Psychiatry & Psychotherapy Podcast - Connecting with the Psychotic Patient, Therapeutic Alliance Part 7

Episode Date: January 11, 2020

In this episode, Dr. Puder talks about the importance of therapeutic alliance in the psychiatric interview, emphasizing the need for a strong therapeutic alliance in order to help patients with psychosis continue their medication.   By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast? Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is email to you in seconds.

All right, welcome back to the podcast. I am going to do an episode today on how. how to connect with a patient with a psychotic illness like schizophrenia, schizophrenia, schizoaffective disorder. And before we start, I would also like to thank you for all the kind words that I've gotten over the break. People have sent me nice DMs, emails, and I appreciate that. I am on Instagram at d.r. david pewter, and I'm most recently on TikTok and been posting

some really funny, goofy videos. It's DR.D.D.D. David Puter there as well. So join me there. Laugh with me. Have some fun. And this episode is one of my favorites, actually, for first year residents because they're often in the thick of it with the most psychotic patients in the ER and in the inpatient setting. That's where the most psychotic patients are.

And the work of building a therapeutic alliance with these clients is crucial. We know from the KD trial that 74% of patients discontinued their medications before 18 months. 74%. So three out of four patients enrolled in a study nonetheless, where you have good supervision, you're watching these people. In a subsequent study, they looked at the Kiti study. They also looked at a U-Fest study. By the way, these are huge studies.

Both of these studies together had about 2,000 patients in total. And they looked at compliance and what led to better compliance. And what they found in this specific study was that substance use, higher hostility and impaired insight led to poor compliance. So substance use, hostility, impaired insight. And they conclude that the clinical implications of the results point to the importance of routine assessments and interventions to address patients' insight and comorbid substance

use and the establishment of a therapeutic alliance. So further studies have shown that poor compliance is related to side effects and patients not quite knowing how to best deal with side effects or what these side effects are and then they go all bad on the medications. Also there have been studies showing that course cognitive functioning leads to more issues with compliance. And all of this kind of points back to how we talk to patients about the medications they're on, their diagnosis, help them gain insight and their family gain insight into what is going

on. And these are all things that start in a psychiatric hospital usually because that's where people with severe psychosis end up usually. And it follows in the outpatient setting. So both stages are so important. And I would also say that every little bit that you can provide education, help the family understand what's going on, is going to be all important for the long-term trajectory. There's another study where they looked at, you know, what are the key principles that we can actually do to improve treatment adherence in patients with schizophrenia. Remember, in one of the greatest, biggest studies ever done, 75% did not adhere with the treatment. So what are the things that we could do? This study says there's six things.

Number one, we can recognize that most patients with schizophrenia are at risk of partial or non-adherence. Number two, the benefit of a good therapeutic alliance. Number three, tailored treatment plans that meet the individual's need, including the most suitable route of delivery of antipsychotic medication. Number four, involving family or key persons in the care and psychoeducation of the patient. assuming the patient agrees with this. And then number five, ensuing optimal effectiveness of care, and six, ensuing continuity in the care of the patient's with schizophrenia. And this was a KANAS 2013 article, which is very nice.

The article further goes through this principle two, which is the establishment of the therapeutic alliance. And they emphasize that there's a non-judgmental attitude and specifically a non-judgmental attitude around discussing adherence difficulties. I think we should almost expect that adherence is going to be an issue with these patients. We shouldn't be surprised.

We shouldn't be judgmental of it. We should have them put words to it, have them tell us their frustrations, listen to those frustrations. And see the frustrations as like, they feel like at some points the medication is an obstacle towards their goals of wellness. and so we need to listen to why they feel it's an obstacle and sometimes use really good

psychopharmacological practices to reduce the side effects they may experience or help them overcome side effects or understand what's going on, right? So there's a lot of studies that have linked poor therapeutic alliance to medication non-adherence. And that is well documented. and it's not something I want to belabor. It's the why this episode is important, I guess. But in this prior study, they really looked at the insight

as being one of the key sort of things with a non-inherence, insight. So insight is something that's difficult. In a person with schizophrenia, in a psychotic illness, they lose their insight. They lose their insight on what is real and not real. and so we know that people with more severe disease will have lower insight and more difficulty with adherence okay we know that but we also know that strengthening the therapeutic alliance

may also help improve the patient's insight into the disease and there's a study that looked at that so we want to have this like non-blame non-judgmental environment for the patient to connect with another human being in the worst of worst situations that they probably have gone through, right, a psychotic episode. We want to listen to the patient, we want to listen to the family, we want to understand that there's going to be high emotionality in the family usually. It's hard not to have someone's psychotic in their household. It takes time to build trust, and so we shouldn't expect them to trust us right away.

It takes time to build respect. and so, you know, understanding the pathophysiology of both the diseases and the treatment, I think, can help build the respect. And then also getting the family members to a level of understanding before even the patient can understand is so important because then the family members can really champion the treatment. And I could tell you stories of that. I mean, the most successful cases that I've had, the families have been involved in a helpful way. And the families have brought the patient to the visits. The families have taken their patients to get weekly blood draws for clozapine. So what are the other things that help with the Therapeutic Alliance?

Things that we've already talked about. Actually, every single Therapeutic Alliance episode kind of builds up to this episode. So empathy is well known to improve therapeutic clients. Other things with this population uniquely, maybe, or not so uniquely. Well-scheduled appointments, you know, appointments that are scheduled with little waiting time as possible, sufficient time for the patients to express their attitudes, uncertainties, concerns. And there's something about a patient with active schizophrenia, a waiting in a wait room, waiting room, which is very distressing to them. I've talked to one homeless

person in particular who said he would go into these walking clinics and he would have to wait for three to four hours to see a psychiatrist. And he said that after about 40 minutes or so, he was so agitated by what was going on in the wait room and all of the things that go along with, you know, waiting, that he would just get up and leave. So we shouldn't be surprised that, you know, having certainty that appointments are going to start on time is huge for this population. And other things that we can do are to allow the patient to be part of the decision-making process. Now, understandably, when someone's asking,

at an extreme psychotic level, like there may be a time that we're giving medications against their desires. But as treatment progresses, there are options in treatment. You know, there are different medications which cause different side effects. There is a process of allowing the patient

to make decisions in their care, which I think is really important. And also educating them on what the side effects are, and then what to expect. There's something about the unexpected, which is very frightening. So the question, of course, is how do we get to a place in our mind where we don't have any judgment

of their psychotic and troubling thoughts, you know, their paranoid thoughts? When you're with a patient like this, if you feel a little fear, maybe you're feeling their fear. You know, I've talked about mere neurons, how our brain lights up in similar ways to patients. And you may actually have that sort of lighting up in the way that the psychotic person's brain is lighting up.

Just a little bit, just enough to make you fearful or suspicious. Okay. So, of course, we're most comfortable with people like ourselves. we are not inclined to desire to attune to things like depression, aggression, aggression, hostility, paranoia. But patients are more like us when we really consider all of our humanness. We've all had dreams that are psychotic. We've all had times where we wake up in the middle of the night

where maybe our frontal lobe isn't fully lit up and we're a little bit more paranoid. you know, like the taxes are going to get me, or maybe I'll get caught for this or that, or, you know, it's like the anxiety leaks through. We have to learn how to therefore see the patient as not that much different than ourselves, and they may have strange or frightening symptoms. You know, for example, I've had patients who are stomping the shower to try to kill scorpions or feel like everyone's watching them like in a Truman show. So some of their symptoms may be strange or fascinating,

but maybe we can look at them in different ways that allow us to be more curious than frightened. Maybe if we feel our own sort of mere neuron experience of frightenedness, fear, we can just even by noticing that that might be coming from their experience, that creates a little bit of a cognitive distance between our experience of it and the rest of our brain and how the rest of the brain is catabolizing that fear that we're experiencing from them. So it can give us an idea on actually what they might be struggling with. And so just like any other pathway that that sort of affective empathy leads us to,

right so for example if someone's feeling sadness we feel some of that sadness and then we're able to empathize with them in the same way when we feel that fear that paranoia that aggression maybe or that mostly it's the paranoia it's it's like a it's like an unsettledness or fear like i'm gonna crawl out of my skin that sort of fear we can we can start to think about we're feeling that because that's we're feeling maybe 10 15% of their experience The problem is that usually when we feel someone's stuff, then we put our own narratives to it. So we get paranoid about them, right? Or something about them.

That's what kind of our brain goes to. So the trick is to start to notice that we feel this way, and then instead of putting that our own narratives on it, we start to use it as a way of understanding, as a way of empathizing with their distress. So most patients want you to know what is going on inside of them. Most patients want you to accept them. I would say the shame meter for schizophrenia is still very high. Most of them will not tell you the stories of their psychosis because of the extreme amounts of shame.

They want to protect their image just as much as anyone else. also they may actually have fear about you being a part of the fear that they're feeling right so sometimes I'll ask them like if a patient and impatient says you know I'm I fear that people were chasing me I'll say hey do you feel like anyone here is chasing you like anyone in a psychiatric hospital oh no just the people on the outside okay that's that's good okay well if you ever feel that with me and you want me to leave, just let me know. So I try to take that fear that they might have and empower them with the power to do something. Kick me out of their room. What are the patient's expectations of the interview and of the treatment? What are their wishes,

aspirations, and fears? Do they wish for someone to take it away? Do they fear you are somehow part of the world that's against them, right? So some paranoia is that, you know, everyone in the world is out to get me. And someone with a personality disorder might have certain thoughts like that, but they don't believe it 100%. And so someone who's in a sort of a psychotic episode,

they really believe that to be true. They really, there's no doubt that they have. With some treatment, the doubt starts to become stronger and stronger. So things that you can do, you can avoid being hurried. If you have hurried anxiety, they can feel that. Now that's hard early on in training. It's hard not to feel hurried, especially if you are hurried. You have lots of patience to see.

But it's best if you in your mind say, okay, this is my amount of time with this patient. so during this time I don't need to be hurried. Calm inquiry helps. So it really does help to calm our own body, to bring calmness to our mind, to relax ourself when we're talking to them. I've experienced this with a very anxious person if I become aware that I'm starting to feel their tension,

if I can calm myself. It's that calmness that then they feel from you. that is calming to them as well. Okay. You have to imagine that most people who are psychotic freak people out that they come into contact with or they make people feel very uncomfortable. Most people who have been psychotic for a while

do not have any relationships. Maybe one family member, maybe a couple family members, but very rarely will they have a large social life. So being calm yourself is very, very powerful to helping this group of people. Sometimes you want to check in with them. Do you feel more or less agitated while I'm here with you?

I would like to help you feel safe and secure. Is there any way that I can do that more? Is it more helpful if I leave the door open? Or is it more helpful if I shut the door? Thinking like an outpatient clinic, inpatient you probably want to keep the door open. Is there anything I can do to put you IDs or help you? One other thing I'm going to mention here is that

schizophrenic patients are not any more violent than the general population. Early first break, there's a slight increase in the rate of violence, but in general, schizophrenic patients are no more violent than you or me. Actually, 95% of violent acts are committed by people with not mental illness. Remember that. So if a person does look violent, obviously keep the safeguards of having some boundaries, you know, having security at hand. You know, there are inpatient settings where that occurs.

But in general, these patients are not more violent. So that can help us put us at ease a little bit. Okay, so this population has a strong sensitivity to rejection, meaning they have sensitivity to steam maintenance, or that they will easily feel if you are looking down on them, think that they are crazy, think that they are less than, think that they're not a person, not someone in need of connection. And on that point, this strong sense,

sensitivity to rejection is often, it also shows a deep yearning for connection, right? We all want connection. We all desire to be heard, to be understood, to be empathized with. And this population is no different. And so to listen attentively, respectfully, seeing meaningfulness in everything about the patient is important. and meaningfulness in some of their fears, right? So there's both a desire to be seen as valuable. So a lot of the delusions are around them having a position of power.

You know, maybe there's also a desire in us for attention. And so there's often a lot of delusions around, situations where they're getting either positive or negative attention. If someone, for example, let me give an example, this might make it more meaningful to you as my listener. If someone had a delusion that everyone in the world was watching them, let's say everyone in the world was critically watching them, okay, there would be at the same time a lot of large importance in everyone observing them.

But everyone being critical at them would be negative attention. So there's both the desire for attention, but then there's a twist that it's all negative. Interestingly, I think some narcissists don't mind if they get negative attention. And they actually thrive off of it. That's a side note. it's different though with this population. Obviously, it's very frightening, very scary. There's paranoia that comes with it.

But at the same time, it would be nice for people to actually pay attention. And so with you, paying attention is probably one of the first steps. You know, paying attention, listening. I like to read micro-expressions. and so reading the different expressions of anger or disgust or fear and then attuning to those individual moments of that, very, very powerful in building therapeutic alliance. Can you diminish their fears that you will reject them?

This takes time sometimes, you're not rejecting them. I've had patients who, it's after a year or two, they tell me the experience. extent of their delusions. And I try to meet it with gratitude that they would feel comfortable sharing it with me. I try to meet it with curiosity, but not I'm just being curious of them, like in a sort of I'm looking through a microscope type of attitude, but more like, hey, let's look at what this might mean, you know, that these are some of your thoughts or, but, but.

But also leading with empathy, of course, that would be very distressing to have these thoughts. Were these thoughts distressing to have? Was there a part of this that was more distressing than another part? You know, of course, that would be incredibly scary to have these thoughts. And I'm wondering if you had any fears about sharing this with me. Yeah, you know, I feared that you would think I was crazy. Yeah, that would be scary.

And if I were to think you were crazy, then what? well, then you might reject me. Well, that would be very scary to think that I might reject you. So we want to, if possible, diminish the fears of rejection that they might experience, enhance their feelings of worthwhileness. They're entitled to their emotions. So whether the emotion is anger, fear, or sadness, or disgust, they're entitled to their emotions.

That's one of my basic sort of fundamental. thoughts on how to build a therapeutic alliance. You know, it's okay to have emotions, desires. It's okay to put that to words. Okay, I might say something like that. And even if they feel strong, those are the ones that we want to put to words. I'll remember a patient that I had during my residency. I was still in a point in my journey where I was suspicious that this guy really had a psychotic

illness. You know, he had a diagnosis of schizoaffective. But I was thinking, is this just personality disorders? It's just like borderline personality disorder. And so I took him off slowly, some of his medications specifically. He was on an antipsychotic lithium. And he was doing okay for a couple months. I was seeing him weekly. So I was going to find out what happened. And then he started getting really angry. And I really have a very strong imprint on just how angry he got. He he got so angry that he heard a family member. And then he subsequently, when he came in, he was just yelling at me that I wasn't understanding that something was wrong with his brain. And I was like, oh my gosh, this guy is, he is manic. And he really needs these medications.

And from this experience and many others, I've learned the power and the necessity of medications at times. And also the suspiciousness of medications, because I myself went into this field with a healthy, I think, degree of suspiciousness. So when patients are suspicious or family members are suspicious, I sometimes think to myself about the early times when I was suspicious. and I can empathize with their thoughts, you know, that this might in some way hurt them or this might in some way not be beneficial to them. So they're entitled to their emotions, they're entitled to their concerns,

and the empathic posture is healing in and of itself. So we can acknowledge their entitlement to ambivalent feelings we can acknowledge their entitlement to be their upsetness at being held against their will. One of my other thoughts is like, okay, this journey through mental health is a bumpy road. I cannot imagine having a psychotic illness being put in a mental hospital against my will,

being brought in front of a court, put on medications against my will. Strap down at times, I mean, I don't think it happens like it does in the movies. Like at least in my hospital, we very rarely put someone in restraints, maybe like once a year in the adult side. But can you imagine having had some of these events?

I think they're like traumas. They can feel in a psychotic episode like a life or death situation, right? So the care itself can become a trauma, unfortunately. And so as we listen to their stories, listen in an empathic way and that could be healing to them. Okay. So it's like we're doing the best we can. At least I would hope that 99.9% of psychiatrists are doing the best they can.

I think that and other mental health professionals in the team. But there's times when bad things happen and unfortunate things happen and people are psychotic to the degree that we need to, in a loving way, start them on medications against their will, and sometimes being forced into something, if you believe that you're being forced to take poison, it could feel like a life for death situation. So one of the things that I've found in building the therapeutic alliance

is listening to their stories and empathizing with their distress, even if the distress is caused by the mental health field. And it's also interesting to note that I know a lot of the doctors who are treating these people, some of which they have strong feelings about it. I had no way take this as like an insult against the doctor. Actually, having worked with many of the doctors who are inpatient doctors in the area, I feel very competent that they were doing what they needed to do at that time

and the person treatment. What I'm saying, though, is that I'm listening from their perspective and empathizing with the emotions. If I can give a little bit of meaning on what might have been going on, that can also help. If they can understand the system and how the system works and how the system is trying to help as many people

live the most, you know, the lives that will give them the most satisfaction, long term. Okay, so we want to focus on the emotions, focus on the here and now, and the current emotions, the present emotions in the moment. So if a patient's telling me a story

of something that happened in the past and they're feeling an emotion. That's the emotion that I want to empathize with, not the emotion that they were feeling in the past that they're telling me about. So a good example of this is sometimes I'll have a patient who's a little bit more histrionic or something,

not a psychotic patient, not a schizophrenic patient, but they'll be telling me a story of something that was a pretty bad thing that happened to them, but they'll be telling me with a right-sided smile or a left-sided smile. It's like the one-sided smile of pride. So the emotion is not trauma or sadness.

The emotion is they're proud about something. So if their emotion is pride, then I'm going to empathize with that. So what about their story are they feeling proud about? Maybe it is overcoming. So that's what I'm going to say. I'm going to say, I imagine you're fairly proud about overcoming this. And although some are telling me this, story or have told this story in the past to elicit emotions, maybe attention, they are kind of

struck by, yeah, I guess I am kind of proud about overcoming this. They're struck by the accuracy of the empathy for the moment-to-moment emotion that they're actually experiencing. So all this to say is that patients in their journey through mental health are going to experience something that might be like a trauma and in the process of that in the later therapy that we're doing as we're helping build a therapy alliance we're going to be listening to those things one thing about psychosis is there's like a disorganized thought process traditionally this was thought to be like there's a blurred ego boundaries basically what that means is where I start and others begin as well as, you know, where my internal world is and external world is, there's a blurring

of those things. Okay. In the midst of doing this work, there may be defenses that come up. So one of the defenses is a bias towards external attribution of thoughts and internal events. So there may be external attribution of their thoughts and internal events. of their thoughts and internal events onto other people. So other people are thinking these thoughts that they're thinking, they aren't thinking

these thoughts. Okay. So hallucinations and delusions are creations with significant emotional and idiosyncratic meaning to the patient. So have the patient state their story first and attuned to the point

of view that the patient has. Okay. So delusions can embody core wishes and concerns. And in a similar way to dreams, they can be a royal road to understanding the unconscious or what's going on inside of them. Delusions are a fixed belief system that are clung to despite evidence to the contrary.

And actually if you, usually if you poke at them and poke at their delusion, they will actually just believe the delusion even more. So approach the delusion with curiosity about the content of the delusion and their larger meanings to the patient. Okay. So ask questions concerning the details of the delusion as though the delusion were real.

So that's how we were, tell me, we're not co-authoring or co-opting the delusion, but we want to hear it. Okay. We want genuine interest into the content of the delusion and hallucination, as well as what it might symbolize to the patient. Hallucinations can be unintegrated and inconsistent representations of central relationships. So sometimes they are negative thoughts towards themselves

that are maybe blown up from prior relationships with other people. So 88% of hallucinations are associated with delusions. So if you find the hallucinations, usually there's the delusions. But like I said, it might take you a couple, it might be like literally a couple years before they actually tell you what they're thinking or what the delusions are. So I feel like if they're too solicitous or if they put it out there too easily, it's unusual. It's usually they're very guarded about it. So it's like, you know, they're not telling you all the food that's not coming out of a jar as poisonous. They're just not eating any food that's not coming out of a jar, right?

And interestingly, with these hallucinations, they can often be distracted against. So helping them improve their ability to distract themselves in the midst of these can be helpful. So what are some things that can lead to anger and violence, them feeling devalued, not being understood? understood, brought against their will, feeling controlled, fear. Other predictors of violence are history of violence. Delusions and command auditory hallucinations aligning, for example, everyone in the world is, they believe their mother is the devil, and then their command auditory hallucination tells them to kill the devil.

So the delusion and the auditory hallucination aligning. Now, if a patient were to tell you that this is what happened, and let's say you were a mental health professional, treating someone in a jail system, but also it was well known that they tried to hide their, they're having done this act. You know, they threw away the knife in a river. They took bleach out and wiped all the blood from their car,

and then they, you know, blah, blah, blah, right? They tried to hide that. this act that they did, that would be less likely to be actually schizophrenia. That would be probably more something else. Because usually someone with schizophrenia who does these things, a violent act, which by the way is extremely rare, but in the cases that we do know about when this does occur, they are usually hiding their tracks. Okay.

So I also talked about violence in a prior episode of Dr. Gillian. if you haven't heard that one, go check that one out. And in that, just the highlight that I want to share with you is that I talk about listen, empathize, and then tell them what you want them to do. So listen to why they're upset, empathize with what they said. And then, hey, before we go on, can you come sit down here so we can have this conversation in this room?

So you tell them what you want them to do. And so it's just listen, empathize, tell them what you're going. you want to do. And most people don't repeat that more than one or two times, but if you want to de-escalate an angry or potentially violent patient, doing that 12 times can be a really good number. So try to do it 12 times. And you want better results than if you just do it once. So we talked a lot about different aspects of how to build a therapeutic alliance. We want to do everything we can with someone who's fearful or paranoid to reduce our physical profile, you know, try to get ourselves, don't be looming over a patient. Don't, if they're sitting,

sit down. If you can't get at their level, keep your hands in front of you. You know, don't hide them behind your back. Don't, you know, your body posture means something. So consider what your body posture is saying to the patient. Make sure that both you and the patient have a way to leave the interview if you feel uncomfortable and take time to talk about the importance of the safety, of the environment, of how you would like to keep them having a feeling of safety. You can also check in with them and see if they are feeling more secure or less secure, more frustrated or less frustrated, if they're feeling more fearful or less fearful,

as you continue to talk with them. At times, we do need to have boundaries with patients. We need to have limits. And if you're not feeling safe, then I would definitely try to find a way that you could feel safe while you're talking to this patient. And sometimes it just requires good supervision and talking to a supervisor about how to deal with this situation,

how to feel more comfortable. if you feel uncomfortable yourself, then that's a sign that you're feeling something from them. So putting that to words can be helpful. But as well, like, if you feel really, really uncomfortable and it's really out of the abnormal, then maybe take a little bit of a break and come back later. Sometimes especially if someone's psychotic

while they're detoxing off of methamphetamines, those are going to be short interviews because you may have only, you know, five or 10 minutes before they become very, very irritable. And honestly, the best thing for someone coming off meth to do who's psychotic is to get some initial medication and then to be able to sleep. So I wanted to end this with a little bit of a twist. I read this book called The Clinical Assessment of Malingering and Deception.

And it actually was really helpful for me to understand what's normal. Okay. And so they have a really good chapter on genuine hallucinations. For example, like most, you know, 88% of hallucinations are associated with delusions. They're intermittent rather than continuous. Olfactory or tactile hallucinations are uncommon except when associated with medical causes, okay? Or latent onset schizophrenia. immediate improvement in genuine hallucinations is unlikely. So the median days they will clear before their first hallucination is 27 days.

So that's helpful because on day three, if they're really minimizing their symptoms, maybe they just want to leave the hospital. But at the same time, maybe it's decreased to the point that it doesn't bother them as much anymore. 75% here are both genders, 88% here. both familiar and unfamiliar voices, only 7% are vague and inaudible. So usually the hallucinations are clear. Most psychotic patients hear voices both internally and externally, so this should not be used to determine their genuineness.

And often the hallucinations have to do something with the culture that they're living in. So depending on the religious superstitions of the culture, and it will change the nature of the hallucinations. So other themes about hallucinations is that usually they're omnipotent and omniscient, so the voices know the patient's thoughts and are able to predict the patient's future. There are both benevolent and malevolent voices,

and 81% of them are worried and upset about their hallucinations. The malevolent voices usually provoke negative emotions, such as fear, which the patients respond to by shouting, arguing, noncompliance, avoidance, of cues that trigger the voices. And there are benevolent voices which can provoke emotions, which patients respond to by elective listening, well, in compliance, doing things that bring on the voices. In schizophrenia, they're usually persecutory or instructive.

So they're insulting, obscene, accusatory. They tend to be egotistonic, derogatory comments about the patient or the activities of others. They can be chastising rather than information seeking, or they're usually chastising rather than information seeking. Their negative hallucinations may focus on sexuality with women being described as sluts or men as, men as gay, which is stigmatizing and therefore usually not faked. Okay, so the negative hallucinations that patients have usually are negative towards themselves in some way. And often they are not going to tell you what that is because that would make them feel bad

about themselves. So it takes time to get to the truth sometimes there. So I've had patients who will tell you that they don't know what it is. saying, but that's because they don't really want to tell you what it's saying. Hallucinations associated with music are rare, except with organic brain pathology. So when we're talking about genuine command auditory hallucinations, 38% of auditory hallucinations are command auditory hallucinations. And around 50% of mood disorders and schizophrenia have command auditory hallucinations at some point.

34% of alcohol withdrawal hallucinations are command auditory hallucinations. And of those with command auditory hallucinations, they also have non-command-auditorial hallucinations. And 75% also have delusions. So all of this to say that what is normal is to sometimes have the command auditory hallucinations, sometimes not. And some will hear and will act on them. and compliance with the dangerous commands are less likely to be obeyed. So they don't need to always obey the dangerous commands.

If they're gonna put themselves or others at risk, they usually won't obey them. And so how do patients cope with them? First and foremost, I would ask the patient how they try to lessen their hallucinations. And they'll tell you. They will try to do things like listen to music, watch TV, see contact with other people,

take medications. So learning to successfully distract oneself is really important in this case. And 69% of patients report some success with strategies. 98% reported experiencing adverse effects from their hallucinations, like holding jobs, emotional distress, feeling threatened. So often the hallucinations will lead to things being more difficult. So the reason why I go into a little bit on what it looks like from a forensic perspective is one, because I found it fascinating and helpful.

And two, because it gives us a little bit of information on how and what to expect from patients. And so I'll put this, of course, in the resource library. You can look through it. I think it's a great resource. And I think what's important to take away from these resources, statistics and things like that is that when someone has a genuine hallucination and it's derogatory and it's about them and it's saying bad things about them, it's going to be hard to actually get them to talk about it. We can ask them specific questions. And they don't

like that those things are going on, that those things are persecutory or making less of them. and they're also worried that maybe those things are true. So I've had some schizophrenic patients who are very frightened that they might be gay. I've had some female patients who are very frightened that they might have, that everyone might be thinking they're a slut or things that are fears, you know, that they feel very, very intensely. And so saying something first with empathy, like it could be incredibly hard to think that, that they're,

that there are a lot of people who are very critical of you and who are saying horrible things about you, but that would be very difficult. And then, you know, also sometimes giving them insight over time into that this is very common, actually, for someone who suffers from schizophrenia. That can be really helpful. And then to look at, like,

what could be some strategies that have worked and what could be some strategies that you could do, you know, outside of medications, and with medications, right? What are some strategies from both of them? So knowing a little bit about, you know, what are the types of hallucinations, what are the types of fears?

And you'll be able to dive into my prior episodes on schizophrenia if you haven't listened to those, and those will be helpful as well to give you a lot of more information. Both of my episodes of Dr. Cummings and with Arianna Cunningham are really good on these topics. It helps.

someone with schizophrenia to know that they are not the only one who has suffered from this. It helps them to know that you are there to empathize with their distress, to seek to understand and to seek to help them, and that you have experience helping them. Trust takes time. Expect noncompliance. Expect them to have trauma from prior health care that was given to them. if you can help them get stable on some medication, if you can help them be compliant with medication. There are a lot of good things that can follow from years of compliance.

In my Closopine episode of Dr. Cummings, we talked about out with Closbein. Sometimes it takes a couple years of being on the Closamine to really get the full benefit of it. And I prefer to, if someone's psychotic, if someone's really suffering, I prefer to see them more frequently, especially early on, until we have a good treatment plan until there's some good trust aligned. And even if you're doing medication management stuff,

seeing someone once a week, I don't think is unreasonable early on and insurance companies will pay for it because they, well, they have to because you're billing them. but even if they weren't paying for it, it would be valuable for the family to invest in that sort of treatment because with that sort of trust will increase compliance and also decrease stress, right? With both the traumas of the psychotic events, because believing a lot of life or death situations

creates a very traumatic space in your brain and also going through different aspects of life, like losing friends and losing your, job maybe you're losing your you know what you thought was going to become of your career or schooling those are very difficult things that they have to overcome as well and so it's for me that the therapeutic alliance transitions into working through some of those things that have been traumatic in the same way we'd work through any trauma or any difficulty that a patient might experience and the common factors, I think, being the most important of the empathy and the therapeutic

alliance, but then, you know, and then transitioning to finding a life worth living, right? So what are some things that they aspire towards and helping them take small steps towards those things? I have a lot of hope that with our treatment that we currently have, like, people can't get into remission and live lives that are meaningful. And it usually takes, you know, family help. It takes a good psychiatrist, a good team, a good therapist, good mental health professional to do this and to walk with someone who has struggled with these issues. So I hope that you have enjoyed this episode.

I'm really passionate about it. I'm very interested in anyone who's listening to this of taking this to heart. and really trying to live out this stuff day to day, right? Because you can't just listen and sort of gain the knowledge. You have to actually practice these things. You have to try some new things. You have to spend the time to learn how to read emotions, microexpression.

It takes probably around 40 to 80 hours just to learn how to read the micro expressions efficiently. And if you think you've mastered it, there is more advanced training that I'm working on. so stay tuned. But if you are listening to this and you would like these resources, check them out of the resource library,

I read every message that people write to me, and there's a link in the show notes. And I really hope that this creates some value for your patience, because my hope is that through making these podcast episodes, your patients would benefit. At the end of the day, that's what it's about, the CME, the Patreon, on, all the other things that go along with it are just people partnering with me and trying

to get their CME credits while they're doing this type of work of growing in this way. So on that note, I hope you have a great day.