Michael Garrett on Treating Psychotic Disorders: Part the First

Back in the early summer, outside the pressures of the academic year, I ordered a half-dozen books on psychosis and schizophrenia, thinking, in my slightly manic way, that I'd have abundant time and energy to "read, mark, and inwardly digest" each of them in great detail (to borrow one of Cranmer's genteel phrases from my Anglican childhood in Canada that doesn't quite describe how I often brutally ransack books like some kind of shameless Vandal), and perhaps even to re-read some of them. 

Well that didn't happen, but I did make steady, though much slower, progress on two of them, including Michael Garrett's Psychotherapy for Psychosis: Integrating Cognitive-Behavioral and Psychodynamic Treatment (Guilford, 2019). xiv+354pp. 

Part-way through the book, I learned on Twitter that Dr Garrett would be leading a 9-hour training workshop on Zoom discussing cases and techniques--both CBT and psychodynamic--for treating patients with psychotic disorders, whom he has had some considerable success in treating over the decades. So I signed up, and just completed it with him in early November. It was very useful in all sorts of ways, and in fact the week after the first session, I had occasion to meet with a heavily delusional patient and the "peripheral questioning" technique Garrett described in both the book and the seminar were extremely useful in beginning to chip away slowly at the delusional thinking. 

What follows, then, are my initial thoughts on the first third of the book (I won't have time profitably and deeply to read the rest until my Christmas break) farced with some comments and examples of his from the training, and my thoughts in response to that.

Garrett endeared himself to me in the first paragraph of the first page of the book in which he said (with no false modesty evident here or in person in our seminar) that "I make no claim to have invented a new therapy." To which let all the masses say: Amen! Alleluia! Blessing and Glory and Thanksgiving Be to Our Author! Later, at the end of ch.1, he will further outline a second important caveat that "I make no claim that the approach outlined in this book will be useful with all patients" (p.26). 

Instead of attempting to invent something de novo, he says his approach in the book will be to "fix two existing therapies together" (p.1). This he does by drawing in a careful and respectful way on longstanding training in both CBT and psychoanalytic methods. For those who are immediately nervous about such an approach, which has been attempted in the past by some apologists for therapy "integration," and often seems to end up trying to jam (one is tempted to write repress) dynamic ideas and practices into a Procrustean CBT bed, rest assured this is most certainly not Garrett's approach. He is, after all, first trained psychoanalytically long before he did CBT training. And second, he's married to the incomparable Nancy McWilliams (to whom he dedicates this book), arguably one of the great psychoanalytic psychotherapists practicing today in the anglophone world, whose praises I sang here. 

Aware that pulling two traditions together, especially in service of psychotic disorders, may seem a tall order, Garrett rightly says that "psychotherapy for psychosis should be ambitious" (p.1, his emphasis), and a little later on notes that the lack of ambition means many, perhaps most, patients are drugged and given little beyond that to help. Their suffering is relatively unabated by clinicians who are not ambitious enough on their behalf, seeking little more than symptom control via neuroleptics.

Garrett's approach is, as noted, twofold, and in the book and seminar he noted that it is usually important to begin with CBT methods in the first phase of treatment to try to "examine the literal falsity of delusional ideas" before trying, via psychodynamic methods and theory (especially that of object relations) to "examine the figurative truth (specific personal meaning) contained in psychotic symptoms" (p.2). Garrett thus takes his place alongside others we have noted on here who believe that "psychotic symptoms are a symbolic expression of the psychotic person's mental life" (p.3). 

In putting CBT and dynamic practices together, he will later argue in the book that there are "many differences of terminology rather than substance" (p.24). His one caution about integrating them is again the timing, noting that a weakness of dynamic therapists is to interpret the unconscious meaning of symptoms too early in the treatment. Doing so before a well-established foundation of trust is laid means that the therapist is likely to fail to help for the simple reason that "it isn't a clever point of logic that proves the delusion wrong and wins the therapeutic day; rather it is the patient's trust in the therapist" (p.25). 

Also in the introduction Garrett notes that as a prescriber he is not opposed to neuroleptics, but he rightly insists we should be aware of at least two things: first, that "the longitudinal data indicate that in the majority of patients long-term neuroleptics do not restore premorbid functional capacity" and second that "some individuals can recover without medication" (p.4). If treatment should be ambitious, then it should be open to using drugs where necessary, but even more it should be committed to long-term intensive psychotherapy for the latter lacks the notoriously nasty side-effects of neuroleptics. 

To argue for such intensive therapy requires that we counter the "discrediting myths about psychotherapy for psychosis," which he does very smartly and without polemics or fireworks in the the last half of the introduction to the book. I will not repeat those arguments here for I am utterly convinced by them and would regard their demonstration as tedious. But for those who are less convinced (e.g., most of mainstream psychiatry it seems), this is important reading.  

The first chapter begins with challenging head-on another excuse for avoiding psychotherapy with psychosis: that it is too difficult. Au contraire, he says: "it is doable and is often no more difficult than psychotherapy with people who have severe personality disorders" (p.17). I would second this based on my limited clinical experience. I find psychotic disorders more straightforward than the histrionic and borderline conditions I have attempted, with little success so far, to treat.

The chapter ends with Garrett saying something that I find so refreshing about work with psychotic patients: their directness and earnestness. "When a psychotic person talks in earnest with a clinician, there is no idle chit-chat...[or] half-truths and social niceties....The conversation is densely meaningful" (p.26). I find this very true, which is why I find myself greatly looking forward to seeing my psychotic patients.

Ch.2: "Biological and Psychological Models of Psychosis" does not pretend to be exhaustive, but it is wide-ranging and fair-minded enough to give readers with little background a good introduction to various theories. Like other authors, he notes that psychosis often begins with a prodromal period in which things begin somehow to feel 'off.' (This put me in mind of Christopher Bollas' image of When the Sun Bursts which I discussed here.) 

The prodromal phase may, he told us in the seminar, be brought back to mind in taking a history by asking such questions as "have you noticed any changes in the way your thoughts come to you lately?" Often, he says, patients "hear" their thoughts more than think them per se. Often, too, this phase is marked by a more intense awareness of the environment--its colours are more intense, or its suns and planets (cf. Bollas) more prominent in odd ways. 

In putting this chapter together, Garrett ranges widely, back to Harry Stack Sullivan and Karl Jaspers. An important sign of this prodromal phase, Garrett says, may be found in patients who report no longer thinking their thoughts, but instead "perceiving their thoughts." This, to put it into Fonagy's terms, could be described as a collapse of any ability to mentalize. Or to put it in Lysaker's terms--with which Garrett shows some familiarity at several points in the book--we see the inability to engage in any sort of metacognition. (One of these days, dear longsuffering reader, I will get around to writing about Lysaker's very rich and dense book, which I read nearly a year ago now.) 

As for the question of how to define psychosis--is it a 'disease' that is 'other' than or radically breaks with, common human experience, or is it on a continuum (Ophir's book examines these issues with great skill), Garrett reviews the evidence that "roughly 20% of the general population report transient psychotic experiences of some sort, which indicates that psychotic states exist along a continuum with ordinary mental life" (p.46). I like to scandalize my students by following Bion and altering Freud's famous phrase to say to them that the dream is the royal road to the psychotic mind, and to the extent we all dream, we all experience our own 'psychotic' minds. If nothing else, this claim of mine usually momentarily rouses the sleepers and Instagramers in the back of the room to raise their heads to lodge some desultory protest ("Whaddya mean we're all psychotic?") I laugh at with a little bit of smug sadism. 

Ch.3 advances Garrett's argument that psychosis is "an autobiographical play staged in the real world" (p.58). As compelling as I found this metaphor upon initially hearing it, I challenged him (in an amicus curiae sort of way) in our seminar, saying that I found Bion's argument about "Attacks on Linking" very powerful, and to just that extent wondered how a psychotic patient could link together his or her life in such a way as to mount a play that an audience could follow with some coherence and facility. In our exchange, which was very helpful and cordial, he was able to 'rescue' the metaphor, as it were, by suggesting that the play might make sense and cohere, more or less, to the patient, but of course would do so far less to the 'audience' (clinician, etc.). The job of the clinician, then, is partly to help the patient recover the ability to make sense not just to himself but especially to others, thus overcoming much of the profound isolation that so often marks psychotic disorders. In other words, the recondite meaning of the psychotic play needs, via psychotherapy, to become gradually more and more apparent and understandable to others. 

Also in this chapter Garrett advances his argument that delusions of grandeur exist in part to "fend off self-hatred and shore up self-esteem" (p.68). Thus, instead of rolling your eyes (as Garrett of course rightly said in our seminar a good psychotherapist should not do) at a patient who reports being a messenger of the divine, or perhaps even God himself, we can instead see this as valuable material, testifying to how little self-regard the patient has for him/herself: the more grandiose the delusion, perhaps the more depleted the sense of self.

Following the same logic, MG later in this chapter says that command delusions point to ambivalence in the patient: if they are uncertain about about a course of action, the delusion might resolve this for them in a kind of 'absolutist' way that you can decipher to find the uncertainty behind it. In other words, the more demanding the delusion, the more there might lurk ambivalence and confusion behind it in inverse proportion. 

On the topic of delusions, our seminar noted that one key hallmark here is the background becoming foreground, and things usually not noticed in daily life (e.g., the particular colour of cars in a parking lot) become hyper-salient details, perhaps revealing hidden meaning (apophenia). In addition, any sense of self disappears into the background and thoughts are no longer something I have, but malignant and persecutory outsiders that come to me unwanted and unbidden. 

Finally for this chapter, MG notes that any thespian metaphors are time-limited and prone to instability: "clinicians should not regard psychosis as essentially a static mistaken idea or cognitive bias. Psychosis is more like an ongoing improvisational drama, with unexpected twists and turns in the plot and an expanding cast of characters" (p.82). 

In Ch.4 MG notes that an important thing to keep in mind is that figurative language is almost always replaced by very concrete language and metaphors. We will return to this point later.

Well, that's it for now. I hope to finish the book in December and post the next part then.