How Does Riggs Treat Psychosis? An Interview with Staff Psychologist Dr. Jeremy Ridenour (Part 2 of 3)
Q: How does Riggs approach the treatment of psychosis? Why?
JR: Like everything at the Austen Riggs Center, there is an integration across different disciplines – each patient’s treatment team, which meets twice a week, is comprised of a psychiatrist, a psychotherapist, a social worker (who is also doing family work), substance abuse counselor, a nurse, and community staff. All of the team members work together to understand what’s going on with a patient, to understand how their mind works, to understand how they make sense of other people’s minds, and to try to figure out how to deliver truly integrative care.
One of the larger goals of treatment is to help patients develop a greater sense of direction or self-agency – to know what their goals are, to act on those goals, and to bear the emotions that come up when they are frustrated in the search of those goals. We work to understand how patients’ symptoms emerge and the contexts under which they come up, so that we can help them learn about their symptoms and then also find the kind of interventions that might be helpful to manage their symptoms.
Our approach to psychotherapy is broadly psychodynamic. We are working to help people understand the nature of how they think, like cognitive therapy does, and we are also focusing on interpersonal relationships, which helps patients improve their social cognition – how they make sense of their thoughts and emotions and other people’s thoughts, feelings, and intentions.
The other thing we get to see, which is unique here, is how someone relates to communities and groups, and how someone manages those situations. Our aim is to help patients improve their social skills and their capacity for emotional communication in social situations – basic skills that are needed to work in the world and pursue personally meaningful goals.
Q: What role does medication play?
JR: While I’m not a psychiatrist, I can say that an important part of the work at Riggs is focusing on the relationship patients have with the medications they are taking as well as the relationship they have with their prescribing psychiatrist. It is not uncommon for people with schizophrenia or psychosis to be wary about taking their medications – they may not trust the medications or may dislike the side effects – and this can lead to individuals going off their medications.
We’re working with patients to try and understand – and psychiatrists in particular are trying to understand – “How does the patient relate to the medication?” “Do they trust the medication?” “Do they trust their prescriber?” In addition, we’re thinking about the context in which patients may choose to not take their medications, because that happens both in and outside of treatment. The broader world of psychiatry often views medication non-compliance as a lack of insight or someone not accepting their diagnosis. At Riggs, we’re trying to make sense of why a patient might choose not to take medications and to uncover a patient’s motivation. The more we can help patients make sense of how they make the choices they do, the more we can understand together the effects of those choices both on themselves and also on their relationships with other people.
Q: What does the successful treatment of psychosis look like?
JR: Every treatment is individual, because people come here with individualized goals. One person’s goal might be to stop hearing voices, someone else’s goal might be to develop a better relationship with their voices so they can work in the world and not argue so much with their voices.
We tend not to have predetermined goals related to symptom reduction. Rather than trying to take away someone’s delusions or voices, we focus on talking about and understanding someone’s relationship with their voices, and their relationship with their ideas. Delusions, in particular, are often resistant to treatment because they can be world-shaping and an important part of how someone defines themselves, which makes it very difficult for someone to give them up. Our work with psychotic patients involves helping people develop goals that matter to them, and then working collaboratively to try and figure out what’s realistic, which can be difficult work.
A research study by Dr. Thomas McGlashan that came out in the 1970s found that there were two ways of managing psychosis – one was “integration” and the other was “sealing over.” Psychotic patients who “sealed over” tended to distance themselves from their symptoms, not think too much about their symptoms, and hope they could stabilize on medications alone. In this way, they tended not to incorporate their psychosis into their self-concept or personality and tended to have worse outcomes. What McGlashan found and what we’ve found at Riggs is that “integration” – which involves thinking about the psychosis as personally meaningful, understanding the context under which it emerged, and recognizing that it’s part of one’s general make up – allows someone to develop a more adaptive way of coping with their symptoms.
At Riggs, we are often working at integration and trying to understand the themes that are relevant in the psychosis and trying to find some kind of personal significance within a psychotic symptom. For example, a person might have a belief that, on the surface, appears to be blatantly irrational, such as a belief that their girlfriend is Mary Magdalene from the Bible. As a therapist, I would recognize that as irrational and see if the other person could recognize that, but, more importantly, I would be interested in “How do you think about Mary Magdalene?” “What are your ideas about her?” “Are there similarities about your ideas about Mary Magdalen and your experience of your girlfriend?” The effort to try to understand the kernel of reality within the delusional shell of an idea often reveals personal themes that can open up someone’s deepest fears and wishes about themselves and others. Understanding and working with those fears and wishes can lead to more positive outcomes for people struggling with psychosis.
McGlashan, T.H., S. T. Levy, W. T. Carpenter Jr., “Integration and sealing over. Clinically distinct recovery styles from schizophrenia,” Archives of General Psychiatry 32, no. 10 (1975): 1269-72.