Beyond the Myths of Psychosis: Understanding, Acceptance, and Paths Forward

In this episode, Dr. David Puder sits down with Dr. Stijn Vanheule, professor of clinical psychology and psychoanalysis, to challenge misconceptions about psychosis and explore paths to understanding and recovery. They discuss psychosis as more than a clinical label, delving into its connection to existential struggles and creative expression. Dr. Vanheule explains primary-process thinking, how traumatic events can disrupt the mind's coherence, and the importance of empathic listening in therapy. Drawing on examples like Carl Jung's Red Book and Annie Rogers' creative processes, the conversation highlights the therapeutic potential of integrating psychoanalysis, creativity, and supportive environments. Whether you're a mental health professional, caregiver, or curious listener, this episode provides insights into how psychotic experiences can be understood, respected, and addressed through innovative approaches. By listening to this episode, you can earn 1.25 Psychiatry CME Credits. https://www.psychiatrypodcast.com/cme-program Link to blog. https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-229-beyond-myths-of-psychosis-understanding-recovery Link to YouTube video. https://youtu.be/i0aiGArW9x4

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:13David Puder?

  All right, welcome to the podcast. I am joined with Stijn van Hulo. He is a PhD psychology, clinical psychology psychoanalyst at Ghent University in Belgium. He wrote a recent book called Why Psychosis Is Not So Crazy. He has over 220 peer-reviewed papers and seven monographs and has studied this extensively. And welcome to the podcast.

• 0:44Speaker 01

  Hi, David.

• 0:46David Puder?

  So I think it's always good to start out with kind of like, what is your elevator pitch for why you wrote this specific book and what the book hopes to communicate?

• 0:55Speaker 01

  Yeah, so this is a book in which I try to explain to a very broad audience, meaning both of professionals, like nurses and social workers, but also like families and people who have problems with psychosis, to bring them a message about psychosis, a message about what is a psychotic experience and why is it not a fatal experience? Because I experienced in my clinical practice and also when I talk to people, that many people have a very negative idea about psychosis.

• 1:33Speaker 01

  And I wanted to shake that idea a little bit by adding like a more subjective perspective, like what is happening to someone and how and why is it not the end of the world when you start struggling with psychotic experiences?

• 1:51David Puder?

  Yeah, that is great. I always want to increase empathy, especially for things that seem very scary. And I think what I've experienced is that a lot of therapists specifically, and there'll be a lot of therapists who are listening to this, are still somewhat intimidated, maybe, working with patients with schizophrenia and psychosis. And at least if they're early career clinicians, they may be that way. So I think this will be helpful. And it's a lot more common in the general population than maybe we would think. Tell me, how common is it? And beyond schizophrenia, beyond that level of severity?

• 2:30Speaker 01

  Well, the good thing is that there has been quite some epidemiological research in the past decades, and they show kind of an interesting picture, which on the one hand indicates that psychosis-like experiences are quite common in the general population. And it is estimated that about 15% of all people, once or twice or sometimes in their life, will have a psychosis-like experience, which means maybe like thinking that they see a ghost or an identified flying object, something like that. But then it's just a moment that

• 3:15Speaker 01

  they think that and it goes away. So 15% of the people have this kind of experience in their lives. And then it's estimated that about 7% really has something like a psychosis symptom, like hearing a voice, for example. And then it's still a smaller group, of course, like about 3% that actually needs clinical help for psychosis experiences. And this could be like helped by a therapist, by a psychiatrist. Yeah, because they need clinical support for it. So interesting about it, I thought, is what, well, look, it's a bit of a continuum, and some people end up in a real psychotic crisis, in which their lives is turned down.

• 4:01Speaker 01

  But on the other hand, you also have like this kind of experiences in normal people. And so, yeah.

• 4:10David Puder?

  Yeah, and so it's it's like there's a break in in reality. And you talk about how often this occurs after something very stressful. Or a large amounts of stress. And yeah, tell me about that.

• 4:28Speaker 01

  Well, OK, you have to know, of course, that this book. I'm a I'm a psychoanalyst, so I have this specific viewpoint and a specific approach in therapy. And both at the level of theory. And here I'm trained in the Lacanian psycholitic tradition. So both at the level of their theory, but also what I observe in my clinical practice is that many people start having psychotic experiences at moments of ruptures in their lives. Moments when they have to change identity roles. Like, maybe it's because something good happens to you because you you you you have your degree in a college, or maybe you you have a first child.

• 5:13Speaker 01

  Or you start a relationship with someone. That can be a trigger for some people, but also negative experiences, of course, like a breakup in a relationship or severe conflicts in in your job or retirement, which are all like life changing experiences are often like the trigger for people to to to be a bit destabilized in how they experience themselves in the world. And it's specifically at that at that point, that something of a psychosis like experienced or or or full psychosis can can occur.

• 5:53David Puder?

  Okay. And so historically, we sometimes could go back to Freud and how he talked about primary process thinking, secondary process thinking. Can you define those? Can you share with us like what? How you feel that relates to this?

• 6:11Speaker 01

  Yeah, so indeed, Freud, in his theory, distinguished between two modes of thinking that we kind of use. And one is the one that we use in daily life, and he called it secondary process mentation or secondary process thinking. And Freud describes like, this is what we do in everyday life when we approach the world in a narrative way, when we think of how events are linked to one another, and then we try to understand what happens, and the world starts to be comprehensible. So we build lines of reasoning, and then we can start imagining, like, if I have words,

• 6:54Speaker 01

  if I have scenarios, I can think about my past, because I remember it in a certain way as a narrative, like, I can remember what I did yesterday as a little story, but I can also imagine what I will do this night. So I can anticipate with the story. And in Freud's line of reasoning, this is one way in which we organize reality, and this is dominant when we are awake. And then Freud distinguishes another way of thinking, which is far more associative, and he calls it primary process. And proper to primary process mentation or primary process thinking is that it builds

• 7:33Speaker 01

  on trivial details, like maybe similarities between sounds or colors or repetitions, repetitions of numbers, of letters, and this brings about a far more out-of-the-box way of thinking. And Freud's point is that when we sleep and we dream, this is the way of thinking, this more primitive primary process thinking, that's what then comes to the fore, and that's because when we sleep, our secondary process control is also asleep, and therefore the primary process thinking is fully awake.

• 8:13Speaker 01

  And then his idea, which was taken up by other psychoanalysts, is that in psychotic symptoms, we actually see that this more primary process associative way of thinking dominates the moment people have psychotic experiences. So it's a different way of relating to the world with thoughts and language.

• 8:36David Puder?

  Yeah, I was, I was thinking about the, the neuroscience linked to this and in primary process, thinking you can have a hyperactivity of the limbic system, reduced activity of the prefrontal cortex,

• 8:50Speaker 01

  Hmm.

• 8:50David Puder?

  disrupted communication between the two, which is what happens in dreaming. And it's common in psychosis that that happens as well, right?

• 8:59Speaker 01

  Yeah, yeah.

• 9:00David Puder?

  Have you thought about the neuroscience of this at all and kind of, you know, because I think a lot of people may hear like Freud and primary process, secondary process, they may be like, oh gosh, are we really, are we really talking about stuff that, you know, science has proved to not be true, right? Where it's like, actually, there's some good, good neuroscience correlates to this that we could look at.

• 9:19Speaker 01

  Yeah, this, this surely is this neurobiological side to psychosis and also to, the two ways of thinking, but I'm, I'm not a neuropsychologist. And I also thought that maybe it's interesting to write a book without delving into the biology of psychosis, because I think that this is often the dominant discourse about psychosis. And it maybe leads a bit attention away from the fact that it's especially a human experience, a subjective experience, meaning it's something that happens in your, in, in, in your mind, in your consciousness. And my main question was, what is it doing with people?

• 10:03Speaker 01

  So I wanted to stay more closely like to the psychological experience without adding this more, you could say, academic perspective, traditional academic perspective, where we indeed look for more causal lines of reasoning or the ground of, of, of this line of reasoning in biology. And this is exactly what I tried to avoid a little bit in that book.

• 10:26David Puder?

  Interesting.

• 10:28David Puder?

  Interesting. So, yeah, okay. I appreciate that. I think the brain is infinitely complex, you know, and do you think about 10, 6 to 10 billion neurons, some with 50,000 connections?

• 10:42Speaker 01

  Yeah.

• 10:43David Puder?

  We can, so sometimes neuroscience can almost like make something that's so complex so simple. But I think, I think about the interplay between creativity and psychosis as well, about how often there's a link between highly creative people and having some, and high openness people, super high openness people, and having some sort of psychotic associations or things that we might consider psychosis, right? But I might consider it more normal. Have you thought about that link?

• 11:17Speaker 01

  Yeah, absolutely. Because also, from a psychedelic perspective, you could say that people who are very creative tend to make use during the day of that more associative way of thinking, which is a bit beyond the traditional lines of thinking that we share that is the common way of thinking. So it's out of the box thinking is typical also for creativity. And I think also for psychosis. But the main difference is that when people are creative and then it's usually located in the context, it's limited in time and space. When someone is writing a book, well, then you sit down at your desk with your pen

• 12:00Speaker 01

  and your paper, and then you start writing. But the moment you put your pen down, it stops. Maybe you think a little bit about it later on, but actually the creation itself stops. And of course, there in psychosis, we have this endless going on of that associative process. And that's often what people with psychotic vulnerabilities are struggling with, that it doesn't stop. And then maybe in the night, they can't sleep because the process doesn't stop. The associations go on and go on and go on. And so therefore, you could say that psychosis is like an overdrive, like creativity is some, in some way or another, an overdrive.

• 12:45David Puder?

  Yeah, and just for like clarification, how you view this like, where do you view the boundary between maybe dissociation and psychosis? Or extreme panic and psychosis?

• 13:00Speaker 01

  Well, clinically speaking, it's often not so easy to make that distinction. It's exactly a conceptual distinction that we make. But the thing is that in the context of a panic attack, this will be like very temporarily.

• 13:19Speaker 01

  Then you expect that maybe the moment someone is having that panic attack, that then suddenly they start thinking about about specific scenarios where something very bad can happen. And then it's in a state of panic that some associations are made. But but you won't have that that very deep effect where people start questioning reality itself. Does reality exist? Do I exist? How is reality organized? It's more that they have something of a timeout experience like, because what is happening in their mind is so extreme that suddenly they seem to be out of reality. But reality itself does not become like a strange thing to them.

• 14:03Speaker 01

  So that's for panic, I think. And then for dissociation, well, that's, I think, a very difficult dilemma. Because classically, we have been dividing in the world of psychiatry and clinical psychology, like psychotic experiences and dissociative experiences, indicating that dissociation is an effect of trauma. While psychosis is most probably something that has to do with the brain. But this is already also a bit shaken up in literature, because we now observe that trauma is very prevalent in people with psychotic problems.

• 14:40Speaker 01

  That that's a bit of a difficulty. But then to to answer your question about the phenomenological characteristics of psychotic experiences versus dissociative experiences, I think that in dissociation, you will have this sudden shifts in reality, where where where people are in a certain identity role, and then at other moments in in another identity role, and that often this rather be as witness to to something what I would call from a psychologic perspective of a repression. Um, like, uh, there's something overwhelming that they don't want to know about, and that at this point, people switch between different modes of experiencing reality and dissociation.

• 15:24Speaker 01

  Whilst in psychosis, it's not so much the question of a conflict, but rather that reality is overwhelming and and starts to be unthinkable in in using common sense lines of reasoning.

• 15:38David Puder?

  Hmm.

• 15:40David Puder?

  Okay. Because because when I think about psychosis, I tend to think in categories of like, is this a personality disorder that is leading to some quasi psychotic episodes, like borderline precise disorder can have these quasi psychotic episodes, or is this more of a primary psychosis like schizophrenia? Those are the two large sort of groupings that I have when I'm when I'm sort of trying to delineate patient in front of me, what am I dealing with? The the person with borderline precise disorder, I would kind of consider more of a dissociative psychotic phenomenon that that that is presenting. So is is that how you view it, or you view it very differently?

• 16:24Speaker 01

  I think it's I I view it quite differently, yes. Um, I rather focus on the the idea of the psychotic experience as such, assuming that it it it might be very extreme, that psychotic experience. Uh, and then you maybe end up with what, from a D S M perspective, is called schizophrenia. But on the other hand, psychotic experience can be mild. And then it's maybe more related to what we call personality disorders, or some of the personality disorders. But I rather see it as as a continuum, not as like distinct categories, but rather as as something of the the severity of the impact of the psychotic experience.

• 17:07David Puder?

  Right, right. So I mean, I've. I have a lot of patients who don't fit into either of those two categories. And they'll have, you know, occasional psychotic episodes. One of the categories I'm seeing is people who use a lot of psychedelics. And it's like their brain has opened up to a more common psychotic psychotic like symptom.

• 17:31Speaker 01

  Yeah.

• 17:33David Puder?

  And I'm curious, it seems like they're more in that primary process, especially during the psychedelics, but even afterwards, it can kind of linger and it can be very destabilizing.

• 17:45Speaker 01

  Well, I think that's quite well known that these drugs are one of the triggers also of psychotic experiences and maybe also of clinical psychotic episode. And yeah, I think that that's absolutely the case.

• 18:01David Puder?

  So sometimes that, okay, so we may be getting away from kind of like the what you want to talk about or what the the value of this. It's, it seems to me that the, what we're talking about is some stressor will hit and someone may have some elements of psychosis, even if they're not meeting criteria of schizophrenia.

• 18:30Speaker 01

  Absolutely, yeah.

• 18:31David Puder?

  And it's not like necessarily this is depression with psychosis, because sometimes I'll see psychosis in severely severely depressed people, especially older, older adults who have very severe depression, they can, they can get psychotic. But you're, but what I, what I think is that there's another sort of type of patient that you're seeing maybe that like has some psychotic events. And especially like as they're maybe even doing the work of therapy, they can have some psychotic events as they become more associative or more regressive. I don't know, any. Are we, uh, am I missing your, your point here?

• 19:14David Puder?

  Or missing, I'm trying to understand it from my perspective, I guess.

• 19:18Speaker 01

  Yeah, yeah. Well, when I think about psychosis, I also especially think about the people who,

• 19:26Speaker 01

  not the ones who have psychosis-like experiences during therapy, but rather like indeed people who, and who start with problems of, of psychosis, like, like schizophrenia-like problems, or delusional problems, or bipolar ways of functioning, where often something of that psychotic flair will be present in, in, in how they function. And I think that the focusing on the psychosis part of the experience is most interesting, and especially since I also observe that many therapists don't work with it,

• 20:11Speaker 01

  or are a bit afraid of, of addressing this kind of experience. Whilst I think that often the psychotic experience is, is saying a lot of what the person is especially struggling with. And the problem that many people who have psychotic experience have is that when they talk about it with their relatives, maybe, or friends, that it leads to misunderstanding, because it creates a barrier when you talk about things that in the mind of the other cannot happen, but you do have this experience, this leads to a barrier. And so therefore, especially when they start consulting a therapist, a psychologist, a psychiatrist,

• 20:56Speaker 01

  it's very important, I think, that we as professionals are available to kind of work with it. And so therefore, we, we need something of the, of an understanding of the subjective experience of this psychotic way of functioning. So I think it, for me, it's, it's, it's broad. Psychotic experiences can occur in, in many clinical categories, like also in people with addiction, in severe depression, in bipolar problems, like, but also in schizophrenia and delusional disorder. So I think it's, I, I think of it as a broader category, like, yeah.

• 21:36David Puder?

  Okay, so there's like a curiosity of an openness, a calmness that you bring to this. And I think that that is so much better than if we have fear, if we have worry, if we're scared of the other. How has that shifted in your sort of, over the sense of your career, over the, you know, course of your career? Like, have you become more patient, more calm with these types of patients? Or has there been a shift in that?

• 22:05Speaker 01

  Well, I do believe that I started to be more open and that I do try far more to be present for people and to stay in touch with them and to try to connect. And in the book also, I described this very early experience in my clinical work that maybe we can talk about with, with, with one of my early patients, which helped me to kind of shift, like, okay, but you, you have to be open, you have to be present for, for that person, otherwise it will not work.

• 22:40David Puder?

  Yeah, tell me the story of this patient.

• 22:42Speaker 01

  Okay, so, but that's the patient, it's Mario, I described him in the book.

• 22:47David Puder?

  With the, the young man with Down syndrome, right?

• 22:51Speaker 01

  Yeah.

• 22:52David Puder?

  Okay.

• 22:53Speaker 01

  So, he was like, it was indeed a young man, 18 years old, Down syndrome, and he lived up locked up in, in the house of his parents, while locked up in meaning that he refused to leave his, his bedroom and he stayed there all day, talking in himself, addressing someone and having like these kind of confused dialogues. And so I did outreach work for an outreach service for people with.

• 23:27Speaker 01

  Intellectual disability as well as psychiatric problems. And so I started to to treat him and also have counseling sessions with his parents. And what I observed in my work with Mario is that, first of all, it was indeed difficult to have contact with him, both because of the fact that he had Down's syndrome and didn't have a very rich vocabulary, but especially also because as soon as I started talking to him, he started hallucinating and he started like talking to the voice that was addressing him. So sometimes he was saying something to me, then he was like of listening and his eyes looking into nowhere.

• 24:10Speaker 01

  And then he was responding to the voice and then again to me. So it was very difficult to to be in touch with him. And then I also observed later on that I did very, very well. I I did everything I could to be like a good psychologist. I tried to be an expert psychologist and to kind of very knowledgeable about psychosis at that time. And I observed that, actually, I didn't, I I did only really got in touch with him because of a of a little accident that happened. And the little accident was that one day I I arrived at his, the house of his parents with my car and it was raining and I stepped out of my car

• 24:53Speaker 01

  and I wanted to run to the front door, but I slipped and I fell on the on on the ground. And Mario had been observing it from that bedroom. And then suddenly he ran down from that bedroom and and shouted like stain, pollen.

• 25:09David Puder?

  You got him out of his room, huh?

• 25:11Speaker 01

  Yeah, yeah, but it was not because of my knowledge, but but because of my stupidity. And that led to a connection. And he had fun. He made fun of me as as the one who had been falling down. And then he also went to the bathroom and he came down with the handkerchief to for me. And this was very functional, a very functional way of relating to the world. Which exactly that he the thing that he didn't do anymore up until then for for many months. So there I observed like, okay, but to be connected with someone means that you have to to to be at the same level. And it it's not with impressing an individual who has psychotic experiences.

• 25:56Speaker 01

  For example, with your knowledge, which I tried to do, I think, as a junior psychologist at that point. That I want to be smart in relation to my clients. But then I observed, no, no, I have to be available to them. Um, and that that's what I think this is exactly what we need. And I do observe that in mental health care, we have a serious problem at that level. Because what we see is is is lots of escalation in relation to psychotic patients.

• 26:24David Puder?

  Yeah.

• 26:24Speaker 01

  Uh, uh, also in mental health care. And so this is the point that, well, I thought like, okay, but it's in in trying to be connected to someone. That the true value of of therapeutic work where it starts.

• 26:39David Puder?

  Hmm.

• 26:41David Puder?

  Yeah, so it's like the, especially with this type of patient, maybe that more hierarchical. Paternalistic approach would never work, right? It's like, yeah, I've I've kind of thought about this as like, sometimes I find myself naturally.

• 26:57David Puder?

  Taking a more like friend like experience with someone who's very psychotic of like. There's a collaborating, more of a collaborating take, right?

• 27:07Speaker 01

  Hmm.

• 27:07David Puder?

  And um, I think you falling down and him coming to help you, right?

• 27:13Speaker 01

  Yeah.

• 27:13David Puder?

  Here's here's him having a role in this relationship, which you guys had built over months. It seems like he's probably really appreciated that you were attempting to listen to him and attempting to connect with him, right? Like that was valuable for him.

• 27:30Speaker 01

  But suddenly we had a joint reality to be concerned about.

• 27:33David Puder?

  Yeah.

• 27:34Speaker 01

  Uh, and, and this was something new that, that there was a common ground and the common ground was what accidentally happened with me. Uh, but this was very important that it was not him having this strange experience and me being, uh, the normal, uh, caregiver who was there to help him. But then I was suddenly in, in a different role and he could step out of his illness role, so to speak. And then we could connect around that very event of me falling down. And that started off with creating something of a common ground. And that's very important when you want to work with someone who has psychotic experiences

• 28:16Speaker 01

  to find something of a common ground where we can talk. Maybe also about the psychotic experiences in the next step, but, but maybe to, to first of all, find something of that common thing.

• 28:28David Puder?

  Do you think it helped him long-term? Like, did it, did it change how he related to you after that incident? Or did he improve his psychotic symptoms?

• 28:38Speaker 01

  Well, the psychotic symptoms indeed improved over time, but it especially created an openness while, whilst before he had problems in saying to me what the voice that he was hearing was telling him. He started to be more open about it and he said what the voice said and then he started laughing about it. Um, and, um, it was like he was also laughing with me. I was, uh, and, and returning to me falling down. Often when I came to him and when, when, when he saw me, he, he said, "Oh, Stan, you've fallen down." And then he started laughing, uh, with, with it. It was a little joke.

• 29:20Speaker 01

  And then the same joking nature returned when he started talking about what the voice was saying to him.

• 29:28David Puder?

  Hmm. Um. And what was the voice saying to him?

• 29:31Speaker 01

  Well, for example, like, uh, feeling the breasts. Uh, touching the breasts. This was something that he, he, he was hearing. And then he said it to me and then he started laughing because this was, was the thing that he was hearing. And I think that especially for him also, there was a huge taboo before that. And he would never say it to, to me or to his parents that this was the thing that he was hearing. And, and maybe it's, it's because of the connectedness that was created in the first step that this openness actually occurred.

• 30:05David Puder?

  Yeah, I think that's really important. I think it's been, there, there's been a couple of patients where it's like, you don't really get the full story of the psychosis until years of connectedness, you know? It's like, um, it's one patient I had, felt like he was in the Truman Show. Right? So like everyone was watching him, cameras were on him. And it wasn't till maybe a year of elanzipine and, uh, you know, a lot of relational space before he started telling me that this was like what he had been experiencing for so long.

• 30:41Speaker 01

  Yeah.

• 30:42David Puder?

  Um, how would you, how would you interact with someone who felt like they were in like a Truman Show, like they felt like, um, you know, the whole world was built to watch him, basically?

• 30:52Speaker 01

  Well, of course we must know that many people, many psychotic patients have this experience. And so many of them refer to the film, The Truman Show. Um, and this as such is already very interesting. And I would also like immediately think about the parallel between that movie and some philosophical reflections that we have had in, in, in Western philosophy. Like Descartes, he also wondered whether there was a God that was deceiving us. And that maybe reality is just a big game where we are and, and it's God deceiving us. So that's a philosophical thought within our tradition.

• 31:37Speaker 01

  And then of course, when someone at a very subjective level starts, starts feeling this. And for me, it's not just craziness or But but also like, okay, but this is something of human reflection that there occurs in a very extreme form. So I I do find it also interesting, the fact that a human being can have this kind of imagination. So out of that curiosity of what someone is living through, I would listen to him in the first instance and and ask him like, okay, but tell me what is happening. Um, and how is it for you? How do you think it is organized? Explain me, it's not something that I think or I believe.

• 32:18Speaker 01

  Um, but I do hear that you say that for you, this is the case. So explain it to me so that I maybe can understand a bit what what it is that you are that you are observing or that you're living through. So I would invite him to to say more about it. Also, out of the idea that that it's a very specific way of thinking that human beings can have. And that can, of course, go in a direction of starting to be very painful for them. But I would try to create that common ground in in the listening as such to the story.

• 32:58Speaker 01

  And then, of course, we will hear something of what it does with people. So some people might, we we will be very suspicious because of that. Um, and and they will tell us that that they are very suspicious because they are deceived all the time. Um, and then I think it's it it it could be a good idea to to echo something of it that that indeed that I hear that he's suspicious. And that that I can imagine that if you think that reality is organized like that, that you start to be suspicious. That's not not surprising, maybe. So I would express something of of of of how I'm a bit in touch with that experience

• 33:39Speaker 01

  without confirming that he's he's right in his in experience or that he's wrong in his in experience in that experience. But rather to to take it really as a subjective experience of an individual in relation to reality.

• 33:54David Puder?

  Yeah, it sounds like it sounds like how I think about we, you know, if this is like new for people, they kind of consider it this way. Uh, this is how you would do good dream analysis too, right? It's like you you're you're curious about it. You see where their associations come from.

• 34:14David Puder?

  What emotions are there?

• 34:16Speaker 01

  Yeah, but the difference would be for me with dream analysis, the way I do it in psychoanalysis is rather that in dream analysis, I would focus more specifically as an analyst to specific topics in the dream.

• 34:30Speaker 01

  And I'll invite the patient to say more about something very specific. So if someone would have had like a Truman Show like dream, and he says that he was sitting in a boat. And he was sailing like in the case Truman Show in the movie. And that's specifically in the dream. I would maybe invite my patient to say a bit more about the boat. What does it make you think of? The fact that you're in a boat in the dream? And I wouldn't do that in the context of a psychotic experience.

• 35:01David Puder?

  Why not?

• 35:02Speaker 01

  I would then go for the holistic approach of the story and not so much the analytical details of it, which I would do in the context of dream analysis. But what is similar, of course, is that I would take the subjective experience as a subjective experience, like very seriously and invite people to talk about it and to devote time to talking about it.

• 35:28David Puder?

  Okay. Very good. Yeah. Let's talk about Jung. That's probably the most. It's a fascinating kind of thing to talk about his psychosis, talk about the break with Freud, how you think that that related to it. So do you want to share with my audience kind of like how you think?

• 35:49Speaker 01

  Yeah.

• 35:50David Puder?

  The break and his stress from that led to some of his psychotic writings that were detailed in The Red Book?

• 35:59Speaker 01

  Yeah, yeah, yeah. So the thing is that with Jung, I'm not a Jung specialist for, I must say it, I'm a psychoanalyst, but I'm not a Jung specialist. But at a certain point, I got very intrigued by Jung, the man.

• 36:17Speaker 01

  Because Jung has produced a very curious set of books. And the first one of that curious book that was published was the so-called Red Book. And the Red Book is a very big leather volume, where Jung had been writing in Gothic letters, and he added like small paintings and mandalas to it, and it looks like a medieval manuscript. And for Jung, that manuscript is something of a big revelation. It's not something that he has consciously thought out and then written down, but there is something of an inner truth that has been revealed to him, and he has written it down.

• 37:01Speaker 01

  And then I started searching about the book, and it all indeed starts with the relationship between Jung and Freud. Jung was, like for Freud, a very promising colleague to work with. He was a bit younger than Freud, and he was not a Jew, and he was a psychiatrist. And that was interesting for Freud, because he, as a Jew, was excluded from academic positions in Austria.

• 37:27Speaker 01

  And also, he was not a psychiatrist. He was, he had a neurological training. And Freud believed that Jung was like the one who could follow him up in psychoanalysis, and they had a very intense exchange of ideas. But then, of course, Jung had his very own ideas on certain topics. And then there was a break between Freud and Jung. And it's especially at the moment of that break between both that Jung actually started having psychotic experiences, like he started hearing voices that told him like vague things. And in the end, he said, he decided to start listening to what he was experiencing and assuming that something was being told to him.

• 38:12Speaker 01

  And that then became, he first wrote it down in little black books, and then he brought it together in that Red Book,

• 38:22Speaker 01

  of which he also says that the crucial ideas of his later theory are all in that Red Book. So not so much as a product of rational reflection, but rather of creative revelations that he has had.

• 38:38David Puder?

  Yeah, so, so interesting. So it was like, um, the break, the final break with Freud occurred around age thirty eight. His Red Book coming out age thirty eight, age thirty nine. You know, in like one vision, he sees Europe flooded with blood.

• 38:55Speaker 01

  Yeah.

• 38:57David Puder?

  Often an image associated with the coming of World War One. Do you think there's any, uh, beyond sort of like, um, how do you, how do you make sense of like the people who might see links to like, okay, he's seeing things in the future, you know, prophecy, you know, kind of like this, like, beyond just a psychotic event, right?

• 39:21Speaker 01

  Yeah, yeah. Well, personally, I'm, I'm, I'm rather, I think, a very rational person in that perspective, and I wouldn't see it as prophecy.

• 39:31David Puder?

  Okay.

• 39:32Speaker 01

  I don't think that Jung was a seer, so to speak, who could foresee specific events. But at the same time, I do think that he was probably a very clever man, and that he was maybe linking already things that had to do with politics in Europe, um, together with also conflicts with, with Freud, and that something of that dramatic thing provoked this vision that indeed he once had in a train. But as I note in the book that I wrote, it's kind of interesting to see that, um, the blood is flooding just onto the Alps, where Freud was living.

• 40:10David Puder?

  Mm hmm. Yeah, you pointed that out. I found that really curious.

• 40:13Speaker 01

  Yeah. So I, I think it's, it's not unrelated to, to his conflict with Freud, because when, when you see the, the logic of events, there is first this rupture with Freud, and then he starts having the psychotic experiences. And then, of course, these psychotic experiences, they say something, but I wouldn't read them as prophecy about the future.

• 40:36Speaker 01

  It's maybe a way of guessing about the future.

• 40:39David Puder?

  But what about, what about like a, um, a deep knowing? It seems like from a lot of his psychotic things, there was a sense of like, a lot of his future ideas came like a deeper sense of knowing, the archetypes,

• 40:54David Puder?

  stuff that we'd appreciate like, oh, there's some real beauty in that. Like, how does, how does, um, his creativity in the midst of his psychosis

• 41:04David Puder?

  lead to ideas and how do you see that that is productive? Cause not all people who have psychotic symptoms,

• 41:13David Puder?

  it doesn't always lead to something productive, you know, in the future.

• 41:18Speaker 01

  No, but there is a surprising big portion of people who have been very creative in their work.

• 41:24David Puder?

  Oh, 100%.

• 41:25Speaker 01

  But also a couple of, of people in, in, in the arts who started off from psychotic experiences. So in my view, the psychotic experience is already a way of thinking. And I, um, some people managed to kind of do something with it, with the fact that there is a thought, it's a way of thinking, it's a primary process thinking around specific events that occurs in the psychotic experience. And I do think that, um, people can, that you can learn something from it, that maybe tells something about you in your context

• 42:04Speaker 01

  and that you can learn something about it that is not crazy, that is not just very idiosyncratic, but, but maybe relevant to, to other people. Like in Jung's case, he took it very seriously. He studied the content of what was revealed to him in the psychotic experience. And of course Jung was a human being, so it's not surprising that something of the conflicts that are typical for human beings. Occurred there in that experience. And so he took it seriously. But maybe because he was also already like a psychiatrist and a psychoanalyst. Uh, and he was aware of the fact that psychotic experiences might communicate something.

• 42:49Speaker 01

  Because before he had the experiences, he already wrote about it. That we should listen to the content of our of what psychotic patients say. So he applied it to himself and then kind of saw probably that it articulated something about typical human struggle. And I think that this is what he uh took from it. Uh, and then in his very own language, which is a specific Jungian language like about the archetypes. But he's saying something about what human beings are struggling with. That that's how I see it.

• 43:28David Puder?

  Hmm. Okay. Appreciate your your thoughts. So so I'm I'm reading that um Jung's relationship with this one patient. Sop Soprene, maybe I'm pronouncing it wrong. Where there was some professional boundaries potentially crossed led to part of the the rupture.

• 43:48Speaker 01

  Yeah.

• 43:49David Puder?

  With Freud. Freud was seemingly critical of this relationship.

• 43:53Speaker 01

  Hmm.

• 43:54David Puder?

  So it seems like there's quite a bit of stresses going on in Jung. Um, Jung's life, right? So how do you see that in the timeline? Is this that part of it? Um, I think some of his visions started earlier, like for, you know, around thirty four. He was having some marvelous visions that he was reporting to Freud in letters. So was there? It it seems like in your book, you you say the psychosis started after the rupture.

• 44:23Speaker 01

  Hmm.

• 44:24David Puder?

  Was was it? Was it more pronounced after the rupture? Or how would you sort of, or did he have more freedom to express it after the rupture? Or, you know, was it happening in the midst of the sort of the conflict? What's your thoughts on that?

• 44:38Speaker 01

  Yeah, well, I think that the rupture with Freud brought more the distressing aspect of this, of this kind of experience to the fore. So that's more closely connected to how we as professionals usually encounter psychotic experiences like disruptive elements that suddenly pop up in people's minds. But of course, like there are traces in Jung also when he describes his childhood that he had a very wild imagination and meaning like a very wild primary process thinking that he tended to apply to the world. And maybe, I can think that maybe this was also annoying Freud.

• 45:19Speaker 01

  Freud, to be very like, although he was speculative in many domains, he wanted to have a very logical theory because he, because he wanted that it, it should be able to test the theory. He wanted to discuss with scientists and not with people who tended to go in a direction of spirituality and religion. That was not the way Freud wanted to, to go. But you see that Jung is more in that direction, of course.

• 45:48David Puder?

  Okay. Yeah. So from your, from your read on this, he was, he was having more access to that primary mode of thinking because of the stress of the rupture in the relationship. And that was like, sort of magnifying things. So, so if you were his patient, or if he was your patient, how would you explore that with him?

• 46:17Speaker 01

  Wow, that's a difficult question.

• 46:21David Puder?

  Like, let's say he's bringing to you these visions, he's bringing to you these, um, these, these stories. What do you do with that? Yeah.

• 46:30Speaker 01

  Yeah, I would first of all invite him to say more about it. Um, and to contextualize it, like, what, what is it that you've written down? What, what is it that you've been drawing? Um, and what, what is the content of it? On the one hand, but also like to situate it in time and space, like, when did you make it? And at which, uh, how, how can you situate it in a chain of events? What has happened last, la, la, la, last night or last week? That now you have been making specifically this? What is it telling about the past week? Or maybe about the past weeks and what has happened? Is it responding to something?

• 47:14Speaker 01

  Um, so I would try to, to contextualize it to, and, and invite the, him to, to say more about it. Because my hypothesis would be that, um, it is indeed like, it's an answer to something. Uh, it's an attempt to, to solve something of a problem. Um, and therefore he has been creating it. And, and I would try, if it was a patient, to, to, to bring it into the transference relationship, into the therapeutic space. And to, to see how maybe the, the conversations with him provide some ground to kind of contain the experience

• 47:57Speaker 01

  that, that, that maybe what is starting with the writing down of, of the experience with Gothic letters, um, and, and paintings, that it's not taking over his entire life, that maybe it can stay limited. Because maybe the problem that he's responding to is something that because we talk about it and we discuss it, can, maybe we can also produce ideas that help him to, to deal with that problem that he's been confronted with. Because for me, the creative writing would already be an answer to something of a problem. And therapy as, can also provide something of an answer to, to the problem a person has been confronted with.

• 48:40Speaker 01

  So I, I would, that, that's, I think how I, I would try to work with him.

• 48:45David Puder?

  Okay. And so, what was the first question that you had there? Okay, so if I was young and I heard you asking me in that, I would be like, you know, I feel like you're critical of my these visions. I feel like, in just the way that you're asking that, there's a sense of critique. Like, you're trying to show me that this is not real.

• 49:14Speaker 01

  Yeah.

• 49:16Speaker 01

  And then I would say that I'm not saying it's not real, but rather that it's not everybody has these experiences.

• 49:23David Puder?

  Can we try a role play here? And I'll be young and

• 49:31David Puder?

  pretend I'm young and I just say to you this, okay? Like, the way that you say that, Stain, is I feel like you're saying you continually are trying to look for

• 49:47David Puder?

  some sort of analytical reason behind this. And I feel like there's a form of critique in that.

• 49:53Speaker 01

  Yeah.

• 49:56Speaker 01

  Well, my answer would then be that I'm curious about the experience because when you say about it,

• 50:05Speaker 01

  when I look to everybody who's coming here, it's not that it's so common that people have this thing, that people have this religious revelations. And so for me, it's something new. It's something a bit surprising to hear it from someone. But at the same time, I'm curious about it. And I'm not saying it's nonsense, but rather like, okay, but why is it you that is having it, that experience? And well, something along these lines, I would try to engage with him.

• 50:42David Puder?

  Okay, we gotta, we gotta get you more into this like role play here, okay? And there's no right answer, right? See, I, I'll pause for a role play and I'm, I'm, I'm actually leading with some transference, right? Cause I'm thinking that there would be some Freud transference because of the disruptiveness of the relationship, right? So I, I would be transferring as Jung that you are like Freud and critical of him because there were some letters that kind of like, you know, you feel like Freud is like the superego of Jung in these letters, the way that Jung is responding to it. So in one letter I read, it was like Jung was like, "I know that you're not going to

• 51:26David Puder?

  be happy with this." It's like, so it's like Freud is like the superego structure of, in the midst of his like sort of internal thinking, right? So I was, I was thinking I would lead with some of that transference towards you and be like, you know, as you, as you are talking to me about this, I feel like you're critical of me.

• 51:50Speaker 01

  But I think that the difference would be that when Freud was working with Jung, Freud did have an agenda.

• 51:56David Puder?

  Oh, 100%.

• 51:58Speaker 01

  Yeah. And as a therapist, of course, like I wouldn't want him to be rational per se. That's, that's his own choice. And I would rather like societally think when someone would come with something like a medieval manuscript to the fact that indeed there are lots of medieval manuscripts in the world. There are lots of many libraries with this kind of manuscripts.

• 52:22Speaker 01

  And there's lots of religious manuscripts that are kind of interesting, both at the sense, in the sense of the stories that they're recounting, but also in terms of the aesthetics of what, of how it has been made. And, and that this is interesting because in a consumption culture like today, we don't make this anymore. So if someone takes the effort to do something along these lines, I think it's a bit surprising, but at the same time, I'm curious about it. So that, that would be the attitude that, along which I would listen to, to you when you would, with your Jung manuscript come to me.

• 53:03David Puder?

  Okay.

• 53:06David Puder?

  That's good. Well, we don't have to, uh, we don't have to continue this. Maybe the, uh, the audience will be like, hey, that we want a full, we want a full role play.

• 53:18David Puder?

  Like step by step, you know? I was actually thinking it would be fun to write a book where it's kind of like a, uh, more of an artistic, you know, like if, if Jung was in, in, in therapy, right?

• 53:31Speaker 01

  Yeah.

• 53:32David Puder?

  And, um, he would, he would bring out some of the letters from Freud and be like, this is what, this is what he wrote. Do you see how critical he is of me? Like, I'm trying to, I'm trying to be open and explore. And all he wants to talk about is this libidinal theory of early sexual development, where I think there's so much more beautiful, like we need, like, we need to invite more archaeologists into our endeavor to, to understand human nature. We need to, we need to look at icons of the past.

• 54:07Speaker 01

  Well, it could be a great novel, a great novel indeed to, to kind of address how a therapist could work with someone who has this psychotic-like experiences or psychotic experiences.

• 54:21David Puder?

  What, what would you have said to Jung if he would have said that? Just what I said right there?

• 54:26Speaker 01

  Well, I would say that maybe Freud, that has his own agenda.

• 54:31Speaker 01

  Freud was probably not a neutral listener. He wanted to promote his theory. He had his own stakes. He had his own specific things that he wanted to realize. And that maybe Jung was looking for more, for someone who was closer to his hypothesis and to his dogmatic starting points. And that, that maybe there was a problem for Freud to be open to what Jung was expressing. And, and that maybe that's what he felt in relation to Freud.

• 55:02David Puder?

  So maybe it's like in the throwing off of that dogmatism, that structure, right? It's almost like his, his brain kind of like had too much freedom to explore for, for, you know, and the psychosis kind of picked up quite a bit in the midst of that. And also the pain of the separation.

• 55:23David Puder?

  In the, in the pain of the, uh, the disconnection.

• 55:27Speaker 01

  But probably what you hear that I would try to do is like recognize Jung, recognize him as someone who is doing something, who is thinking, who is trying to produce something, who is trying to do something creative, to make an own point. That would be my starting point. And I think that if I would try to do it like that, that maybe in the Jung patient, something of an openness could occur, like we should especially avoid that he feels judged by me as a therapist.

• 56:04David Puder?

  Right, okay.

• 56:05Speaker 01

  It's not that he would have to think that I'm a believer. Maybe he would feel that I'm a bit critical about

• 56:16Speaker 01

  when he says something of the spiritual revelations, that it could be that he feels that I'm not like fully at the same line, but I'm not judging it. And I think that that's very crucial.

• 56:34David Puder?

  Yeah.

• 56:37David Puder?

  Yeah, okay. And we can move on to kind of like other other points that you've made and reflections you've had. Are there other cases, famous cases of psychosis that you've kind of thought through and thought about how they might relate to this kind of holistic view of how to approach psychosis?

• 57:00Speaker 01

  Well, in the book, there's a couple of people who are a bit or quite famous, whose work I'm discussing, like there is Annie Rogers, a professor of psychology who has had psychotic experiences. There is Yaya Okusama, the artist who started painting, starting from hallucinations already as a young child and who well makes art installations with

• 57:30Speaker 01

  The hallucinatory experience. Um, there is, of course, Ellen Sacks, who wrote a memoir about her own psychotic experiences. So I, I, I tried to go rather broad in, in, in, in the field of, well, with, within our culture. Who are people who have been talking quite openly about psychotic experiences that they have had? Um, and who also have this, who have been exploring this twist that psychosis is not, or the psychotic crisis is not the end of life, but maybe like the start for something new. And that can also be functional in, in how you afterwards relate to the world.

• 58:15David Puder?

  Um, yeah, I, um, I met Evelyn Sacks, I hope I'm saying that right. She, she gave a lecture when I was at the New Center for Psychoanalysis.

• 58:26Speaker 01

  Yeah.

• 58:26David Puder?

  And, um, I read her book and it was impactful decades ago. Anything about her story in particular that spoke to you or that was interesting to you?

• 58:38Speaker 01

  Well, what, what I would also recommend it to, to everybody who has not read the memoir to read it. Because it shows so beautifully that although she has this problem that has been diagnosed as schizophrenia. And I think that clinically speaking, the diagnosis is correct. Um, but at the same time, she, she shows that, um, what she was experiencing is indeed kind of always linked to specific triggers in her life. Um, like it's when she has her degree or her first sexual encounter with a boyfriend. It's often at these moments that she starts having the psychotic experiences. And when we only look at the psychotic experience.

• 59:21Speaker 01

  It's only the strangeness that that stands to the form. But in her memoir, she makes clear, because it's the accounts of the when she talks about psychotic experience, it's embedded within events in life. And that's how that memoir is so beautiful in how you see that the rupture occurs as an answer to something. Um, so therefore I thought that was very useful. And also, um, the difference in how different clinicians have been reacting on to this psychotic crisis of Ellen Sacks. So where she has both had this very brutal encounters in some psychiatric hospitals,

• 1:00:04Speaker 01

  but at the same time has also had like very good clinicians, both like biological psychiatrists and at a certain point, like a clientian analyst who was working with her and trying to to delve into the psychotic experience. And yeah, I was amazed by how how profound that work was and how stressing it must have been also with a therapist to work with her. But but it's such a beautiful story of how something is possible if we try to be there for the psychotic patients and don't immediately think only about the strangeness of the experience.

• 1:00:46David Puder?

  I think in the book, um, one of the most stark examples of poor mental health care that she received was being kind of like in this psychiatric hospital in restraints for a very long period of time and how traumatic that was to her.

• 1:01:02David Puder?

  And how difficult it was for her to move past that into a place of acceptance of like, I do have psychosis.

• 1:01:12Speaker 01

  Yeah.

• 1:01:14David Puder?

  That was one of the things that really stuck out with me. I was reading it, just kind of like how horrific that seemed. And I've seen this with a number of patients who are describing their psychiatric hospital visit.

• 1:01:28David Puder?

  It's just kind of like becomes a new trauma of sorts, you know? Even even if it's like, maybe the professionals were

• 1:01:37David Puder?

  well meaning, you know, as well meaning as they could have been, given the situation. It seems awful. And I've actually

• 1:01:46David Puder?

  there was one patient I had who who was homeless and his mom would bring him to me and we would give him injections. And he thought I was, he hated it. He thought I was part of the CIA's sort of operation to harm him. And once he got maybe a year into being on good doses of an antipsychotic. He was back in school, doing well, straight A's. And he was writing books for his class on the psychiatrists linked up with the CIA

• 1:02:29David Puder?

  against the person, you know, type of thing, but like, you know, in a very sort of thoughtful way, not necessarily like psychotic way. And we had, we were able to put words to what happened between us and how hard it was. But I wonder, like, Evelyn's ax, you know, was on, I think, clozapine and Zyprexa. She mentioned in a TED Talk. Do you, having this approach with more of the therapy, do you see it as the as the thing that should be only used? Or are you also open to, you know, patients being on antipsychotics, clozapine? Like, do you think therapy is enough?

• 1:03:10Speaker 01

  No, no, of course not. I think it's, in most cases, it's a combination of both that is that is useful.

• 1:03:19Speaker 01

  Like, both the medications and therapy, I think.

• 1:03:24Speaker 01

  It's in the combination and I'm I'm not a psychiatrist, so I'm not allowed to prescribe medication. Um, but I'm not, I'm not, I'm not struggling against them, not fighting against medication. But I do share some concerns about medication. So I do think there is a tendency to over-medicate people with psychotic problems. And once they are on one antipsychotic and maybe it doesn't work the way that we want. And that they, and in the end, they they take several ones. So that's why I often observe in patients here in Belgium, that many of them take like four or five different um uh psycho pharmacological products.

• 1:04:10Speaker 01

  Um, in the end, and there I would be a bit concerned like. Oh, absolutely. Very, uh, and so therefore, uh, I think it it, if we use uh pharmaceuticals, we should use it in a very rational way and in minimal doses, as minimal as possible. But sometimes it's very good that someone has this medication, of course. And I wouldn't, I would never advise to stop people um uh just like that. Um, I I would also say, always say to people, you have to discuss it with your psychiatrist. And if you want to stop, you should do it very slowly and and and really in a very considerate way with guidance um fr- from from from a psychiatrist.

• 1:04:52Speaker 01

  But I also believe that therapy is not working for everybody with psychotic problems. Some people will get more psychotic because of having psychotherapy. So I think we should be very smart in when when we observe that it is destabilizing people, that it's better not to to continue with it. Um, but the same is true for medication. So there is no one cure for psychosis. And often it's in the combination of both social support, psychosocial support and um good healthcare, um physical health, pharmacological care and psychotherapy. If we can combine these things together, I think that that's a better way of thinking about

• 1:05:36Speaker 01

  a strategy to to approach psychosis. And if we can leave one of these way and the person is still functioning well, of course, we can, we can drop it. And maybe you can drop the psychotherapy, or maybe you can drop the medication. I don't know. We will have to see patient per patient what is working. So have very functional way of thinking about it.

• 1:05:58David Puder?

  And I think, I think the reason why I think in categories, like I said, like borderline precise disorder can have quasi psychotic episodes. They often have a history of self harm. They often have a history of passive suicidality. They often have a history of, you know, deep interpersonal conflicts, leading to ruptures, leading to high stress, leading to self harm. These patients, new standards are to not leave them on antipsychotics forever. And I see that this is what clinicians have been doing. I came out with an episode recently that talked about this. So actually, new recommendations from a lot of organizations are like maybe a week of antipsychotics, but don't leave them on it forever. And so in my partial program, when these patients get hospitalized, they come into

• 1:06:41David Puder?

  my partial program, I'll take them off of risperdal pretty quickly. If they fit that category of borderline precise disorder, if they fit the category of like schizophrenia, you know, delusions, auditory hallucinations being the predominant symptoms, right? And the, you know, usually starts twenties, late twenties. And usually it leads to them being very isolated, you know, at home, in their bedroom, homeless for years before they actually get good treatment, right? So there's like schizophrenia and they're not showering, they're not taking care of themselves. These patients, I believe, are probably going to need to be on some dose of antipsychotic.

• 1:07:24David Puder?

  Now, if the first medication like risperdal, spironine, alazepine doesn't work, you know, then my sort of way that I've talked about on the podcast is get blood levels, make sure the blood level is optimized. There's numbers that we use to kind of see if it's optimized. Before we switch, if it's not working, the chance that a second one is going to work is like pretty low. And so I've done a lot of episodes on clozapine for treatment resistance schizophrenia.

• 1:07:56David Puder?

  I think it's very important to kind of delineate schizophrenia from the personality disorders and then further delineate something like a bipolar because bipolar people, when they get ramped up, they can get psychotic. They don't need to be on antipsychotics forever. Lithium is probably the best choice if that one works for a long term. And so I'll have people on lithium and then if they're getting more manic, they'll be on, I'll put them on, you know, an antipsychotic on top of that for a couple of weeks to bring them down. And I'll bring them down off that antipsychotic as soon as I can. But I think what you're seeing and what I'm, I am as critical as you are, is they'll get put on one antipsychotic. Now, clozapine is hard to monitor. So we don't want to, a lot of people are afraid

• 1:08:39David Puder?

  of putting them on it. They don't want to have, you know, I have clinicians, I had just one clinician the other day saying, if I could never prescribe clozapine again, I would. Just because you have to check the blood levels and the, or the, you know, the complete blood panel to see, you know, if they're white blood, what their white blood cells, what their neutrophils are doing. So a lot of people don't want to do that. So what people do in practice is they stick on a second antipsychotic, which is really just sedating. And the other thing I noticed, which I'm very critical of, is they, they

• 1:09:17David Puder?

  get put on multiple anticholinergic medications, which lead to like a decrease in their brain function. So it makes it very hard to do therapy.

• 1:09:28Speaker 01

  Yeah.

• 1:09:29David Puder?

  And so I've, I've done episodes as well on like anticholinergic burden and the necessity to decrease the anticholinergic burden so they can do psychotherapy.

• 1:09:40Speaker 01

  Yeah.

• 1:09:41David Puder?

  And so it's, it's a, that's, that's a general summary of my perspective.

• 1:09:47Speaker 01

  Yeah, yeah, yeah. But I can really follow you with that very like logical way of thinking about using these medications. And that's exactly the kind of psychiatrists that I would like to collaborate with. And of course, I can follow that from your perspective, you would want to make distinctions between the categories much more than I would do as a psychotherapist. Because for me, it's often not so different, the way I would speak to someone who's suffering from a bipolar. Uh, problem with psychotic experiences connected to it compared to someone who more fits a schizophrenic profile. For me, it's, it doesn't make such a difference.

• 1:10:31Speaker 01

  Uh, I, I rather see there, I would focus always, always on the individual and, and, and the question, of course, of psychotic experiences and the impact of psychotic experiences. For, so for me, as, as, as a psychotherapist, as a psychoanalyst, it doesn't, that, that's not the clue of how I think about the problem, but I do believe that, of course, if you approach it from a different way of, of, of thinking, like a biological model, some categorical distinctions are more relevant. I'm very open to, to combining both ways of thinking about same person.

• 1:11:07David Puder?

  I think, um, I don't, I don't know if I would purely say mine is a biological, cause I, I think I am leaning more towards, um, this, this approach of being patient with someone who's outright refusing medication.

• 1:11:24Speaker 01

  Hmm.

• 1:11:24David Puder?

  Um, and there's a couple of patients on my panel that, um, have anosognomia. So they do not believe that they're psychotic.

• 1:11:34Speaker 01

  Yeah.

• 1:11:35David Puder?

  Um, and they've created a lot of frustration for a lot of providers because, you know, they don't believe that they, they, they need to be on medication, they refuse it.

• 1:11:46Speaker 01

  Yeah.

• 1:11:47David Puder?

  And they may be not sick enough to be hospitalized. So they're kind of in this in-between place. And so I, I've tried to build connection over time and then get to a place where maybe they are open to it, but it's, this is very difficult work.

• 1:12:04Speaker 01

  Hmm.

• 1:12:05David Puder?

  Uh, especially if they're like, you know, not showering, not taking care of themselves, um, at home for a number of years. Um, this is probably the, the biggest pain point I would see of like, you know, people are trying to like help this kind of unique population that just are not getting better. They're stuck.

• 1:12:23Speaker 01

  Yeah.

• 1:12:24David Puder?

  You know, do you have any insight on this group, what you would say to, to a provider who's trying to help this type of person?

• 1:12:31Speaker 01

  Well, um, I would always try to look for the common ground. Um, what could be a common ground that creates something of a connection between a therapist, the clinician, and the person? Because it's only if there is something of a common ground, that maybe an openness for further interaction and maybe discussing, like, for example, the possibility of medications. It's only because of that that it will happen. Um, and well, yesterday I was talking with a psychologist working in a prison, and they were talking also about a psychotic man in prison, and he's connecting with no one.

• 1:13:17Speaker 01

  Uh, but they were describing that there was one thing that he has an interest in, and that's in getting crisps.

• 1:13:26David Puder?

  Getting crisps, what's that?

• 1:13:27Speaker 01

  Yeah, well, chips.

• 1:13:29David Puder?

  Chips?

• 1:13:30Speaker 01

  Yeah, just little things to eat.

• 1:13:33David Puder?

  Okay.

• 1:13:34Speaker 01

  But they should give it in the back to him, because he's very suspicious. And so if chips are being offered to him, then he's willing to interact with people. And so maybe if he's interested in chips, then maybe you can start talking about that. Does he want salted chips, or paprika, or different taste? And to really start like, maybe around very simple things, if there is something of a common dialogue possible, uh, to try to build some trust in relation to him. And of course, I'm not sure whether that will work in the longer term, whether that will lead to something of a trust and therapeutic relationship.

• 1:14:16Speaker 01

  But I think it's the only point we can start from as a therapist, to try to look for, what could it be? This little thing where we don't have to discuss about, that the patient does not need to be suspicious that I might be doing something to him when I do this very thing. And often it's very difficult to find it and a very minimal element. But it could be like, maybe there's a joint interest in a specific band. Because he's wearing a T shirt with Nirvana. And maybe we can, we can say, ask if he's a fan of Nirvana. Because I also know some of the songs of Nirvana. And maybe that could be a connection with someone.

• 1:14:55David Puder?

  Right. And, and I think.

• 1:14:57Speaker 01

  Minimal element.

• 1:14:58David Puder?

  I think that can be somewhat counterintuitive to some providers who are like, well, if all he wants to talk about is conspiracy theories, should I engage him in that? I have this one, I have this one client, he's, that he spends all day online reading conspiracy theories. That's all he thinks about. And, and conspiracy theories, you know, not like, um, you know, there's some things that are like, okay, the CIA finally released these files. Like, that's not the stuff that I'm talking about. It's the stuff of like, it's, it's the level of absurdity is much higher, right?

• 1:15:32Speaker 01

  Yeah.

• 1:15:32David Puder?

  But for me, just engaging him in that and allowing him to talk about what he, you know, some of it doesn't quite make sense. Like, he thinks, he thinks he's a genius in it, you know? But it's like, it does, it may not make as much sense as he talks about, right? But yeah, it's like looking for that one thing that he's curious about and allowing him

• 1:15:55David Puder?

  or her space to, to kind of like, talk about it, connect through that, right? I love that. That's a good point.

• 1:16:02Speaker 01

  And also, if someone only wants to talk about conspiracy theories, the question of course is, like, what is it metaphorically saying about his life? Um, what, what is the central concern? And if he thinks he's a genius, um, in, in, in some respects, what, what is it saying about him, about his, what, what he needs, what he wants? Um, what is he missing in his life? What has been missing in relation to his friends and, and his family and, and his job? If he has a job, um, that, that, that brings him to having this conspiracy theory as something of a solution? Because for me, it would be an attempt to solve something, something that's far more problematic for him

• 1:16:44Speaker 01

  than spending all day, uh, with his conspiracy theories. So I would always, in the back of my mind, wonder, yeah, but what is he trying to treat? Which subjective problem is he trying to treat with that conspiracy theory? And to maybe open to, to when it's about threats, when he feels threatened by some, something, to kind of stress, of course, like being threatened is for people a very difficult situation. Everybody would respond with anger or anxiety to, to being threatened. And this could be something of a common thing that we could draw from a conspiracy theory, not the content of the conspiracy theory.

• 1:17:27Speaker 01

  But if you feel threatened as a human being by someone else who is wanting to harm you, that's of course very damaging and very, and, and there is something maybe of a common ground that can be found. For example, in terms of the emotional response that we see in the patient and that we might make sense of in, in, in a certain way.

• 1:17:50David Puder?

  Yeah. Yeah, very good. Okay, so, so I think some of the things I'm pulling away are to look for, to look for the meanings, exploring the paradoxes, to put words to things, to bring a calm presence, to remain engaged and receptive without being overwhelmed by the chaos or the fear that the psychosis can induce, to, uh,

• 1:18:20David Puder?

  to have patience with the process. Kind of as we wrap up our time together, are there, are there any other sort of final pearls or final things you'd like to share as, as we seek to help these people?

• 1:18:37Speaker 01

  Well, um, maybe two things. The connectedness is, but, but you, you summarized it, but I believe that looking for something of, of a connectedness is crucial. And then also looking and checking with people how something of their concerns can be translated in, in, in different activities. So I do believe, for example, that artistic expression is often a good idea because artistic expression appeals to creativity, appeals to something of the primary process thinking, but also is something that creates a social bond. So I observed that, for example, that people with severe psychiatric problems.

• 1:19:24Speaker 01

  Like for example, maybe they are interested in playing music, in, in, in, in making up a rock band. And if you can make, if you can play music in a rock band and you can perform with your rock band the music, um, then you are being appreciated maybe by an audience. And for many people who are living in a very isolated state, because they're so deeply into their psychotic experiences, this way of appreciation, again, creates a connection that maybe also leads to discussions with people about the music. Because maybe someone says, wow, your cover of, let's say Nirvana, that was very, very good one. Your guitar sounded like very, very crazy.

• 1:20:07Speaker 01

  And, and then maybe they, they, you can talk about that. And that, and so something of the creativity is for me an underestimated thing. Um, and I, I think that's supporting people in it. Uh, but of course, the creativity and the feel that they are interested in. Maybe someone is interested in gardening and someone else in rock music or in painting or in poetry. I, so, but to be very open in which domains of human creating that people are open to, that, that connect to their talents and passions, that this is also something to, to put to the fore. And also as clinicians or me as a therapist, I would always be very attentive to

• 1:20:50Speaker 01

  what are people capable of in terms of what might create a link with other people and also be an outlet of, of, of something of, of, of the thing that they have in them and that they do want to express, like something of the psychotic experience. So supporting that is also, um, very important and also a topic, of course, that I discuss in, in, in the book.

• 1:21:15David Puder?

  Great, fantastic. I love it. Thank you so much. I appreciate your, your time. Appreciate your willingness to come. Uh, share with us here.

• 1:21:23Speaker 01

  Thank you, David. Yeah. Um, these were great questions and your invitation for the role playing with you.

• 1:21:33David Puder?

  It's new.

• 1:21:34Speaker 01

  Yeah, yeah.

• 1:21:35David Puder?

  Yeah, that's good. It's fun. Well, we will leave it there for today. Thank you for your time. And I would love, at some point, I would love to come to Belgium. It'd be beautiful to visit.

• 1:21:48Speaker 01

  Yeah, you're welcome.

• 1:21:49David Puder?

  It's on my bucket list.