So today we want to think together about ways of working beyond the biomedical or beyond the medical model and really thinking about how do we add patient-centered aspects to that. And I will start by saying that while I do have some conflicts, none of them are financial, and my co-presenters I think don't have any conflicts at all. And we just want to start by saying something about the medical model. The definition of the medical model in the APA Dictionary of Psychology is that it's the concept that mental and emotional problems are analogous to biological problems. That is, they have detectable specific physiologic causes, for example, an abnormal gene or damaged cell and are amenable to cure or improvement by specific treatment. Now of course this has been criticized all over the place. Some critiques are that an illness-centered approach overemphasizes biomedical factors and the genesis of illness, neglects all the biopsychosocial factors, underestimates the complexity of mental illness and recovery from mental illness as if the problem is only biomedical and the solution is only biomedical. It has the potential to medicalize problems of living. Lots of our suffering has to do with psychosocial factors, the environments we're in, although, of course, the brain is reacting to that. And it's potentially dehumanizing, right, contributing to a kind of stigma. And we know that for people and clinicians who have a narrowly biomedical model that increases stigma and decreases empathy. An illness-centered approach also has the potential to overemphasize biomedical factors in the process of recovery. So we're only thinking medications. It eclipses the uniqueness and experiences of each individual as if each person's illness isn't their illness and maybe blinds us to the ways that, you know, there's a person there whose history shapes the illness. It often prioritizes symptom reduction over long-term recovery and well-being and pushes for medical solutions to potentially complex problems leading to a neglect of psychosocial interventions. But I'm going to suggest that for the most part amongst the people in this room, I think there's very few people that ascribe to a real narrow biomedical model. Most of us understand that our patients are dealing with complex problems, that there's biological, psychological, and social factors that are all contributing or coming together in very complicated ways. But the problem, I think, for us as clinicians is that we are working in systems. The people that ascribe to a biomedical model are the people designing the systems, the bureaucrats, you know, the economists, the people that really are running the show. So we are developing models which push us towards practicing in a biomedical way. So we reify the DSM and then, and I think it's, you know, there's probably a lot of people in this room who feel like they're pushed to work in a more narrowly biomedical way than they really feel is optimal for their patients and really for themselves as well. So we want to talk a little bit about that. And of course, the medical model is not the only available framework. We know that, you know, third-person medical approaches tend to think of people as objects, whereas first-person patient-centered models or person-centered models think of our patients more as subjects. In a third-person approach, you would tend to ask what is this patient rather than who is this patient in a patient-centered approach. Again, in a third-person perspective, really the biomedical perspective, the question is what to prescribe. Once we add in a first-person perspective, we start to also ask how to prescribe in order to optimize the patient's ability to benefit from the treatments we have to offer. In a third-person perspective, we're the ones with the medical knowledge, so we tend to be the expert. But once we get, you know, focus on the person, now we have distributed expertise because the person is the one who knows what their developmental goals are, what they want out of treatment. And so we then have to negotiate around that. A third-person model tends to be a I-it model as opposed to an I-thou model. And in a first-person perspective, you know, where we're really focused on the person and their developmental aims and their function, and the person themselves, you know, we're working as mental health professionals. But as we narrow our focus to, like, a symptom focus, and we think of what we really are trying to do is just decrease symptoms, as we do that, we are becoming mental illness professionals as opposed to mental health professionals. Now, there are a range of alternative models. There's patient-centered medicine. The coin was termed initially by Michael Ballant and actually says, should say, yeah, 1967. The biopsychosocial model of Engels, need-adapted care that we're going to talk about, recovery-oriented treatment. I think Dr. Steingart will also talk about that. Trauma-informed care, drug-centered pharmacology, which I guess we'll also talk about, and then psychodynamic psychopharmacology. Now, I want to start just with a case to maybe make this point. So Em, a few of you, I guess, heard about Em yesterday. But Em is a 23-year-old single trans woman. She's an art history graduate student. She's of Lebanese Christian descent. The presenting problem is that she had her first manic episode about five months before I met her. At the time, she was started on lithium and quetiapine, but very quickly became non-adherent on the quetiapine. And then as soon as she became euthymic, started decreasing her lithium against the recommendations of her clinician. She had a second manic episode about six weeks later. The second one was a terrifying episode where she developed a delusion. And this is, she's from Lebanon. Things are flaring up in the Middle East. And she develops the delusion that she could become the burning bush that is not consumed and bring a message of peace to the world. So she's about, literally about to light herself on fire thinking she will survive. She will be fine. Her psychiatrist catches wind and says, you must take the quetiapine, which she does. But then overwhelmed with the feeling that now she's betrayed God, she takes the whole bottle and ends up in the hospital. I meet her about two and a half months after that. She has a past history of gender dysphoria, social anxiety, cutting, anorexia and remission, depression with low-grade suicidality, and a high degree of perfectionism since high school. She's been treated intermittently with SSRIs over the previous five years, but seldom really took it for more than a few weeks or maybe months. Medical history is non-contributory. Now when I meet her, she's on lithium 600 milligrams with a blood level of 0.5 milliequivalents per liter. So what treatment does this patient need? Right? Any residents or medical students who want to answer this question? Mood stabilizer, right. Yeah, I mean, you don't have to be Stephen Stahl to know that this patient needs an adequate dose of a mood stabilizer and probably an adjunctive antipsychotic. However, we start to get some other information that makes it more complicated. This social history. She grew up in a high-achieving family with an overbearing, critical, controlling, episodically explosive and violent father and an emotionally withdrawn absent mother. She felt chronically socially alienated, used mimicry to fit in, which undercut a solid sense of self. And really, despite her efforts to fit in, didn't. And so didn't have friends really until she got to college where she found her tribe. She was often growing up in a conservative mid-sized southern city subjected to bullying, targeting both ethnic and gender issues. And felt the school system really neglected her and minimized the significance of the bullying. For example, school administrators saying, well, that's just boys being boys, you know. So what's the effective treatment for this patient? Let's add a few more things. We know that she has characterologic deficits around identity, affect regulation, and ability to form healthy relationships. Her faith in others is easily shaken, plunging her into devaluation. She's highly sensitive to power dynamics and easily becomes oppositional. So basically, everywhere she goes, she's in a relationship with her violent, abusive, controlling father. Her transference to her authority complicates the task of forming a solid alliance because she really sees people through the lens of clinicians, through the lens of her father. So she figures you will use your authority not to help her get where she wants to get, but to bend you to her will, bend her to your will. So she thinks you're gonna manipulate her into doing what you want, so she resists. And medications are scary for her because precisely because of her identity diffusion, she's left with questions of is this me or is this the medication? And we know that experiences of dependency are alarming to her. So she defensively moves in a counter-dependent direction. She says she's averse, quote, to the feeling of being tied to something. This applies to both people, but also shows up around medications, which is why when a medication works, she needs to try to get off of it because she gets scared she's gonna need it. And lastly, her baseline is dysphoria. And so manias offer her a temporary seductive relief and you can watch her, or you can hear from the history that as soon as she starts to feel it, she wants to lean into the mania rather than leaning out of it. So clearly, I think the main point of this is that just a simple biomedical approach of knowing what to prescribe is very often the easy part of our job. The hard part is knowing how to prescribe, how to meet this particular person in a way that we enter into some kind of alliance where they can use the treatments we have to offer. And so we're gonna talk about three, four, five different models that really bring in the person part of this. And I think will help us think about how to get out of that medical model that's pushed by the systems that we're in. And so with that, I think I'll hand it over to Dr. Jiang. Thanks very much, Dr. Mintz. Yeah, I think that's a really nice setup and framing for the various perspectives that we're gonna try to get into now. You know, small disclosure, I am a candidate in psychoanalysis in addition to being a psychiatrist. But I'm going to do my best to represent just the trauma model without cross-pollinating too much of my thinking with my other main perspective. So of course, we have to define trauma. People always get upset if you don't define it correctly. The DSM-5 has a particularly restrictive definition of trauma. They call it an exposure to actual or threatened death, serious injury, or sexual violence. Many people in trauma-informed care, sort of the trauma-informed care world, you know, find this to be quite restrictive as it clearly omits the very impactful experiences of things like emotional abuse, emotional neglect, which do track a lot with the research on adverse outcomes. ICD-10, ICD-11 has a slightly more expansive definition. It's extremely threatening or harrowing, I don't have it in here, but it's like an extremely threatening or harrowing event or series of events, something to that effect. So a good bit more expansive in its necessary vagueness. Then there's adversities, which encompass certain traumas which are bolded, but also include emotional abuse, emotional and physical neglect, household challenges such as domestic violence, substance abuse, mental illness in the home, parental abandonment, separation, divorce, and incarceration in family members. So what is trauma-informed care? There is no single definition, but a panel of experts came up with this statement in 2010 that I'll use. Trauma-informed care is a strengths-based framework that is grounded in an understanding and responsive to the impact of trauma that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment. I think I also want to take a second, in addition to using that definition, to kind of underscore that there's a difference between trauma-informed care and trauma-specific services. Trauma-specific services might be what you think of as trauma-focused CBT, trauma therapies, people processing their traumas or talking about them or having emotional sort of cathexes about them. Trauma-informed care is more limited in scope in that I would argue is something that all psychiatrists and all therapists can practice and all should be practicing in my view, but that it's to inform our psychiatric or usual therapy care with trauma. We don't necessarily have to have subspecialized training, maybe just a little bit of extra training to bring a trauma-informed sensibility into our approach. I think when I was in residency, there was a lot of ideas about we have to refer people to some sort of specialized trauma center. I think we all know that those are few and far between and it's not really that accessible. So the point is kind of there's no second line, there's no other specific special services out there. We have to be the ones addressing this, especially given how prevalent it is, which I'll get into. So what are some key principles of trauma-informed care? They include trauma awareness and emphasis on safety, opportunities to rebuild control, choice, and empowerment, and the use of a strengths-based approach. So what do awareness and safety encompass? Awareness includes awareness of the high prevalence of trauma adversity, especially in psychiatric patients, which I'll get into some quick numbers in a second. It includes an awareness that there's a big impact that trauma has on emotional and physical health. You know, no surprise to anyone here. And it involves keeping in mind that trauma can impact the behaviors and our patients' engagement with services or their willingness to engage with services. Safety also involves having respect for the fact that us as clinicians, our services, and our symptoms, as Dr. Mintz was talking about, can cause anxiety or even re-traumatize patients, especially if, you know, we're among the few who use a very biomedic, or strictly biological model, or paternalistic medical model. So what is the prevalence of trauma adversity? Well, nationally, 61%, so this is adversity, not trauma, for those who are definition-sensitive. So nationally, 61% of Americans have experienced one or more ACEs, 38% two or more, 60% four or more. So, you know, so that's just striking in itself. I always like to observe when I present this that a majority of people have adversities, life is hard, things happen to people, not that surprising. Resilience factors are relevant in counteracting the delirious effects of ACEs, it's theorized, and I think it's nice to think that they may explain why not having, not everyone with a high number of ACEs goes on to have high psychiatric comorbidity. Someone could have four ACEs with a lot of difficult things going on and having gone on in their childhood, but they had a safe harbor with a certain attachment figure or someone they could rely on and trust and confide in, and that makes a huge difference for people's trajectories. So what's the prevalence of trauma adversity? I like to use my own figure, but because I find it particularly clear that here we have those national numbers, and do you guys see an arrow? No, you don't see the arrow that I'm doing here. So in the light gray in the figure on the right is the national numbers that I was just presenting. You can't see the percentages, but the second sort of pair of bars is 61%, then two or more is 38%. Those are the kind of national numbers for ACEs. In our own hospital-based outpatient psychiatric academic clinic at Mount Sinai Morningside West, this is the prevalence of ACEs that we got when we did a study on the prevalence of ACEs in our population, and you may not be able to see the numbers that well, but the one or more category is 82%, the two or more category is 68%, the four or more category is 42%, and there's a seven or more category which doesn't exist in the national numbers, which is 15%, and I just can't really underscore how kind of harrowing that is to look at an ACE questionnaire where there's so many potential things, each of which is very jarring and developmentally impactful and see that so little can have gone right in a person's life. So I think that's just, I think it just really underscores that the psychiatric population that all of us are seeing, it has a high degree of trauma adversity. Again, probably no surprise, but we found the numbers quite striking. And then there's just a further breakdown in the figure on the left around physical, emotional, sexual abuse and tracking with different kinds of diagnoses, but it's a busy figure, I'm not gonna get too into it. So impacts of trauma adversity. So we know that our patients have a lot of trauma adversity now. What kind of impacts do they have? Even the CDC has a nice figure about all the things that ACEs can impact, certainly depression, anxiety, suicide, PTSD, not that surprising, alcohol and drug abuse, unsafe sex, what they call health risk behaviors, but also a lot of medical issues and sort of medical issues with behaviors that can contribute to medical and emotional difficulties that are represented in some of the other bubbles. Beyond what the CDC mentions though, the depression, anxiety, suicidality, trauma is also correlates in the literature with bipolar disorder, both the chances of having a bipolar disorder, but also what Nemerov and Lippard call the perniciousness of bipolar disorder, which means it makes it more complex, more difficult to treat, more treatment resistant. It correlates with borderline personality disorder, correlates with dissociative disorders. And I always like to make the point that there's definitely and it's established now a correlation between trauma, adversities and psychotic disorders. And this extends from to both the unspecified kind of psychoses, patients with PTSD who might occasionally have auditory hallucinations, as well as full-on schizophrenia syndromes or schizophrenia spectrum syndromes. So it can be helpful, so how do we use trauma-informed care clinically? And the way I like to think about it, it can be helpful to just try to consider the impact of trauma and adversity on certain themes when we're working with people. We can think about how a patient's difficulties with trust might relate to trauma. Someone with a lot of emotional, physical abuse and neglect may not be the most trusting of you, may not be the most forthcoming working with you. We can think about their engagement with treatment, how open they are to receiving treatment or attending it. How medication-adherent they're gonna be or how prone they are to kind of feel like, I don't think my psychiatrist really cares about me, which might be a transference kind of experience, but that we have to mentalize our patients and understand where we're coming from is kind of what trauma-informed care is about. It can impact agency that people, trauma is often very disempowering and creates feelings of helplessness, especially when it's prolonged and perpetrated on people in a prolonged way. And so it can impair people's capacity to express their concerns, to express their preferences, to be willful and self-advocating, as opposed to maybe say, angrily disengaging from treatment, which you might not even know what they're thinking when they stop showing up. It can also impair people's emotional awareness of themselves, their ability to interocept, to feel within and to know what they're feeling or even what their needs are. That's something that comes up in our case conferences at our program with the residents is that I think every year, I always hear about a patient in therapy who's not doing the therapy well. They're not talking about their feelings. They're not sharing anything. I think my point to this is that we have to be the experts that know how to mentalize that patient to say, of course, they don't know how to speak about their feelings. They were neglected or they were abused and they never had a space to learn how to express these things. So the trauma-informed perspective is ultimately about understandalizing and mentalizing why a patient might manifest non-compliant or difficult behavior. This can apply to these bullets of common difficult behaviors, poor attendance, not talking about feelings, not being aware of what they want or need, being concrete, not taking medicines, being quick to anger, and certainly being quick to perceive threat or abandonment by us clinicians or other people in their lives. So how might patients experience retraumatization in care? It's maybe a little bit of a straw man, but if we take an overly paternalistic medical approach where even if you don't say it, but if your felt attitude in your mind is one of this patient is either adherence or non-adherence or they're either a good, compliant, or bad patient, that really I do believe leaks into the therapeutic alliance and damages it. And inherently in that approach, a patient may be forced into a position of what they experience, low power and agency. They may be less likely to listen and to work, and a clinician working that way may be less likely to listen and to work with a patient's concerns, because they're just thinking, okay, good or bad, in or out, and may overuse sort of blaming and judging implicitly shaming terms. So we don't want to do that. So what is the alternative ultimately? We only have 15 minutes, so I think this is the best thing that I could think of to present on this topic. But treatment decisions can be made with a shared decision-making approach, which is probably not new to most of you, as opposed to a paternalistic one. Shared decision-making is sort of advocated by trauma experts, and it's an approach where clinicians and patients share and look at the evidence together. We share what we know, they share with us their experiences and what they know and their past experiences with medications or treatments or therapies, and we work together around the task of making decisions, as opposed to imposing our recommendations paternalistically in an old-school medical way. We support the patients in considering options and try to support them in making informed choices. So we want to invite the patient to participate, we want to present options, we want to provide information on benefits and risks, which people doing the medical model do do, and we want to assist them in evaluating options and making decisions. So none of that sounds all that new, but I think the area that I find this helpful when teaching residents that this approach is nice because it preserves the therapeutic alliance when the patient doesn't make the choice that we think is medically indicated or psychiatrically indicated. So say this patient with bipolar disorder and a lot of adversities, say she doesn't want to take her medications. So we could either kind of implicitly have this feeling, okay, bad patient, you're non-adherent, or we can say the shared decision-making approach might have a sensibility that's to the effect of, it is important to be firm, and it is important to stand behind your recommendation, but we kind of leave it at that, that it's just the recommendation. Our view, I might say something to a patient who's trying to not take meds that I think are strongly indicated. I think that it's very important that you take this. I'm concerned about X, Y, and Z, and your ability to possibly not meet X, Y, Z goals that we talked about, but it's ultimately your choice. It's your body. It's your choice what you put into it, and if you want to come off these medicines, I will work with you on that. I will de-prescribe with you, and I'm just letting you know there are gonna be risks to that, but we can still work together. And so that preserves space for both the patient and for us, and our recommendation in that relationship or with that kind of sensibility. I think there's a lot more to what you can do in terms of thinking about trauma-informed ways of intervening, but at least thinking about trauma-informed prescribing. It's about mentalizing, understanding, and about having this sort of open, safe dialogue. And with that, I'll turn it over to Dr. Steinberg. Just get the timer. So, I'm Sandy Steingart, and we're, a little disclosure, you know, we're talking about understanding the context in which people live. I think that's a theme through our presentations as opposed to being someone who has a problem that's completely within them, within their brain, let's say, that we're fixing. So we gave some disclosures, and I thought, for me, a disclosure is I've spent my career in community mental health. My major interest has been working with people with psychotic disorders, and that will come out in this brief talk. But I also came towards the end of my career to define myself as a critical psychiatrist, which, you know, meant engaging critically with some of the dominant paradigms of the field, being pretty concerned about certain problems, the limits of our diagnostic system, let's say, the influence of commercial interest, pharmaceutical interest, and questioning some of the dominant treatment paradigms that we have. So this'll come through, and it's what led me to these ideas. So what I wanna talk today about, I'm gonna introduce, I think some of you may be familiar with these ideas, but I wanna introduce a couple of concepts, need-adapted and drug-centered approaches to pharmacology. And I'm gonna talk about how these approaches, I think, can help us to embody a recovery-informed approach to treatment. So that's where I'm going here. The recovery movement is about 30 years old, and came about a lot through people in the psychiatric rehabilitation field, but also got a lot of energy from people with lived experience. And the idea was, rather than conceptualizing, let's say, something like schizophrenia as a chronic disorder that was inevitably associated with a poor outcome, which was the paradigm that we've kind of carried with us for about 100 years, the idea of the recovery-oriented idea was to say that we have hope, that a person may have a lot of different ideas about how they want their treatment or their life to go. And these are recovery principles that I have up here where, if you look up in SAMHSA what recovery principles are, it included many pathways that a person might take. It's holistic, involving peer support, and incorporating in relational aspects. Again, this is what we're kind of as a theme here, that we're talking with a person, the person in the context of their life. It's sensitive to culture, trauma-informed, and based on a person having strengths and responsibilities for their care and having respect. So, being in community mental health, this became a big deal for us, but I think it risks becoming a slogan. And what I'm gonna suggest today is how one can truly embody this. And I have this idea that these concepts that I'm gonna introduce, for me at least, became ways to truly embody a recovery-oriented approach to care. So, need-adapted treatment. Need-adapted treatment is, some of you may have heard of something called open dialogue, which is practiced in northern Finland. And need-adapted treatment is a term that's a little bit more of an umbrella term. And this came up in the late 80s, early 90s, as they were in Finland and we were here talking about deinstitutionalization and trying to help people live outside of mental hospitals. And they, at the time, when the sort of biomedical model was not as entrenched, certainly as entrenched as in the United States, they acknowledged that there were a lot of different models to think about mental disorders, and they were very interested in psychosis. So there were biological models, psychological models, family systems approaches, social ideas, and they all came with their own package of treatment. And they noticed that some people seemed to respond to some and not to others, but they weren't really sure which one, so it was a dilemma. And what they did was to bring the person at the center of concern and the network, the social network, often the family, into the room with the clinicians and have these open conversations about this. And they found that this process seemed to lead to improvement, sometimes to resolution of the problem, and they began to study that. And in northern Finland, this is what evolved into what they called open dialogue. And there's a lot to open dialogue in 15 minutes here. I'm not gonna go into it, but I'm gonna emphasize certain aspects, which is this basic therapeutic attitude, which was A, acknowledging different paradigms, being kind of open about uncertainty, and valuing humility on the part of the professionals in the room, being flexible, so there wasn't a approach. There were multiple approach. Being democratic, everybody in the room had a voice, including the person who might be labeled as being psychotic. And as a part of that was a less hierarchical approach. I mean, I would argue that the biomedical model, even though we don't, I agree with David, that we don't all accept it, it's still hierarchical. Someone comes to the expert, and the expert uses his or her knowledge to render either a formulation or a diagnosis, and then treatment evolves from that. And in this approach, it wasn't that way. There was much more of a curiosity about the phenomenon, curiosity, and not holding on to any model, and a belief that the system, the person, the network, had a knowledge that was of value, and you wanted to help them to find that. Other aspects of it is very much in the present moment, slowing down. Some of this I've said, everyone has a voice. So the person who might be hearing voices or having ideas that we might label as delusion was taken as seriously as everyone else. That doesn't mean you needed to agree with the delusion. Like you might say, you know, you have an idea that there's an implant in your brain. I've never heard of that, help me understand that. I'm curious about that. So there's a lot of curiosity about the experiences, and having a belief that these experiences may have some meaning, and being curious about the meaning of these experiences. There's listening, using local language. I would argue that the medical model risks us colonizing people's experiences because we give them language. The standard treatment is very much based on psychoeducation. So the expert tells you what the problem is and educates you about this. And this way of working is much more about, you know, a deep understanding of how the person and the network has come to understand that. And the values of appreciation, invitation, and wondering are very much incorporated into this. So this is a little overview of what need-adapted treatment is. So now I'm gonna shift into the other concept that I've introduced, I just wanna get a time check, which is a drug-centered orientation to psychopharmacology. So this comes from a British psychiatrist, Joanna Moncrief, who's written a lot about this. And she has posited that the standard approach to pharmacology is disease-centered. We might say disordered-centered because, like, a lot of the things that we're treating are disordered. This, you know, has evolved since, let's say, the 60s, 70s, in part. The FDA has kind of enshrined it because they required, starting in the early 60s, to demonstrate a particular drug target if you're gonna get FDA approval. And if you watch TV now, you'll see, like, every problem has some fancy acronym. And, you know, like, it's almost kind of silly sometimes. Like, constipation isn't constipation. It has some, you know, acronym because in order to get a drug approved, you need to demonstrate that it's effective for whatever the syndrome is. And so there was this overlap of both that law that got passed, a lot of new drugs coming out into the market, and then the sort of shift in American psychiatry to kind of a reliance on the DSM. The DSM-III came out in 81. And there was very much this focus on these drugs are targeting a disorder. And the idea that they were correcting some abnormal brain chemistry. So let's say it was psychosis. The idea was there was some abnormality in the dopamine system and these drugs were correcting it. So in a drug-centered approach, the concept is that these are fundamentally psychoactive substances. They create abnormal brain states and they alter the expression of psychiatric problems through the superimposition of these effects. So when I give this talk, I often say I'm a socially awful person. And if I go into some social event, I may have a half a glass of wine. I'm very sensitive to wine. And it helps me. Now, you could say I have cocktail party deficit disorder. And this alcohol is a treatment for my disorder. You could say I'm a person with a brain. My brain reacts to alcohol the way most brains do. In the short term, it's a euphoria. It's a little disinhibiting. And that helps me in my particular way of being in the world to get through an event that might not be so pleasant for me. So that's kind of the essence of this model. Now, in thinking about antipsychotic drugs in a disease-centered model, the idea is someone comes in and very early on, you need to land on a diagnosis. I mean, I see this with people with a first psychotic experience. And within 15 minutes, you're labeling it and talking to them about this condition that carries a whole lot of baggage that may not really have that much validity in a lot of ways. And you're saying either implicitly or explicitly, this drug is for this condition that I've just diagnosed. Now, going along with that, I'm not gonna go too much into this. There are other implications that I think are problematic, which is that when the drugs are stopped and we know that there's a higher rate of recurrence of symptoms when they're stopped, we tend to think, oh, it's because they needed it and now this thing is coming back. And then we also have, I think, tended to think that long-term apathy or poor social functioning that's associated with a diagnosis like schizophrenia is due to this disorder. Now, in a drug-centered way, we think that we're not really needing to rely on this diagnostic category that I would argue is a little fuzzy, certainly early on. And you can basically talk about using the drugs to help a person feel more comfortable in the short run. Now, these drugs, if you go back to when they were first introduced, the reason why people got curious about them is they cause a state of cognitive indifference. And I think a state of cognitive indifference and sometimes behavioral difference may be very helpful when a person is in the throes of psychosis, this kind of, whoops, I'm sorry, dampening down. If you're hearing a lot of voices, this dampening down may really give you some space to talk to the person. Someone who wants to immolate themselves because of a belief about the burning bush is a very frightening, potentially horrifying situation and dampening that down, I think, does some good. But that's different from saying I'm, it's a different way of talking about it. It's a different way of having a conversation. The other thing that, again, for time, I'm not gonna go into too much, but you're gonna be more likely with these drugs to think about what it means to have perturbed the dopamine system, that there's alterations that we haven't really fully reckoned with in our field about that may have implications for what happens when the drugs are stopped. And it may have implications for rehabilitation. The dopamine system is part of the drive that we have and to dampen it down over not just weeks, but years, decades, may have some implications that I don't think we fully reckoned with. It's more of a different talk, really, in terms of time, although people are curious, we can talk about it. So bringing this all together, I think these two ways of being with people, being with their networks, being with them, as I said before, really deeply embody a recovery-oriented approach. Need-adapted approaches provide a way of being with people that are more humble, less hierarchical, and more open to multiple explanations and multiple understandings of the problem. I think it fully can incorporate a trauma-informed approach. I think they're, in my view, very overlapping. And the drug-centered pharmacology allows one to offer these medications, but without being so entrenched in one understanding, the one understanding being the psychiatric diagnostic process. It's more about a symptom focus and can put off, I think, for a while, questions about long-term use of the drug. It's about giving people relief. And I think that, again, very much aligns with the recovery principles that I articulated earlier. So I will stop. I think I'm on time. Thank you very much. Thank you. So we're going to talk about now a third model. I work at the Austin Riggs Center, which is a psychodynamic therapeutic community for patients who have proven generally treatment refractory. So they've been on typically multiple, multiple medications. And do we have the clicker here? Oh there. And so in that context, I think we developed a model of thinking psychodynamically about pharmacologic treatment resistance and ways to address it. And so I'm going to talk a little bit about that. So first of all, we know, I think, that medications are symbolically active as well as biologically active. I mean, the placebo response contributes to a significant proportion of treatment response to many of our illnesses. And with conditions like major depressive disorder, may contribute as much as 75% to 81% of the outcome. When the meanings of medications are concordant with the desired effect, that's what we get, is we get placebo responses. It boosts the effectiveness. But for many of our patients, the meanings attached to medications are antithetical to the intended effect. They experience it like the patient M, as confusing, as containing, as controlling. And so for patients like that, you end up with real problems. And of course, these meanings can be unconscious. It's not like M thinks, oh, you're my, you know, you're my, you're like my, consciously thinks you're like my authoritarian father. It's just, it's kind of more in her bones. So treatment resistance, you know, from that perspective, often we can think of it, I think, in several different ways. We can have treatment resistance to medications, from medications, or ways that treatment resistance has to do with what we bring. Treatment resistance to medications often has to do with ambivalence, and patients can be ambivalent about medications. How many of you have patients that seem, that are ambivalent about getting better, right? Patients can be ambivalent about illness. And how many of you have patients, actually, how many of you have a majority of patients who have histories of early adversity, right? And how often does that leave patients ambivalent about caregivers, caregiving authority, authority figures, right? And so these are patients who don't take the medications. If they do, they don't respond, or if they do because they have to, like the kinds of patients who just have to acquiesce, these are patients who are more prone to nocebo responses. So they can't say no with their mouths, they say no with their bodies instead. Other patients are treatment resistant from medications. These are patients, quite the opposite, who desire medications, want medications, want more medications, love medications. And, you know, even if you can, you know, like your symptom measures are going down, you're left in a position of, I don't, I actually don't want to give more, I want to give less, I want to take it away, right? That countertransference, I think, is a key that you're dealing with a patient who is in some way turning medications to serve some kind of defensive end. And, you know, these are patients who then really become chronic patients. These are patients who are never going to get better, are never going to stop needing treatment. And then there's our own contributions where we approach the patient in ways that, you know, a reasonable person might want to resist us, or where we, you know, treat the patient as an object as opposed to a subject. Or, you know, again, you know, we work with complicated feelings. Our patients have lots of rage and guilt and hopelessness and their hopelessness becomes our hopelessness, their helplessness becomes our helplessness, their rage becomes our rage. And so we're often left, I think, prescribing in a kind of a complex situation where it's less clear whose suffering we are trying to reduce with those prescriptions. And when we are prescribing to reduce our suffering, chances are it's not having the most beneficial effect for our patients. So psychodynamic psychopharmacology, just briefly, is an approach that explicitly acknowledges and addresses the central role of meaning and interpersonal factors in pharmacotherapy. It recognizes that medications bear potent meanings that should be explored by therapists and pharmacologists, not just therapists. It doesn't tell us what to prescribe. So it complements a traditional objective descriptive approach, and it gives us guidance instead about what to prescribe, not how to prescribe, to help the patient benefit optimally. And it gives us some basic psychodynamic techniques for exploring the meaning of medications and addressing potential resistances. And not only does this help the patient, but given that most of us become psychiatrists because we're interested in people, and then we're operating in systems which have us, you know, reduce us to the role of prescriber, this gives us ways of bringing back the human-centered, psychodynamic way of thinking. And I think oftentimes it helps make the way, but certainly for me it makes the work much more enjoyable. So what psychodynamic concepts are relevant to psychopharmacology? Unconscious, we've already touched on. Defense, resistance, transference, counter-transference, projective identification, enactment, splitting, transitional object protection, acting out, false self, eco-function, et cetera, et cetera, et cetera. So basically everything that happens in a psychotherapeutic setting is also happening in a pharmacotherapeutic setting. But if you don't have the tools for recognizing and addressing it, it is just going to take whatever direction it's going to take, and you're going to have no control over what's going on. So I'm going to quickly go through the six technical principles of psychodynamic psychopharmacology. The first is avoiding a mind-body split, knowing who the patient is, attending to ambivalence, focus on the alliance, be aware of counter-therapeutic uses of medications, or what I already called treatment resistance from medications, and addressing counter-transference enactments in prescribing. The first thing to do, actually, is to just be aware of all of the pressures we are under to think dualistically or reductionistically. Again, we are operating in systems which are pushing us to think reductionistically about our patients, that are trying to get us not to know what we know about working with human beings, right? Now, some ways of doing this establish a developmental focus. So I often start with a question, not of, you know, what are your symptoms, but what are you trying to get in your life? And then secondarily, how are the symptoms in the way of that? I want to negotiate a realistic, complex appreciation of symptoms and treatment, not to elevate the medications like they're the only solution, because that risks putting the patient into a passive position where then they're just waiting to be fixed, right? And it's a terrible place from which to be trying to get better. And I think a part of this means knowing the evidence base for how much psychosocial factors impact pharmacologic treatment outcomes. Knowing who the patient is, I think, involves obtaining a focused developmental history, which really consists of two things. I want to know what are the internalized models of caregiving, because that is going to affect how the patient relates to me, how they're going to trust my recommendations, and what are the negative transferences that are going to be undermining our work. And I want to know basic relational patterns. So if somebody is the kind of patient who is on one level dependent and on another level deeply counterdependent, scared of their dependency, and so when they get into relationships and somebody starts to get dependent, they find a way to blow that relationship up, right? Anybody have that patient? They will do the same thing with medication. So like Em, she might be able to take a medication that didn't work, but a medication that does work alarms her because she feels like, maybe I need this, and that makes her want to stop it. And I already know that because I know something about her developmental history. We also want to know about the patient's relationship to pharmacotherapy. What's it like for you to take medications? What's it been like for you with previous psychiatrists? The patients will tell you about the problems before you've even started. And I think part of what I'm suggesting here too is that, at least for treatment-resistant patients, it's often helpful to turn the evaluation on its head and start first with the question of who am I treating? And then second, what am I treating? Because that puts you into a better position to work with the resistances that are coming your way. We want to attend to ambivalence about medications, and so a simple question to ask takes two minutes or one. What's it like for you to take medications? We should ask this early on. The patients may tell you all the reasons they don't want to, and then that's above board and you can work with it. As I've gotten a developmental history, a patient may, like with Em, tell me about her authoritarian father. The next question is, so how does that influence how you relate to authority figures? And she tells me she doesn't trust authority. She fights authority. And one of the things that's happened when I do that is I'm just curious at this point. I've started a frontal lobe-to-frontal lobe communication about this, so that in some month's time when now the limbic system is telling her that I'm a danger, I can refer back to that frontal lobe-frontal lobe conversation and say, I wonder if this is the spot we're in, is you're seeing me through that lens. And sometimes that really helps restore the alliance to a much more stable place. And finding out, again, what the patient's experience as a psychiatrist has been. And in terms of ambivalence about health, we may want to know, a question I will often ask in my treatment-resistant patients, is there anything you might stand to lose if treatment works? And a third of the patients will tell you. So somebody recently said, who was another trans man who had felt also let down by the system, said, if I get better, it will say to all those people that it didn't matter. So there was an attachment to symptoms as a kind of way of saying, I have been harmed. Now, this question you have to ask in the first session. If you wait till like four months down the road when you're feeling frustrated and now you ask, what do you stand to lose if treatment works? The patient gets defensive. And rightly so, because now you're blaming them as opposed to just being curious. You want to foster the alliance, and we do that with a person-centered developmental focus, establishing a treatment agreement that integrates the psychosocial dimension, which means I am doing psychoeducation with this patient in the first session, not just about their medications, but about the influence of the placebo effect. If they have a lot of side effects, a nocebo effect will tell them about the impact of the therapeutic alliance. And along with that, I will say, so that means if I'm doing something you don't like, not only do I want you to tell me, I need you to tell me, right? And we're developing a way of thinking where in any given moment, we're not gonna be, it's gonna be really unclear the way it realistically is, how much of this response is due to the medication and how much is due to the meanings attached to treatment. We want to elicit medication preferences when reasonable, giving patients choices. And when patients are mucking around with their medications, the patient stops their mood stabilizer. I see them the next time. My question to them is, what happened with us that you didn't feel? Did I do something to make you feel you couldn't tell me that you wanted to stop this medication? And what I'm saying to the patient is, the alliance is serious. This means something. And the next time they're thinking of stopping their medications, they're more likely to think, you know what, maybe I'll wait till I can talk to Dr. Mintz. We want to be aware of counter-therapeutic uses of medications, noticing, for example, where the medications maybe help the patient feel better, but the patient is not getting better because they're using medications in some way that is actually not in the service of health. And in those cases, we may want to highlight the dissonance between their developmental goals and the way they're using medications, which kind of keep them as a chronic patient. And sometimes we have to stop the medications when it really is in the way of our patients getting better. And we want to address counter-transference enactments in prescribing. So, you know, some ways of doing that are to develop a dynamic formulation because it helps us think about, you know, the things that may come up in us and why. We may want to consult with colleagues. And I think that we have rushed through three different models because we wanted to leave time to now have some discussion. And so, you know, and roughly, I'm just going to throw this slide up and then we're going to talk about M and maybe some of the different ways that we would think of approaching this patient. Maybe I'll stay here near the mic. You each have your own mics. So maybe we'll follow the order of our presentation. So you want to start? Yeah, so I think what struck me most about your initial, Dr. Mintz's initial presentation of the case is that there's already a great trauma and psychosocial and kind of developmental history explored there. And so, you know, it's almost like we didn't, because one of the points I like to make when I teach about trauma is that, one, we have to take that history. So let's, I think we should go back to that and just appreciate the wealth of information that was already there. There's already a focus on, you know, the mentioned, the violence, the volatility in the father, the other adversities that the patient experienced. In addition to certain, you know, already some documentation, you know, I don't know if this is a medical record we're reading this in, or some psychoanalytic bullet points, but already some formulation about the patient's sort of issues with authority, you know. So, you know, if we use the straw man of the medical model, let's just go ahead and say that is minimal. And so the first thing we want to do is to be curious and to take that history and to be thinking along those lines. I think there's different ways of doing that. You can certainly ask the questions. In our outpatient program, we administer the adverse child experiences questionnaire, which is 10 items. And that's, I would say 10 items, is probably on average seven items more. Most people probably ask emotional, physical, sexual abuse. I would say if people take away one thing additional from at least my section, it would be to ask about neglect because neglect is equally impactful to abuse. It's established in the research and it's a very, very powerful piece of adversity. So I would just appreciate that aspect of the history. And then beyond that, I mean, I think, you know, just drawing the connections from the bullet points in my slides to the case, you know, of course, we want to think about where this patient's coming from. Clearly, as Dr. Mintz is already talking about, she's going to have a lot of reasons to not want to take her meds, to feel all kinds of ways about us prescribing. You know, I've personally had the experience recently with a patient with bipolar disorder where I thought I was being fair in my counseling of him. He wanted to try a certain medication. I didn't think it was such a great idea because he wanted to get on an SSRI. And I was worried about it, you know, kind of putting him to a manic episode. But he experienced that as though I were his neglecting, punishing father. And he became enraged and psychotic some months later and told me that just like, I am not the doctor for him. I'm not listening to him. I clearly don't care. You know, we might experience ourselves very differently from how our patients are experiencing themselves. So I guess, you know, those are just my chain of associations and yeah, and you know, using shared decision-making, we want to keep the space for dialogue in addition to, you know, whatever else the other models, subsequent models are going to be thinking about. So in the models that I'm talking about, the way ideally this would work is that the person at the center of concern would be invited in and you would ask who else would be helpful in understanding this problem. And it's a very much of a network approach. So often the family, you know, people often say, well, what if the person's alienated from the family? It's an invitation. You know what I'm saying? It's an invitation, but you might bring these people in. And then in open dialogue, people work as teams. So let's say I might be with one of the Davids or both of the Davids ideally, or someone else. Let's say, you know, someone else is a partner. And the first thing is to be really curious about how the network understands the problem. So how the person, this is M, right? Let's say how M understands it, whoever else is there, and to be slow about labeling the stuff. And then, you know, there are some serious safety concerns here. And so maybe sooner rather than later, the idea of medications might come up, and it would be for safety. And if I'm the person prescribing, I might say to my partner, I'm really worried that M is gonna get injured. And I think that, you know, I'm thinking that this drug, whatever I'm recommending might be helpful. And David might be in a place of saying, I think it's too soon. I think there's more that we want to explore. We might have a conversation between us, and it models disagreement, a plurality of viewpoints. And not talking directly to the person is a way of not pushing them to have to answer. I mean, I've sort of thought like, you know, in the traditional psychoanalytic thing, why are you on a couch? There's something about not having that face-to-face contact that I think is helpful. And this is a different way of doing it because you're talking to your partner. So, I mean, that's how it would start. And I don't know how it would go and what the objections would be, but presumably you would allow this respect for how the person is talking about it, and you would use that language going forward in discussing what you're gonna do. So let me pop out of this. Okay. I'm gonna go way back for a second. Sorry. Oh, actually I have to go way, way back. How do I pop out of this? Okay, here. So I'm gonna go back to Em for a second. So I will say the first, so of course when I met Em, I'm in a psychoanalytic hospital. I have a little bit of history. I know that, I know something about these previous manic episodes. I know how scary they are. And I don't feel, you know, and I know she has not taken her medications or won't, is struggling to take medications in an adequate dose. I know all that already. So I don't feel like I have to spend that, you know, 50 minutes that I have for initial session trying to get, spending that all trying to figure out what the diagnosis is. Because it's, you know, and you know, I may be over, you know, in the next session I figure out is this schizoaffective, is it bipolar? But it's pretty clear what medication the patient needs. What is, you know, the real issue already is very obvious is how do I work with this person so that this doesn't keep happening? And so all this stuff on this slide, oh, you're not seeing it. That's okay. Slide show from current slide. Okay. Okay, so all this stuff that I showed before, this, I knew all this by the end of the first session. Right? Because these were the things I needed to, felt like I needed to know, to understand what is the problem. Now, in this session also, as I think I was saying, I was making it clear to the patient that it's so complicated to sort out what's psychological and biological. I'm emphasizing her, the role of her behavior and the outcomes for treatment. I'm emphasizing my own limitations, you know, for being able to do, be helpful if we're not working together well. I'm asking, you know, as I did, well, how does this, how does the model of your authoritarian father influence how you deal with caregiving authority? She let, you know, she right in here, she lays it all out for me. And we start that frontal lobe to frontal lobe conversation that really does let us kind of turn, you know, get things back on track when the transference starts to pop up. And I think, as we're saying, I negotiated recognizing she was very alarmed about medications, that we needed to be cautious, but also that she needed more medication than she was taking. And so, you know, we agreed we were gonna work to find the lowest effective dose. And basically within two days of my starting to increase her lithium, so we could get up to at least 0.6, she had her third manic episode or hypomanic episode. And I felt like, because she was in the contained setting of Riggs, I didn't need to slam her with medications. And we could see if we could bring her in for a soft landing. And the really, the main adverse consequence of that third manic episode was she had sore feet because she did a lot of walking around the town of Stockbridge, you know, 15 miles in a day. And in that, we started to establish a kind of trust. She could believe that I was actually trying to meet her needs rather than getting her to meet mine. And in that context, then we could start to talk about adding a not as sedating second-generation antipsychotic, taripeprazole, I think, in a way that could just balance it out a little bit. And she, you know, over that time, she changed her orientation to medications. You know, it was no longer just a tool of control. It was also a sign of care. There was a sense that, you know, I conveyed to her that, you know, I don't know we're at the right doses. You know, we, this is, these are experiments. We're gonna learn. And we learned, for example, that just lithium at a slightly higher dose was probably not enough because you did have a second or third manic episode. But we were doing that shoulder to shoulder. We were learning together. And, you know, and I think this model is in a way a long-term model where you maybe have more troubles right at the beginning, but by next year, you know, you're working together and you've got a patient who is now adherent. And at the end of her treatment, she had then been stable for, it was a longer treatment. She'd been stable for, you know, 10 months or something when she discharged. And what she said to me was, through our work, she had learned to treat herself with respect. And to expect, and which involved also respecting her illness and how dangerous it was to her. So I am gonna then just jump back ahead. Can I make a comment? Can I make a comment, Dr. Mintz? What's that? I just wanted to make a comment. Yes. I just really appreciated what you said about being in the structure of the sort of intensive treatment program at Austin Riggs allowed you to not use the, to not just snow the patient, you know. And that, you know, I don't know if, I'm sure some of you in here work in New York inpatient psychiatry. I don't know what, you know, what the pressures are in other states, but it is certainly a common, and I'm about to talk about, you know, how systems can be traumatizing or coercive that our inpatient units, at least here in New York, are under a lot of pressure by insurance companies to increase the dose and to be making changes to the medication regimen, and to get rapid turnover of patients and to get them discharged. So that's just an example of how systems can be traumatizing, or coercive, or pull it, play into problematic dynamics. You know, that's a little bit beyond what each of us individually is capable of addressing, but it's great to have, you know, examples of alternative models out there like you're talking about. I just want to say something about, you know, as when I asked, when I asked David and Sandy to join me in bringing a number of different patient-centered, you know, beyond the medical model models, I was surprised as we pulled things together to find out how, you know, how many commonalities there were between the different models. So we, you know, in each model, there's a way that we're talking about prioritizing individual needs, not lumping together patients as a diagnosis, but really thinking who is the person and how do I meet your needs in particular. All of them have ways of addressing ambivalence, which is, you know, of course, key in our work because the majority of our patients actually, I mean, again, like, how many of you, how many of you want to take medication, right? Right, people don't want to take medication, so our patients are almost all of them ambivalent, at least to some extent, and then patients like Em, and many of our more treatment-resistant patients are highly ambivalent. All of these models have a way of sharing power and responsibility. It's not all on the doctor. It's trying to find a way to empower the patient to be a partner in the enterprise of treatment. All of them, I think, have a developmental, longer-term focus. You know, you're working with people to get them to a good place, and you may sacrifice some stability in the beginning to develop an alliance that will help the patient get into a healthier relationship with treatment, you know, over months, or maybe even years. In all of them, I think the alliance is key, and, you know, in a sense, all of them emphasize that the psychosocial dimension is equally important to the biomedical dimension, if not more so. I think there may be some differences, certainly, and, you know, we may have some arguments up here. You may disagree, but I often think of, like, the recovery model as turning the authority structure on its head, and the patient is the authority in many ways. Like, in the psychodynamic psychopharmacology model, I think the patient can't be an authority because they have an unconscious. They're not rational, but the fact of the matter is neither is the doctor, right? We are not rational either. We cannot have full authority, so the work, in that sense, is to work together towards optimizing the authority of each participant in the relationship. I don't know if you wanna fight with me about that. Well, yeah, I mean, what I worry about with the psychoanalytic enterprise is that it can be another hierarchy, and what I value in this need-adapted approach is that it's really centered on a deep humility and uncertainty, and to me, that's, for me, personally, that's the only way I can work in psychiatry. I just think there's too much that we don't know, so I suspect, because I like you, that in your way of working with people, you don't have a heavy-handed hierarchical approach, but I think some, I think this, I don't think that's necessarily inherent to the model that you're using. I mean, I say that with respect, and I could be wrong, so I really like a model that's very much centered on uncertainty and humility because I don't think, it's not discounting what we do. I mean, I respect what you're all doing because I think it's really hard, but I think that's the most honest way to be. So that's how I would go about it. So it turns out, actually, I wanna argue with you. You wanna argue? Yeah, yeah, I mean, in the sense that, as I said, I think the model is one where we recognize that I don't have any more authority than the patient. I'm not creating a hierarchy. Yeah, okay, so that's what I'm saying. I think what you're saying, like, in the room, it might not look that different, but I'm just telling you what I worry about with the model. So, yeah. Yeah, and maybe this, oh, go ahead. I would like to comment that my understanding, and let me know your guys' perspective at Riggs, but as a sixth-year student in psychoanalysis, I do think psychoanalysis has a history of very paternalistic, you know, there's just kind of an old-school way of practicing where the analyst knows, and you unilaterally, authoritatively offer patients, not offer, you tell them, their interpretation, you are doing this because, blah, you know, your mother, and that there are more, it's always low-hanging fruit, you know, but that there is a more contemporary, relational, interpersonal, psychoanalytic sensibility these days that's about sort of shared meaning-making and working with the patient, and where interpretations are offered wonderingly, like, I wonder if this might be going on in how you feel about me today, inviting the patient to speak to, also to speak in about what's going on, and I imagine that's how Dr. Minton is. Well, it's in the tone, and I think I mentioned, you know, I started out wanting to be an analyst, but I'm so old, so I, like, fell off the couch back in the authoritarian phase, and it worried me when I came back, but it's just coming together, I think, you know. A lot of the people that developed open dialogue were analytically trained. Yeah, although I think one difference, maybe, that we are talking about is, you know, in your, particularly in the model you're talking about, you're really mainly focused on listening, and I think in the psychodynamic model, you know, there's a lot of listening because you need to listen enough to get a story, but then we start raising these kinds of questions. Oh, is that, does that mean, you know, you're gonna experience me this particular way, and so there's, you know, bringing some interpretation into the mix. I think another difference is, I really am focused on the patient's history, and I think you're probably, you know, talking more about the here and now. Very much so, and the difference between reflecting and interpreting, it would be like a whole other talk, and it was interesting for me, having sort of left that world, seeing how much I was interpreting in my head and to be more conscious of it, but, yeah. Yeah, and along the same lines, just the point that then that means in my model, and I think David's probably as well, there's a lot more focus on the patient's psychology and the doctor's psychology in those interactions, and it may be less so in yours, Sandy, would you say? Well, I think of it as a hub and spoke kind of thing, so that need-adapted treatment is the hub, and someone might say, I'm wondering if there's this approach that looks more at, let's say, you know, you explain it, and I'm wondering if that might be of use to you, that that may be of interest, and someone can go and pursue that, but it doesn't center it as the first way of working, and it gives more flexibility, so. So we have tried to, we'd wanted to leave 15 minutes, and I think we left just about that. We left 13 minutes for discussion. So questions, comments, objections? Yes. This is wonderful, thank you, it's really incredible. I do addiction medicine, I'm a primary care, with my background from psychiatry, and I've not known if there were words for some of the ways that I do, and I'm gonna encourage the three of you to think of something a little different, because I'm looking at this. Actually, you know what, if you go to a mic, people on the other side of the room will be able to hear you. There's one over here. Yeah, actually, bring your questions to the mic so the room can hear. Thank you, this was amazing. And so I'm looking at this through the lens of substance use disorder, and people coming in in active use, and one of the things I wanna encourage you, and you've said it in the beginning, is, you know, we tend to silo and put people in, so let me give you a diagnosis of opiate use disorder, or alcohol use disorder, instead of saying, what are you here for, and how can I help you? With three of you, what's really kind of struck me is this concept of all three of you also have valid ways of doing this, and we can flow in and out of different ways, depending on what the person needs at the time, and what works for them. So I frequently say the same thing, like, I'm not here to tell you what medication you need to be on, or what you need to do for recovery. You tell me what you want, and I'll meet you part way. But sometimes I also need to say, Vivitrol's the way to go, because clearly you're having a hard time taking something every day, so can I give you an injectable for a month? And then I'm the authoritarian. And so the beauty of really meeting people where they are is flowing in and out. We have so much more commonality than differences in these ways. And thank you for giving me, like, words. I never knew that this was a thing. And this is how I've been working with people. I really appreciate it. Thank you. Thank you. I don't have anything to add. I mean, it's just sort of a comment. Yes. Thank you also for me, for all three of you. That was really useful and very validating to hear that. I guess I just had some questions. If you have any tips on how to approach a patient that's sort of, what I might feel, is over-invested in a diagnosis. I think Dr. Minchia talked briefly about that yesterday with that vertical split. How do we address that without? Anybody else want to go? Yeah, I mean, it's a good question. It's similar. You were talking about the person who's very invested in medications. I mean, I've been in this situation where as I was kind of becoming more openly critical, I would be sitting with people who had a more kind of traditional approach than I did. And basically, I would just be honest about it. And sometimes because I would be alone, I might have like this sort of mythical other psychiatrist in the room. And I would say, I've challenged these diagnoses and this is why. But if there was another doctor in the room, you might hear something different about this. And so I'm just kind of, I try to be transparent about why I've taken this sort of critical position on how the drugs are used, what diagnosis is. But it can be challenging because you're trying to be person-centered. And so if the person has a view that's not aligned with yours, it's tough. But it's the same idea as when someone says, there's nothing wrong with me, it's the government implanting in my brain. How do you, and I don't think the government, the government does bad things, I don't think they've implanted chips yet. So how do I have a respectful discussion about that? It's kind of an analogous thing for me. I think in many ways what we're talking about here is a variation of what I would call treatment resistance from medications. And really, it's not the medication, but it's the diagnosis that's attached to the medication. So the patient develops a defensive attachment to a diagnosis for some reason. And sometimes that's a, more and more we're seeing people that are, I think for a while it was bipolar disorder, for a long while now it's more like autistic spectrum disorders. And that's a complicated thing because there's power attached to that. For a lot of people that means, oh, you have to, I don't have to accommodate to you, you have to accommodate to me because this is my disability. And I think working, well, first of all, I think one thing I'm doing from the beginning is again, like what I'm saying to somebody, is what you have, in terms of diagnosis, what I'm really treating would be David Mintz syndrome, or whatever your name is. I'm treating you, I'm treating the individual, and we're trying to figure out not what the diagnosis is, but what the troubles are. And I will often, I have a favorite, I'm a quote collector, so I have a favorite Nietzsche quote where he said, we set up a word at the point where our ignorance begins. The word is the thing that stops us from thinking. And so I'm really working with them at really understanding, what's the formulation? What's really going on? And there may be all sorts of biological derangements, but the bigger question is, how is this affecting your life and your functioning? And over time, of course, optimally if you're developing a good alliance, you start to move into a place, like you don't go after that with a sledgehammer in session one or two. You work on an alliance, and in that context is where you start raising questions, and start asking about what the person has to gain from the diagnosis, what they have to lose from being attached to that diagnosis. And again, in long-term work over time, for some people, you can really help loosen that up, but it takes time, it takes patience, and it takes, I think, some humility about knowing about what we know. So hopefully that helps. Yeah, I think that on the note of humility, a way that I personally like to think about DSM diagnosing, and I'll say this to patients to try to kind of chop diagnoses down to size, basically the way our research works is that people meet certain criteria, and if they meet certain criteria, they meet criteria for diagnosis. And then certain people, there's enough research a lot of the times that certain medications will make enough symptoms better for people. So if you frame it that way, that kind of makes it so that you can understand this diagnosis isn't some sort of deeply piercing, deeply understanding way, it's just statistics at the end of the day. And we can just let people know that, look, you seem to meet criteria for a bipolar disorder, and people with these constellations of symptoms seem to respond enough in certain symptom domains. And that's really what our research does. It doesn't tell about what it deeply means. It's a much more limited thing that's happening. And I like to keep that in mind and share that way of thinking about diagnosing with patients. So I think that's another commonality in the different approaches is a de-emphasis of the diagnosis and a greater emphasis on the person in that sense. Yes. I was wondering if you could speak to how we could incorporate some of these practices or approaches in correctional or casserole settings where the environment has its own inherent influence in the dynamics of things. There already is some kind of hierarchy if someone is incarcerated. And so I'm just curious how if that changes or how that changes things. Also, there isn't always the time or safety to allow people to sort of make slow, I guess, steps or agreements in their medication journey. So I'm just curious how that changes or if you have tips for those settings. Well, I think there certainly is probably massive, massive amounts of histories of trauma and adversity in the correctional settings. So I would certainly at least be screening for it and in a dynamically meaningful way, psychodynamically meaningful way, attending to the issues of power, authority. Clearly, probably very, very increased those kinds of issues and dynamics. I haven't worked in that setting. So in the spirit of humility, we need to be careful and I respect the work you're doing. But from what I understand, it's an incredibly stressful place to be. And so in addition to the trauma someone has historically to just acknowledge that you're gonna respond to this. You're a human being, you're gonna respond to this. So how can we help you to do the best you can given what's going on? Just a couple other thoughts. I mean, one of the things that I do is I write a dynamic formulation on every patient. And I think what you're talking about patients who are obviously in an authority structure, you're almost on some level, almost certainly in a fight because of the power dynamics. And that can be trying for both participants, both the people who are trying to help the patient as well as the patient. One of the things I think that I will do, I write a dynamic formulation. This is one of the longest ones I've written because M was so complex. Usually they're like more like five or six lines. But one of the things we know is that having a dynamic formulation helps return us to a position of empathy with difficult to treat patients. And so it puts us just in a better place to do the work and it feeds the alliance. I think even in that setting, for example, giving our patients choices is really important. There's one study, a study by Woolley looking at patients who had been hospitalized with suicidal depression. They were started on an SSRI, but they were given a choice. Do you wanna take this medication once a day or three times a day? And just, of course, that's a medically meaningless choice, but just that choice almost tripled the likelihood that that patient was gonna be taking that medication six months down the road. And we're always making, between one antipsychotic and another antipsychotic, or again, one SSRI and another, there's lots of, the differences are so small. We should always, especially in disempowered populations, be giving people as many choices as possible. So that's two simple thoughts. And how are we on time? Okay, time for one more question. Thank you, thank you very much. Very interesting presentations. I just had a question about dangerousness and working with your models in crisis situations and how do you adapt and having difficulty with times and all the rest of it, and having limited access to previous information about patients. Because it sounds like in all these circumstances, there's a need to gather information or to have information in order to be able to do the best you can for your patients. I just wondered how you'd respond to that. I mean, open dialogue is a crisis orientation. I mean, the way they set it up, they would go into people's homes and they viewed these events as a crisis that people would come out of. And, you know, you do what you need to do. I mean, we're all gonna do it differently based on the resources that we have. For me, you know, a sort of important shift in terms of like transparency and humility is that to not use language, let's say I decide that I'm gonna start the process of forcing a person into the hospital against their will, to say, I'm worried. You know, I have some responsibility here and I don't think this is safe. I mean, you also can bring in the family. Who else feels that this is unsafe? Who else, you know, is here? And it's a transparent conversation. So not avoiding something like I'm doing this for your own good. I mean, that's a caricature, but I think that is sometimes an implications that we have. Like I'm doing it because you have this illness. Like, I'll be transparent. I'm doing it because I can't leave without having you in a safe place. And I think that that is, it feels more respectful and it allows for the conversation to go on down the road because you're wanting to continue to have a relationship with the person. So there's nothing in the model that I'm having. Like I said, it's not anti-medication, although they tend to use medicines in a lighter way, but it's being transparent. Like you, you know, if someone's living in the home and is not sleeping, your parents need to get sleep. We need to get sleep. We need to do something to help you sleep because it's not tenable for you to be up 24 hours a day and ranting and raving or whatever is going on. So it's just that transparency and addressing directly what the worries are and acknowledging your own worries. Yeah, maybe just to say, of course, I think you're also speaking to something that, and it seems to me that we have a system which is not really designed at all for optimal use of our resources, you know, to create a system where we don't have the time to develop an alliance, we don't have the time to understand. It's penny wise and pound foolish. Like we're saving time up front and it is, and then we're creating chronic patients or patients who are fighting us or patients who aren't getting the care they need. Patients who aren't getting better. And so, you know, and I think probably this room is filled with people that feel that way. And, you know, I mean, hopefully as a field, eventually we can get our act together to push back against the bean counters who are designing these systems because it really doesn't work for our patients. We need, I think we need, we probably should have optimally two hours for initial evaluation because that gives us the place for that information. But that being said, I think a lot of what I was talking about, these are questions that are more like a half step sideways. And you're not radically changing your approach, but you're adding in a few other questions about the patient's feelings about medications. And we can do that in a way that only takes about, you know, 10 minutes, maybe 15 of an initial evaluation if you want to just get the most basic information. And so I don't think the models, even in the time restraints we have, I think you can work this way or at least partially work this way in ways that you are starting to focus on the alliance. So I don't think they're necessarily at odds, I would say. Hope that helps. And thank you guys very much. Thank you.

psychiatric models

biomedical approach

patient-centered methods

biopsychosocial model

trauma-informed care

psychodynamic psychopharmacology

holistic treatment

individualized approach

treatment-resistant patients

trauma impact

drug-centered approaches

patient autonomy

collaborative approach