Dr. Garrett's Email:
Mar 20, 2024, 7:12 PM
Andrew needs to successfully engage with the PROS program. In the hope of aiding his success, I have identified what I would consider potential obstacle he will need to overcome to use the PROS program effectively. If this summary is alright, I will sign it and send you a PDF. My schedule is tight tomorrow. I am hoping you both can respond by 11 am tomorrow.
DRAFT psychosocial summary attached:
I am a psychiatrist who conducts psychotherapy with Mr. Andrew Koloski while another psychiatrist (Jeremy Coplan, MD) prescribes medication. I first began seeing him in 2017 and since then, and in the last year, I have seen him 1-3 times a month for 45 minute individual psychotherapy sessions. He carries a psychiatric diagnosis of schizo-affective disorder (F 25.0). I am writing you this note with his permission. He was hospitalized repeatedly in 2011, but did not require admission again until 2023, when he was briefly hospitalized in January and March. Although he is not disabled in terms of activities of daily living, he is quite impaired in social and work relationships. Since becoming ill he has lived with his parents, now in a separate apartment attached to the main family house. He has not been suicidal, and with the exception of occasional outburst of anger at his mother that have not resulted in significant physical harm, he is not a danger to others.
Of central importance to Mr. Koloski’s psychological health, he was a sensitive adolescent who was bullied in middle school. As a result of this abuse, he internalized a mental representation of the world as being full of sadistic persecutors who aim to harm him. Although the bullies of his childhood did in fact take sadistic pleasure in his suffering, these experiences and his subsequent difficulties in interpersonal relationships have left him with a conviction that the world is a dangerous place full of suspicious people who are not who they claim to be. Although to the positive, he has in the last year sustained several social interactions – an art group, appearances in a comedy club, and a few acquaintances - he spends most of his time in his room. He posts descriptions daily of how he believes others are abusing him and lying to him about what they are doing.
The year before last he maintained an intimate relationship with a woman that lasted many months. Although she and he enjoyed each other’s company, the relationship eventually ran its course. He intermittently held the fantasy that she was not in fact the person she purported herself to be. Rather she was someone from his former life or someone connected to a celebrity who was working behind the scenes, and sometimes with malignant intent (e.g., she planned to give him HIV and intentionally “gas lit” him to make him fear HIV). Instead of facing the anxieties he feels when he tries to remain engaged with the real world, he tends to blame others for making him feel anxious rather than acknowledging that he himself is the source of the anxiety he feels. He also tends to imagine that instead of doing the hard work of recovery and pressing ahead in the real world with real people, he will be rescued by a celebrity or it will be revealed that he is the biological son of a wealthy man who will make good on his birthright by providing him with money. My efforts, the effort of his psychopharmacologist, and his mother, have been to try to help Mr. Koloski more independence in the real world. I think the PROS program would be an excellent resource for Mr. Koloski.
Of central importance to Mr. Koloski’s psychological health, he was a sensitive adolescent who was bullied in middle school. As a result of this abuse, he internalized a mental representation of the world as being full of sadistic persecutors who aim to harm him. Although the bullies of his childhood did in fact take sadistic pleasure in his suffering, these experiences and his subsequent difficulties in interpersonal relationships have left him with a conviction that the world is a dangerous place full of suspicious people who are not who they claim to be. Although to the positive, he has in the last year sustained several social interactions – an art group, appearances in a comedy club, and a few acquaintances - he spends most of his time in his room. He posts descriptions daily of how he believes others are abusing him and lying to him about what they are doing.
The year before last he maintained an intimate relationship with a woman that lasted many months. Although she and he enjoyed each other’s company, the relationship eventually ran its course. He intermittently held the fantasy that she was not in fact the person she purported herself to be. Rather she was someone from his former life or someone connected to a celebrity who was working behind the scenes, and sometimes with malignant intent (e.g., she planned to give him HIV and intentionally “gas lit” him to make him fear HIV). Instead of facing the anxieties he feels when he tries to remain engaged with the real world, he tends to blame others for making him feel anxious rather than acknowledging that he himself is the source of the anxiety he feels. He also tends to imagine that instead of doing the hard work of recovery and pressing ahead in the real world with real people, he will be rescued by a celebrity or it will be revealed that he is the biological son of a wealthy man who will make good on his birthright by providing him with money. My efforts, the effort of his psychopharmacologist, and his mother, have been to try to help Mr. Koloski more independence in the real world. I think the PROS program would be an excellent resource for Mr. Koloski.
As a result of psychotherapy, Mr. Koloski has gained considerable insight into what we have come to call his “daydream world,” but the insight is intermittent. He flips back and forth between regarding himself as being delusional as a result of a “tsunami of emotion” to re-affirming his conviction that his mother is a sadist who is the bane of his existence, that his parents and others are “gas lighting” him. He is preoccupied in his emails with demands that his parents “confess” to what they are doing, which never happens because his parents are not engaged in the clandestine plots he imagines. Although when he takes medication as prescribed, he is less adamant in his accusations against his family and quicker to recover from persecutory “daydreams,” for the last year he has not regularly adhered to his medication regimen. At times he has assured his mother and his providers that he is taking his medication, only to reveal later that he was not telling the truth. When he is on medication, the psychotherapy achieves some traction. Off medication, the psychotherapy work has modest impact at best. Because Mr. Koloski sees no intrinsic benefit to himself from taking medication (he takes it because he fears if he doesn’t his mother will have him hospitalized) and because he has in the past not been truthful about stopping the medication, his actions have proven that the only reliable way to deliver medication is by depot injection.
Despite his wish to live in a “daydream” world Mr. Koloski has real strengths. He has an excellent sense of humor evidenced by several comedy club appearances he has made. He shows talent in art. There is an endearing quality about him despite his tendence to accuse those who are trying to help him. He is highly intelligent. Although his clinical history does not give reason for concern about his being a danger to self or others, his intelligence can at times undermine his commitment to recovery. He tends to consider himself “high functioning” in relationship to other attendees in psychiatric programs. This air of superiority leads him to keep his distance rather than fully engage in the rehabilitation programs he has been offered.
I think it important that I be frank about clinical issues that may have some bearing on Mr. Koloski’s progress in treatment. 1) he has a tendency to imagine he will achieve something by waiting to be rescued by a celebrity rather than doing the hard work of personal recovery; 2) he is inclined to consider himself as too high functioning for rehab programs, which may limit the depth of his commitment treatment; and, 3) he is inclined to stop taking medication, which intensifies his investment in his “daydream” world.
Despite the challenges, having worked with Mr. Koloski for many years, I believe that if he can invest more in the real world and less in his “daydream” world of innuendo and suspicion, he has enough inherent strength to make substantial progress toward independence. I think he is in need of what PROS can offer.
My Email:
Mar 20, 2024, 7:32 PM
It looks good to me, thanks Dr. Garrett.
Dr. Garrett's Email:
| Mar 20, 2024, 7:39 PM |
OK Your mother though it was OK also. I will send a final PDF in the morning.
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