Episode 82 Transcript - Psychotherapy for psychosis

Well welcome back to the Mind Dive podcast. We are thrilled today to be joined by Dr. Michael Garrett. I'll share a little bit about him before we hop in. Dr. Garrett is a board-certified psychiatrist who has spent more than 30 years treating and researching schizophrenia and other related psychosis disorders, including how they can be effectively addressed with psychotherapy. He currently is a professor emeritus of clinical psychiatry at Down State Health Sciences University in Brooklyn, New York. He previously served as medical director at North Central Bronx Hospital and Deputy Director of Psychiatry at Bellevue Hospital Medical Center in Manhattan. Much of Dr. Garrett's career has been devoted to the public sector of psychiatry, helping clinicians, patients, and families understand the complexities of schizophrenia and psychosis and navigating the challenges that come with serious mental illness. He's also the co-founder of the Institute of Cognitive Therapy for Psychosis, ICTP, and the author of Psychotherapy for Psychosis, Integrating Cognitive Behavioral and Psychodynamic Treatment. Today we're going to explore psychosis, what schizophrenia is, how Dr. Garrett, you've really been a pioneer in thinking about talk therapy and having that as part of treatment. So welcome. We're so glad to have you with us.

 

Yeah. Thanks so much for being on.

 

And thank you very much for inviting me.

 

Sure, absolutely. So we're going to start how we usually do here… a little bit, you know, about your career. You've had a long career in psychiatry, psychotherapy, psychoanalysis. You know, so just tell us a little bit about what drew you into psychiatry and eventually, towards people experiencing psychosis.

 

I guess in the format of a little movie that has a flashback, I'll start in medical school.

 

Montage, yeah.

 

Then I'll go back to a montage in college. I went to medical school not really knowing, you know, what I wanted to do. And I had the very naive idea in retrospect that I was going to be a surgeon because I'm quite ill-suited for that kind of work. But that was the level of naivety I had at that point. My career was still forming. And  in one of my medical school rotations, one of the psychiatrists interviewed a patient behind a one-way screen, a psychotic man. And the interview was in the aftermath of a suicide attempt that he had made. And the man seemed coherent. He seemed to be able to tell the story, but then there were  a number of delusions and hallucinations that he had. And it just struck me and it really became the focus of my career. How could this man have been born someone's son, a child, and grown up and now be the way he is now? There must be a path, there must be some way to understand that development and evolution. And that really has become, that day, the focus of my work-- trying to understand psychotic experience in terms of analogies to ordinary mental life.  The flashback to college is that I went to college thinking that I was going to be a chemical engineer. And I didn't understand it at the time, but my father had hinted and alluded to the idea that, my father was in the military, but he said that what he really wanted to do was to  work in the chemical industry. So, without knowing it, I was planning to fulfill my father's life and not my own. So, my junior year in college, I had an existential crisis. I realized this is not me. I don't know quite what I want to do, but I don't want to work in chemistry. And I had  a period of  intense anxiety for several days. I mean, diagnostically, you could say, feelings of derealization, depersonalization on the basis of this decision. And in retrospect, I feel it was a brave moment for me where I left that behind. And that also went into my thinking about being a psychiatrist and working with psychotic patients, because  I would say there, but for the grace of God, go I, you know, in the sense I came very near some kind of precipice, but I stepped back and I got my footing and I went ahead. And  I wonder sometimes what would have become of me  if I had  pushed on in a direction that was a false way for me.

 

And this is the dilemma that many  people who become psychotic face when they break down because of some existential problem they can't resolve in another way. So that's how I got into the business.

 

Well, my sense is sometimes in the field that folks who experience psychosis, especially when they're in some sort of active psychotic process, they can feel a bit…this is kind of a hyperbolic way to say it… but almost like discarded in our field is sort of like this is a brain issue. We just need to get you on meds and once the psychosis clears up, then we can think with you. But when this is a thought disorder, it's a disorder of your thinking. We can't think with this person. We can't really get to know them. We can't get to know their mind if they're psychotic. So it is my sense, and again, I don't think this is everyone in all psychiatry, but it's a common trend to be like, we just need to get them stable, then we can talk to them. And my sense is that's not your approach, and that there's a lot that you try to think about with people who are psychotic. Again, you've dedicated your career to this. So this is a broad question, probably one that's too broad to really answer. But I'm curious when you encounter someone who's psychotic, when you meet somebody and they're psychotic, where do you start to try to understand their experience with them before going into what a treatment plan would look like? Where do you start to kind of look around and think with them?

 

I make the assumption viscerally that what the patient  has to tell me means something, that it's not the outcome of a random number generator, and that it's my job as a clinician to try to understand what the patient is trying to communicate in whatever veiled or confused kind of way. So I make the assumption that there is a continuum between psychotic experience and ordinary mental life, and I'm trying to  understand what is the patient's story and how does it relate  to their life experience. So, I think of psychotic symptoms  as an expression of the person's life history and their current state of mind. One of the things that  I think biologically oriented psychiatrists who are  good and devoted people, you know, who want to be helpful to patients, and  thank God we have neuroleptics because they're lifesaving on occasion, but when you aren't trained to work in a certain way, you don't think of doing it. So, we all use the tools that we were  taught to use. And so  teaching psychotherapy in residency training, psychotherapy in any form, varies from program to program, but there are almost no programs that teach psychotherapy for psychosis. So, here's an example: Can I pretend that the two of you are first-year residents for a second? Sure.  I do a series of consultations with a group of first-year residents,

 

 They present the case, and the task  that they have is to present the patient from a transcript of the interview, and we're supposed to figure out what's the simple common human story that's behind the whole psychotic construction. So, here's a consultation. The resident is presenting the case, and  he asks the patient, this is a 35-year-old woman,”Sso what brought you into the hospital?” And the patient said, “I had an argument with my family. They kicked me out.”  “Why was that? You know, what was the argument about?” And the patient said, with no sense of irony,  in a kind of life and death way, “Well, I believe very firmly that every 10-year-old girl deserves a birthday cake. And my family, they do not believe this. And so we got into a big argument,  and they made me leave the house.”  

 

Now, from a purely rational point of view, we know the reason that she's in the hospital is not an argument over a birthday cake. But I think only someone who's willfully insensitive to the meaning of that story would fail to understand. So, who's the little girl in the story she's talking about? It's her. And she's making a complaint about her place in the family, rightly or wrongly. And the picture in the family may be very complicated, but right there, that's the essence of her sorrow. That's the essence of her problem. The clinician then faces the challenge: is there a way to talk about that? Because that's the way she has already organized the problem in her mind. And another, all right, we could talk for hours, so I'll try to talk faster.

 

No, because it's fascinating.

 

 There was a hope 50 years ago that the schizophrenia gene would be found. And now we know there is no schizophrenia gene. There are over 120, probably a thousand genes, that make small contributions to the overall clinical picture. And if you have 120 genes and you do a calculation of the gene-by-gene interactions that could happen in that matrix of genes, it runs into the millions.

 

Ok, I think that’s impossible. That's impossible.

 

Yeah. So the question is the biological knowledge that we have and the psychological knowledge that we have, what is actionable by clinicians? And so far, we don't have much that's actionable  from the genetic side. We do have things that are actionable with diagnosis and the prescription of medication. So  that has immediate benefit to patients. And what clinicians don't realize is that the patient has already done the initial work to organize their sorrow to point the way to what the conversation needs to be about. So that's what I'm looking for when I'm  trying to engage with the patient. What's their simple human life story? What's their sorrow?  And trying to answer the question: What happened to you that led you, you know, to be in this position now? And then once  getting an idea about that, to think about treatment planning.

 

Yeah, I mean, it in a way you've already answered this, but I did want to talk a little bit more and hear a little bit more from you about how you attribute psychological meaning to the symptoms. I mean,  so I'm obviously the older of us two, and I trained in a very different system, a very psychoanalytic system, actually, where a lot of what you said would have been part of what they did back then. There was a lot of attributing meaning to that, but we were kind of burned by some of that. Some of it I think reflected more the creativity of the examiner than it did the actual ability to listen to patients and stuff. And it was all, very, very entertaining sometimes and interesting to hear what people came up with and how they made sort of meaning out of madness, as they would say. But  we didn't always find it helpful at the time. And it seems like you're doing something  more rigorous and very different than what I experienced.

 

 I very much value my own psychoanalytic training, and I would say that  the core of the way I see the world.  And it did seem to me, and this occurred to me about 20 years ago when I started shifting over and feeling I really need to learn a CBT approach because I'm not getting the kind of results that I that I would like to get with patients. So I went back to school. I  connected with some British CBT clinicians and researchers and had the good fortune to join that group. And there was a   a meeting  once a year with Aaron Beck and the preeminent British psychologists who were working on this, and they'd meet in North America one year and then meet somewhere in Europe the other. So, I was the hidden psychoanalyst in that group. I was there to learn and to add something to my  techniques. But I came to  an approach, this is my personal approach, which is outlined in my book, is that a good place to start with patients is not with a psychological interpretation of the meaning of the symptoms. And sometimes that meaning is obvious, you know, within 15 minutes of the interview to somebody who's been psychologically trained. But it's pointless and even sometimes you lose the patient if you move too quickly before the field is even prepared to share that understanding. So I start  by thinking about what is the patient's conscious experience, not what are their unconscious thoughts, but what are their conscious experiences and what kind of sense have they made of them. So I try to meet the patient in their conscious experience of the world. And very typically, and this is central to  really all theories, models of psychosis, psychotic people often have anomalous experiences in with the onset of the psychosis, and then they try to make meaning of those anomalous experiences. And so I listen carefully to what exactly did you hear?

 

 What exactly did you see, how did you think about it? So I first want to understand what one could call the evidentiary chain in the patient's mind. And analysts typically don't do this. They don't focus on the minute logical conclusions because if you feel you've got the heart of the matter and your psychodynamic interpretation, you're just kind of looking at your watch until you deliver, you know, deliver the godsend. No, there's a lot of preliminary work that has to be done. There's also a lot of work that needs to be done with the transference because people  are taught that they're crazy  and devalued, and so one has to convey, which is easy for me to do, it's just comes to me naturally because I really am curious about how this person put their life together. You have to convey an earnestness and genuineness of your interest in the patient, and that can be redeeming for people  who  typically are dismissed, you know, and thought of diagnostically, rather than as  complicated people.

 

 

I'm thinking about so when I was a postdoctoral fellow, you know, I was leading an inpatient psychopsychotherapy group  twice weekly with a psychologist, Lindsay Hogan, who's brilliant. And I remember when I was training, I just kind of thought, I wish the psychotic patients weren't in group. They feel like they say kind of off-the-wall stuff and it feels distracting. And I remember Dr. Hogan really cued me into something that once she helped me to see it, I it was like I couldn't unsee it. And it was so true. Which she said a lot of times they might say things that sound random or tangential, but if you listen for it, they're often picking up on a dynamic in the group that's being unspoken. And these are people who can feel things so they're often feeling things so powerfully at the moment. To give an example of this, we had a group where there were some peers in the group who were  frustrated with each other and they were being very passive aggressive. There's a lot of eye rolling and a lot of like, okay, you know, Bobby, whatever. And this patient was rubbing their head and they were getting more and more stressed. And they just said, “I feel like someone's gonna die. I  feel scared, someone's gonna die.” And of course, everyone was okay, so that's really off the wall. And I remember when Dr. Hogan I talk about it after, she goes I think that patient was picking up on the aggression in the room that wasn't getting spoken to. This person was probably quite painfully absorbing it. And the way it was coming out maybe seemed out of touch, you know. You know, of course, I don't think anybody was gonna die in the group, but there was something really important about what they were saying. And again, we didn't use that as a moment to interpret that to the patient, but we tried to actually, you know, like even with that group moving forward for the next several weeks, we tried to sort of think about like, gosh, sometimes it gets really uncomfortable in here. Like people get really frustrated and it almost feels so intense. So-and-so feels like someone might even die. You know, it was really useful. And so again, I think these moments of moving from this idea of what's coming from a psychotic mind is just nonsense. It's nothing to be thought about until they're stable. It's often really powerfully the opposite. It might be really like again, I don't know what language you might use, like warped, or again, like there's difficulty with reality testing, but the core of it is quite meaningful to the point you were making.

 

Absolutely. And  I mean, you're describing skillful work  with psychotic patients in a group  where there is no individual direct interpretation to the patient, but the patient's talking about their  experience in the room  in a metaphorical way. And in your explanation of what might be said in the group, you know, it's almost like somebody could die, you put it as a metaphor. It's almost like a metaphor is this is like that. And one of the things that happens in psychosis is that the comparison part of the metaphor is lost. So the person says, “This is not like that, this is that.” So it's not that I have a feeling that's reminiscent or reminds me of a dangerous situation. No, the person may feel in  imminent danger of being killed or something horrible happening. So you've got it. I would have little to say to you.

 

I have to say I could deeply imagine that was a Dr. Hogan actual interpretation, but it was, you know, intervention. But I think the thing that I really want to point out, and I think what you're saying is that as a trainee at that moment, I could have easily been like, I just wish a person like that wasn't in group. “They're not ready for group.” I'm putting that in quotes. That's the thing people say a lot. “They're just not ready for group.” It could be seen as distracting to the group. And I think when we can take some moments to think about this, in group setting, in talk therapy in general, I think there's more when you have the eye for it. Because once that shifted in me, every time I had someone psychotic in my group, I was like, oh no, they're actually contributing a lot to the understanding of the process of the room, even if it's coming out in ways that feel again warped, or I can't think of a better word than that right now, but yeah. Maybe I have another thought I'd love to hear from you about is, and II try not to flatter too much on our podcast, though I'm prone to flattery, but you are incredibly humble, even as you're talking about, well, I needed to learn CBT, and I’m trying to understand things. I can hear like the humility in in how you're thinking about this. And even as you're talking about it, my sense from reading your work is you're not somebody who's discounting obviously the biological aspects, the medication treatment, you know, some of these things, you're balancing that with adding and thinking about psychotherapy and meaning making. Again, it sounds like you've really been a pioneer in doing the same for psychosis around inner, you know, putting together CBT with psychodynamic perspectives. And I wonder, I heard you say how maybe at the beginning you use the CBT framework or more of a behavioral framework to think about conscious experience and how you might help them think about that. Where does, if ever, the psychodynamic intervention sort of emerge in the work with a psychotic patient? Is it more conceptual? That's always a tough question, I realize, but yeah, curious where you'll go with that.

 

 It emerged in  two ways. The first is something that, as you know, is universal  to all forms of psychotherapy or  all forms of one human being trying to comfort another. It's the relationship.  It’s not the feeling that one is alone with one's suffering. And when patients feel that their doctor is conceptualizing them only diagnostically and symptomatically,  they don't feel  a sense of deep interest and regard  from the clinician.  And similarly in CBT there are some very empathic CBT clinicians, so I don't want to generalize too much about the approach, but making too strong a contrast, the original CBT work, which has evolved, attempts to show the patient  the cognitive biases that are operating in their assessments of the world. So there's a bit of a hint in the background of  “you're not thinking about this right. You've made a mistake.” And then as CBTers began thinking about core schema, which is basically what analysts talk about, it's the object-related internal world.  They were a little late coming to that idea, but it's part of CBT thinking now.  Then you have the platform for a longer relationship with the patient and there's something that is, in a complicated way, reparative about that. Because a fact that wasn't known 40 years ago is that a family history of  child abuse significantly increases the risk of psychosis. And in the general public, about 15% of people report a history of family abuse and in a psychotic population, the low number is 50%, the high number is almost 90%, that leaves 10%, where if an analyst were to talk to that 10%, you'd find some sorrows in their life that didn't turn up on the childhood trauma questionnaire. So,  trauma is an enormous ethological factor in the inception of psychosis. And so that has led me to evolve in the direction of thinking about psychosis,  typically diagnosed schizophrenia, as a form of  complex PTSD. And I'm not the first person to have this idea, this idea has been around for a while. And where I think biology comes in is that  you can take a similar trauma and you have one person who's resilient to it, they don't become psychotic and they don't become symptomatic. You have another person, they have PTSD, they have flashbacks, and between the flashbacks, they're hypersensitive or they're emotionally numb. That's a different phenotype. You have people with  dissociative identity disorder, where they fracture into different altars that carry different parts of the trauma. So, what I think is going on with psychosis is it's a different phenotype, which is largely determined by the person's biology. And the person's biology facilitates the fracturing of the mind and projective processes  and shapes them into  hallucinatory phenomena and delusional claims, which are fundamentally metaphorical claims, you know, about the world and their life. And I think it's probably a vain wish, but I think it having been established that there is no schizophrenia gene, and with a very strong evidence of the importance of trauma, I think it would be terrific if biological researchers turned their full attention to  the question, and there is research on this: Why do people respond so differently to trauma? And fold into that the idea of psychosis as a phenotype. And then you can understand the effect of medication in that whole picture, that neuroleptics… we don't prescribe those for people who don't have psychotic symptoms but have PTSD.  They may respond to benzodiazepines, it's a different ecosystem in the brain.   But  people may respond to neuroleptics when the phenotype of the trauma picture is hallucinations and delusions and other psychotic symptoms.

 

You know, I mean one thing practically that comes up is the amount of work that it must entail that you're doing with patients, compared to how psychotherapy is generally approached with patients with psychosis. To do the things you do, you have to develop quite a relationship with the patients and a lot of trust along the way.

 

Yes.

 

 Which doesn't always happen  these days, so to speak.

 

The insurance saying, you know,  you get this many sessions, or you know, these sort of problems in terms of the goals and stuff.

 

Can you talk a little bit about some of the barriers to doing good psychotherapy work with psychotic patients?

 

 Yes, thanks for asking that question.  First, let me tell you about a failure.  About 10 years ago when I was full-time at the hospital, I was  working in the outpatient clinic at Kings County Hospital, which is a very big community hospital in Brooklyn.

 

Well known, yeah.

 

Yeah. So myself and another attending there  would have a  PRM consultation group for clinicians who are interested in doing psychological work with patients. And I had the ambition of setting up a psychotherapy for psychosis service there. And I wanted to get broad involvement, you know, from  the community, and  I got the okay from the medical director of psychiatry about it, so okay, you know, let's go over to it. And so I tried to get the psychologists involved, and I had a meeting with the chief of Psychology  and he was  immediately  suspicious of my motives and thought that I was encroaching on his territory. Interesting. It immediately became a slammed door in my face and he had no interest in developing this, and no interest in my even attending any  psychology conference. So the psychotherapy service there didn't get off the ground. I am trying again. So right now at Kings County,  a wonderful  younger psychiatrist, she's an experienced clinician, but she's interested in working with psychotic patients, and  she's trying again.  It’s a new administration, it's new folks, and  I'm helping out with that.  I'm going to be seeing her later today.

 

Love that.

 

Trying to build a psychotherapy for psychosis service. And the public need for psychological work with psychotic patients is enormous, and it's much more than the resources that we have to provide. And at the risk of sounding melodramatic,  I feel a bit like, you know, when I used to be full-time at the hospital, sort of like a battlefield surgeon walking around seeing all these people, you know, who needed care, knowing  that many of them weren't going to get it and then triaging, just trying to get a sense of  who might you be able to work with and where to invest your time. So that's the first question.  I think to develop a psychotherapy service, you can't try to provide this in-depth treatment to everybody. You have to have  a sense of making an assessment of who might really benefit from the  treatment. And that's a whole other discussion. You can do that, you know, in a couple of interviews with a patient, you can get a sense of that. The other thing is that  it's really a moral problem, social problem, financial problem, political problem. And the question is what do we owe our fellow man  and  people who have fallen by the wayside  for whatever reason. At one extreme, social Darwinism would say  it's their fault that they're that way. They're lazy and you know they've been living wrongly, so they deserve their psychotic fate.  the other side  is no, I think part of living and trying to enjoy yourself and family life and have an interesting life, part of it  is to try to do some good and make the make the world an easier place for people who are  less fortunate. So that's no saintly pronouncement. It's just a good way to live, you know. It's good, it's a good way to spend your day. So, we've got to triage in my book,  I didn't think the publisher would take those chapters actually because they were a little maybe too administrative, but I outlined what would be necessary to construct a triage like this where  all the clinicians who  were full-time  would be assigned protected time to work with  two  long-term patients. And the idea would be if you can get started with that, maybe there would be some  momentum. And  we're making a good start at Kings County now with this second time around. And there's a group of residents who are interested in learning, you know, this they're very eager to learn this, when you can  teach them. Some fingers crossed, I'm hoping that this experiment at Kings County then could result in a publication about the implementation of  a psychotherapy for psychosis program in public psychiatry, which is where most of the folks are, you know, who need this kind of care.

 

Maybe this is a silly analogy, but maybe much like how schizophrenia has hundreds of genes and different facets and factors that would go into why it develops. I feel similarly that to develop a world where we attend to severe mental illness differently, there will be hundreds of different factors and people and reasons that that go into that. And it's reminiscent to me. We just a couple months ago had Dr. Linda Michaels on the podcast, who's one of the co-founders of the Psychotherapy Action Network and her work of really trying to educate the public and kind of change policy on making depth-oriented psychotherapy, longer-term, you know, talk therapy more affordable, more accessible to people. And so, I mean, I think that also being accessible to people with psychotic disorders would be huge. And so, again, just many, many voices and people coming together to do this, I think will be the slow incremental change.

 

I guess you were talking about, I mean, to me, one very basic, like bare bones benefit , as I reflect on it, I'm thinking I was actually reflecting thinking back because you're talking about some long-term patients with psychosis I had actually as a resident. So we're going back some. And I remember I used to always kind of constantly question myself, so you'd be meeting with these patients at least weekly, sometimes more. And often that we'd get into debates, like the patients would do well for a bit, and then they question their need for meds, and at some point they decide to go off the meds and they’d disappear for a bit, and then they'd come back, and then we'd kind of continue working. And I remember at some point, because there's some patients who, at certain points of illness would truly distrust me. I'm just someone trying to somehow poison them with these medications and things like that. And I used to always question myself if they really believe all this, how can they come back? Like every week these patients would come and see me. Even if we were debating it and disagreeing about it and stuff and had fundamentally different views of what the goals of this were, somehow they still came. I think obviously the supervisor and stuff like that, is puzzling. I said kind of like, well, because you don't reject them, you sit there, you listen to them, you kind of tolerate their disagreements and you kind of are always there. And so to me, if nothing else, even if your main goals are just to get them to take their meds, if you don't have a relationship with them and a trusting sort of ongoing exploration with them, I don't see how that could happen.

 

Yeah.

 

Yes, and there's a spectrum of patients, as we all know. There's some folks  who do very well  in  what I came to call in my book “ambitious psychotherapy.” And I like that way of saying it because being ambitious doesn't ensure a magical outcome. It's an intent. It's an intent to work hard, it's an intent to have an ambition for the patient, to not write them off.  Some people do very well with that. There are other people  who can't tolerate the closeness and the connection that would be required to do that work.  And then there's a different goal,  where just having  a sympathetic doctor that you see once a month, maybe that's all that can be done, but that's an important thing.

 

Yeah.

 

And  I have a patient that I worked with before  I semi-retired around COVID. So, I haven't been going to the hospital directly for a while, but he continues to call me. And he's a man who believed that  his thoughts were being monitored by a tribunal of four men who were deciding  what he was allowed to do in his life. Classic dilemma in a psychotic form.

 

Yeah.

 

 So  he calls me everyone once in a while and, in a kind of jocular way: “Hey doc, how you doing?” “Oh James, oh good to hear from you. What's up?” “Oh well, you know, it's not good. You know, they still haven't let me off.” “ Oh yeah, you know, oh boy, you've really endured this for a long time.” “Yeah, I know,10 years I've been waiting for them to give me the green light.”  “And so, but you're hanging in there?”  “Yeah, I'm hanging in there.” “And anything else going on in your life? You know, how's your mother? And James, I remember you were betting on sports before, how's that going?” “I've been winning. I've been winning recently.” I said, “Well, I guess you gotta be careful about that.” And then he instructs me, “You know,” he says, “Doc, if you're gonna be a gambler, you gotta know how much you're prepared to lose.”  And good advice. So he has no one else to talk to about this dimension of his life, and those occasional calls, because they're prompted by him, make a difference. So there's a whole range, but it all comes down to the basic thing of relatedness. And  I know who the tribunal is because I worked with him.

 

Sure. Yes.

 

It’s his uncle who was the  enforcer in the in the family. And  so, but  you know, I don't talk to him about that anymore. It's just  you know,  how's it going? You know, yeah.

 

It's so reminiscent to me of I think around psychosis, especially, there can be this huge urgency to get diagnoses right and then to use the diagnosis to move treatment forward, which again, I'm not saying that's not an important aspect, but yeah, like that we can get caught up in the weeds of is this this or is this this? And it's like we sometimes just miss what is this person experiencing and how can we use our whole formulation of them and their life and what we know about them to think about what they need and then place them along a spectrum, think about how much they can tolerate, because again, and I think we think about this well with other disorders. Like I say regularly to patients, I say, I could take four people with major depressive disorder, line them like up against a wall, and their treatments could look vastly different based on what their depression looks like, how it's impacting their life, what kind of treatments are they responding to, what kind of treatments do they need? And I think this is an important set, you know, segue to saying we should be thinking about this for many kinds of disorders, including the psychotic ones.

 

 May I have your permission to make a psychoanalytic interpretation? Oh, please.

 

It would it would be my own.

 

Okay.  we all know that it's a very  common thing to see in a medical chart  a psychotic person is admitted, and the admission note says rule out schizophrenia, rule out schizoaffective, rule out  paranoid personality, rule out psychosis NOS.

 

And I once had a patient tell me, Doc, how many diagnoses do I have in my chart? And so I looked through and I said,” Well, you know, I guess you probably know because you're asking the question. I mean, I'm seeing seven, you know, right here.” He says, “Yeah, seven diagnoses. You know what that means to me, doc? You really don't know what's the matter with me.”  And my interpretation of this is that, as well-meaning as the  psychiatric community is, there's a fantasy. This is the interpretation, there's a fantasy that, if I can just get the diagnosis right, then the situation will be less puzzling. I'll know what to do. And this is an illusion because the rule-out is never resolved. The next time it's the same rule-out, there's no movement forward. And I think personally, I've written my share of scripts, you know, over the years, and I think it probably would be people who disagree with me. And I'm not an expert, really skilled pharmacologist, and I know people who are very good at it in a way that I never reached that level. But for me as a prescribing psychiatrist, one of the most essential decisions, it's a very important one, is this situation primarily affective disorder, where I would want to be thinking about mood stabilizers, or is the central issue here psychosis, where  neuroleptics have to be in the picture, and maybe even some benzos given the amount of anxiety that the patient has. So, I think diagnosis is essential in guiding pharmacology. But as you say, you line up four people with a diagnosis of depression, it doesn't tell you anything about the inner world of those people. And its an illusion, it's an illusion to think if you just get the diagnosis right, then you'll know what to do.

 

Yeah, then it all comes clear.

 

Dr. Garrett, this has been a remarkably useful and thoughtful episode. I'm already so excited to be able to share it with folks. And I'm so grateful for not only what you're sharing with us, but just your work in this field and really, again, I think being a pioneer in thinking about these psychotic illnesses with a different mindset. So thank you so much for joining us.

 

You're very welcome. And  again, I really appreciate your interest  in this point of view. And  I know that you're psychologically oriented, but every little bit of putting the word out helps. So thank you  as brothers and sisters in the cause.

 

Well, thank you.

 

I do also want to remind our listeners who might be interested. The book that Dr. Garrett has been referring to is Psychotherapy for Psychosis, Integrating Cognitive Behavioral and Psychodynamic Treatment. I believe this came out in 2019.

 

Correct.

 

Yeah. So just want people to be aware of that. And so again, you've been listening to Dr. Michael Garrett on the Mind Dive podcast. I'm one of your hosts, Kerry Horrell.

 

And I'm Dr. Bob Boland.