Ep. 25 – Reality Check – Dr Michael Garrett (SUNY Downstate Medical Center)

Good afternoon and welcome to Reality Check. It's Serena.... and Ashley. And we're here today with our mentor and friend, Dr. Michael Garrett. Welcome to Reality Check, Dr. Garrett.

And Ashley.

I'm delighted to be here.

We're delighted to have you.

It's

We met Dr. Garrett years ago, a lot of years ago at a conference.

my gosh, it was a lot of years ago. It was a

ISPS in Portland.

Portland.

Yeah, yeah, yeah,

yeah. It's all coming back,

you

Hahaha

And we heard your presentation and we're definitely struck by the manner in which you presented and the compassion that you brought to the case you presented. And we were struck so much so that we decided to approach you after your presentation and present our challenging case to you. And you were so gracious with your time and your sharing your expertise.

Sure.

laughs

that really made an impression and so much so that a couple years later we asked you to come on and do a consultation with the Epic team and that you've done for several years now and it's been amazing.

What goes around comes around, including goodness in the world.

You

Yes. I would love to, for our listeners, for you to speak about what you do in terms of psychotherapy or people experiencing psychosis and like try to put it into, or put it into words for, you know, non-therapists, non-clinicians, but to like give listeners the

Like what is behind what you're trying to do, how you're trying to help an individual. Yeah, we'd just love to hear you explain

As you know, we could probably talk for a long time about that, but how to be precise about it. I think one of the things that happens almost inevitably to people who receive a diagnosis of schizophrenia or some other Axis I disorder is that they become defined by that. They're defined by that, by the community around them, by family, by clinicians.

You

it's important to make a diagnosis. But what I try to do when talking to a person who suffering from psychosis is to relate to them as an individual

guess I would say that the emotional essence of it, the heart of the matter, is to find a way of listening to people who are suffering from psychosis, to listen to them as more ordinary people who are trying to express things about their life history, things about their current experience through the somewhat disguised metaphorical discourse of psychotic symptoms. So if you assume that

what a psychotic person says is meaningless and that it's just an aberration from a genetically determined brain disease, you're going to listen to the person in a very different way and they will also have a very different experience of themselves. So if you listen to people as though they're a diagnostic category, that becomes, it's devaluing of the person and their personhood.

gets lost in the diagnostic category. I've been at this for a while, decades. And it didn't come all at once, but I'm happy to say that with most folks, I can sit down with them and have a conversation as though I understand their language. I understand what the concerns are. It's like being able to speak

Greek or something like that. And sometimes they're puzzling things. But I hope to convey to the person the idea that I'm seeing them as a human being. I take them seriously. I really want to hear about their sorrows. And I want to engage with them, not as a diagnosis, but as a person who is ⁓ suffering from

most likely bad stuff that's happened to them.

I love the fact that you brought up the idea that everything one says matters. And it brings me back to some pearls of wisdom you shared in our consultation about there's meaning, there's meaning behind everything that is shared and said in a session. And that has stuck with me in something. It is something that I think about constantly when I'm providing therapy to patients.

One of the ironies, I think, actually, is that, of course, it depends on the individual, but for the most part, a person suffering from psychosis says something that's quite significant, like every five seconds, because there's no room for a chit chat. There's no room for, you know, sort of idle, defensive, you know, meandering. Everything's a bit more desperate and essential than that. So it's, there can be a surprising clarity.

actually when the mind turns inside out and you see a person's deepest concerns dramatically portrayed in a story as opposed to trying to get through to somebody who's very heavily defended and keeping you at arm's length at all times.

So from my clinical perspective, the fact that you treat each of these conversations as, you treat each of your patients as a real human who they are experiencing life in your attentives to their feelings and their thoughts and their reflections. My clinical perspective is that this facilitates recovery. And I know you have been very focused on that process in our consultations.

I love you.

you

And I'm curious what is surprised you most over the years that you've been doing this? What is surprised you most about one's ability to recover or the recovery process in general?

Yeah.

Of course, it's quite varied. And I would say that on the one hand, it's important for clinicians to have ambitious goals for patients, even if they can't always achieve them. Because having an ambitious goal for a person is a form of believing in them, believing in their possibilities, believing in their future. And over the years that I've been doing this,

There are a good number of people that I think I've helped to a significant point of recovery in their lives, where they've gotten their lives back. But something that I've learned over the years was that, and this is probably a naive idea when I was beginning, that it's the long game. And folks remain fragile.

so that you can help somebody to a state of recovery, given the current relative stable conditions of their life. But then life deals you cards points. And then in the future, something may change, which again, destabilizes the person. And then they may drift back into the same kind of seeing the world. And so they need additional help. dramatic recovery.

over a period of time, it takes months, sometimes even longer than that. It's definitely possible, but people remain ⁓ fragile and need to stay in connection with therapists ⁓ or a clinic or a service like you all have that can help keep them healthy.

Can you give us an example or listeners an example of kind of what you mean by like the metaphor? Is that, you know, I think that there's a.

you

maybe a, it's hard to step into the shoes of someone experiencing psychosis. And then it's really challenging, especially for new therapists or for therapists at all to then know kind of how to manage what's being said or how to manage the content in a way that. You know, get that leads them to feel like they're offering something helpful. You know, know a lot of my time.

Right currently right now the people I'm supervising in psychotherapy. It's like always this urge to like do something help really do something or how do I make sense of this and It was very useful for me of like learning to see things through a different lens and being comfortable with kind of exploring a way to connect what someone is saying to

something that I can understand too, but could you give an example of kind of what that metaphor might look like in a session?

Sure To underscore what you were saying if you listen to people with the intent to understand the meaning of what they're trying to convey and assume that there may be a metaphorical dimension to it or that it's more like listening to the content of a fairy tale or a fable Where things that defy conventional reality occur in fairy tales and yet we know what they're about

know what the source of the story is. So if you make that shift and you're listening in a metaphorical frame of mind, and also with genuineness and earnestness, you try to clarify with the patient, giving them feedback. And this is something that I think that any early career clinician can learn, paraphrasing what the patient is saying, not like a parrot just repeating something rote, but

more this way, if I have it right, that's when you really felt frightened. Or if I understand you correctly, it was that moment that led you to a real sense of despair. And this conveys to the patient that you're trying as hard as you can to really see the meaning of what they're conveying to you. So here's an example. I recently consulted on a patient who was admitted to the hospital.

And in her chart, the central problem that presented on admission was that she got into ⁓ a conflict with her family because she was adamantly demanding with her family in a strident way, in a way that got the family to take her to the emergency room. She was saying over and over again, a 10-year-old girl deserves a birthday cake. A 10-year-old girl deserves a birthday cake.

And and was kind of in a in the loop, you know about this Now the clinician the listener has two directions you can go with this one is this is the incoherence of a genetically determined brain disease or No This is a this is a sad story about a little girl who didn't get a birthday cake and

that this is her metaphorical way of claiming that she's been hurt, she's been not adequately taken care of. And we know in the story who the real person is who never got the birthday cake, it's her. And it's easier actually, but it's lazy for clinicians to dismiss this. She's delusional, this is incoherent.

Right.

loosening of a self's birthday cake. No. This was a symbolic condensation. And if I asked you, either of you, could you condense in one metaphor, in one sentence, the central theme of your life? You'd have to struggle at it a bit. But she did it. She did it. Every 10-year-old deserves a birthday cake. Boom, there it is.

Right.

you

truth

It's

the whole thing. clinicians actually possess a lot of the skills and empathy that they need to understand what the psychotic story is about. But they have to make the shift to the idea, this is a meaningful story. This is not just something to be categorized in confirming the diagnosis of psychosis. It takes probably 10 seconds.

Understand that a person psychotic that's the beginning of it. But the real question is what's the story about? What's being expressed in that so? So yes all 10 year old girls deserve a birthday cake they they deserve a celebration a joyous celebration of their birth and their importance and the fact that the world welcomes them and cherishes the fact that they were born And she was pointing out

That didn't happen to me. And she's standing up for all 10-year-old girls by proxy in the delusion.

I should add. Now, why would her family be irritated with this claim? they're the ones that didn't make the birthday cake. That's

It didn't make the birthday cake. Exactly.

Maybe a hint of guilt.

the work that is you've been doing this work over the many years you have, do you think your idea about schizophrenia has changed?

Yes, yeah

How so?

I probably shouldn't say this, but I'm even more confident of it now. I've come to think about, and I'm not the only one, there's more evidence, and I know that you all are of like mind, I've come to think of schizophrenia as a trauma-related, stress-related disorder. And it's a phenotype.

of an expression of ⁓ sorrow, where I think genes and biology play a big role in the selection of the phenotype. But the driver of the whole thing is given the very high risks of psychosis with abused people, people who have had very hard lives. That's the driver of the process. And then what happens is that people deal.

with the sorrows in their life in different ways. And somebody that has a biological predisposition to psychosis, mind fractures along the familiar lines of voices, delusions, and their mind goes in that direction to deal with their sorrows. People that don't have those fracture lines for biological reasons, they deal

with their trauma in different ways. And that's when you get, for example, pure PTSD, where the person doesn't fall apart into trauma, but they split, they dissociate, and they're anxious and nervous or numbed all the time, and then suddenly the trauma breaks through. Or people who become absorbed with substance abuse, where they're constantly changing their state of mind. They can't stand to be who they are, so they're constantly medicating it.

people with DID, which is a trauma-related disorder. And the difference there is that there's some research evidence that people with DID, they're skilled at self-hypnosis. So when that biological capacity is available to them, they deal with the trauma by splitting into a number of alters that carry different parts of their experience, the baby alter, the...

violent alter, the sexual alter. So yeah, I've become more, I've gone from thinking that trauma, life experience is an important part of schizophrenia to thinking even more. No, this is a trauma-related disorder, and the symptoms are a phenotypic expression that come through in a different way.

than with borderline personality or depression and so forth. To put it simply, the main source of human suffering is bad things happening to you. It's as simple as that, really. But then it gets played out in a lot of different ways.

Yeah, that's so true.

Just thinking of even, you know, just developmental trauma, like the biological, the biological trauma when we think about the risk factors, when we think about what is happening just in like early development that, you know,

We always talk about psychological trauma. You just can't be thinking about, you know.

trauma that is happening during the developmental process in and of itself, and then being influenced by environmental trauma. Because something's going awry, and then we just add fuel to the fire to our multiple, there's multiple avenues where things can go awry. ⁓ I wanted to, as I know you're short on time.

Yes.

Right.

I wanted to get your opinion on like therapeutic Alliance. Cause I think in sort of, we're sort of forced within our system to maybe think about, kind of short-term therapies, and the need to be able to move on from therapist to therapist to clinician to clinician. Like that's something that we should expect is it not to have the same caregivers in our life?

when it comes to medical and from a therapy standpoint. And I wanted to get your opinion on that because what I find is that a lot of what has happened in patients that have been with, especially Serena and I, because I'm often the psychiatrist, she's often the therapist, especially to our people that we've had for like six, seven, eight years, that we almost kind of develop like our own language.

⁓ and one would maybe call that like a LAR, well, someone has told me I'm only creating learned helplessness. and I'm, ⁓ I'm positioning myself to become the only person that can take care of this person. And so therefore I should have some better boundaries, but.

I struggle, of course that makes me very defensive, you know, when I'm told that, because the amount of time that it took to establish kind of a secure attachment was years, you know, and for better or for worse for this individual, that is what it took. And...

Hahaha

the in and out of different providers in their life and forcing that on someone because of maybe a systemic problem, just feels very unfair. And I guess like in a world where we're always getting told kind of how to do therapy, how many sessions that you have, like I should, I'm creating someone that can't be taken care of except for by me. And somehow I've got to like,

Thank

Avoid that by discharging them. I'm just, I would love to hear your ⁓ take on, on that problem of, ⁓ well, not really the problem, but the reality that I believe that the, the Alliance is central, to, having better understanding for someone.

That's a complicated question and important one. And I would say I don't have a solution. I only have reflections. But if I were on your posse, you know, when, when, when somebody challenges you in this way, if we were to tag off, this is what I would say. I would say to this interlocutor, you know, there's a real

you

you

Well, I definitely, I definitely tried to like channel you to prepare for my response.

Hahaha

There's a real dilemma here. And you're choosing one solution for you to the dilemma, which is to keep a superficial relationship to the patient. And I think, if you permit me, that you have a fantasy that there's a certain kind of emotional growth and development that can be achieved without an extended, ⁓ close, therapeutic relationship with the patient.

So I want to give you room to tell me what that is, how it is that you, in your work, create long-term internalizations of emotional growth in patients without the length of time that it seemed to take me to establish that kind of intimacy with the patient. Because if you can do that and I'm not doing that, then you're right. I'm taking people on too long a road, and I should do what you're doing. Then the interlocutor responds.

And then you say, well, I don't know. I'm not completely convinced by what you said. Yeah, you got him out of the clinic. But tell me, give me a case example of the richness of a person's life that you brought them to by keeping them at a distance and paying a lot of attention to the danger of them becoming too dependent on an individual relationship.

It's a dilemma. And the mental health system has no solution to this. And the way I tend to think about it is that the best we can do in medicine, well, in some circumstances, is to triage. So that there are some folks that if you spend a year with them, it probably won't make a significant difference because they're too damaged.

there's too much resistance to it. But there are other folks, you spend a year with them and things are gonna happen that are emotionally enriching for them. And then we get back to the interlocutor and say, well, I I believe that a person's quality of life is important and this is part of our mission. And I want to be for my patients, I wanna be a significant.

person in their life, and I want to have enriched their life because they enrich mine. And that's an intimate, personal kind of connection.

I

see for you, it's more kind of keeping things under control and keeping people's needs under control. And I honor that, yes. That's part of the problem. So I make my compromise about this. I triage. I invest in certain people. And you say that I'm creating a forced dependency.

then back to the interlocutor. Tell me, is it that you've resolved the dependency in the patients that you have worked with by keeping things more superficial, keeping things more at a distance? ⁓ I see. I see. I mean, to my ear, it sounds more like you've gotten people to survive on a more limited diet. So it's kind of a thing.

thin broth that everyone can offer. But I have to say, that's not what I'm about. But the other person's partly right, but they're also fundamentally wrong in another way. And it's a real dilemma. It's a real dilemma.

Yeah.

My response was definitely not that eloquent. I think I said something to the effect of, maybe I was like meant to be a doctor back when like you're the doctor for the village and that everyone came to you while they were growing up and you had generations of people that you took care of. Maybe that's when I was meant to be in practice because it seems to me that longitudinal care is one of the beauties about being a physician.

Hmm.

Mm-hmm

Yes, and

that's part of it. The industrial society creates that dilemma. So instead of families sheltering these folks, they're fragmented and the clinic becomes the family. And the family says, wait a minute, the clinic family says, well, we don't have the resources really to give you the attention that you need. So this is a dilemma for all of us, how to triage, how to invest our time.

Mm-hmm.

Mm-hmm.

Mm-hmm.

Thank you.

Well, I think that is a yes.

It's been a delight as always, but

I have to actually go talk to a dear soul, a man who always surprises me and has interesting things to say.

Well, thank you for coming on our podcast.

Okay, so we have Dr.

Okay, anyway, it's a lot of fun.

Thank

you so much. Bye bye.

We'll see you soon. Bye.