Smith began to feel safer within the therapeutic context, he also became more receptive to benign explanations of others' behaviors toward him. By the end of treatment, he was able to acknowledge the possibility that at least some of his perceptions might be erroneous. In addition, he was able to distance himself enough from his paranoid thinking, that he experienced a greater degree of choice about whether to focus on the suspicious behavior of others.

With the help of a continuing care therapist, Fr. Smith arranged a network of support, including ongoing psychotherapy, in order to assist him in his long-term recovery after leaving residential treatment. His support network was helped to understand his illness, particularly his need to prevent the most common cause of relapse, a failure to take his medication.

LUKENOTES is a bimonthly publication of Saint Luke Institute.
Permission to use these materials must be requested in writing by contacting
lukenotes@sli.org

SLI EDUCATION DEPARTMENT
Saint Luke Institute
8901 New Hampshire Ave.
Silver Spring, MD 20903
(301) 422-5499 • (301) 422-5519 (fax)

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