Psychiatry & Psychotherapy Podcast - Psychotherapy for Psychosis with Dr. Michael Garrett

Episode Date: May 19, 2023

In this week's episode of the podcast, we interview Dr. Michael Garrett, Professor Emeritus of Clinical Psychiatry and former Vice Chair and Director of Psychotherapy Education at SUNY Downstate Medical Center, Brooklyn, NY. He also wrote a book called, Psychotherapy for Psychosis: Integrating Cognitive-Behavioral and Psychodynamic treatment. He is husband to the prior beloved presenter, Dr. Nancy McWilliams. In this episode, we will discuss how psychotherapy can be effective for patients experiencing psychosis.  By listening to this episode, you can earn 1.5 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Welcome back to the podcast. I am joined today by psychiatrist Dr. Michael Garrett. He is a professor of clinical psychiatry and the director of the psychotherapy education in the Department of Psychiatry and Behavioral Sciences at this State University of New York, Sunny, downtown medical center in Brooklyn. He is a psychiatrist and was a psychoanalyst and then went back and studied CBT and he wrote a book, called Psychotherapy for Psychosis, Integrating Cognitive Behavioral and Psychodynamic Treatment. He is also married to a prior presenter of mine, Dr. Nancy McWilliams. Some of you may remember that episode as well. So welcome to the podcast. Very glad to be here, and thanks for inviting me. I was going to say, probably one of your biggest accomplishments was marry Nancy McWilliams. Absolutely.

That's right at the top of my... CV. That's nice. Yeah. Yeah. How, um, how was this, uh, like, writing process? Like, do you, do you guys, like, have, like, coffee and talk about what you're writing or what she's writing or how does that, what does that look like? Uh, we live in a small town in New Jersey. And, uh, we have separate office spaces. So, uh, we come back and forth and back and forth through the day. Yeah, I, I read pretty much everything she writes and, uh, She reads stuff that I write. I'm working on a second book now, and she's at this very moment reading a chapter.

Nice. It's a good collaboration. That's great. Yeah, that's wonderful. So, yeah, I think it might be worthwhile to kind of talk a little bit about your journey through psychiatry. It sounds like you were in the public sector quite a long time, in the public sector, as in, like, treating people with more severe mental illness. Yes, that's correct.

In my roughly 40 years of experiences as a psychiatrist, I started out just after residency training, interested in inpatient psychiatry. I also got my psychoanalytic training at that time, and I was wanting to do psychological work with more disturbed patients. and I found that the preparation I got from my psychoanalytic training, it was helpful in understanding what was going on, but didn't necessarily lead to effective results with patients. So that sort of remained in the background of my interest for many years until about 20 years ago. I had the good fortune to connect up with and get some,

training in CBT for psychosis. And the kind of treatment that I've evolved is a combination of CBT and a psychoanalytic perspective. And to put it simply, CBT is a good method for helping patients examine the literal falsity of their belief. And a psychodynamic psychoanalytic perspective helps people to understand the figurative truth, the emotional meaning of the delusional symptom. So the combination of those two I found has led to some effective results in treatment. Nice. And so what is your sort of day in and day out week look like at this point? Are you still seeing clients or you still seeing patients? Are you doing more therapy with psychotic patients teaching? Yes. Most of my professional time

is now supervising first episode psychosis teams. I have ongoing relationships with a number of teams around the country, even some international connections where groups present usually a particularly difficult or problematic case. And then we discuss what might be the most helpful approach with the patient. So I'd say half of my, I'm semi-retired now and I'm busier than ever with stuff that I really enjoy doing. So, yeah, so most of my time is in teaching and supervising. But I still do have a few private patients that I see on Zoom these days.

And then writing, biking and cooking and all the other good things you can do. do when you're semi-retired. That's great. That's great. Okay. And so, yeah, let's, I was thinking we could maybe start with just getting super practical on how to approach different aspects of like a psychotic person's presentation. And I'm, I'm going to use this as well as like a bit of supervision or sort of see if I can

increase my insight. So the first situation that I often get presented with... You're going to present a case. Well, I'm an amalgamation of cases that occur on a regular basis, right? I always change variables, details, and HIPAA to protect people's identity, of course. But one of the things that I'm getting a lot of calls with lately is patients who just do not want to see a psychiatrist. So I'll get the mother or the brother or the brother or the... family on a Zoom call and we're talking about the situation and you know usually it's a 20 or 30 year old

male let's just say let's just say male who's living at home who is incredibly socially isolated who maybe has had some encounters with psychiatry to that they're absolutely not wanting any contact with a psychiatrist. So yeah, it's like when you can't even get them in the door to do psychotherapy, one time I even showed up at the, I did a family visit, you know, I visited the home because I could not give advice without laying eyes on this person. You know, I couldn't give any treatment without doing a mental status examination. So I'm curious, like what, how would you start to talk to the family? How would you start to work with the family? family to sort of coach them maybe to help their child get into treatment?

Well, as I know you know, there are certain patients, not just in psychiatry, but in internal medicine and surgery, who are beyond the reach of our engagement, people that we really can't help. So I think psychotherapy is still in its initial stages of development, there's an application in psychosis. So there's, that's much left to be done in developing techniques to approach the kind of patient that you're talking about. There are approaches developed primarily in Scandinavia, the so-called open dialogue approach, which tries to avoid hospitalization and medication if possible, which focuses on a family intervention and there are islands of this kind of capacity

around the world and a few places in the United States that's do this. And the process involves the small team going to the house, you know, where the identified patient is, and then they open a dialogue so that the person that's of concern that the family is not necessarily the identified patient. But the family talks about what they're worried about. And out of that kind of open

dialogue where there's a sense of respect for everybody and the doctor isn't coming in to impose some holier-than-thou medical perspective on the whole situation. But the family explores the dilemma together and they success rates with this approach in Scandinavian country. countries is quite a bit higher than the typical results that we get in the U.S. with a straightening medical approach. Some other possibilities because we don't have a good base of open dialogue in the United States. I might start with a family consultation without the patient to get a sense of what's going on, what are their concerns, what are their worries. and sometimes, not always, somebody in the family, and it may not be the parents, but somebody in the family,

has some sort of emotional influence with the patient. There's somebody that the patient listens to, and I would try to understand their point of view, develop an alliance with that person, and then maybe see if the person of concern could be invited in to join in a discussion of what's going on, what are their concerns, what are the issues. In situations where there's a psychotic family member living at home, everyone is suffering in some way. And the effort to engage somebody in treatment is to try to empathize. with their suffering to approach them from the point of view of what worries them, of what pains them.

So, for example, and this is a very different attitude than a DSM-5 diagnostic approach where you're trying to reduce symptoms. I worked with a man who was very distressed by voices that he heard, but not to the reasons that most people would think. His real source of distress was that his family didn't believe his claim that he was really hearing voices. So the fact that he was hearing voices actually was of interest to him, and some of the voices were quite warm and supportive and would say good things about him. So that wasn't his concern. It was the breach of connection with the family that was the concern. So you have to offer the patient something that they want. something that they need, something they're interested in.

So that treatment would begin with the premise, not of eliminating the voices, which the person was attached to, but why might it be that things that are quite obvious to you and voices that you hear, that your family doesn't have the same experience and you feel alienated from your family? So that would be one approach.

Another, I mean, as you can imagine, There are not infinite variations, but lots of every family is different. Every situation is different. You never know what you're going to wade into and it keeps changing. But at another extreme, and I'm working with the patient right now in this similar situation, a person living at home, they have to behave in a civil manner. They can't be threatening the family members. that there has to be the possibility of safe living for everyone in the family.

And sometimes when a person is behaving in a way that is threatening or unsafe for other family members, there has to be an ultimatum on the part of the family. Either you get into treatment and do something about this behavior, or you can't live here anymore. You know, we have to find some other place for you to live. And surprisingly, sometimes when people are forced into treatment, even though it's coerced by a family demand and they don't think they need it, it's possible for the therapist to develop a relationship with the person under those circumstances once you get them in the room because of the family demand. another thing that sometimes makes a difference is that in the example that you were giving, this person had a bad experience with psychiatry in the past.

This is very common. Inpatient admissions are themselves traumatic. You know, can you imagine the police come into your house and dragging you out and, you know, locked up behind the door? It's awful. It's awful. It's terrifying. Yeah. So people remember those things and they have bad experiences.

They have bad experiences with forced medication, with the side effects of medication, all these things, which can't be entirely avoided necessarily, but they really have a bad aftermath. So I've been able to get psychotherapy relationships going with patients by saying, it's not my intent to prescribe any medication for you. so I'm happy to see you without the requirement that you take medication and sometimes over a period of time that evolves into an interest in medication acceptance of medication but the condition of that they won't be forced to take medication right is a condition of the conversation I can give you a brief example of that yeah that would be great yeah it sounds so I like that

it's like their greatest fear is that the only reason they're seeing you is because you're going to either hospitalize them or force a medication. And so you kind of like take those off the table. Right.

And then, okay, what happened with this one patient? Go ahead. And if it gets back on the table, it won't be by my hand. It'll be by something that has happened in the person's life. necessitated admission or something like that. But I'm not watching the patient for signs to justify they're going into the hospital.

And I'm not really. So here's an example. I worked with a woman some years ago who had very bad experiences with psychiatry. She, among the other things that she never forgot is that she was treated with some medication, including depicote, and had a reaction, which is not so usual, but it was dramatic for her. She lost all of her hair. It was very traumatizing for her in addition to the involuntary admission. So she had vowed that she would never take any psychiatric medications again.

And one of her family members heard about psychotherapy, got my name. I made an appointment with the patient. And the patient says, you know, I don't want to take any medication. And I said, you know, that's okay. I'm happy to talk to you and see what's going on without the medication. So the story that unfolded was that she heard voices that were telling her that someone was going to die. And being a responsible person, she thought it was her job to figure out who was. it was that was going to die.

And she would spend hours a day reading license plates trying to get clues about who this person at risk was. And in the process of psychotherapy, these were once a week meetings that took about four months to achieve this. We talked about her voices as a particular variant of the internal conversations that we all have. We all talk to ourselves. I tell myself frequently that I don't need dessert. I'm to keep trying to. I tell myself, I don't need two desserts. So sometimes we speak to ourselves about things that we are not entirely secure of, you know, in our own right.

So voices are messages from the interior. They carry a meaning. They're therefore. purpose. So she's worried about something. I don't know what it was at the beginning of the treatment, but I found out. So someone's going to die. I normalized, this is a clinical term, normalized the voice hearing experience. It's not some bizarre from Mars kind of experience. Everybody talks to themselves. We all have an internal dialogue. Plato thought about thinking as a conversation with oneself. So it's all just a variant of quite normal human experience. Once she understood that and felt less stigmatized, got interested in her own internal experience, we were able to develop an understanding of what the meaning of the voice was. And to make a long story short, it took

some weeks to accumulate this understanding, but she was in her mid-50s by this point, and she'd suffered a number of losses in her life. And her mother had recently died, and she was very attached to her mother. And she was beginning to feel the distant waterfall of her own mortality. She could hear that she was moving into the next generation. to pass away and she was surrounded by these losses, the loss of her father, she'd lost her marriage, her beloved dog, it's into his 13th year and might not have long to go. So she was full of the kind of atmosphere of grief and the person that was going to die in the end is the kind of

amalgam of all these losses and her anticipation of her own death. So the psychological purpose of the voice hearing experience, the defensive purpose of it, and this is a typical thing with psychotherapy. We deal with defenses. The defense was she had to find out who was going to die because it certainly wasn't her in the delusion. She's trying to figure out some external puzzle, but in the end it was her. And she came to understand this. And then finally, I said in what we call a Colombo style. I don't know. You're younger than I am,

but you may remember the Colombo detective series. Like a mentalizing stance, right, of not knowing. Exactly. Yeah. So you know this. You know this. So Columbo style, I don't know that we have some medication that might take the edge off the voice hearing experience.

would you like to try it? We'd try the very low dose and, you know, it's your call, you know, whether to continue it. And the voices had already diminished. She said about 50%, so she wasn't really preoccupied with them anymore. But now she had enough trust in the relationship to give the medication to try. And then with a very low dose of aeropryproprozole, almost a homeopathic dose, the biological window to the voices closed, and the voice hearing experience ended. So that was a treatment that combined early CBT techniques, sort of normalizing and teaching

about the voice hearing experience, a psychodynamic, psychoanalytic perspective about what the conflict was, her losses, brief, and how that was being dealt with. And finally, pharmacology to close the biological window. And she did very well. She went back to work and began working as a responsible job and earning some income, which also bolstered her self-esteem. So that's one example of looking for the meaning in the symptom and using a variety of clinical approaches to try to help the patient in the end. Yeah, I had a patient who felt like he was stuck in the Truman Show.

Interestingly, it didn't come out until he got on a good dose of an antipsychotic for a while that he shared that with me. So he was very guarded about that reality that he felt like he was in. But after a while of being on a pretty good dose of an antipsychotic, he kind of came to this point where he told me. And we looked at the meaning underneath it and kind of like the desire to be important and to be famous and to be seen. and like under you know like it's kind of like there even before he got psychotic in his 20s so he had always had that desire and then when he got psychotic it like kind of fulfilled that desire

so it like gave him that meaning piece or they gave you know it's like it was like a defensive way of achieving his psychological need right is that kind of what you're talking about talking about with like the meaning making of the psychosis or the delusions yes but at the the risk of sounding like a supervisor which is what I do that the my guess about why he shared that with you was trust having built I I don't think that the necessarily that the neuroleptic brought him to the the point, you know, where he could tell you about that. I think that probably some trust developed over time, so he could tell you that.

And that he knew that most people would think that was a bit crazy. So he would hold on to that. But then he could trust that you would listen to him and accept that and then not, you know, react in some melodramatic way. It was a funny result in the early research in CBT for psychosis. They're trying to test whether it was really effective. And using the pans as an outcome measure, some of the early studies seemed to show that patients had an increase in psychotic symptoms with CBT.

But what eventually came to light was that, no, the patient would just tell them the truth finally was going on. Absolutely. And so it led to a good faith conversation about what was really happening. And on a lot of inpatient services where there's a lot of institutional and insurance pressure to get people out, the staff are happy to collude with the patient, that everything's understood. You know, they're good to go. Right.

And, you know, oh, you know, you're not, you're not. you're not thinking you're Lucifer anymore you know how many days have you been thinking that a day well that's good enough you know okay no we don't need to think about why you thought that in the first place or the background of that was so the other thing about the Truman show as you know this is a very common

kind of idea and the way I think about that is that psychosis consists not only of deluselious beliefs, which appear to be false truth claims about the world. There is that, but it also involves changes in the subjective experience of consciousness, where the mind kind of turns inside out, and there's a name for this,

in schizophrenia literature, hyper-reflexive self-awareness, where instead of becoming just a fluent thinker and speaker, people become hyper-reflexively self-aware of their own thoughts. They begin listening to their own thoughts. They begin tracking their own thoughts. So the mind turns inside out and then mental processes become objects of perception. So in the Truman Show, there's a heightened sense of observation, which from a psychoanalytic point of view is a projection of the person's own. self-awareness.

So they are, without realizing it, they're noticing, registering their own stream of consciousness, and this is experienced, this uncanny shift in self-consciousness is experienced as being observed from the outside. They're in the middle of a show. And also the idea that it's a show, it's not a real life, is another. idea that explains the uncanny feeling of fraudulence, not being fully in one's subjective experience. So it makes sense to me that this man who had a proceeding wish to be famous, that that that would be, that that would fit and reinforce the delusion with the change in subjective experience. of consciousness where he is more hyper-reflexibly self-aware.

And the end result of that is somebody who may become then firmly convinced of this particular idea, you know, that there's a feels to them like their center of retention. Here's another normalizing example of that. As an interviewer and podcaster, and I put a tie on today for the the interview. I haven't had a tie on a while. It doesn't make any sense. But, but,

you, you want to be presentable, as do I, you know, for the interview. So there's a little bit of, a tiny bit of self-consciousness. One's preparing for an interview or, you know, talking to somebody.

Absolutely. And then, I don't know if you've ever had a bad hair day, that kind of thing. where there's something that is off. Right. Okay. And that used to happen to be occasionally at the hospital where, you know, I enjoyed my morning coffee.

And every once in a while there was a slip between the cup and the lip. And I would get a little coffee drip. I typically wear a white shirt to work. And then I'm looking at it on the tie. It's on the tie. It's not on a white shirt. Will they notice, you know? So when I go into the meeting,

For a moment, I'm thinking, all eyes are on me. Are they noticing the Poffice's name? That's a moment of hyper self-awareness in relationship to one's internal state at that point where you were imagining that all eyes are on you, that you're the center of attention. And even if somebody glances at you for a moment, depending on how you're feeling that day.

Oh, no, they did see it. They did see it. And then you settle in to try to manage your shame and pretend like nothing is going on. And you go on with the meeting. It's like that. So that's like a little mini version. The mind turned inside out.

Where for folks that have, who carry great shame, every day is a, not just a bad hair day, every day is a terrible day. is a terrible day where their flaws, their weaknesses, their fears are turned inside out and revealed to the world for all to see. And then you get the man thinking that his whole life is being observed or the very common

belief that their agents stationed in the neighborhood, FBI agents who are surveying the patient and watching the patient and observing. Yeah. Yeah, it's like, I like how you put that. it's it's like you are noticing the extremes of it in someone who's psychotic but also how there's variance and those of us who are not psychotic um it seems it seems to me that the insight into it you know it's like one part of my brain is like this is illogical but i'm feeling this way and then the other part is like very high guilt high shame like

You know, but there's a little bit of like a check there, right? And then with someone who's psychotic, sometimes it's not like they don't really have that logical check. They just believe that it is the case, right? It's like I am. It's not that this person could be looking at this coffee stain. This person is looking at the coffee stain. And therefore, I am stupid. right and it's like an absolute of sorts i don't know is that would you say that that's what you found

or how would you describe that yes and uh as won't surprise you there's a range so yes it's exactly like that for for many people uh who have psychotic experience the the feeling of shame is so intense that they're convinced that it's happening because it's absurd when somebody is ashamed or afraid to say, you are imagining you are afraid, you are imagining that you feel shame. When we feel something, we really feel it. So the reality of the feeling

gets translated into a conviction about the claim that one is being observed. So there's some people who are completely convinced of that, but there's another very interesting phenomenon, which is not uncommon, which is called double bookkeeping, where the person will say, I know this doesn't make any sense. I know this can't be true, but I believe it anyway.

So just as you say, there's a cognition that's asserting that something is true, not true, rather, and there's a visceral feeling that it is true. And there's a tension between those two things. Okay, so getting into kind of like an early example when I was a resident, there was this patient who believed that his parents tortured him. And I remember talking to him and thinking to myself, oh gosh, how horrible that this

patient was tortured by his parents. And then after listening to him for a long time, I realized like some of this torture that he's describing is like, it's impossible. right and and then I started realizing like oh this guy he is coming up with you like some of these are delusions right this is this is very early on in residency but it's like I wanted I wanted to approach it I was approaching it concretely as if it really did happen at first until like as his story progressed as he talked more and more. It was like, oh, either this guy's been through the worst of the worst or like it just doesn't, like he would talk about how he was kept up for eight days straight, you know, tied to a chair, you know, the worst of the worst. So how do you like start to help someone who's in the midst of believing something like that so strongly without aligning with the delusion?

it's a complicated question but a little bit of research background as you know Freud from the beginning over 100 years ago was saying that psychological suffering is chiefly a matter of remembrances that hysterics suffer from remembrances they suffer from memories, the things that have happened to them. And then Freud went through a period where he couldn't credit that the complaints of sexual abuse that women were talking about, that this couldn't have happened in Victorian Europe. It must be a fantasy, and that led to edible fantasies.

we now know from research in the last two decades that the histories of sexual, physical abuse, and people who become psychotic are quite high. And sexual abuse, physical abuse is a very high risk factor for the development of psychosis in adult life. And there are some people who don't have a history that's identifiable, of abuse who becomes psychotic. But for example, in cases of incest, when there has been forced penetrative sex on the part of a family member, this increases the risk of psychosis 10 times. And this is a much higher number than any single gene that's associated with an increased

risk factor in psychosis. So with the patient that you're talking about, the attitude of that you're talking about, the attitude I would have initially as I wouldn't discount that something had happened to him. Not precisely the way he described it, but that what he was describing was a disguised, distorted memory of something that happened to him. And I would not assume at the beginning or that I would eventually clearly find out what the balance was between actual events and fantasies. But it would be certainly the things that if a person says that they were flown to Mars and tortured there by aliens, I mean, we know that to be a delusion.

But oftentimes people report their traumatic events in disguise and delusional form because they can't bear to speak about the particulars of what has. happen to them. So it's complicated, and Silvano Arietti, who is a brilliant analyst who wrote probably, in my opinion, the best book ever written about psychotherapy of psychosis, he talks about how in the late stages of a successful psychotherapy, images of parents who earlier in the treatment were monsters start to become more ordinary. flawed human beings in the patient's

representation of them. So there can be some evolution of those things. Another thing to be said about it is that when the patient is describing to you unspeakable tortures,

the delusion that he is telling you may be perfectly commensurate with the feeling that he had at the time, even though it didn't literally occur in that way. Yeah, I have other patients

describe dreams like that, you know, like it was a, it was a hurricane crashing over me, you know, like kind of thing where it's like, this is the feeling of overwhelm or this is the feeling of suffocation that they feel in a situation. Right, right.

So you're saying it's just like a dream that's going on and it's kind of expressing maybe some congruent emotion. Yes, right. One other way that I think people can find an empathic door into psychotic experience and this tension between what's rational and what's not rational is I think most people have had moments of overreaction to situations in ordinary life. And before I started my own psychoanalytic training, I had a morbid fear of, of the IRS for no good reason.

My tax returns, actually my account would say, come on, don't you have some more deductions? You know, here you can throw in some other stuff, you know. Here, so my returns were always squeaky clean. But every time I would get a letter from the IRS, I would kind of freeze up. Absolutely. Jesus, you know, they're going to audit me.

The rational thing would be, so they're going to to audit you, you know, big deal, you know, you haven't done anything, you know, even if you have to pay a little bit more, you know, but no, I was really made me anxious and, you know, it approached completely irrational ideas of, I'm going to be ruined, you know, the IRS is coming after me. That was the feeling of the moment. So I'm looking, getting ready to open this letter, my rational mind is telling me, this. This can't be a big deal. Usually they're just telling you that they substituted form 501 for 502, something of no consequence. Open the letter, you know, get on.

Yeah, yeah, yeah. The way, because I feel, you know, it's the beginning of the end when I leather. So in moments of overreaction to things, and then I'll tell you the happy endings of the story, actually, but. It was a refund. in overreactions to things everybody feels the pressure of an unconscious fantasy of some kind of catastrophe oh the terrible thing i fear it's about to happen it's already happening it's just beginning and then you try to fight it off with rational cognition but you feel the tension of those two things

in psychosis, that unconscious fantasy pushes through, and it has such force, emotional force behind it, that the person believes that the thing that they worst fear has actually come true and is now depicted and realized in the outside environment. The happy ending to the IRS story is that I learned. in my own training analysis, my own treatment, where I was talking about a lot of different things, including this fear of the IRS. And I came to understand it that even though I had a lot of warm feelings for my father, he was a strict military man, and I had a certain fear of him also. And I learned in my psychoanalysis that the authorities that were coming for me was an exaggerated image of my father, you know, in the moment where I imagined him being most fierce or, you know, judgmental toward me. So once I understood that, now I open letters from the IRS without, this is on my mind because my wife and I just finished, tax returns and sent them in.

It's completely relaxed manner. It's traumatizing me. It's traumatizing me. No, I'm joking. I haven't worked through this yet. I need to still work through my, the punitive father transference writer, like on the to the IRS, my projections. That's good.

I need to do some of that work myself. No, this is probably coming out after tax day, so it's going to, It's going to create some nightmares for people. Okay. What do they miss? What do they, you know. But not everybody, just the people that have that unconscious vulnerability. Right.

Yeah. Yeah. You know, I like that with your approach, there's a lot of openness and there's a lot of curiosity. And the empathy and the ability to see a lot of the psychotic. symptoms is not too far from your own, you know, paranoia of the IRS or your own, like, conflicts. I think it's helpful because it takes off some of the pressure that maybe some of us were given in residency of, like, you have to get them on an antipsychotic right away. You have to, you know, get this injection in them, which I feel myself, like, I feel myself, like, I,

I feel, you know, it's like, how do I get this patient with very low insight, getting something that's actually going to help them? And so your approach is very different. It's typically the doctor that lacks insight into the patient's psychology, just to turn the phrase the other way around, because as you know, doctors are trained to make decisions. and something I say with some irony to the psychology interns that I supervise and the psychiatric residence is that the psychology interns are generally better trained in psychology and the psychiatric residence, but they can't make a decision. They can't deal with a crisis. They punt that to the psychiatrist.

The psychiatrists don't know that much about interviewing or understanding the meaning of things, but they can make a decision, and the buck stops with them. So you can't lollygag for days and days and days. You have to make a decision. But the mental health system forces us to make decisions quickly. The interaction with the patient leads the patient to feel objectified, that your main interest is to diagnose them and prescribe for them. And something that's quite therapeutic just in its own struggle is the intent to understand patient. And if you're sitting with somebody, I mean, you and I are talking here, and I'm enjoying the conversation, and I know that you have an intent to understand me, and me too.

That's good. I have a mirror. You're picking up my mirror neuron intention of like learning something here. But that gives dignity. to the conversation, you know, that you're worth understanding. I'm interested in you. I'm understanding you.

That's a whole different premise than you're schizophrenic and you're denying it. And if you don't take the medicine voluntarily, we're going to get the court order to insist that you do it. Sometimes you have to go that route, but it's a costly route. It's like if I can avoid that route,

I will avoid that route because it's a painful route. But it's interesting because as residents, it's like that's the first thing that they learn how to do they're you know 80 hours a week in the ER and in the psychiatric unit and they are seeing the worst of the worst over and over again and they have to make these very quick decisions yes to you know how do we get enough medications on so this person continues the medications when they leave right and I think you know the why this discussion is so important

is because like the Katie study showed there was like 30% compliance with taking the medication. So it's like patients are not taking the medications. Anasinomia, I almost want to do a whole episode on anisthenomy and just this like low insight into the nature of the disease and how do we work with someone like that.

And I think this is actually a good first episode towards that goal. It's like how do we how do we meet the patient, not with our medical mind, but with a curiosity? And I imagine some residents are listening to this and they're going like, yeah, but I only have half an hour with this patient before I have to get to the next three on my list, if half an hour, you know, like half an hour might be more generous. So yeah, where do you, like, how do you start to talk to that person who's listening to this and being like this you know how do I how do I really do any of this and in the

confines of the matrix that I'm in of residency a quick aside about a nocognosia lack of insight um I have quite a different view of the use of that term I think than most psychiatrists and I the the patient's assertion that they're in the Truman show is it's not the absence of a cognitive capacity. It's not a deficit state. It is the presence of something. It's the presence of something that's more compelling than their previous experiences of logic and common sense. So the idea of lack of insight, I think, is not a good.

good way to think about this kind of dilemma. We don't understand what it means, you know, but the idea is, it's that damn schizophrenia. These patients, they don't know what's going on with them. You know, they've got to get with the program and understand they're ill and take their medication. Okay, so I'm, so I'm confused. So it's not the lack of them not knowing something. it's it's they know something but they know something different right right is that is that what you're saying yes the metaphor that they have come to uh is the most apt expressive metaphor that anybody could come up with uh in that sense it's it's it's a perfectly apt metaphor for their experience so uh here's another example.

I would imagine you've had an experience of deja vu. Most people have, you know, you have a brief feeling that time is repeating itself. And when that happens, that's an altered state of consciousness,

an altered relationship to time. You have a name for it. It doesn't last very long, so you dismiss it. What if you started having it's like the Groundhog Day movie, you start having deja vu experiences off and on throughout the day. And then finally, you're in a state of constant deja vu.

There's an alteration of your relationship to time where you feel everything is repeating. How would you explain that? It would be, you couldn't ignore it. How would you explain that? and they're all different explanations. And you and I could trade explanations here, and I'm sure come up with 10. But my explanation is,

well, this is the way it works. I'm a good person. I'm a time traveler. And I've been going back in time. And just like in the Schwarzenegger movies, I'm preventing bad things from happening. But there's a computer glitch.

So when I'm getting injected back into the present, I'm not fully back in. So it feels like the whole thing is repeated. I mean, there are endless different ways to explain it. So what's going on is not a lack of insight, but it's the presence of a much more complicated psychological structure, which the psychiatrist doesn't understand and can't make sense of. Okay, so sometimes I go lift weights in the morning, and I'm lifting weights, And I'm like, okay, if like aliens had taken over the earth and if I was in some sort of simulation, right?

And they wanted to harvest my rib-eyes. Like, this would be the simulation that they would create for me. Like, they would create a world that I would consciously choose to go power lift everybody. Yes, there you go. So what do you think? You're in a deep groove there. You're in a deep groove. Yeah, that's where it comes from.

That's right. Yeah, there are people who, I mean, like, for me, it's like a humorous, it's a humorous sort of line of thinking, right? But there are people who really think, like, they're in a simulation or they're, you know, they're in a groundhog day that's repeating over and over again. And so what you're saying is you approach it with a curiosity of like, okay, how is this, how is this picture or this image or scenario? how is this somehow an accurate representation of something going on?

Right, right. So for me, you would maybe be like, what would you say about the power lifting simulation for rib-eyes? What would be an accurate representation of? I think it's a lovely example.

No, it is. It's a lovely example. Thank you. And perfectly ordinary, a passing fantasy about a situation. So you invited me. So with your permission, it's all good. It's all good. Let me start with a more dramatic example and then slowly creep up on you, lifting weights. I worked with a man some years.

ago, and we're talking here about oral concerns. All of us have oral concerns and oral fantasies. So I worked with a man some years ago who, when he was a kid, was afraid to go in little kitty pools because he thought there might be sharks in there that would eat him. So for reasons of his own development, he had terrified oral concerns being bitten. And, he got through school and then when his marriage began to fail, the delusion that he developed was that his wife was a cannibal and that she intended to eat him. And that some night when he was asleep, she would kill him and eat him. So this childhood fear, this oral fear took a different form in the expression of the delusion.

but it's an oral anxiety about eating and being eaten. So the rib-eye steak, this is eating muscle, and you're imagining that you might be the prime rib offering, you know, and the aliens are buffing you up, you know, so that your cattle on the farm. So this is just a perfectly ordinary sort of unconscious association to eating, muscle, you know, this sort of stuff, which coalesces into a little story. You know, the adolescents or, the aliens are, you know, the Earth is an alien beef farm, you know,

and your prime rib, you know, in this story. So there it is, the human imagination making a story out of, you know, some kind of concern. But it's a daydream for you. It's funny. It's a fantasy. We can talk about it here. Okay. Okay, go ahead.

And then I'll tell you the second layer of it. Oh, sure. If you were traumatized in some way and something was seared into your imagination that had an oral feeling to it, it wouldn't necessarily come as such a daydream. there would be it might actually emerge in the fantasy. So, for example, I had a patient who believed that she was the matrodess in a cannibal restaurant. And her job was to intuit who the cannibals were and take them to the special dining area where the cannibals would be served. And so this is a primitive expression of her internal.

mental life. Anyway, so what's the second layer here? Oh, the second layer is that that this is a joke that I'm preparing to tell on the Joe Rogan podcast, and Joe Rogan enjoys it.

Right. Yeah. There you go. And that could you know, elaborate in the story of your relationship in mind to Joe Rogan and you being on somebody else's

podcast. Then it gets interesting and complicated and so forth, but it's a passing daydream and it's the presence of something. And it would be ridiculous for me to say, you lack insight, you know, about

the fact that there's no aliens out there. You think there's aliens? No, I know that you don't take it seriously. It's a daydream. But some people take those daydreams deadly seriously, and it becomes their reality. But it comes from the same source and from the same font. Yeah.

Yeah. So coming back to the schizophrenic patient who says, well, this one doctor tried to put me on six meds, and I felt absolutely awful, and he was putting poison in me, and there's no way I'm going to touch a seventh medication in my life. You know, that for you is not a lack of insight. it's actually maybe it makes sense, right,

that they wouldn't want to put a seventh medication in them. Of course. And I've had smart patients tell me things like, Doc, look at my chart. How many diagnoses do I have in there? I must have seven or eight

different diagnoses. I can reel them off. Zizapheriniose, schizoaffective, bipolar, borderline, and I know that if you really knew what was the matter with me, I wouldn't have 10 diagnoses in my chart. You guys don't know what's the matter. You're making this long list of stuff, and you really don't know what's the matter.

And I've been on, you know, 10 different medications, and my life isn't any better than it was when all of this started. So, no, I don't think you have the answer to, you know, my situation. And the record of psychiatry with severely ill patients is not as good as it is in some other branches of medicine. You know, it's harder work, I think. So I don't think we need to be ashamed of that. But where there have been dramatic advances in oncology, dramatic advances in surgery, there was a significant advance with medication in the 50s with neuroleptics. but there hasn't been another quantum leap, as the KD study shows.

There hasn't been a huge surge forward in the efficacy of these medications. So we're kind of idling at that level, but not rapidly advancing. Patients know they're not getting better. If they really were getting better, there'd be no argument about taking the medicine. Yeah. Yeah. Well, I think, I don't know. I think, you know, I feel a shift.

I've been told by many people across the U.S. and across the world that there is a shift towards more interest in psychotherapy amongst professionals. You know, this podcast success is largely from that as well. Right. there's people that are leaving jobs that would not allow them to see people more frequently so they can start their own private practice and be able to do the type of work that they want to do. So I think that there's been a movement towards that, and I think the physicians that I know that are doing that work,

they feel a lot of gratification about the success rates. I just talked, you know, coach different psychiatrists across the U.S. and talked to one just this week. And she was, she said, I looked at my results and I realized I was getting about 95% of my patients better, you know, looking at their, what the symptoms that they came in with and the different measuring scales that she's doing, which is way better than, you know, Star D. But it comes with a full integrative approach that we're talking about today, like the psychotherapy and the, you know, connection and medication light, you know, not medications to the point of huge amounts of side effects, right? Right. That's right.

Yeah. I agree with you that I think the tide is turning a bit because I certainly in the area of interest for me, you know, medications for psychosis. The research shows that if you do long, term follow-up studies, 15 years out with medication. It's kind of the usual rule of thirds that a third of people have recovered their lives. A third are in and out of the hospital, and a third are chronically gravely ill. But interestingly, that group that fully recovered, those are the patients that are not taking medication. There's a higher percentage. There's a higher

percentage of those folks that aren't taking heads. Okay, so this is observational study. So my kickback would be observational study. And so, you know, there's a severity difference in patients, patients who are less severe need less medications. Therefore, the patients that are going to do better need less medications. But if you look at other studies where they try, if someone who has a diagnosis of schizophrenia, they try to take them off the antipsychotic.

The relapse rate is ginormous. It's like 95% relapse in the first three months. And then there's a quick response to that. Yeah, let's hear it. Which is that we know that there are some serious side effects to neuroleptic medications, including tard of dyskinesia. And how is it that as a psychiatrist, we don't know which of those third people don't need the medicine? in the long run so that we make the default decision to prescribe it for everybody.

And we should be worried a lot more about who are the folks that might be in that third that really don't need the medicine and who can recover in a different way. And the second question, people relapsing. This is a source of a lot of, I think, conflict and debate. but a case can be made that the psychotic relapse from stopping the medicines is a kind of withdrawal phenomena in some cases where there's been an adjustment of neurotransmitter levels, which when you withdraw the medicine, if the patient comes off the medicine and they haven't had sufficient psychotherapy, to manage their lives, they're going to relapse. But it doesn't mean that the relapse from going off medicine does not prove that this is a chemical imbalance that's corrected by the medication. It's a very complicated question.

And I would just say, we don't know the answer to this. Well, I mean, go back a couple hundred years, like where did people, with psychotic illness end up, they ended up in like sanitariums and ended up in psychiatric hospitals for their whole life, right? And with severe catatonia, things that we don't see anymore, you know, it was called dementia precox for a reason. Not only were they seeing psychotic symptoms, but they were seeing eventually something that looked like dementia. That's true. And a lot of those folks that were in the moral treatments, you know, the Victorian house of the country and so forth.

A lot of those folks got better, too. Well, with good moral treatment, right? Yeah, that's right. That was like not always the case. That's right. I don't know. Sometimes when I hear patients who get better without meds, my skepticism is like, was this person really someone with schizophrenia?

Were they someone who were like borderline per size or with some dissociation? and psychotic symptoms. Have ever thought about that? Many times. Many times. When I give a presentation, I have a couple of grand rounds that I can give where I have permission from the patient to show vignettes

from the interview with them. Yeah. They got all better. And I've learned from giving a talk a couple of times that I have to actually show DSM-5 diagnostic criteria for schizophrenia to show that the patient I'm going to present to you meets diagnostic criteria for schizophrenia.

And then when they see the patient all better, I still get an argument from psychiatrists. Well, this person's not schizophrenic. That's why they got better. Yeah. So there's a schizophrenic according to what criteria And unfortunately, one of the criteria, the implicit criteria that psychiatry has is that schizophrenia is a condition that doesn't get better. And if somebody does get better, the psychotherapy, that the diagnosis was wrong.

That's a madness of a different sort. That doesn't make any sense to think about a medical condition that way. if the person gets better, they didn't have it. That's like saying somebody's got cancer and they got better so they couldn't have had cancer in the first place. They must have had some other variant of something that looked like cancer. It all has to do with one's attitude toward the illness. And sure, there are misdiagnoses or one can argue about the diagnosis.

But getting better is, to my mind, it's a way of rationalizing the limitations of psychiatry. So we can say, well, the patient didn't get better because they have a terrible illness, doesn't get better, rather than saying, okay, the patient didn't get better. I did my best. I tried, but that should spur us to think, how do we fall short? How can we do better? why didn't the treatment work? And in my consultations with first episode of Teams,

a typical kind of consultation is the service that has been reasonably well trained in medication and oftentimes CBT techniques. And then as a psychoanalyst, I try to ask the question, why isn't the patient getting better? Why isn't the treatment really getting traction so the patient's improving? And one mustn't say they're not getting better because they have schizophrenia. That's a that's a tautology. That's a lack of ambition about understanding what the clinical problem is.

Here's a very brief example. I consulted some months ago with a patient who felt that he was being tortured by the government and they were intrude and they were giving him all these body probes and things going on. So the CBT therapist was diligently applying correctly techniques about, or could there be another explanation for the sensation that you have in your hands or your stomach exploring alternative explanations? And what was missing in the formulation, the reason the patient wasn't getting better is that the patient had, and as a psychotherapist, you'll understand this, the patient had a masochistic character structure

so that his suffering was actually the source of his self-esteem, was the source of his pride. And his father had told him, and this came out when you really listened to him, his father had told him, son, you will be challenged in life. so his psychotic suffering was a monument to standing up and to his father's expectations of him so he couldn't let himself really believe in the possibilities

of the therapy so that's somebody you could write off they got a nocognosia he's got a brain deficit he doesn't know no he was just different he had a different view about his suffering

and the therapist had to understand that in order to make an approach to him that would let him use the CDT techniques. That's good. It's good. I was thinking of several thoughts in there. One of which is there are people with NSOGIO that have brain damage from like strokes. Yes. Would you put that in a different category?

Definitely. Yeah. And I don't have it on my fingertips at a moment, but some years ago I wrote a paper about this, arguing this, the presence of something rather than the absence of something. And there are, as you know, there are clear examples of the biological deficit that leads to neglect of paralysis on one side or the other. and that's clearly the result of an identifiable brain injury. But even in those cases, there's a neurologist Yamashandran, I think, I'm not getting the citation right,

but there's some evidence even of psychodynamic forces operating in when you look closely at clinical anosignal. So, and Freud in his early papers about aphasia, clearly a biologically derived condition, he noticed that the words that people forgot, the lapses, the paraproxies, they had a psychodynamic element to them. So there's an interlacing of the brain and the mind in these ways. but for most folks, until proven otherwise, in my approach, one maintains an intent to understand. One assumes that the symptom is communicative in some way, that it's the patient's best effort to express what it is that they are thinking, feeling. It's the best effort they can make to coalesce their life history in,

a metaphor in an image. And then you you lean into that. You try to maintain the patients to understand. I never answered your question about, you know, okay, yeah, this is all philosophically, you know, very interesting and so forth. Yeah, but what about in the clinic, you know?

Yeah, okay. So let's get to that. Okay, let's get to that. The last two chapters of my book, which you have in front of you there, it's a template for how to introduce ambitious psychotherapy into public psychiatry. And so one of the elements in it is the idea that residency training programs and outpatient clinics in general should, in a very real. way, create protected time for one or two long-term ambitious psychotherapy patients and provide supervision for people to do that work. So the thing to do in the clinic is triage.

You have to triage because you can't bring ambitious psychotherapy to all the patients in the clinic. As you know, a typical case load for a psychiatrist in the general hospital is easily 200 people in the outpatient department. You can barely recognize the patient, you know, when you see them for treatment. So I think we have to triage. We have to identify a few people that seem like good candidates for psychotherapy. And that's not so hard to do. You can do that on the basis of a clinical interview. There's even criteria that you can kind of use, but you can get a feel for Yeah, this person, I think, might be worth investing the time in. And then you start with that.

And then the hope would be that when the psychiatrist feels a bit more adept at doing psychotherapy with a couple people, all of a sudden, they'll be able to say something that's on the mark with another patient and will improve the level of empathic relatedness to patients as you're not engaging in once a week. treatment and like that. The ultimate answer is revolution. It's a real change is needed in the way care is provided. And I think the way that would look would be a psychiatrist who is knowledgeable and skilled in psychotherapy supervising a clinical program where psychologists, social workers, people who do nothing but psychotherapy are supported and doing ambitious psychotherapy with psychotic folks.

And that's not a pie in the sky idea. It would take some doing to create that, but it's not impossible to do. Okay. Yeah. Yeah, I think that the one thing as I'm thinking about this is like the patients that I have that are doing, really well with what I would consider like true schizophrenia.

True schizophrenia. True schizophrenia, yeah. You know, they're on Clozapine 600 milligrams. And I have some that are like finishing grad school or, you know, they're doing really well. Or Ellen Sachs, you know, the center cannot hold. She's on, I think, Clozapine and Cyprexa in the end of the book. I've met her once.

You know, like, so I guess I'm just like wondering, is it, is it your thought that everyone will be able to taper off of antipsychotics if they just get the right ambitious psychotherapy? No. Is that what you're saying? No, absolutely not. Absolutely not. That the challenge for psychiatry is to try to be nuanced and sophisticated about it. so that in my experience with patients, most of whom come to me after years of being ill, I've not been very successful in completely withdrawing people from medication.

So that I have been successful in tapering down to lower doses, but not such good luck in tapering people completely off. I have been successful in assisting people to what I would say is essentially a full recovery who have been on medication, including clozapine, for I'm thinking one man who was being treated for eight years, he thought he was going to be arrested every day when he went to work. And with six months of psychotherapy, he wasn't afraid of that anymore. And the meds had not done that for him. So there are complicated interactions where there are some people who do very well just with medication.

And I would say supportive psychotherapy supporting their life and their work. There are other folks where the medication really, you know, it makes them more manageable in some way. But it doesn't restore their life and everything in between. So these are complicated clinical decisions to be made in collaboration with patients. So no, I'm not romanticizing, just give people psychotherapy and we won't be medication. That's not true. There's no mental health system in the world that has ever managed, including Scandinavia, that has managed psychosis without resort to neuroleptics at times.

Yeah. Okay. Another lingering sort of thought I was recently reached out to interview an author who... I want to get that thought that if they don't get better, they weren't schizophrenic out of your head, but we may have to do that another time. Oh, okay. Okay. With that thought in the book you talk about how it's like the delusion may still be there to some degree or the hallucination may be there, but they may think about it differently. Or they, you know, it's like they may not be influenced or they may have an increased awareness that it's not true. Talk about that, but it's still there. Like, what does that process look like? Is that the process we're talking about?

Yes, I think for some people, and there's some evidence for this in the few studies that have been done that ask patients, what's your experience on anorelectic? What difference does it make? And a typical response, I'm thinking of a series of papers by Mizrahi, patients will say things like, I still have that thought, you know, that's going on, but I don't think about it that much anymore.

It doesn't bother me that much anymore. So I think, And I'm not the only one, but I think that one of the ways that neuroleptics work for some patients is that they diminish the affective charge, the affective fuel that drives the psychotic symptom. So in that way, they are anxiolytics of a certain sort with a particular kind of condition. So if the person is less agitated, if they're calmer by the medication, they can distance themselves from the symptom. And judicious use of neuroleptics actually can open up the possibility of psychotherapy with some people because they can get enough distance on it that they can talk about it. So that's a way to understand that. So the person isn't all better in the sense that they're still preoccupied by the idea.

But that goes along in continuum. I suffered from the IRS for years until I got right about that. So it's a range of different effects from neuroleptic syndication. But you had another question you wanted to ask before I got us back on this. If you got better, you weren't schizophrenic. We'll put that to rest from them. Yeah, I think it means like, well, I think the question is like what is better, you know? And what is, like how severe of a disease?

You know, like there was a patient recently in my office. It's a pretty new patient who was jumping from topic to topic in a very sort of tangential way with a lot of paranoid ideation in there. you know CIA FBI Twitter you know the FBI is working with Twitter and no I'm joking that's actually happening and then he was he was like going through all this stuff and when I sat with him for a while

it was like and he calmed down he talked more normal but then when his mother brought up potentially you know putting a boundary on like funding his life or not funding his life, then he got really elevated again. And he started kind of like moving

and doing little paranoid hand motions and responding to internal stimuli. And it was interesting within like a couple hours of working with this guy the first week, how I could see so many varieties of functioning. Yeah. Yeah, what do you make of someone who kind of like has these lapses back

into more disorganized thinking but then can come out of it when there is a lot of calmness and like, you know, in the room, right? Compared to when there's more agitation or more... Well, I think it's related to what we were talking about that psychosis, it's a stress-related condition both in terms of its causality in many cases,

the complex PTSD stress of child abuse, and it also, your observation in the room with the patient, this has been demonstrated in research studies where they do random sampling on a cell phone where they call the patient up at a certain time. How are you feeling now? They do a symptom rating and understand the context of the patient's in.

So when a patient is waiting in line to get their Medicare, Medicaid recertification, their symptoms are sky high. They're hallucinating, they're delusional. They get home, they're watching their TV. They have a dinner, the symptoms come down. So psychotic symptoms are quite volatile, even though the core of the idea endure.

And that's where I think neuroleptics can be helpful in modulating that, you know, affective zone, keeping people in a zone, where they can hold a conversation. Until you mentioned that the mother was present or, you know, upsetting the patient, I might be inclined to tell a patient like that.

I don't think I completely understand everything that you're telling me, but I want to. I'm going to try to. But one thing, I do. understand, I think very clearly, you're quite afraid. So I would want to get some ground of understanding with the patient first about the affect, the emotion. So we may not agree about whether the FBI has him at the center of their attention, but I think one can easily agree that he's frightened. He's afraid.

that's a way to begin the conversation. It sounds like you see a lot of psychotic people in your practice. Yeah, I think it's something that's been an interest of mine. I think inevitably a lot of therapists don't know how to do therapy on psychotic patients. And so they kind of like refer them on, right? and I've done a lot of episodes on psychosis and schizophrenia and I think other people find me through those episodes. So, yeah. I know that true.

Yeah, I've done a lot of treatment resistant episodes, clozapine, blood levels, stuff like that, agitation, aggression. I've tried, you know, I feel like I'm pretty on board with slowly decreasing meds and seeing what happens, maybe a little bit more. Like if someone comes in, I'll often take them off of cogentin right away because I'm like, why are they on this? And then if they're on, you know, medications like depocode, it's like, okay, that doesn't really help that much unless you have true bipolar. So let's get you off that. And then see what, see what happens. you know and so do that while i'm doing some psychotherapy so it's something i enjoy see if i can clear up their brain their sensorium a little bit especially when they're cloudy from a lot of extra

mess that they don't need to be on yes yeah and then i think i think i get a you know there's like a desperation that happens i think in family members after a while of like what do we do and they go on a search of learning about psychosis and schizophrenia, and I get emails like that all the time. So try to connect them with the local doctor, if possible, but sometimes I'll talk to them and do a coaching session, kind of see what the situation is and what I would recommend. So this is a good.

This is a good episode. It's good discussion. I feel like we could probably do a part two or part three even. What's the new book that you're writing? the book has two parts to it the first part is a more a model for thinking about trauma and psychosis and how psychotic symptoms in many cases have disguised memories of traumatic experiences and we've talked about some examples of that you know this morning and i also want to make an argument in terms of basian brain science that my understanding of the way the Bayesian brain works

is that there's inevitable requirement for psychotherapy because the Brazian brain cannot correct its misperceptions of the world because it's constantly manufacturing a false reality that it's then iterating in a false way

And the only way to bootstrap a mind out of a psychotic state is another mind that the patient trusts. And so that predicts the inevitability of psychotherapy as a treatment for psychosis. And the second part of the book will be 50 examples of kind of case conference presentations with lots of transcripts, of what patients actually say, where I'm working with a woman who was a graduate from my training program some years ago, who had a very good year for understanding psychotic patients. So we'll have 50 examples in there, and the idea is kind of, well, you know, this sounds crazy, but no, this is what the person's saying, you know, a way to try to understand it. why 50 cases well you know if i told you i had three cases i could understand you could write that

off as well you're cherry picking right okay yeah 10 cases well yeah maybe you were like 50 50 if you got 50 maybe you got 100 maybe there are a thousand maybe there's an effort to understand everybody you know that you could make so that's the second book that's good Well, yeah, I think this has been a great discussion, and I'm curious if there's anything else lingering on your mind that you wanted to say before we wrap it up. No, I just want to thank you again for the opportunity to talk about these things, because your broadcasts have a reach, you know, that get the word out. and as an educator on psychotherapy in general and in this particular area, it's a real service to the public and other professionals to get people involved. And so I'm pleased to be included along with,

I looked over some of the other people you've interviewed, not just my wife, but some other, you know, very good people. So I can't say this about myself. but you have good taste in who you're. I'm trying. I'm trying to develop my, and you don't know how many people reach out and want to be on who I look at their stuff

and I'm just like, oh gosh, I can't do that. Like, I think I look for people like yourself who you've written a book, you've obviously done a lot of digging, you've done a lot of thinking about this topic, but you've also spent a lifetime in this role, right? And so you don't have a megaphone.

You don't have, you know, ad dollars broadcasting you forward. You don't have, you know, and books are accessible to some, but some people prefer to learn in other modality. So I really appreciate you coming on and giving you this chance, you know, giving the chance to my audience to hear from your wisdom. And, yeah, we'll leave it. for today.