Ep. 29 – Reality Check – Dr Irene Hurford

Good afternoon, welcome to Reality Check. Hi Serena... That was a lot of energy.

Hi, Serena. I know.

It was the same allergies we were just talking about. Hi, Serena.

Hi, we're excited to have Dr. Irene Hurford with us today. She is a psychiatrist, hey, who has spent from what I understand the entirety

Hi

of her career focused on treating patients with psychosis. She started this program in Philadelphia and the Heads Up first episode program. And we all connected or my memory of us connecting was on a call

around psychodynamic psychotherapy, which is one of our favorite topics. So I'm hoping that that inserts itself into the conversation today. But I just wanted to start by welcoming you and asking you to share a little bit with our audience about how you got into this work.

Yeah, that's right.

from a long

time ago. Yeah.

Sure.

Sure. So thanks for having me, first of all. It's really lovely. So yeah, so I actually went to medical school because I was interested in working with psychosis. So like really my whole career was about my interest in psychotic disorders. And that actually started because when I was in middle school, I read this book called, I Never Promised You a Rose Garden, which is a

Wow, yeah.

it's a memoir, although it's written as a novel about a young girl who has schizophrenia and gets cured with psychoanalysis. so lots of that was interesting to me. One, it's a really moving account of what it's like to be psychotic. And so if anybody's interested in sort of a first-person account of the psychotic experience, it's really very vivid. But also this idea that

psychodynamic approaches to psychosis or even meaning making. mean, when I was in medical school, and this might sound familiar, you know, if I walked into a patient's room and they were telling me about their overtly psychotic material, the attendings I was working with said, you know, look, okay, move on, like, don't engage around this, like, okay, the meds need to be upped, they can't get discharged yet, they're just psychotic, and we moved on, like, there was no interest.

in what is the meaning behind these symptoms. So that's kind of how I trained. So then I was in like a biological psychiatric frame of mind for a long time. I did research in genetics and cognition and schizophrenia. And then clinically, I was working at the VA where people with psychosis were often very chronically ill.

And I felt really discouraged because we just didn't seem to be making any inroads into actually improving people's lives. And I thought, you know, it might just be too late, like 20, 30 years into an illness. And at the time, globally, although not yet in the US, there was a lot of interest in first episode psychosis. So Patrick McGorry's work in Australia, the UK was picking it up, Canada was picking it up. And I...

I was really following along and I proposed to the city of Philadelphia, could we consider starting a first episode program like what is happening in other parts of the world? This was just before Lisa Dixon released the, I'm like blanking on the name of the main trial, the RAISE, thank you, the RAISE study. So that data was like yet to be published, but it was sort of happening.

The Raise

Raise.

And the city of Philadelphia to their credit really took a chance because before that was published, the profile of first episode psychosis in the US didn't exist. And we started the peace program kind of simultaneous to that getting published. And then along with the Raise trials getting published, SAMHSA released all this money to each state to develop these programs and we were able to expand peace and then develop the statewide center, which is heads up.

And that work was incredibly powerful and really meaningful. And I really felt like finally we're making a difference because these kids were getting so much better. And then we graduated them from the program in two years or three or whatever we decided to do. And I don't know about your data, but our data was pretty consistent, which was that a couple of years after they left the program, it was as though they'd never been in it. Like all of their gains dissipated.

And that was really disheartening. And we started a step down program and there were all these efforts to try to understand that. But I was also having several kind of revelations happening at once. The first was that it was becoming clear to me and really everybody working in the area that what we were calling first episode psychosis was really like end stage trauma and attachment disorders. Like these kids didn't need us.

at the onset of psychosis, they needed us like five, 10 years earlier. So that was becoming very clear to me. The other thing that was becoming very clear to me was that despite what I had been taught, which is that like, I don't know, psychosis is sort of random neuronal misfiring. There was clearly a lot of deeply held meaning in people's psychotic experiences. I just didn't have the training to really interpret it.

And so, amongst other reasons, like it's not quite that straightforward, but I left academia, left peace, left heads up and started a private practice and started analytic training. And I'm now finished analytic training. I'm still in private practice and I'm working with almost exclusively people with a history of psychosis or active psychosis.

And it's not that I'm doing analysis with them, although actually I do have one patient in analysis with psychosis, but I am working dynamically with most of them. And it is really powerful to have the vocabulary and the background to understand or at least be curious with people about the unconscious meaning of their symptoms.

like gives me chills. So what year did you guys start your program in Philadelphia?

Mm-hmm.

Mm-hmm.

And you and I actually met at a conference and you had just started Epic and you and I had a conversation like in person

about dynamic understandings of psychotic illness way back then. So I know we were both interested in it from a long time ago.

Mm-hmm.

Yeah.

Yeah,

Dr. Sirhari, you know, good friend and mentor was like my first intense connection to people doing early psychosis work. I could not, I mean, from the beginning could not buy into this notion that it was going to be a two or three year thing. And especially with

Mm-hmm.

Mm-hmm.

Can y'all hear that in my background? Okay. Well, I think that it's a Wednesday at 315 forever problem where someone gets their yard done on the Wednesday that we have set out to do this podcast. Yeah, there they are. And we don't even have like a lot of grass around here, which doesn't make sense. couldn't that whole idea

a little bit, but it's okay.

Surprise!

funny.

Ahem.

was just kind of strange considering, and then when you got into the work, considering how long it took for someone to come around to be able to like connect enough to go into some of the depth and then to just heal from the recovery, like going from, you know, a patient that we're to this weekend's graduation. And it was like,

His IQ is probably like 40 points higher than mine. But it took like a couple years for him cognitively to really get well. And then we could start doing more of the psychotherapy work. So we've decided to keep them. We don't discharge anyone, which is just because of that reason that

Yeah.

That's good.

specifically you said. And it's a big sell. It's just like, you have to really sell that idea, like in talking to stakeholders and other people.

how are you get well, I'm very curious about how you get that paid for. So it's interesting, because what before I did analytic training, I was like, why don't people retain these gains? And then after analytic training, I'm like, well, obviously, like, I don't know what I was thinking. But essentially, the way I think about it now is like, when people develop psychosis, they really like

Yeah

dissolved their ego in a way to talk analytically. I you could talk CBT-wise and say that they've sort of like lost the ability to mentalize or that their schemas have sort of fallen apart. I mean, there's all sorts of different ways to talk about it. But if I'm to talk about it more from a psychoanalytic perspective, like they really don't have a functioning ego when they're psychotic, I mean, kind of by definition.

Right.

And then what we do in these first episode programs is we sort of like

surround the person with all of this external ego support. We sort of like scaffold them and like literally like hold them up like a scarecrow on a stilt. Like we're like literally just holding them up. And then, yeah, I mean, if we're holding them up, then they can like do stuff and make progress. But then when we graduate them, we haven't actually done any work to help

them like reintegrate their ego really, we've just kind of held them together. So when they graduate, they just kind of like fall apart again. We pull the scaffolding from under them. So really, I think that either we have to, you know, as Ashley, you're doing like just keep them in a program forever, or we need to really think about how do we rebuild somebody's ego strength so that they are not dependent

We pull a scaffolding from under them.

on all of these external supports to keep moving forward.

so agree, and that's an eloquent way of saying, or just of putting into words how the team sort of becomes this like bigger object that one is relating to. And that, you know, it's traumatizing for people to lose that.

Yes.

I mean, it's like we're talking about early attachment disorders. I feel like, especially for my people that already, I mean, most people come with some attachment issues that we're almost like redoing it and making them relive it. And I remember.

Mm-hmm.

Yeah.

Yeah, mean, absolutely. And that and the like

high turnover rates, which I don't know if you guys experienced, but we certainly did.

I don't even want to say anything out loud, but we are very lucky, blessed, whatever, to have like, I was telling Patricia the other day, was like, y'all are really like some of the best psychotherapists on the planet. Like truly, like you really are. I mean, and I hear it when I am in meetings and hearing them talk to other people, I'm like, oh my gosh, they're like the real thing. And we,

That's amazing.

I remember had a patient a few years ago when Serena and I were like, we've had to contemplate this longitudinal program a lot because of our census, you know, ever increasing and us having this evolving need for team members. And one of my patients was like, if you had asked me if I was ready to graduate and knowing that I trusted you when nothing made sense,

Mm-hmm.

Mm hmm. Right. Yeah.

to me and then if you were to tell me I'm ready to graduate, I would have said, absolutely. I trust what Dr. Weiss says, even though it's not what I feel I want or need. But if I was able to trust her then, I definitely should be able to trust her now that I'm ready. But I don't feel, I feel like this is what's keeping me, what's keeping me okay. so it is so complicated and so much.

Mm-hmm.

Yeah.

more complicated than a graduation.

Yeah, I couldn't agree more.

And I think no matter which clinical approach you take, be it psychoanalytic, be it like a systems approach, like a young person who has had a, has a trauma history and is experiencing a first episode of psychosis is often not ready to move on to another system of care after just one or two years. Like baseline, and it's the same, we bring this up often is

Mm-hmm.

you know, any other physical illness. Like you're not gonna, you know, take someone with cancer or a heart condition and just throw them out into the wild and let them find another provider. I also wanted to just bring it back to two things that were said already. One, I love that you referenced, I Never Promised You a Rose Garden and we just recently read it. It was a reread for me too and I was definitely struck by it in middle school, but it was a read in our EPIC in our book club that some of the,

you

team members partake in and so struck by the power of the psychiatrist, right? And we were talking amongst the team about whether or not, you know, long patient, long inpatient stays could and should be part of the treatment again, right? We want anyone to be removed from their home, their family for that period of time.

Mm-hmm.

Mm-hmm.

But the power of being able to be in a conversation with one human that can hold you and help you, right, heal and sort of prepare the ego is so powerful. And so I just, appreciate that you brought that up. And I think that's very much at the heart of right, what we're all trying to do. And then the second part, I was going to comment on our team and just how wonderful they are. And I just think it is, it is

Mm-hmm.

challenging in this work to find like-minded clinicians. And I think we have found like-minded clinicians who are passionate about serving this population, and that has helped with our retention for sure.

Yeah.

That's amazing. think that we, PEACE was, know, even though I'm, I was at Penn, PEACE was run out of a community mental health center where the staff were not attached to the university. Like I was sort of contracted out to run this. And so I think in community mental health centers, unlike university settings where there might be some other advantages and, you know, tuition discounts and very nice like benefit packages and sort of some golden hand, I mean,

I hate to say golden handcuffs, but like some other reasons for retention. In general, community mental health clinics do not have great retention in part because they don't have great advancement opportunities, but also because, you know, this work is incredibly draining and difficult. And like, I don't need to tell you guys, but people with psychotic illnesses have a lot of

Mm-hmm.

and

Bye.

like psychological needs, their families have a lot of psychological needs. And, you know, we worked with an inner city Medicaid population that had a lot of just pragmatic needs. You know, we would have these situations where like someone would get so much better that they were like actually like a spokesman for a program. And then their family home got infested with bedbugs and they couldn't afford to eradicate them.

but our patient couldn't sleep anymore because they were being literally bitten all night. And we were never able to get that person stable again after that. takes a toll on people after a while. And so we, I think, suffered attrition for lots of reasons. But one of them was just the work is really difficult. And there's an easier way to make a buck out there, really.

Yeah.

Yeah, I mean, this is the story of one of our patients currently in this moment. The Golden Handcuffs is like a perfect way to describe it. We started this program, started within a community mental health center. then Louisiana is interesting because that

Mm-hmm.

Okay.

Medicaid has been privatized, so there really is no true community mental health center. There's probably a private equity firm behind most quote unquote community mental health centers. However, being faculty did create an opportunity for the School of Medicine and Department of Psychiatry to step in when this company was looking at

Hmm.

see.

Mm-hmm.

Financial instability to the point that they were going to disintegrate and we had, you know, a hundred patients already and their families. And so we just sort of transitioned into kind of a big private practice where we're billing, collecting, luckily have, you know, LCSWs and LPCs that can be staff, you know, that can have jobs within.

Mm-hmm.

Mm-hmm.

Mm-hmm.

our department, like from a system standpoint, we definitely couldn't do it alone. And just being, know, having, I think the handcuff part, what makes it gold is like, even though we don't have people, all of the people working with us, there's also other learners, there's other teachers or other supervisors. There's support for, you know, I was with a patient earlier this week and like,

Mm-hmm. Mm-hmm.

Mm-hmm.

Yeah.

call my boss, like, because she's so sick and I don't know what to do about it anymore. And we all, have connections like that, that can keep us kind of.

Mm-hmm.

Yeah.

Our infrastructure

is strong and therefore we can do this work to create a lasting infrastructure for our patients over time.

Yes.

Mm-hmm.

Yeah.

Yeah,

that's huge and very special, like very unique, I think.

It

is and just I was just reflecting on the fact that four of us started at Community Mental Health Center and we're still together 10 years later, right? One, two, five, five, which is that is really special. There is we have a very, very, very special team and I don't think we have enough opportunities to give them a shout out. So if any of them have any less infamous, want to tell them that we appreciate them.

Mm-hmm.

Right. Yep.

That's amazing. That's really special.

That's really lucky.

You

It's not like

a direct ask for all of you to listen, but a strong request.

We go back to, right, this is a systems issue simultaneous with it being a clinical issue. And we have to be able to give good continuous care to young people while at the same time work in a system that supports that so that we can work at a clinical level and maintain our patients and or in a private practice capacity where they can.

Mm-hmm.

And honestly, I think what you're doing is amazing because we have zero places to refer our patients, which is in part why we kept them. And to have a community member, I believe it takes all parts. You need clinics like ours and peace, and you need humans like you out in the community who can give them really, really good care.

Yes.

Yes.

Yeah.

Well, thank you. Yeah, I mean, I don't know, maybe like sometimes like I don't it's you know, so so it's interesting. When I worked at peace, there was really no one who was like too ill for our program because we had so much support. I mean, they were like, you know, like when I was there at the height of it, there were like 15 - 20 staff learners, know, people.

I don't know how you feel.

you

on the team. so even if someone was really like extremely ill, we had a lot of support for them. Someone could go out and see them every day if we needed that. People could meet them in their homes. In the beginning, I had the flexibility to go to people's homes and I did that a lot. And now in private practice, it's just me and I like that I have a lot more sort of

you

like control over how care is delivered than I did once peace got very big. Once peace got very big, it was hard for me to like feel like I had a good understanding of every single patient that we were treating. But there now there are people that are too ill for me. Like, can't, know, because I just can't see somebody in their home every day. Like I can't do that.

It is different and it's meant that the kind of person I treat with psychosis doesn't look like the kind of person I was treating with psychosis all the time at peace. Like they're not exactly the same. For one thing, people have to want to see me, which was not necessarily true at peace. Like we could work with people whose families wanted us to see them, but they didn't. Whereas now, like the...

.

you

Yeah.

would be great if the family wanted me to see them that is actually less important than that they want me to continue to see them.

Well, brings to mind, I mean, what we experienced at Epic kind of have moved to talking about just early psychosis and not this like first episode of just seeing how different every individual is. And, you know, in the beginning we would have, five referrals in a row that just did amazing.

And then we were definitely having patients same, look the same on paper maybe, but just there was nothing that we were doing that was like stopping this train that was happening. And being ready for that as a clinician of like, that's the expectation is that people are gonna kind of go down different paths and that you've got to.

Yeah.

Yeah.

be ready to be flexible and you have to be ready as a clinician when they're ready to go down a more intensive psychotherapy path, like to be ready to go because like you can't throw away those opportunities. You know, when someone is like knocking on the door with a major attachment or psychodynamic issue, like you can't call it, they just don't want to come. You know, you got to like do it, address it and

Mm.

Yeah.

push through and it's hard finding clinicians that are comfortable with that.

that takes me back to inadequate training, I believe clinical professionals have, be it in social work, be it in medicine, around psychosis, and that needs to strengthen so that, right, that different parts of the field can all have an awareness of symptoms, know, get people, identify them, get people into care early, and they care for them over the course of their lives.

Mm-hmm. Mm-hmm.

Mm-hmm.

I don't, in all honesty, I mean, we're totally willing to keep whoever wants to stay with us, but I don't know that everyone needs to stay with us, but people need really good care outside of our clinic if they're not gonna do it, which, you know, makes me excited to think about people like you out there, you know, providing it. It's not for everyone. And no, you can't, shouldn't quite honestly be seeing people who we're seeing. They're two different piles of care.

Right.

Mm-hmm.

Yeah.

Yeah, and it's interesting, like thinking about the type of people that might look the same on paper, but have very different outcomes. And I'm sure you think about this a lot. I certainly do. what, how can I predict early if somebody is going to respond well or not well to like, for instance, a psychodynamic treatment, but it could be any treatment. doesn't have to be psychodynamic.

Mm-hmm.

My child fellowship is very zero to three focused. So we have, cause we have like infant mental health experts here. So to me, it like made sense. I was always sort of thinking, and I wonder about this and want to actually wish like this is on our.

Mm-hmm.

Serena has a long list of like study agendas, is to look at people's attachment style and then look at predictors, predictors of not just like medication adherence or whatever, but these longer term predictors that would be markers of better like ego integration, even in the times of stress and, you know, being able to function more independently.

Mm-hmm.

because anecdotally we see it all over the place. and, you know, and would that be better for the system to look at people more, or to even have that question in mind when people are coming into care that like, need to understand that part of them in order to do this team thing because

Also, I would argue that not everybody needs five and oop people in their life. Like some people just need their doctor and their therapist and they don't need a peer support. They don't need, it's like, it's something that we've prescribed to them without.

Yeah, agreed with that.

Mm-hmm. Yes, I agree with that.

without even

like evidence.

I know many of our patients who agree with you.

right. And then there's this whole issue of, but then is, are you adhering to the evidence-based model? And I would say, like, we need to be flexible. I mean, to be sort of rigidly inherent is for like who? It's for us, you know, it's not for the patient.

Yes.

and even like the evidence-based model that we somehow created in the United... I mean, I think that's like an argument unto itself and what population that looked at and whatever, comparatively, how can you outperform? I mean, nevermind. But speaking of a little bit controversial issues, I would love to...

Mm-hmm.

Yes, for sure.

Get your opinion on how it's been as a more psychoanalytically focused clinician dealing with probably some of the people that have their own opinion about psychoanalysis and the history and what that's been like for you in this journey.

Mm-hmm.

Yeah, I I think it's helpful that I didn't start out psychoanalytically, like I started out biologically. So I feel a little bit more empowered to say, listen, I tried the biological model. I mean, if it had worked, I would have stayed in it. It doesn't work for me. I think, you know, one of the things that's important to recognize is that because we really don't understand the brain very well, which we don't, our models of the brain

Mm-hmm.

are inherently metaphors. They're metaphors, right? So for me, the metaphors that we were using to understand psychosis biologically just fell short compared to the psychological metaphors, right? Which are also metaphors. I also am not a Cartesian dualist. So I don't think that the brain and the mind are different. So if I want to talk about

Mm-hmm.

psychological reasons for psychosis, to me that doesn't mean that there aren't biological correlates for the psychological reasons. Like to say something is happening at the level of GABA neurons doesn't to me in any way mean that it isn't also happening at an attachment level or an unconscious fantasy level because all of those have biological correlates which we don't understand very well, right? So,

So then it comes down to like, so one of the things that I think makes analytic understandings of psychosis controversial is the role of the family and the mother. Like, so ideas like the Schizophrenic Mother and things like that. while I certainly appreciate that that really led to mothers and families feeling incredibly like shamed by their children's illness.

I think to go completely in the other direction and say families have really nothing to do with their children's psychosis is as wrong as it is to say that they have everything to do with it. I have not met a lot of family, I mean, it's not zero, but I've not met a lot of families where I was like, well, I just can't imagine how you contributed, right?

Mm-hmm.

Okay.

These things are so, these things are so nuanced. So for instance, a child is born with their own temperament. Temperament is genetic, right? And maybe intrauterine. But like, everybody who's been a mother of more than one child can say, these children were different in utero. Like my kids were different in utero. They had different movement patterns, like

Some of them I was like, are you in there? Like, are you alive? And other ones were like bouncing off the walls. children are different temperamentally. Temperamentally, parents and children can be mismatched. And that's not like, it's the parents fault. That's a mismatch, right? A very exquisitely sensitive child born to a fairly insensitive parent. That's not a great match, but it happens, right?

Right.

All

right.

And then, and then parents, I have never met a parent who didn't love their child, although I've met some parents who hated their child, right? Loved them, but hated them as well. I've never met a parent who didn't love their child, but I've met a lot of parents whose own trauma prevented them from parenting their child the way the child needed to be parented. I don't consider that the parents fault.

I consider that the intergenerational transmission of trauma. However, what it means for the child is that their parent was not able to meet their psychological needs in such a way that they became more vulnerable to psychosis. And I have lots of thoughts about like, what exactly is that pathway? So to your question about the controversial nature of it,

I think it's controversial because I think we have a lot of wishes and fantasies that we can decouple parental responsibility from child outcome. And I think that that is a fantasy and a wish.

Yes.

We are, this type of idea came up recently in a talk that Dr. Zena gave about when, know, science and systems and politics sort of are not communicating. Like when we're talking about the, you know, they primarily take care of children that have come into child protective custody.

Mm-hmm.

Mm-hmm.

And we know about this like exquisitely sensitive period. And when reunification is even the science that we know about attachment, we know that that's not going to give the best outcome for this kid. And we continue to do it.

Mm-hmm.

Mm-hmm.

Where do you envision the next five years and what you would like to be doing in this work and maybe other exciting things on the horizon?

that's a nice question. Well, the last five years were really like being in a new private practice and also doing analytic training and hoping that those two things would start to help me understand my patients better because I really came out of peace feeling like I certainly understood things better than I did before I started first episode psychosis work, but

Okay.

that had left me with a lot of questions. And now that I'm finished analytic training and I'm in the practice, it's been five years, I have different questions, but not fewer questions. So that is, I guess, like the nature of reality is like you're never done learning. I have started writing more on Substack because a lot of the things I want to write about are

Brave.

Right.

maybe not like what I think would be suited for academic journals, but I would like the public to have access to. So I'm hoping to do a lot more of that because I think that there are things that people should know, people who have psychosis, people who love people with psychosis, people who treat psychosis about the

Mm-hmm.

dynamic reasons that people might have psychosis, but also like what is it like to treat people with psychosis dynamically? So I'm doing a lot more writing and I'd like to continue that and see where that leads.

I

I think that I'm coming to appreciate like a lot of nuances about this work and one of them is just how incredibly difficult it is. Not that I didn't know that already, but I think that I had my own fantasies, like we all have our fantasies, spoken like a true analyst, but like I think I had a fantasy that the work would get easier when I understood it better. So like.

You

When I was at the VA, I was like, well, it'll get easier when I work with people earlier in the illness so I can understand it better. And then when I was working with people earlier in the illness, I was like, well, this is really hard, even harder than the VA, but it'll get easier when I understand the analytic, like unconscious motives and fantasies and conflicts. So then I did that. And now I'm like, no, God damn it. It's just really hard work. Like there's no getting easier because I learned the right thing.

Yeah.

it's very hard and that actually brings me back to the issue of why do some people not get better, right? Like, and I have a couple of thoughts about it. One is that people who are people whose psychotic fantasy structures are grandiose or narcissistically gratifying. So I'm God, I'm Jesus, I'm in, you know, this, the celebrities in love with me, I'm

Taylor Swift, whatever it is, when that's the fantasy, it's really, really hard to get somebody to let go of it. Which, again, it's like, why did that not occur to me sooner? Because it's really obvious when you say it like that. But I think that because maybe there are some, again, like wishes.

that psychosis is always unpleasant for people and people in their right mind would never choose psychosis. It was like the question wasn't asked or at least it wasn't asked for me. But I have lots of patients where I'm kind of offering them like the worst deal ever, which is give up this fantasy that makes you feel incredibly powerful and special. And in return, I'll give you chronic mental illness and no future. Like who's going to take that deal?

Right.

Yeah, and this system,

it doesn't respect your care.

Like, nobody would take that deal.

we have lists of mutual patients like this and we've, um, you know, my first, I kind of feel like the holding, like in the therapeutic relationship, we have to hold different perspective. Um, and in your own life, right? You're like maintaining multiple paths, so to speak, and perspectives.

And I remember telling one of my patients that has grandiose delusions when he is not well, that like, cause he really wanted love. That's what he said. And I was like, what do you want? know, besides this fantasy that he's God and he's gonna, you know, he's like in charge of that. This is what was happening. He said love. And I was like, okay, so we were working like just like a date.

having a date and wanting to fix, wanting to heal the world, it's not gonna go well over pizza. And like, so can we just hold that on the side to allow for this person into like a view into you, in that you're not wanting to save her. And it was...

Mm-hmm.

I think something that we like carry with a lot of our patients is that there's like multiple realities that we all have to hold onto. And there's moments that are very vulnerable. and when, and it's not to say that they're bad or they're good or that it's just another one just makes it's complex. Like how do I navigate this without feeling the need to like heal microorganisms? Like,

Yeah.

Yeah.

Because I could maybe have a fantasy of doing it all, but then that doing everything fantasy hasn't worked out really well for anybody.

Yeah.

Right.

Yeah, and

yet we're, every academic is like struggling with that same fantasy.

Right. Exactly. This is why

I gravitated towards Dr. Garrett so much is because of the, while it is very serious and like we all, it is very serious that he's able to like bring kind of a real life, not humor, but like that part of humans to like come out. And it's really awesome to see patients when that part.

Mm-hmm.

Mm-hmm.

Yeah.

can come into the conversation, you know, that they can like laugh and cry in the middle. And that's completely normal. And,

Yeah, for sure.

Mm hmm.

think your example is a fabulous one, which is that like, in the midst of wanting to be God, this patient was also able to say, on some other sphere, like on some other in some other realm of reality, I just kind of want to date somebody, right? And as you say, like hold those two in some ways at the same time, although not exactly. Yeah, and

Mm-hmm. Right.

But it's tricky. It's really tricky for those patients because I think the seduction, like the lure of their psychotic worlds is really intense. I think we underestimate how much we are asking of them when we ask them to give it up.

That's true. Totally.

Absolutely.

absolutely.

No, absolutely. I think

I personally on a clinical level, like struggle with the reality of what we're able to give because it's not what they have.

Yeah, it's not great. It's not great.

The other group that I find ultimately doesn't do well is the group for whom like being ill is a way to punish the people who disappointed them early in life. Where like for all sorts of complex psychological reasons, they have chosen being ill

as their way of exerting some control over a family system where they were often had no control. And they are reluctant to give up the destructiveness of mental illness because it would like let their family off the hook. And those are specifically the words that are often used. I can't let them off the hook. If I get better and graduate high school, they'll be off the hook and I can't allow that kind of thing.

And.

If a patient doesn't want to get better, they won't get better. And that's true for depression. We see that a lot in treatment resistant depression patients where like, on one hand, they do wanna get better, but there's also some very complicated reasons that they do not wanna get better. And it's very true for psychotic patients, especially psychotic patients who might be like organized at a more sort of borderline level of.

Great.

to maintain it.

personality organization, I'm not talking about borderline personality disorder, but where their core issue is around like attachment issues, so around abandonment, around symbiosis, they may in particular use their illness as a way to exact some revenge and also try to control the family that they felt let them down in these really important ways.

And then the reverse happened, or then it happens with the family that their loved one can, they adapt to maintain their loved one as the ill person that as a way of, as a way of explaining their own potential contributions to the situation.

Mm-hmm.

Yeah. Right.

for sure. Well, the patient who's actually holding the family together by being ill is another kind of patient that may not have a great prognosis because if the family system is so chaotic and dysfunctional that it only really works if the identified patient is a patient, then they might out of love this time instead of out of anger feel like they cannot get better.

Mm-hmm.

Right, you're ill.

Yeah. One more thing I would like to hear. What are your, so our most difficult, I would say, are young people with, not particularly young, but just people that have more disorganized behavior and disorganized thoughts. Not loosely associated, but like,

Ugh, I want to continue this conversation.

Sure,

absolutely.

Mm-hmm.

the disorganization is severe. And as you were talking right now, I mean, I have my own like formulation about how and why disorganization takes form psychologically, but, and as a way to almost, I'm just wondering your thoughts about disorganization before I go down a rabbit.

Okay.

Well, I'd love to hear your thoughts. mean, I think that like, well, I have a lot of thoughts. One is that actually,

you

thank God, disorganization, unlike delusions, actually gets so much better with the antipsychotics. And so I'm like really grateful for that because it is so difficult when you can't be sure that a person understands you and you're not sure you understand them. But I think that that might have protective,

Qualities right so if somebody is is now we're talking more organized at a psychotic level than a borderline level if they're organized at a psychotic level Then one of their greatest fears is that like to be close to someone is to be swallowed up by them to be engulfed by them to be no longer their own person in any way and By not speaking a language that can be understood and by not behaving in a way that can be understood

It's an amazing protection against that fear of engulfment. However, know, psychotically it's been held. But then the D2 antagonists do their thing and people get a little bit more organized.

I just in particular thinking of a couple of my patients that there was the element of paranoia, delusion. And then, you know, as you see sort of progression.

Mm-hmm.

which is I think where the biology does come into play so much where you just see sort of the like cognitive order and everything just really starts disintegrating even with like functional movement, with movement and intention. Like it's all disintegrating. actually the two of those people have really significant

Yeah, yes. Yeah.

attachment issues. And some of the like affect, I guess, within the disorganization, and one of them is sheer rage. And another one is really this, like intense desire for love and connection. So it's like a very different. It's a very, it's like disorganization that

Yeah.

you

if I were to write a mental status exam and be like thought process, like nearly word salad or like, and, but the affect behind it is on the different spectrum and, looking at their family of origin and looking at the dynamics within the family, especially that, that I, you know, I don't think that it's necessarily.

Mm-hmm.

I don't know what I'm doing with them, right? Like I'm having trouble managing it and also understanding it and understanding like medication choices, but also managing the rage, which rightfully so. Like when you do, it makes me, I feel rageful and so sorry. It's just cause it's so horrible that, know, the toll that it's taken on her.

Mm-hmm.

Yeah.

family that it makes sense. But, you know, just thinking when it's maybe that too difficult to bear, you know, that it, you know, it loosens up even more as a protective.

Okay.

Yeah. Yeah. Well, I mean,

you know, there's like, again, sort of thinking analytically, I mean, autistic withdrawal is like one of the most primitive defenses we have. And we see it a lot in patients at the psychotic level where they withdraw very much into themselves into so like that they're almost not there anymore. That's right. That's negative symptoms. But

Right. As a negative symptom.

but also as disorganization symptoms. The other possibility is that if all defenses fail a person, then they become very fragmented, right? And that might also be at the core of this. If they're really that very, very ill person, they might be truly fragmented. But know, catatonia, like what treats catatonia? Like anti-anxiety meds. Like that, if that isn't dynamic, I don't know what is, right?

Mm-hmm. Mm-hmm.

Right.

Yeah.

Right,

Well,

Exactly.

Our brain chemistry was actually very psychologically wired and minded. It was ready. Everything was ready to do this complicated thing, such as becoming an ego.

Yeah.

I mean, again, we're not, unless you're Cartesian dualist, if you're talking about the brain, you're talking about the mind.

Yeah.

in so many arguments with other physicians about how, why I can't believe you keep someone on benzos for so long. And they're my people with catatonic features and they usually have disorganized features. And I was like, to leave them like laying in their bed, like caught in a body and like caught, like, what are we talking about?

Yeah.

Yeah, 100%

Do you work with Dr. Claret at all? Yeah, I was just thinking you should come to her consultation with him, monthly consultation. All right, I'm gonna send you the link. I just think this is you share a very similar clinical perspective to our team and I think it would be really fun to have your voice at the table.

Mm-hmm. I do, yeah.

Yeah. Yeah.

Anytime, yeah. Let me know. Okay.

yeah, he

He was a great mentor to me when I was first at peace and before I did analytic training. And he was very instrumental in me deciding to do analytic training, actually. Yeah.

Thank

Yeah, this journey

is really inspiring.

You

know, we have a psychoanalytic institute down here in New Orleans. I put off the psychoanalytic psychotherapy training because this fall was just getting too wild.

Maybe you'll pick it up.

one day.

Yeah, they'll talk to you and

get encouraged.

Yeah, I mean, I will say that I like failed out of being both an academic and in analytic training. was like, I have to choose. Like, I want to do the analytic training. I cannot do both. I also had like a lot of little kids at the time. It just was like not happening. But some people have more energy than I do. So maybe you can do it. You can do it all.

Yeah.

You

thank you so much for joining us.

Such a pleasure.

I know, thank you.