E135 - Are we Failing Patients with Psychosis? (w/ Dr. Patte Randal)

Dr. Patte Randal is a doctor trained in psychiatry, now retired from practice after working for over 30 years in mental health. She has lived experience of recovery from psychosis, and has told her story publicly in many contexts, including her  published book, Finding Hope in the Lived Experience of Psychosis: Reflections on Trauma, Use of Power, and Re-visioning Psychiatry - co-authored with Dr. Josephine Stanton.

For more resources on mental health recovery from Patte and her colleages visit:

https://thegiftbox.lovable.app/

https://www.talkthatheals.org

https://www.youtube.com/watch?v=haQvxyw4_9g

Patte's book on Amazon: https://tinyurl.com/bdee66yz

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Interviewed by Dr. Alex Curmi. Dr. Alex is a consultant psychiatrist and a UKCP registered psychotherapist in-training.

If you would like to invite Alex to speak at your organisation please email alexcurmitherapy@gmail.com with "Speaking Enquiry" in the subject line.

Alex is not currently taking on new psychotherapy clients, if you are interested in working with Alex for focused behaviour change coaching , you can email - alexcurmitherapy@gmail.com with "Coaching" in the subject line.

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Transcript

Welcome back to The Thinking Mind, a podcast about psychiatry, psychology, psychotherapy, and self development. Today we're gonna be talking about what it's like to be in an extreme state of mind and what psychiatry can do to better understand, treat, and help people when they are in these extreme states.

With us to have that conversation is Dr. Patti Randall. Dr. Randall is a doctor, trained in psychiatry now, retired from practice after working for over 30 years in mental health. She has lived experience of recovery from psychosis. She's told her story publicly in many contexts, including in her published book, finding Hope in the Lived Experience of Psychosis, which she co-authored with Dr.

Josephine Stanton. Obviously, it's extremely valuable to have a guest on who has been both Dr and patient, and today we discuss Patti's experience with psychosis, what it was like for her to have that experience. How was treated and crucially what these experiences [00:01:00] may have meant for her psychologically.

We then go on to discuss how these experiences influenced her approach to treating patients with similar issues like psychosis, manic states, et cetera. Patty makes a strong argument for our paradigm shift that we need in psychiatry and we try and make that shift as concrete as possible in today's conversation using a clinical example.

Otherwise, thank you again so much for listening. I hope everyone out there is having a good summer. If you haven't yet, do check out the New Thinking Mind blog. That's the Monthly Companion Newsletter to the podcast, which we're publishing on Substack, and we hope to publish some Substack posts in between as well.

The link for that is in the description. As always, you can direct any and all feedback about the podcast to Thinking Mind podcast@gmail.com. We've had some lovely fan mail this week and we always love getting more, but even if you have some criticisms, don't hesitate to reach out ways you think the podcast could be better.

If you like the [00:02:00] podcast and you want to show us some appreciation, the best way to do that would be to follow or subscribe on whatever platform you're listening on. Leave a rating or even a written review and share with a friend. Thank you very much for listening, and now here's today's conversation with Dr.

Pata Randall. Dr. Randall, thank you so much for joining me. It's good to be here. Thank you for inviting me. As we were discussing offline. I always find it incredibly valuable to have guests who have some kind of lived experience to offer and share with the listeners I was discussing that we recently had a guest on who was talking about their experiences of bipolar.

In your case even more valuable because you're also a doctor trained in psychiatry. You've seen people themselves who are suffering with, with mental health conditions. So your perspective incredibly valuable. I actually haven't read too much about your story 'cause I wanted to hear it from you. So maybe you could tell us a little bit where you think your story begins.

Where, where The best place to start is, I often say [00:03:00] jokingly that I started my training in psychiatry when I was born, actually. Um, but I won't go, I won't go into detail about that moment that you, I think we do learn along the way, you know, that it, it form what, what happens to us, forms us. Yes, absolutely.

I had my first extreme state episode, which I felt and experienced as a mystical experience, which came completely outta the blue when I was 24. And I had begun my training in medicine. I'd, um, got married. I started my training at the Middlesex Hospital in London and was moved to Sussex University, um, to do a neuro neurobiology degree.

And, um, I had a baby. My father died, my marriage broke up and there were a couple of co deaths of children at the university and sudden. And the other thing was, this is the sort of con, this is a [00:04:00] context in which this extreme state happened. I was having sort of being, training, training as a psychiatrist and a doctor.

I was doing my PhD by then. Um, looking at. Um, the pulse diagnosis in traditional acupuncture, so a whole completely different world view, reading Daoism and et cetera, et cetera, and with all these other things, it's almost like the, the whole structure of my life collapsed and my, my marriage was breaking up and a number of things were happening.

Suddenly I found myself in, in a, in an altered state of consciousness, a different reality, and I experienced dying and being reborn. And I experienced being in the vanguard of a, of a massive change in culture and society and pulling people through into this new reality with me is it is a completely new [00:05:00] reality for me.

And suddenly I, I was experiencing this extreme state and I wasn't sleeping and I was behaving oddly, and I ended up in the. Um, in the Student Health Service under, under Dr. Anthony Ryle, who at the time was running the mental health service at SU University, who was the gp, um, he subsequently went on to, to, um, develop.

Cognitive analytic therapy and has become very well known. But at the time he was 48, I was 24 and he was, he was the, um, the lead person at the health center. And um, they admitted me there. And, um, I ended up sleeping on c cushions on the floor. 'cause it was such a weird experience and so strange. What did you think was happening when, when you were admitted?

I knew that they were, I knew they were taking care of me. I mean, I [00:06:00] knew that they were trying to take care of me, but I was in a very, very different state. And, and the nursing staff, um, there, I mean, they, they were trying to look after me, but I was obviously behaving very oddly. I, I was being very childlike apparently.

And they were quite tough on me actually. They sort of said, stop behaving like a child. They didn't realize how unwell I was. I was, I thought it was sort of within my control and, um, yeah, so I, I mean, I didn't really know. I, as I say, I felt I was having some kind of mystical experience, not that I had a worldview that contained mystical experiences.

I was sort of, you know, brought up a, in a sort of. Atheist diagnostic context. There wasn't, you know, that bigger picture even, even though my mother was, is, was Jewish, born in Palestine actually for one of the first Jewish children to be born there. And we, but we weren't brought up in a. You know, with a, a spiritual worldview at [00:07:00] all at the time, in terms of the mystical experience, you know, I'm cur, I'm aware that, that, that can feel very positive or very negative for people, or can feel, you know, doesn't necessarily feel pleasant for you.

How did it feel emotionally? I felt I was traveling on the edge of time. That was an experience I had, and it was an elating feeling. It was absolutely an elate. Mm-hmm. You know? Elating. It's like everything had changed. And actually, actually the thing, I mean, again, bringing it all back to mind as I'm speaking, I felt that even gravity didn't exist anymore.

And at Sussex University there are a very steep steps going down, you know, sort of the, it's on, it's in the south down, so it's very, very steep steps. And I was standing at the top of some steps and I saw. Some people walking down, walking past. Um, for some reason, and I can't remember exactly the reason, but I stepped off because I [00:08:00] felt there was no gravity anymore.

I stepped off the top of this very high steps thinking I would just float to the ground. But of course, I didn't float to the ground. I fell to the ground and as I, as I hit the ground, I felt as if my. All my bones had broken, but I looked up and I saw these people going past and thought, I thought, oh, they, they think a miracles happened.

And I jumped up at as if a miracle had happened and as if all my bones had been fixed. I ran through the, um, campus hugging everybody and saying, we're all the same. We're all the same. We are all, you know, we're all sort of superhuman people. We are all godlike and everybody seemed godlike and I went racing along the corridor and.

Opened at Aura of Anthony Vi's Room thinking that I could just go in and see him because we are all the same. And you know what? [00:09:00] Why do we need to be in therapy? Because we're all godlike. So that was his first realization that I'd flipped. But I, I was completely elated because I felt so connected with everybody and I felt the, the God likeness of our state vow.

How long were you in hospital for on that occasion? It wasn't hospital, it was the Student Health Service. All right. And I was only there for a few days. I mean, I was only, I was only in there for maybe three nights or I can't really remember. Actually, I, I probably remember more when I wrote the book. The detail in the book is more accurate than my memory currently.

Um. I was given chlorpromazine. He, um, he prescribed me chlorpromazine, which at the time was, you know, a typical antipsychotic as they called it, um, which obviously was what they used in those days. And immediately I started to feel very unwell with it. [00:10:00] And actually, I didn't think I needed any medication.

I just needed to sleep. And I was sleeping reasonably well after the first couple of days, probably the cro, and did help with that. But I noticed it, I noticed it was making me feel very sick, so I hid it. I, I hid the medication, um, in a, in a tissue paper and just, I settled down quite quickly actually.

Well, I think I was alre, I wasn't behaving in my usual way. I was much more sort of out there as I'm usually quite shy. I'm usually quite socially shy. Um. It, but I wasn't, obviously it wasn't still in an extreme state. And um, so after a few days he felt, you know, the medication was helping and I said.

Showed him my tissue paper, said, I haven't been taking the medication, so I must be okay. [00:11:00] Yes. Unfortunately for me, Anthony Ryle, who was a pretty amazing person actually, um, he, he didn't force me to take medication. He allowed me to go home, just recover spontaneously, spontaneously. The, the problem was, of course, I'd had this very extreme, severe side effect from even taking.

Three tablets of Chlorpromazine and I developed, um, chlorpromazine jaundice as it was called in the, in those days, which was a, a a, a very rare but very serious side effect of taking Chlorpromazine. And I ended up having a. You know, going yellow and being very sick and having been having to be admitted and having a liver biopsy and et cetera, et cetera, which brought me down with a crash.

And then, was that the only episode you have where, where you were in an extreme state, did you have any episodes after that then after that? I didn't have anymore episodes for 12 years, so a single [00:12:00] parent finished my PhD, go back to medical school, finish my training in in medicine, become a gp, marry, marry my second husband, have another baby.

You know, 12 years of getting on with my. And then we came to New Zealand and I had a second episode 12 years later, and I've, since I've had eight episodes altogether, the last, the last, the last one was in 20 2003. So I haven't had an episode since 2003. Were they all triggered by stressful experiences, like your first one?

Yes, I think so. They were all triggered by lots of things changing at once, and things that were very distressing to me because of my journey, my story that wouldn't necessarily be particularly stressful to other people. But, um. Yeah, they, they, they were all triggered by things that were stressful, stressful [00:13:00] situations, and were they of a similar character as in feeling like you're having a mystical experience standing on the edge of time, kind of like supernatural type phenomena.

Yes. They, they were, they, um, they were like that. There was, um, there were always, it, it was always intense meaning, you know, and synchronicity experiences sort of things. Meaningful coincidence, lining up. And, you know, already in my psychiatrist's brain, like part of me wants to ask kind of what I would think are like trite questions.

Like, were you hallucinating or was there any like, self harm or, you know, what medication worked or did me, was medication a factor? And I guess these questions are important to a degree. I'm also interested in like how, what, what's the meaning you make of those experiences? Like what do those experiences mean to you?

Well, I think that's a really good question because they, they, to me, when I think about them now, they were all sort of dream-like experiences. It's like when [00:14:00] you have a dream, there's meaning in the dream, but you, it's not direct. Meaning it's, it's a symbolic or metaphorical meaning. And, um, it, you often need help to figure out how the pieces all fit together.

That's, and that's how I, you know, I, I do believe that that many of these extreme state experiences that people have, even though they're very, they have very bizarre content. There's very often the, you can put the pieces of the puzzle together. In fact, one of my, one of my experiences, I, I had this very vivid, um.

Experience of, of this cosmic jigsaw puzzle. That, that when, when I was in this extreme state, it was like this cosmic jigsaw puzzle with all the pieces thrown in the air and that I somehow was going to be able to put all those pieces together, which was very terrifying actually. It was like seeing too much, and the odd synchronicity that followed that extreme state [00:15:00] was that I'd had this vision.

Visionary experience in, in this altered state of consciousness and of, of, of jigsaw puzzle pieces. And then I came home and my boys had tipped all the jigsaw puzzle pieces on the floor, and there were about 10 different children's jigsaw puzzles. Which were all meant to be separate, and they were all tipped on the floor, and we had to all sit together and separate out the d different actual literal fig, literal jigsaw puzzles on the floor.

So this kind of odd synchronicity type thing has happened quite a few times for me. How does one, how does one make sense of that? I don't know. It sounds like you're trying to figure something out, some sort of important questions. A hundred percent. A hundred percent. Yeah. What, what are you trying to figure out if you're comfortable sharing it?

Of course. Well, I mean, I think on some level it's like trying to figure out the meaning of life in some ways. What are we doing here and. [00:16:00] You know, how do we make sense of these things? I didn't realize until much later in my life, till I was about 47 actually, that some of the things that had happened to me as a child, which really damaged my trust, were at the root of, um, you know, the, the extreme state experiences that I had.

And I, I've talked about that in the book. I was trying to figure out. How to make sense of, of my, you know, growing up experiences. And I suspect in retrospect, and I, I don't know about this, but my mother's, my mother's Jewish, she's not, she's died now, but, um, and we've recently found that her and the whole side of her family perished in the Holocaust.

And then she was brought up in. What was in Palestine, you know, became, became known as Palestine. You know, the, there was a lot of avoidance in denial. Um, you know, [00:17:00] they trying to reform her whole life there, and as we know, this horrific horror's going on there now. And I, I think she, she learned to cope by avoidance in denial, and we never spoke about some of the things that had happened or she, she really possibly didn't even know about them.

A lot of things were not talked about, and so. Yeah, we, we grew up with this sort of not really being able to express our feelings and always having to kind of somehow take care of our mother. And, I mean, you know, I had very loving parents, but a father who never talked to me. A mother who was very vulnerable and anxious, but also very, very.

It was hard to figure out. It was hard to figure out what had really happened. And also the Jewish thing of being Cho, although we were, although we were not brought up with any religious practices, the Jewish thing that she had with her, that was the chosen people, the special people, as if we were different.

And one of the things that came out during that first [00:18:00] episode, I was running along saying, we are all the same. We're all the same as if. We're not different. We're just the same. We're all the same. So it was an attempt to sort of, yeah, figure out who one can trust and how one can trust, and what, what are we here for and what's our purpose?

What's the meaning of all these things? That makes a lot of sense. And saying that, um, thinking, you know, when people present with stuff like psychosis or manic episodes, we very rarely ask them as psychiatrists, what's the meaning you make of those experiences? We never really try and interrogate the symbolic value of one of these episodes.

We might do it with a dream. So if a client, especially in psychotherapy, if a client comes with a dream, we don't say, okay, you are dreaming. That's a, you know, form of mental illness, that there's no, it's not worth paying attention to at all. We say, okay, you're dreaming. Obviously the dream itself isn't literally true, but if you're dreaming about being alone in a house and encountering some figures within the [00:19:00] house, we might say, what's the symbolic value of that?

We could do that with, with these kinds of states as we're doing now, but we don't. No, exactly. And I was very struck by that when I first started doing psychiatry. I mean, I found that I had a natural. Inclination to work well with people with who were, who had mental health issues. And I just knew that what they needed was to find the meaning in what they'd gone through.

And I, I had a kind of, because of what, because I suppose because I'd had that first episode and, um. Yes. I mean, in fact, I've, I've, um, I'm part of a, this international group who are called the International Society for Psychological and Social Approaches to Psychosis who've published two books, which, I mean, I've, I've got two publications in their book series who are all.

About finding the meaning in these extreme states. So there is a group of us, a small group of us in the world, but when I started, first started, um, to study psychiatry, I was [00:20:00] very horrified that we were only listening to people to get the, the form of what they were saying rather than the content of what they were saying.

We weren't, we weren't trying to help people dis develop their narrative, um, at all. We were, we were trying to diagnose all the time by. Listening only for the oddness in people's ways of talking. And even, so you're making this really crucial distinction, which we made earlier between content and process.

So like what's the content of someone's, let's say, beliefs versus the fact that they are having beliefs, which might not be literally true or literally in keeping with reality. But even as we've been discussing a little bit about your history, which you've been kind enough to share, even the fact that that process is going on is useful.

So. We might ask, okay, if someone is having like a psychotic like episode, what might be going on in their family system? That might cause such an episode to arise, but we don't ask that question [00:21:00] either. So one of the problems is in psychiatry, we'll, typically if someone's having an episode like that, say, okay, you have basically a brain-based mental illness or disorder, basically locating the problem in that individual for better or worse.

And again, so much useful, interesting questions. Not you could ask, not necessarily in a blaming way, like whose fault is it, but what's happening in this person's family system? Culture system, generational system that might be contributing to an episode like this? Absolutely. That. I believe that's how we, we need a paradigm shift in psychiatry, I believe.

Um, which, and I, and actually it's funny because I, I go back to that first episode and think of me. Leaving I was, or seeing myself in the vanguard of a movement and pulling people through into new reality. This is the, in my, I now can see it through the lens of, well, this is the lived experience movement.

This is the paradigm shift of making sense [00:22:00] of our lived experience and supporting one another to do that. Which is helping, which is helping to shed light on. All sorts of aspects of what we value in life and what we are here for and how to support one another to have a meaningful hope inspiring life, which can so easily get ripped away from us if we are caught in the stigmatizing and discriminatory, um, frameworks that, that psychiatry often imposes and culture imposes.

Did you, uh, end up training in psychiatry because you had that first episode? Was that a big reason why? I think it's because I found I could work so well with people and I was working in a different way with people, and I felt that was what I was really called to do. I mean, I, I felt, um. I had, I had something to offer in psychiatry, which was because I'd had that first episode, I wouldn't have known how to do that, except [00:23:00] I knew, I knew I'd recovered from something very extreme.

And I mean, although I didn't, I hadn't put all the pieces of the puzzle together. I think I've more so done it now, but it's taken a lifetime. You know, I didn't really get enough help to do it. Even Tony Ri, who was so wonderful in terms of his capacity for being with me in a healing way. Those days we weren't putting together sexual abuse, trauma and what it leads to, et cetera, et cetera.

It, it, we didn't really even know how to ask the, get the story. We do. We much more so now we do. Um, but we weren't even really getting that story properly. I think the other thing that's really important when it comes to not just being a good psychiatrist but being a good doctor, is to realize when you're sitting opposite a patient, you could be that patient very, very easily and that's the case with a physical health condition.

You know, your patient opposite. You [00:24:00] has Nephrotic syndrome and inness of their kidneys. You vary. If you were born with their genetics and their environment, you would have nephrotic syndrome. And again, in psychiatry, I don't think it happens, you know, as often, but I do see instances where psychiatrists, you know, act almost as if they're above having a mental health condition somehow above having depression or psychosis or what have you.

Obviously, having had some kind of episode yourself, you didn't have that kind of illusion. You're like, yes, I, I am the same as you in some fundamental sense. That's absolutely right. And in fact, what emerged outta that for me, if it's all right for me to carry on just talking as I talk, was this concept, this concept of building a bridge of trust, which is in the gift box that I've talked about.

So, um, this idea that we all have our own story and even in our professional training, part of our story is our, what we've learned. Our [00:25:00] profession and different professions have different stories, you know, different experiences and so on and so on. And in a way, we, we need to learn to put aside that sort of pathologizing perspective, which where there's a, a real sense of power over so that it's not a, it's not a flat bridge that we are building with people, but it's a power, a power dynamic that, um, where we, we.

Feel we, we need to take power over the person, but what we're actually doing is we are, we're putting ourselves in the shoes of the other person, and they then put, and they can put themselves in our shoes too, you know, that we can put each other ourselves in one another's shoes. Um, as you are say, as you are saying, because we are all human, we all share the human condition.

So, so that became a very important concept. Within the, ultimately became the gift box, which I, you know, is as my story unfolded, that's what developed us as the resource that has [00:26:00] come outta my lived experience and the lived experiences of many people who I've worked with and worked, learned from. I'd like to ask more about, like what you see are other problems with, let's say, psychiatric culture and the paradigm shift that needs to happen, but first.

I'd like to, let's say, give the devil his due. Is there any value, do you think, in the episodes you had, you said you had about eight episodes of being an extreme state. Is there any value to seeing that through a medical lens? Do you think? Medication is very helpful for some people at some times. It also has lots of ti, lots of really serious side effects, and I think we le need to learn more and more about how to use it.

Wisely and, and as we were all taught as medical students judiciously, judiciously, which we don't do. Mm-hmm. And we, you know, that unfortunately we are very risk averse and the trouble is when we, we tend to not, [00:27:00] not be keen on responsible risk taking. We try to switch everything off so that we can all kind of hunker down, which is kind of avoidance and denial on everybody's part.

Actually, we, we are trying to kind of just stop it. Rather than seeing the, um, the value in a, in supporting it and taking it through to its meaning making conclusion. Um, but of there is a place for. Understanding what's going on and giving it some kind of descriptive label. People do find that very helpful too.

I mean, you know, I can see myself through the lens of having had a brief psychotic episodes. That also makes sense. And taking medication for that was useful, but actually in retrospect, I realized I didn't need antipsychotics, which aren't really antipsychotic. They used to be called major tranquilizers.

They, I needed, I needed my limbic system to be, you know, my fight, fight, freeze system to [00:28:00] be regulated a bit more, which I didn't know how to do at the time. And the medication helped, especially through helping me sleep. So, you know, I mean, I think psychiatry needs to become much more, um, inclusive of all sorts of modalities, not just the pharmaceutical modality, which needs to take a tiny place.

It's got a tiny place. Um, I pharmaceutical industry, if it weren't all about making money, if it were actually about really supporting wellbeing, we would be, we would be finding all sorts of new ways of doing that with it, with the biochemical. Rebalancing of things, but it just all needs to be much more nuanced and you know, sort of much more, um, yeah, just taking account of many more aspects of, of, um, our physiology and our anatomy and it, you know, which is what psychiatry tries to do.

So it certainly has a place, it just [00:29:00] needs to become more sophisticated in a way. Yeah, I've, I've often talked about, I think one of the major problems I have with. How medication is used in psychiatry is it just used too much like a blunt instrument? Yeah. It is used too much as a blunt instrument.

Absolutely. And it's dangerous for people. It's harming people. That's the, it can be, it can be. It's not always. And if it's used in this nuanced way, it's very helpful. But if it's not, it can, it, it harms people We know that, don't we? I'm interested in what you're saying about risk aversion. Uh, and I'd like to expand on that a bit for the listeners 'cause I think it's a really valid point.

I see this, at least in psychiatry, where I practice in the uk, we're incredibly risk averse. We're very worried about anything going wrong with a patient. That could be some form of self harm that's not lethal, that could be suicide in extreme cases. That could be harm to others in extreme cases. Or it could just be, you know, the patient not [00:30:00] doing well.

The way I see it can be a bit controversial, I suppose. I think avoiding this risk averse culture, which I do think is quite negative necessarily, involves giving more responsibility to the patient sitting across from you and obviously having the facility to support them so that they can make the best decisions possible.

But fundamentally, one of the problems I see with the culture of psychiatry is. We take on all the responsibility of ourselves because we're terrified of anything going wrong, and therefore the way out of it necessarily will involve, and this might include at a legal level or a political level, giving some responsibility back to the patient.

You know, listen, you are also, your decisions that you make in most circumstances are your responsibility. Do, do you agree with that reasoning? Yes, I do. But I also think it's not just the one to one, it's the whole system. It's the whole family system. It's like with, um, an approach [00:31:00] I really have appreciated is the opened of opened dialogue approach that, um, was initiated in Finland by.

Uh, Yako and Cole, um, where everybody is involved. It can be involved in the conversation as long as you can make it a safe conversation and everybody can help everybody else to take more responsibility for understanding what's happening and changing the process, which also the gift box does that, that's, that's also what the resorts are.

We've developed that helps people to do that with one another so that they understand, we understand much more clearly the chain reactions that lead to the crises that can then become the opportunities to, to create what I, from vicious cycles to victorious cycles that where people can, where uh, people can take self responsibility because they've got much more understanding of.

And they're not told what to think, but they can actually get to see [00:32:00] options of what actually has happened and how to make it. 'cause everybody would choose to be in a Victoria cycle if they knew how to change their behavior and their thinking. We would all support one another to do that. It, we just need the tools to, to allow us to, to, we need the tools to facilitate that process, which if you don't have it, the psychiatrist is in a really difficult position and you've got to be able to sleep at night yourself.

Yes. And that's why I love talking to you because you're also, besides having had firsthand experience yourself, you're able to represent that other side of the coin, which I think is not represented enough. In these situations, which is psychiatrists and doctors generally are in really difficult situations we have to make at times very difficult decisions.

Sometimes at 3:00 AM sometimes when there is a lot of risk involved and it's very tempting to fall into the trap of being a little bit istic with your patient and taking a lot of [00:33:00] control because you're being faced often with a lot of chaos and it's a difficult situation that psychiatrists find themselves in often.

Totally. And I think in the acute situation, it's often absolutely the right thing to be doing, to be prescribing whatever it is that's needed in the moment. Um, but I mean, there are lots of other ways we could be going about it as well, which we don't really have access to. And if only we did, 'cause we, it, it's actually not rocket science.

We actually do know how to hold people safely in environments. We just need those environments. I'd like to zoom in on that. So we need to make a distinction about timelines. If someone's unwell or they're having any kind of extreme experience, the timeline is important. What you do in the acute situation, what you do in the medium term, what you do in the long term as the time horizon extends, you do, generally speaking, have more options to work with and perhaps we don't normally take advantage of that.[00:34:00] 

I think that's true and that, and I think we don't go through the process, the detailed process that each person and their family members need to go through to figure out what's happened and to how to prevent it from happening again, which is quite, is is a very detailed sort of self-awareness training, if you like, for the person.

We don't provide it. And I believe that's what we have developed, that we can provide. And the other, the other side of it is using a, taking a more narrative approach rather than a pathologizing. Um, sort of power over, you are going to do this kind of approach. So, so we are, we are drawing out the person's own, um, strengths and resilience that they themselves have, which we as psychiatrists often completely, we don't even listen to it.

We don't even look for it. My co-author, uh, in the book, finding Hope. In the lived experience of psychosis, Josephine Stanton is [00:35:00] working on, um, developing that narrative or, or, or helping people to, to understand and use that narrative approach more. As is a friend of mine who I've just read his book called How Not to Be a Doctor, John Lorna.

It, that's a real confirmation, synchronicity for me that that's the right, that's the right approach. And his books, his work's really worth reading us as is Josephine's, which is on our website. I'd like to paint you a little, a bit of a picture, maybe a bit of a clinical picture, and you can tell me like, what would you be, what would you be worried about happening down a, let's say more conventional path, and then what would be importantly different with the framework you and your colleagues have established?

So imagine, uh, I, I'll ask the listeners to imagine a 20-year-old man who. Perhaps was under a lot of stress, uh, at university, say, and gradually became more and more withdrawn, had difficulties doing his exams, [00:36:00] and then, and ended up having, you know, a set of unusual experiences. He was hearing voices. Uh, he started to believe that people were following him and things came to a head.

He was admitted to hospital. I mean, I should say this is entirely fictional, but it's the kind of thing we see a lot in psychiatry. Perhaps they were admitted to hospital for a couple of weeks, started on some antipsychotic medication, and now the medication seems to be doing what it's supposed to and they're getting better and they're starting to recognize those experiences when sort of literally mapping onto reality and they're gonna get discharged in a few days.

So first I'd like to ask you, in a situation like that, what would do you be worried about happening conventionally in psychiatry? And then maybe after you could tell me what your framework. Might importantly do differently? Yes. Lovely. Well, I mean, I've worked with people exactly like that, so it's a good example.

Yeah, I'd be worried about a number of things. I'd be [00:37:00] worried about that person being. For sort of told they've got to take medication for possibly the rest of their life or even just for two years. Um, them finding that actually the medication really sort of shrinks 'em because I've had antipsychotic medication, you know, and it, even a tiny dose made me feel shrunk.

Like I couldn't. I didn't have the creativity and thinking and so on and so on. So I'm imagining that that would happen to this young man. He'd start putting on weight because a lot of these medications do that. He would be not, although he and his family would sort of, oh yeah, it helped me. He'd, if he didn't have any more symptoms, he'd come to a place where he'd think, well, I don't need it anymore.

And he'd stop it himself. And depending on what the medication was he. He may well have another. If, if nothing else had been done to help him understand how this had happened, he may well have another [00:38:00] episode and, um, then he's likely to get even harder kind of control over him and if that went on and on, which it does Vicious psycho vicious, psycho vicious cycle with the wrong kind of responses.

People get caught in, you know, they get caught on large doses of medication with no framework for understanding what's happened or come, or an ability to come off it. And that happens frequently and with all the physiological damage that that does. And yes, maybe they don't then hear voices or have an other psychotic episode, but they're very shrunk.

Um, can be. I love thinking about things in cycles because cycles, or I often use the word spirals like negative spirals or positive spirals. They really help us understand how different factors affect each other and compound. So for example, if someone was trying to, if I was trying to help someone get healthier.

I might look at sleep, nutrition, and exercise, and I might explain that all of these things will [00:39:00] improve each other. So and so I might explain, you know, you sleep better. You're more likely to exercise and eat healthy. You eat healthy, you're more motivated to exercise and you'll probably sleep better and so on.

In this kind of a situation, psychosis is often a lot about safety and the less safe. People feel, it would seem to me the more vulnerable they are to having something like a psychotic episode. Now, the problem here in terms of interacting with mental health services is if every time you show symptoms, you're also in danger of being sectioned.

You know, I'm not saying that as someone who's anti sectioning in the right circumstances, but if when you show symptom symptoms, you're sectioned or possibly given medication against your will, then you associate getting help with danger. The danger itself might also increase your chances of having an episode and that sense of threat and not being able to trust people.

So I think that's a huge piece in what goes wrong, as you're saying, this is the vicious cycle that happens. We [00:40:00] have a page in here that explains exactly what you've just talked about, which is the trauma informed sequence of events that goes, that happens to people because of the dangers that they've, I mean, we, we usually only see people because they've been a danger to themselves or others on some level.

That's how they come into our imp and then if we respond to them in ways that make them. Feel like the things that they're, that they don't even know have triggered them in the past or even, you know, even if it wasn't clear cut trauma, it becomes a traumatizing experience. And we, we trigger in the present what we're trying to help people recover from.

So this explains, this helps people understand exactly that process. We don't explain that. We don't explain the sequence and we don't even understand it ourselves often because we're so risk averse. So if we go back to the 20-year-old man, what's the best possible [00:41:00] outcome for someone in that situation?

Well, I think for the 20-year-old man, what we're. What we can do with him and his family is help them understand that spiral, wherever, whatever the underlying things are, we don't even necessarily, well, he may begin to understand what his triggers are. He he'll begin to understand the things that. He does and the ways that he thinks, because we will give him some tools to be able to articulate all of that and figure it out.

Because even though people, if people often can't come up with the idea, but if you give them some tools to prompt them, people know they know themselves or other people can help them know and they can work out what that chain reaction was. That, that led to that, like you are saying, um, you know, they need something to help 'em sleep and they need more exercise and they need good nutrition and they need ways of distracting themselves when they, and they need to be able to think about their thinking, et cetera, et cetera.

Or you can [00:42:00] provide a context where all of that becomes available. That's what the gift box does actually, individually and in groups and so. And often what we found actually is that people will say, oh yeah, I know that now. And they have these aha moments and they, oh yeah, I know what I'm, and then of course, what happens is they go around again because we often think we know.

I thought I knew, okay, I know how not to get into a vicious cycle. Again, I know how not to make that happen, but it happened and happened and happened again, which it does, but it doesn't mean you've gotta. Give more and more and more medication. You just need to go through this process again and again and again.

You sometimes you just need to learn as is the case with addiction. I'll often say something like, relapse is kind of a part of recovery. A hundred percent. It is exactly the worst things can turn out to be the best things. If we can understand, if we can support one another in understanding what the patterns are.[00:43:00] 

Another thing I worry about with very commonly with psychosis, you see what's called paranoid psychosis or people being basically very worried they're gonna come to harm or someone is surveying them. I often think about pattern recognition. So we have this wonderful human brain, which is really good at picking up patterns, but not always where they actually exist.

In fact, people might know if they know a bit about cognitive neuroscience. There's two kinds of cognitive areas that you can make one errors seeing a pattern where it doesn't exist, and the second there is not picking up on a pattern which does exist. So you might see like a rustling in the bushes and you might think, okay, they might be a predator.

Every time I see a, those rustling of the bushes, there's a predator behind those bushes. And I do think, you know, human beings, generally speaking, evolve to see patterns more We, we evolve for that bias and generally we tend to see patterns because. Tends to keep you alive a little bit more. And that's really what paranoia is.

It's like, [00:44:00] oh, I see my neighbor looking at me, and maybe I also then jump to the conclusion that they're thinking something negative about me. And then perhaps that might go to, they want to harm me in some way. Perhaps you're better off, you're likely to be more safe if you go down that line where you think rather than thinking nothing's wrong.

And so this is a very long-winded way of leading to. How important is it to have a community around you that feels safe to prevent and treat psychosis? Yes. I think that's very important anyway, to have people who understand, who understand one another and can support one another. As well as being able to understand what the mechanism that's going on that you've just described, which I call a faulty alarm system.

It's like a smoke alarm going off, uh, you know, when the, when the kettle boils. Are you aware of the work of, uh, Randolph Nae? Uh, not sure that I am, no, I don't think I've heard of that. So he's a, he's an evolutionary psychiatrist. Oh, yes. And he's a [00:45:00] big. Proponent of using evolutionary theory to help explain psychiatric phenomena, and he actually has a principle called the smoke alarm principle apply to apply to panic attacks.

That's parallel process, but I think when people come to understand that about themselves and begin to notice body, you see, I call very. Early warning signs, very early warning signs are changes in our body sensations and often we just are not noticing our body sensations at all. Um, if we can teach one another to very, that's where mindfulness comes into sort of everyday life and how important it is to notice a very early warning.

Signs like for me, pressure in my chest. I had no idea about that. Or breathings, you know, sort of learning to breathe properly. People think, oh, who, who breathing, you know? But actually it's vital, um, to breathe properly. Um, and I learned as a very young child to hold my breath so that I didn't take. So I wasn't crying all the [00:46:00] time.

You know, we learned to, and, and that makes us actually much more vulnerable. And so, so, you know, being in a context, there's all, there's so many aspects of what makes a safe, secure context isn't there, right from the start of life and, and forming communities that can support one another Vital. Um, I mean, what we find with these groups that we run now, we using the gift box, is even in a forensic service, when we are using the gift box, people start to become more respectful of one another because they, they learn to be trusting of each other and, and learn to build trust with each other.

It's step, step one, it's, it's the first healing principle. So, you know, being in safe at secure environments, which is about trusting, not locked, not locked, secure environment, but free trusting secure environments where security is on the inside, [00:47:00] not on the outside, which we can do. I feel confident that we can do it.

Some countries are better than others. It is a culture thing. Who do you think, is there a country that's leading the way in terms of a more sophisticated, more nuanced way of treating these kinds of conditions? Well, people have talked about, um, Este, the Este model that, right? So they've talked about that, which is sort of on these lines, I think.

Um, I think so, yes. And you mentioned open dialogue in Finland. Yes, in Western Lapland. I mean, it's not the, the thing is it's these microcultures actually where things can change it. It, um, so Western Lapland apparently developed, you know, this open dialogue and the diagnosis of schizophrenia really fell.

In that little small culture because the people were dealing with it so differently, but the whole country wasn't doing that well, as far as I understand it. I dunno where things are up to now, but then when [00:48:00] you try to do randomized controlled trials, using as far as this is, as I understand it, opened dialogue in different places, like in London or somewhere.

The culture itself is so different that the way it's practiced doesn't necessarily give the same results. It's tricky, you know? How do we, how do it's, you know, how do we form those really solid, safe, trusting communities? And then, then how do you account for other things like disturbances in the family home?

Exactly. Gang culture, recreational drugs, all of which will form a part to play. That's right. And yeah, you see, I think what I, I mean, what I believe is if we, if we. If we can be educating children and families to have a framework, the this framework that we are talking about, which I believe you, it, what you are saying is very, very similar to what's actually here.

You know, that we, we, that we can create tools to support. [00:49:00] Greater conscious awareness of how we develop these patterns. Why go, why gang culture happens? You know how all of that stuff, it's, we can, I believe we can. And, and, and then it just goes to show how much of the issues we're grappling with on the psychiatric front lines are representative of societal and cultural issues.

And therefore, to some extent, you know, psychiatrists can and should do what they can to improve the quality of care. But it does seem like it's gonna take action at a collective societal level, really, to tackle meaningfully. It's a political thing. Yeah, absolutely it is. Yeah. Is there a place people can go to access some of the resources, like the gift box that you mentioned?

Yes. Um, there are a couple of websites. There's a new one being launched. As we speak, which is going to be sort of becoming better in the, in the coming days, which is called the gift box. But we can maybe put [00:50:00] this, put the links on your website. There's also, um, links to the Talk That Heals website, which has Joseph Finn's work on narrative and information about our book and little videos about the gift box project that, um, we've done.

So yeah, those would be the ones. I could see your, your book is available on Spotify. Yes. And I'll also post a link to the Amazon link so that people can find it there. Patti, it's been great to speak with you and to get some of your insights. Thank you so much for joining me today. Well, thank you very much too.

That was a lovely way to spend the last hour. Thank you.