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Psychiatry, Education, Insight. Docs Tracey and Paul Discuss it All! Two psychiatrists — Dr. Paul E. Keck Jr., MD and Dr. Tracey Goodman Skale, MD of TMBO (Two Minds, Better than One) — illuminate mental illness, teach signs and symptoms, dispel myths, and advocate timely care and dignity. Nearly 70 years of combined expertise. DISCLAIMER: educational/general discussion only, not personalized medical advice; in crisis call the 988 Suicide & Crisis Lifeline.
678441
Foreign.
Welcome to the Two Minds
Better Than One podcast.
Docs Tracy and Paul Discuss It All.
Hello everyone and welcome to
Docs Tracy and Paul Discuss It All.
And I'm just extra excited
today because we have a friend and
distinguished guest on today
and it's Dr. Javier Amador.
And and I am going to let Paul
kick it off and you introduce Dr.
Amador.
Well, we're delighted to have
you, Dr. Amador.
And today's topic is
anosognosia and we could not have
had a better expert as a guest
today than Dr. Amador.
Just a little bit about his
background, which is illustrious.
He's an internationally
renowned clinical psychologist, sought
after speaker, forensic
expert, and a leader in our field.
He is the founder and
president of the Leap Institute.
More about LEAP as we proceed today.
And the CEO of the Henry
Amador center on Anosognosia, named
after his brother.
He has pioneered research in
schizophrenia and bipolar disorder,
in particular when people are
challenged with anosognosia and a
common, common clinical problem.
His groundbreaking work in
anosognosia includes two books that
have helped countless people,
especially people with serious mental
illness and their families
complicated by anosognosia.
And we have Alvino White, this
for you.
This is one of my favorite
books of all time.
I am Not Sick, I Don't need
help by Dr. Amador.
You'll see.
Javier, like my look at this,
my notes and my dog ears everywhere.
Well loved copy.
I've personally given out 20
of these at least and recommended
to hundreds and hundreds of
people through national alliance
of Mental Illness and otherwise.
Highly recommend.
In addition to appearing with
us today, Dr. Amador has also appeared
on PBS, Nova, ABC, Primetime
Live, NBC, Bravo, and all kinds of
other media and self help
groups, NAMI, etc.
He is also a caregiver of two
close relatives of schizophrenia
and one with bipolar disorder.
So he has lived what he has
researched and contributed so much
to.
So with that, welcome.
Thank you.
Thanks, Paul.
Thank you so much for being here.
Good to see you, Tracy.
I have a groupie.
I really am a groupie because
I talk about anosinosia all the time.
So.
So to have somebody else that
you know, you're the expert in anosognosia
and I can't wait for you to
tell our audience about what that
really is.
What's that fancy word all about?
Well, I don't know if you
noticed that I gave Paul a thumbs
up when he said anosognosia
when he pronounced it correctly.
It's a hard word.
I did not come up with that term.
Anosognosia in the context of
people with severe and persistent
mental illness is reflected in
the title of that book, of my book,
I'm not sick.
I don't need help.
You're the crazy one, not me.
It's a profound lack of
awareness of having any kind of mental
disorder, any kind of mental
health condition.
And it was originally
identified in neurological patients
who, for example, would be
paralyzed on one side of their body
and completely unaware that
they were paralyzed, would try to
get up out of bed, try to
stand up from a wheelchair and fall
down.
I actually evaluated patients
with anosognosia for paralysis.
And it's remarkable, but it's
no less remarkable than what I saw
in my brother Henry, who had
schizophrenia, and countless patients
I've worked with over the last.
I can't believe I'm going to
say this.
40 years who don't believe
they're ill and they have schizophrenia,
schizoaffective delusional
disorder, bipolar disorder.
It really cuts across
anosognosia, cuts across a wide range
of disorders.
So I was looking, I was
quizzing Paul.
Then I didn't give him the answer.
That was mean.
But I said, paul, do you know
when the term anosognosia started?
And I learned that from you, Javier.
So Is it correct?
1914 is when.
With Dr. Babinski?
Babinski the same.
He's a Hungarian, not people
think he's a French neurologist.
He was a French neurologist.
He was Hungarian neurologist,
working with Charcot, a mentor of
Freud's in France when he
coined the Babinski reflex in infants
as well as the.
The term anosognosia, and in
this syndrome in neurological patients.
So a without noso disease, gnosis.
Knowledge.
So without knowledge.
Correct.
And then I think you were
saying Greek is excellent.
Yes, thank you.
Thank you.
And then I think I read that
you said, though, even though that
was Talked about in 1914, we
didn't start talking about it until
when?
The late 1980s or something
like that.
Oh, early 1990s.
My colleagues and I at
Columbia University at the Schizophrenia
Research center had published
a paper in 91 where we looked at
the empirical research
literature on this problem of poor
insight into having an illness.
Right.
And there was only about a
dozen studies, and we had proposed
in that paper, it was
published in Schizophrenia Bulletin,
that maybe what we're seeing
is really the same thing that Babinski
saw way back in 1914.
Maybe what we're seeing is
another symptom of these brain disorders,
anosognosia.
So People went out after we
proposed that hypothesis and began
testing it immediately.
So first with
neuropsychological studies, using
neuropsychological testing,
then with brain imaging, both functional
and structural brain imaging,
and there is a host of, well, maybe
a host is an overstatement.
There's a lot of research, a
lot of findings of executive dysfunction,
frontal lobe dysfunction, of
reduced gray matter in the prefrontal
cortex, a number of other
anatomical differences.
So what's the headline?
The headline is that when
someone for three to six months or
longer with a diagnosed
serious mental illness says in, in
the psychotic schizophrenia
bipolar spectrum says there's nothing
wrong with me, and that belief
persists for that period of time,
you're dealing with a brain
symptom, a symptom of the brain disorder.
Not denial, not stubbornness,
not stigma.
Those things are all at play,
but they don't explain what we see.
Well, one of the things.
Oh, sorry, Paul.
One of the things in the
teaser we talk about is how can this
person not understand that
there's something wrong?
Are they just being stubborn?
Why are they denial?
And that's.
We're leading into the teaser
for anosognosia.
So can you help explain to our
audience then how is it different?
So is it, it's a cognitive
deficit, Is it a negative symptom
or combination of those?
That's a really great question.
And for your listeners, you
know, positive and negative symptoms
kind of refer to a release of
normal function.
The positive symptoms, so
delusions, hallucinations, thought
disorder, you know,
disorganized speech, and then negative
symptoms is a loss of function.
In our research group, we tend
to think of anosognosia as a negative
symptom.
Even though it kind of looks
like a delusion, which is a positive
symptom.
We think of it more as a loss
of the ability to engage in self
appraisal.
So right now all three of us
are, our frontal lobes are working
at evaluating our body
posture, our tone, are we looking
at each other?
All kinds of things we're evaluating.
Right.
That's a function that seems
to be impaired, if not diminished,
you know, pretty dramatically
in, in people with these disorders.
And we're, we're talking about
roughly the, the, the rate of anosognosia
is about 50 to 60% of people
with schizophrenia, schizoaffective
psychotic disorder, delusional
disorder, bipolar disorder.
So I'm just going to refer to
the, all those disorders as serious
mental illness for, for, for
this conversation.
But 50 to 60%, that's half to
more than half of the people that
we're trying to help, don't
want our help.
I always thought it was
anosognosia is the most pernicious
of all symptoms of those disorders.
Bad enough to have a serious
mental illness that affects your
ability to perceive, think,
understand beliefs.
Worse that you don't
understand that you have a serious
mental illness.
That I think is one of the
cruelest things about people who
suffer from ana.
I don't think that's an
overstatement, by the way.
Paul, don't lose your train of thought.
I have to jump in.
I don't think it's an
overstatement to say it's cruel because
what it does, what happens in
families is so much conflict and
anger at the person who's not
accepting help.
And I experienced that firsthand.
We can talk about that later.
But.
But it's very cruel and it
leaves the person with anosognosia
so alone.
You know, everybody around
them is telling them they're.
From their perspective,
they're telling me I'm crazy.
People, not necessarily are
even using that word, but the person
feels all alone because nobody
understands that in fact they have
a special mission from God or
in fact their problem is the CIA
conspiracy against them.
Etc.
You were, I cut you off.
I'm sorry.
No, I, I don't want to lead us
down a tangent here, but you mentioned
DSM now 5tr and you have a
couple great sentences in there,
instrumental in getting in the
section there recognized.
I continue to be curious
though about why it's actually not
listed as a symptom.
Have you been like in my office?
Because we just finished a 35
page proposal to the APA to have
Anosognosia as a specifier.
When I say we, I have five
colleagues that I worked with together
on this and we'll be
submitting it.
And there's just a absurd
amount of clear evidence, empirical
data indicating that this is a
symptom of the brain disorder.
And clinically it's so
important because it predicts first
and foremost refusal of treatment.
Yeah, well, so you know,
Javier, that most of my practice
is working with people with
schizophrenia, schizoaff, bipolar,
sore, so all the actings.
So I, you know, there's even a
higher percentage in the acting once
you're on an assertive
community treatment team or you're
on assisted outpatient
treatment, even higher percentage
of people.
So we were dealing with that
all day long.
So when you came along and
talked about, you know, your book
and then the leap model that
was so helpful to Our team.
So I would make sure every new
staff person understood LEAP as best
they could and tried to employ it.
And we definitely worked with
our families one on one because as
you said, and you experience
firsthand with your beloved brother
Henry, families get so mad and
so frustrated and like, why are you
putting us through this again?
And so could, maybe we could
segue into LEAP and what that, what
does LEAP stand for?
Well, I mean, LEAP is about
building a relationship where the
person trusts you, whether
you're a family member, a clinician,
a police officer, for that matter.
We train all those groups, we
train judges, believe it or not,
in diversion course.
But LEAP stands for listen in
a very special way, which we can
get into if we have time.
Empathize.
Also in a very kind of special way.
Agree.
Find areas where you can agree
with the person.
And the nature of anosognosia
is you're not going to agree they
have an illness and they need treatment.
And the P stands for partner.
So listen, empathize, agree
and partner.
And what you partner on are
things that the person wants.
Staying out of the hospital,
getting out of the hospital, getting
out from a court ordered
treatment, getting a job, having
a boyfriend or girlfriend, you
know, having a relationship.
There are all kinds of things
we can partner on and link that to
the treatment.
This is going to sound counterintuitive.
Link it to the treatment they
know they don't need.
No, I get it.
Which is what we do.
You know, that is what we do
because we come.
What I would say to myself is
we have to come at it indirectly.
So we're not saying, well, you
have schizophrenia and you need to
do this.
It's more like, you know, what
are you, what are you eating?
So we're not talking about
schizophrenia, but you're, do you
have court next week or you're
being evicted?
How can we help you with that?
And we're roundabout way.
When you talked about the
listening, reflective listening is
what you, you talk about in
the book.
Can you tell our audience more
about reflective listening?
Sure.
It's, it's active reflective listening.
And it, it involves sort of
prefacing your, your statement that
you're going to reflect.
So let's say somebody says to
me, somebody with schizophrenia,
hey, I don't have a mental illness.
There's nothing wrong with me.
If you want to help me, you
know, help me with the FBI surveillance.
Right.
I would reflect that back.
So let me see if I understand you.
There's not.
You don't have schizophrenia
and you need help with the FBI Is,
did I get that right?
So there's three elements.
There's a preface.
Let me see if I understand.
Then you reflect in your own words.
Then this is really important.
You check in with the person
to verify, did I get it right?
Do you.
Do you feel understood?
You know, how many times have
I been in disagreements with my kids
or my wife?
And.
And they say to me, oh, I get you.
I understand you.
And I'm thinking the whole
time, no, they don't.
No, they don't.
But if they ask me, do you
feel understood?
Then I could tell them, right.
And give them a chance to get
it right.
My kids and my wife are great.
Don't get me wrong.
But.
But there's three elements again.
And that last one is so important.
And it's very different than
what you see in other techniques
like motivational
interviewing, which is very similar.
LEAP does draw from.
From motivational interviewing.
But that last question, did I
get it right?
Did I understand you?
Do you feel heard?
Yeah.
And it's so respectful.
So there especially so many of
our patients that we've worked with,
they don't.
They feel so discarded, so
disrespected, and for us to be engaging.
What you say matters to me.
I want to understand.
Help me understand what you're saying.
Yeah, I have.
I had a sign in my office.
I had all kinds of brain
charts and brain models, but I had
one of the signs said, I don't
care how much you know until I know
how much you care.
And I'm not kidding.
That resonated with everybody
more than anything.
When I was leaving, everybody
wanted that sign to take with them,
and I think love it.
That was the success of my
practice, is that my patients genuinely
under.
Believed that I cared about them.
And I had all kinds of people
that were taking long acting injectable
antipsychotics that didn't
think they had schizophrenia like
you said.
So then.
So empathize A.
So I think A gets people confused.
The agree.
So when I would talk about
this with family members, it's not
like saying, I agree with you.
The FBI did put a chip in your brain.
You know, it's not that.
Can you help elaborate on that
a little bit?
Yeah, no, it's.
It's a really common.
Well, active listening, the
leap, reflective listening, and the
empathy both together scare
people when they're first starting
Leap because it sounds like
you agree.
You don't agree.
Leap is 100% honest.
So when I empathize, I might
say something like, wow, you sound
really angry.
That People are telling you
you have schizophren and that the
FBI isn't real, that that's
not a real problem.
You know.
You know, I'd be angry too, if
I was in your shoes.
Oh, so you believe me, then?
What do you do?
There's other, there's three
other tools not in the acronym that
we can touch on that help you
deal with that question.
But the, One of the, One of
the premises of LEAP is it's okay
if the person makes the
mistake of thinking we agree.
We don't have to rush to
correct them.
We do want to verify, clarify
sometimes when it's really necessary.
But we keep our eye on what
our goal is.
And our goal is behavior change.
Not changing the belief, but
changing the health, the health seeking
behavior.
So accepting treatment,
accepting an act team.
Right.
Accepting that a case manager
will come to their apartment and
visit with them and they'll
open the door.
LEAP is about not even persuading.
It's about affecting change
and behavior.
And you do that through your relationship.
It's all.
It's like your sign.
When the person feels that I
really care and you know, for forbid
using this word, that they
feel loved by me, whether I'm a clinician
or a police officer or a
family caregiver, but they feel really
that I care, they're much more
open to, to taking my suggestion.
Right.
Well, I.
No, I.
Such a fan.
In fact, there was some
newspaper article I was on with the
homeless outreach team and the.
At the very end, the quote
said from the journalist and Dr.
Scale loves her patients.
Her patients love her, and she
loves them.
And I thought I love that
because it was true.
I really truly cared.
Right.
But so the whole, the whole
empathizing and I've said that so
many times in my practice.
Well, I would be really mad at
that too, if I thought that.
And the example you've given
and I've definitely used with my
people is what if you, if
someone tells you you have.
Paul, if I tell you you have
diabetes and you need to take insulin
three times a day, and you're
like, but I don't have diabetes.
But no, you need to take
insulin, like, you'd be mad.
That's annoying, you know?
Yeah.
So I try to get people to.
Understand and probably he'd
be scared of you too.
Like, are you trying to kill,
Are you trying to kill us?
Why are you trying to do that?
Yeah.
Especially with injections and
things like that.
So when you were talking about
the other things that I'm assuming
with the other three, as you
talk about, is that part of the the
A and leaps or the.
No, that's.
There's three other tools.
The acronym there is doa.
It may seem like an
unfortunate acronym, but I think
if we're not using some or
more of these tools, our relationships
are dead on arrival if we go
in with our agenda.
So the D stands for delaying,
giving opinions that will be hurtful
to the relationship.
So the person wants to know if
I believe they're mentally ill.
I want to delay giving that.
If I can, I promise I'll
answer your question about whether
you have bipolar disorder.
I promise.
But before I do, could you
tell me more about.
And I get them talking some
more so I can do more listening and,
and empathizing and building,
you know, an alliance.
The O stands for giving your opinion.
That's the three A's.
So how do we give our opinion
with the LEAP approach?
Use one or more of the three A's.
Apologize for my opinion,
acknowledge my fallibility, I could
be wrong and agree to disagree.
So somebody asked me, do you
think I'm mentally ill?
And they have anosognosia?
I would say, well, I want to
start by saying I'm sorry I have
this opinion.
I think it's going to be
hurtful to you, and I could be wrong.
Yes, I think you do have a
mental illness, and I hope we don't
have to argue about it.
You know, I respect your
perspective on this, and, you know,
I just ask that we don't argue.
So, you know, apologize,
acknowledge fallibility, agree to
disagree.
And then the A in the DOA is apologies.
Apologies are powerful tools
for connection.
You know, when we apologize,
we're humbling ourselves and we're,
we're really making an appeal
to the person to forgive us, which
is a very empowering communication.
Javier, you know what?
I'm going to write a book and
I'll need your help someday because
you've written so many books.
But one of my chapter titles,
I've always kept this in the back
of my head, is going to be
thank you for being human, because
I, one of my thousands of the
people I've worked with over the
years, very, very ill. And she
fired the other psychiatrist and
she was really mad at him
because he wanted her to take a long
acting anti.
Long acting, injectable, antipsychotic.
And there was court order
involved in all this.
And the second I met her, she
was very delusional.
But she was also saying, and I
don't want to take any kind of Medication
and you need to make sure I
get off of all this medication, all
this.
So I did the whole delay and
you know all that.
Let me get to know you better
and empathize with some other.
She also had.
Had children taken away which
another things.
We talked about that and how
awful that must have been for her.
And then I said, you know,
we're just getting to know each other
and you're on this medicate.
Why don't we do a couple things?
What maybe we can decrease it
a little bit while I'm getting to
know you better and let's do this.
And we made a plan together.
We partnered and she was very
angry with everything going on.
And she looked at me and I
have chills telling you this because
I'll never forget this either.
And she looked at me, she put
her hand out, she said to shake and
she said thank you for being
human and Right.
It's so powerful.
That might actually be the
title of my book.
I love it.
That kind of thing.
It's like she.
And she's in the court ordered system.
The court said she needs to be
on meds and all these things.
We still wanted to partner,
you know, but I love how you're talking
about humbling ourselves.
I might be wrong.
They've really pushed us.
Yes, I actually do think you
have schizophrenia, but that's not
the important part here.
What's important how you said
that you want a different apartment.
How can we help you with that?
Right.
So.
And I love also you talk about
having a person save face and it
must be very difficult.
Everybody's telling you you
have mental illness and you need
this and that.
And helping people, I think
not just our patients, but in our
real lives, helping people
save face is hugely important.
Yeah.
Even with grandiose delusions,
you know, I.
So you're telling me that you
got a Grammy award for your.
For your album.
That must be very exciting.
With Leap, you normalize by
saying, you know, I'd be excited
too.
Well, do you believe me then?
Well, I promise I'm gonna
answer that question.
I would delay, but before I
do, can you tell me more about, you
know, how this album came to be?
I'll tell you later what I
think and you keep the person talking,
keep them connected.
And then when you do give them
their opinion, they.
They do see the humanity in me
when I say, hey, I could be totally
wrong.
I guess I just haven't seen
your Grammy and.
And heard your record.
You know, maybe I just missed it.
But you know, you pick your
Battles with the leap approach, with
the problem of anosognosia.
And what do I want?
I want the person not to be isolated.
I want them connected to
people and connected to health care.
And if possible, and it often
is, taking medication and accepting
other forms of treatment, not
just medication, like you say.
The goal is not to give them insight.
Right.
It's just, it's the changing
in the behaviors.
Right.
And we're not trying to get
rid of the delusion, that's a fixed
belief.
We're just again, helping them be.
Help themselves.
I think, you know, I think
that's worth emphasizing because
there's a lot of research
showing that, you know, longitudinal
studies looking at people over
two years, that even when the person
is treated successfully, the
delusions, the hallucinations, the
manic episodes go away, the
anosognosia tends to stay not in
everybody, but in the majority
of people.
The correlations on test
retest are very high.
So that means to me, that
tells me, don't try and teach the
person they're ill. That's a
losing battle.
I'm just saying what you just
said, but I'm.
I'm just, you know, anchoring
it in, in the fact that there's.
It's evidence based.
This is not just our opinion.
I wonder if it just gets.
Sometimes it gets quieter over time.
It's there.
If you press them on it, it's
there, but they just don't talk about.
It as much as much.
Yeah.
That leads me to, to your dear
brother Henry, which prompted your
whole career, probably in this
field, I'm assuming.
Can you tell us a little bit
more about your relationship with
Henry and what he's meant to you?
Yeah.
Henry continues to mean a lot
to me.
I think of him a lot.
I'm looking at his picture
right now, actually.
Henry was eight years older
than me.
We.
We got very close when our
family immigrated from Cuba after
the Cuban revolution.
Our father had been killed in
the revolution our mother landed
in.
We ended up in Cincinnati,
Ohio, which is where Tracy and I
met.
I believe that's right.
Right.
And it was a really terrifying
time for me as a little boy.
I was three years old, and
from the age of three to 12, we lived
in Ohio.
And my brother was much more
than an older brother.
He was my father, he was my confidant.
When our mother would talk
about her depression, her understandable
depression and, and even
suicidal ideas that she had, I would
be scared.
And the only person in the
family that would talk to me and
listen to me was Henry.
So we had this foundation of
mutual care, love and respect.
And when he got ill in his
late 20s, that all went to hell in
a handbasket, because I was
trying to educate him, Henry, you've
got schizophrenia.
You need to take this medic medication.
You need to be on it for the
rest of your life.
And he said, there's nothing
wrong with me.
I'm not sick.
I don't need help.
You're the crazy one, not me.
Not that I ever use the word crazy.
And we had seven years of him,
hospitalized three to four times
a year.
Homeless for a time.
A lot of engagement with police.
Luckily, no.
No crimes and convictions, but
isolated, alone and lonely.
And it wasn't until I started to.
To really deepen my engagement
in my.
My training and my career that
I was able to reestablish a relationship
with Henry.
And the way I did that, and
this was the beginning of the leap
program, is I called him up
one day.
I was in New York in training
to be a clinical psychologist.
He was in Tucson living with
my mother, our mother.
And I said, henry, I want to
apologize for all the times I told
you you had schizophrenia.
I will never do it again.
I kept that promise, and I'm
sorry for all the times I told you
you needed to be on medication.
I'll never do that again.
And I kept that promise.
And then we had a thing that
we ended up agreeing on, and it took
six months to partner on it.
And it was basically me giving him.
In exchange, he accepted a
long acting injectable medication,
not believing he had schizophrenia.
He stayed on that for nearly
20 years, for the rest of his life.
And he never believed.
I asked him in the last year
of his life, I didn't know it was
the last year of his life.
He died in a car accident,
being a good Samaritan, actually.
But the year before he passed,
I said, henry, he knew I talked about
him.
He knew I wrote that book that you.
That you mentioned.
It's dedicated to him.
He was very proud of it.
I don't know if he ever read
it, but he was very proud of his
baby brother, his baby
brother's book.
I said, henry, you know people.
So I had his permission to
talk about him.
I said, people ask me all the
time, does your brother think he
has schizophrenia?
I mean, he's been in treatment
for 18 years.
Does he understand?
Well, I haven't asked you in
years, what, do you have schizophrenia?
And he laughed out loud and he
said, no, I don't have schizophrenia.
So then I said, well, then why
are you taking these injections?
I wasn't scared to ask the
question because I think I knew the
answer.
So why are you taking these
injections then if you don't have
schizophrenia?
And he said, I do it, I do it
for you and for mom and pops.
Wow.
Mom and pops were the people
that ran the halfway house he lived
in.
Yeah.
So what's the answer?
Relationship.
Relationship, Absolutely.
All about relationships.
Yeah.
So.
Yeah, really.
So I think especially
community mental health is, it's
so misunderstood.
And you'll hear another
podcast that we do, Javier, us talk
about the shorter and shorter
psychiatric appointments that are
happening and, and especially
in community mental health.
They're just, people are just,
oh, refilling a prescription, this
and that, and we're so against that.
And for me, again, when I was
chief medical officer there, I was
leading by example.
So I saw patients all day long
and loved it.
But I, they would bring a
consultant every few years and they'd
say, you know, you don't need
as many providers, you need shorter
appointments.
And I'd say, not.
Well, I'm the medical
director, because this is actually
hard.
It's important and I need to
establish relationships.
So for me, the model is what
we were trying to get everybody to
do it.
It doesn't happen in a five
minute session.
Building relationships.
So we had many people that
wouldn't take meds for a long time.
And I would say, okay, I was
just wondering, would you come in
and see me next month Anyway?
Because some people thought,
well, if they're not taking meds,
they shouldn't come into the
appointment then, or they're fired,
they're fired as a patient,
like, could you come see me anyway?
And over months, when we
developed a relationship, then good
things started to happen.
So whether it's psychiatry or
it's real life, you know, relationships
are the key.
Well, and what's going to
happen after you share our conversation
with your listeners is you're
going to get inundated with people
asking, how can I get find
somebody like you or Dr. Paul or
Dr. Dr. Javier?
Because a lot of
psychiatrists, a lot of psychotherapists
will say, if you're not
engaged in treatment and capacity
compliant with medication, I
can't see you.
And I train in a residency
training program and they get my
book, they get it for free.
And we talk about how
important it is to build the relationship.
The therapeutic alliance is a
critical treatment and it's foundational
to anything that's going to follow.
It's, it's all foundational.
Thank goodness.
And giving that to the new
people coming up.
It's so important, it makes me wonder.
I was thinking about your book.
I. I reread it in preparation
for today, and really it's profoundly
helpful.
And I was involved in
residency training as a faculty member
for years.
I did not teach the
schizophrenia and psychotic disorders
sections, although I was
teaching residents on the floors
and things like that.
Has your book permeated the
training curriculum?
Because you would think it
would be a key.
Required, right.
Required reading.
It has, but not nearly as much as.
As I would like and people who
believe in the leap approach would
like.
So I know, you know, many
programs that make it required reading
for social work, nursing,
psychiatry, you know, medical students,
even.
So it's permeating, let's say.
I wouldn't say it's past tense yet.
It's translated into 20 languages.
So I know that there are
people training programs overseas
because I hear from them that are.
That are using it in their
training programs and particularly
in the uk.
But that's not a translation,
but kind of.
It might be a little bit.
One of the things I want
people to know.
So I, I again had the good
fortune of working with lots of people
who had in the Sig Nuzi.
So I got to have lots of
experience with this and I felt,
you know, I feel pretty good
about my understanding of it.
And then you were in
Cincinnati doing elite training,
and I went and I encouraged
everybody I knew to go.
Like all.
So much of.
So many of my staff were there
and family members were there and
all these people were there.
NAMI national lines and mental illness.
Everybody's there.
And then you are, you're doing
your thing.
And I knew you were going to
do some kind of role playing.
And I saw you looking at me
and I did one of these like, like
looking down at my paper like,.
She hates role playing.
I hate it.
So it's like I was kind of
like, like, don't.
You can't see me.
And sure enough, did you not
call on me?
And I'm thinking, oh, no.
Oh, no.
But then, okay, so then you
started this thing you went through.
I don't even have.
I don't.
It was magical.
I don't have.
Because.
So you started taking me down
this thing about, you know, do you
have daughters?
And.
Yes, I have two daughters and
all that.
And by the, the end of this
thing, you were saying, you know,
Tracy, we're all really
concerned about you, and the people
were trying to be nice to you,
but you got to stop showing up at
their house and saying that
those are your kids because those
aren't your daughters.
I, again, have chills thinking
of that.
So, like, I can go right back
to that moment.
And, you know, you're.
The people at Greater
Cincinnati Behavioral, and the.
The CEO was there.
He really wasn't in it.
Nobody was even in on it.
But you were like, you're.
We've talked to the CEO, and
they all are concerned about you,
so we need you to get treatment.
And you.
Do you want to go to Good
Samaritan Hospital?
The.
Literally, you're giving me
options of where to go.
And I was.
And then, honestly, the people
next to me started moving away from
me.
Like, oh, gosh, we had no idea
she was psychotic.
Well, I was.
I was role playing the interventionist.
I remember apologizing to the
group and saying, this is not leap,
and I'm sorry I'm doing this,
but I've been asked to help Tracy,
and she desperately needs some help.
And, yeah, it was.
How did that feel?
How did that feel for you to
be told your reality was not true?
So it was.
You asked me that toward the
end, when we processed it, and it
was so real.
And here I obviously know I
actually am blessed.
I don't have schizophrenia,
and I do have two daughters and all
the.
But even that.
Even though I knew that when
you were saying that to me, there
was a brief moment of time, I
thought, wait, maybe I.
Maybe this isn't true.
And am I really going to
psychiatric hospital today?
So all these.
I was scared.
I was upset.
I was physically hot.
I felt warm hot.
I was.
Then I got mad.
I was really annoyed.
Like, why are people saying this?
This is really stupid.
Okay, stop it.
Stop doing this now.
I don't like it.
You know, we're all just
trying to help you.
And you were just trying to
help feel helpful.
It felt really annoying.
And then I was.
It's all the whole array of emotions.
And I thought, what a gift you
gave me to understand what it was
like to be in the shoes of so
many of my patients, you know?
So thank you for that.
And I really encouraged then.
I was so excited, if you
remember, after, I'm like, okay,
Javier, this is it.
We have to go on the road.
We have to take this on the road.
Do this in every city,
country, because this is so powerful.
Remember?
But, yeah, but no, thank you.
Thank you for that.
It really was so impactful.
Well, we're on the road a lot.
We were just in California and
three cities we're going to Tulsa
in two weeks.
And then I forget where else
we're going.
Then we're going back to California.
And yeah, we do a lot of
traveling with Leap Institute and
we have faculty.
We should.
You know, maybe the two of you
would be interested in being faculty.
We.
We should talk offline.
Well, I am.
I'm a believer for sure.
And come to.
Please come to somewhere in Arizona.
We'll do it all again.
But we encourage family
members to understand the lead model.
For sure.
I know you're.
You're instrumental with nami
having been a director, you know,
with nami.
And I didn't realize until I
was doing more of the research on
you about your role with the
ACT teams and all those models and
CIT training.
So again, thank you so much
for that.
Yeah, I was.
It was a real honor to work there.
Yeah.
So Henry inspired this all
these years and then you have a center
named after him as well, don't you?
Well, we did.
And that existed for seven years.
I didn't want to correct Paul
when he was introducing me, but we
actually decided to close that
center and focus our energies just
on Leap Institute.
And there's lots of reasons
for that.
Anybody who has run a
nonprofit, a 501C3, I need to say
no more.
You spend more time on
bureaucracy than you spend on your
mission.
So it was a sad decision for
the board to make and for me to make
with them.
But.
But we had a really good run.
We trained thousands of people.
We did a lot of work that we
feel very, very proud of.
So that.
That is now all been shifted
over to the Leap Institute.
Good.
It's better to consolidate anyway.
That's great.
That's in your.
That's in your.
I was trying to be incredibly
thorough and do you justice.
And I looked up your LinkedIn profile.
So it's still in there.
Yeah, it's still in there.
So I thought, oh, this isn't
in as usual.
You know, I'm gonna be clever, Paul.
Don't update our LinkedIn
profile all the time.
Thank you.
I'm gonna update that.
Sorry about that.
No, my.
It's my fault.
It shouldn't be there.
So I have a million dog eared pages.
We kind of bring this thing.
I love this too.
You were talking about.
So I was thinking about how
are people sort of stuck in this
and when you really don't
believe you have a mental illness,
but you do think the CIA has a
chip in your arm and is controlling
you, how do you explain that
to your loved ones and other People.
And that's when confabulation
comes in.
Can you talk about
confabulation a little bit?
Sure.
Confabulations are when it's a.
It's kind of a brain reflex.
It's a way our brain fills in
gaps in memory and perception.
So a confabulation.
Let me talk about it with
neurological patients first.
I never forget the first
person I evaluated with hemiparesis.
He was paralyzed on one side
of his body.
I asked him, can you move your arm?
He said, sure.
Please move.
It doesn't move because he's paralyzed.
And I said, what happened?
He said, nothing happened.
I moved it.
So that's already a confabulation.
I then asked him, well, you
weren't looking at it.
Would you look at it and move
it again?
So he looks at it.
It doesn't move.
I asked him what happened.
He.
He got flustered, he flushed,
he blushed.
And he said, you did something.
You put something in my iv.
So these are confabulations.
So in people with serious
mental illness, I hear things when
I ask, for example, well, how
did you end up in the hospital?
Oh, it's because my mother
called the police.
Well, why would the police
take you to a hospital?
And then you hear all kinds of
ideas that make absolutely no sense.
Why would the hospital admit you?
And you hear all kinds of
ideas and conspiracy ideas and paranoid
ideas are the most common
confabulatory ideas that come up.
But basically the person's
trying to make sense of what's happening
to them.
That doesn't make sense.
Knowing.
Yeah, but knowing they're not
ill. You know, they're just so grounded
in that knowledge.
It's fun.
It's.
It's just foundational.
Again, I know I'm not.
I'm not psychotic.
I know I'm not mentally ill.
I know I'm not manic.
And.
And so they try to make sense
of it, and the brain reflex kicks
in and you confabulate.
That's what.
What I was reading about it.
And I told Paul this.
I said, paul, I was.
I also reread and was one of
these aha moments, because I think
of anosognosia, like you were
saying, as more of a negative symptom,
cognitive symptom.
But then with that piece, the
confabulation piece, it feels like
we.
How we think of people when
they're in a delusional state.
Yeah, I have these ideas.
I have to make sense out of
something that doesn't make sense.
And then they come up, oh, oh,
well, you know, my mother paid off
the FBI and the police station
and you, and that's why I'm in the
hot, you know, so that, that's
when it crosses over into almost
like the positive symptoms too.
Yep, I agree.
So one of the things you were
saying when I love this part about
they get kind of get stuck in time.
When one's conception of who
one is gets stranded in time, cut
off from important new
information, one can't help ignoring
or explaining away any
evidence that contradicts one self
concept.
I loved that piece of insight too.
So I have the self concept.
You don't have that of me.
This is my self concept and it
didn't advance after my illness started.
It didn't get updated.
The way I think of it is it's
a self concept that is stranded in
the time before the person
became ill.
So, you know, I had a car
accident and it injured my back.
About nine years ago, my self
concept about my agility, my back,
back pain, all got updated.
I incorporated the, the
experience and the consequences of
that experience.
When you have anosognosia for
a mental illness, that update doesn't
happen.
You know, you, you, you don't
understand that your functioning
has changed, that you have
symptoms that other people notice,
but that you, you write off.
You know, these aren't
symptoms because you're not updating
your self schema, your self concept.
No, I love, I thought that was
such a beautiful piece there.
One of the things, since we
have some time, if you're okay with
this, I, we talk about people
that are involuntarily hospitalized
because that's such a, that's
such a tricky part.
So we, I think you and I both
have agreement with this and you're
involved with the treatment
advocacy center.
We want to give a shout out to
that as well.
So the whole ethics, because
you'll hear people, especially if
they don't understand
thinking, how can you hospitalize
someone against their will.
Talk about that a little bit.
Coming as I do from a country
where individual rights were stripped
away from us.
My father in Cuba, after
Castro took, took power, was abducted
and brought to the Committee
for the Defense of the Revolution
nightly for several weeks
before they eventually killed him.
Right.
So I come from a family that
values individual rights and due
process.
Right.
And yet I believe that
involuntary psychiatric treatment
is an absolute something that
we need to have available to us to
help people when we can't
engage them otherwise or when they
can't make an informed decision.
Outpatient, you know, court
ordered aot treatment Inpatient involuntary
treatment.
I've seen it save lives
countless times.
I've seen it begin to rebuild
lives, you know, lead to recovery.
So I'm a big believer in it.
I have participated in
involuntary treatments.
And the way I think about it
is if my loved one had Alzheimer's
and wandered away and I used
to live in New York City for decades
and got on a subway and
disappeared, we would do everything
to get a hold of him and bring
him to a hospital.
And even if he said, no, no,
no, I don't want to go to a hospital.
I'm just trying to get to
Queens to get to my car, whatever
his belief is, because we
understand that he's got a brain
disorder that's impairing his judgment.
It's harder with the serious
mental illnesses we're talking about
because they don't look as
impaired as somebody with Alzheimer
does.
Sometimes.
Sometimes they do, but it gets confusing.
And this person, you know,
they seem to know who they are and
where they are.
So we shouldn't be taking
their personal freedom away from
them.
But especially when the
illnesses lead to a dangerousness
to the person's, you know,
self or health or dangerousness in
terms of other people, we have
to step in and help them, you know,
to turn away.
So what did somebody say to me recently?
It's sort of like giving
somebody the right to die with their
boots on.
You know, it's.
It's like with their rights on.
That's what it was.
Giving someone, you know,
giving someone the right to die.
Giving them the right to die
with their rights on.
I'm just messing this up a
little bit, but you get the idea.
We.
We need.
And I'm.
I'm sorry I'm being so
inarticulate and fumbling here, but,
you know, individual rights
are critically important.
Our country is.
Is based on this, in part.
In large part.
But when we're dealing with
these very severe brain disorders
that impair judgment, there
are times we need to step in and
we need.
We need to treat over objection.
Because the objection is
coming from a symptom of the brain
disorder.
It's not coming from a
knowing, intelligent, voluntary decision.
And it's.
And it's hard for families,
too, to often to encourage involuntary
because they feel like they're
doing something cruel.
Well, they don't.
You're the bad guy too.
And they don't want the.
The loved one to be angry.
So when I talk about this in
my practice, I talk about.
We take this very seriously.
I mean, anyone with, you know,
A psychiatrist or nurse practice,
you can write a whole
psychiatric hold.
You better do it with a lot of thoughtfulness.
You know, we don't.
We take it very seriously.
So for me, people knew me in Cincinnati.
If I said someone needed to be
in the hospital, they really needed
to be hospital because I kept
people out of the hospital most of
the time.
I had one situation.
You bring up the person with dementia.
So why is it, as a society, we
are more likely to help that person
with Alzheimer's that's eating
out of the garbage can than the person
with schizophrenia that's
eating out of the same garbage can?
So I had one of my women who I
again loved dearly, that I had for
years.
She had deterioration of her
illness over time.
So in the early days, she
heard lots of voices and things like
that, but she was mostly happy and.
And got along okay.
Over the years, she started taking.
Not as she couldn't take, as
good care of her health and her.
She had lots of problems with
diabetes and blood pressure and all
kinds of things like that.
And then she started wandering
around naked outside.
And she was in her late 50s,
and somehow people were sort of okay
with that, like.
And I would say, she needs to
go to the hospital.
And I would get pushback from
one particular social worker who
would say to me, and she's
just like, that's just who she is.
Like, so she's just like that.
I'm like, okay, first of all,
you've known her three months.
I've known her 25 years.
But okay, secondly, that's not
how she is.
And by the way, is it.
Are we okay with that?
Are we okay with her eating
out of a garbage can?
Because we're not okay with that.
And so we ended up
involuntarily hospitalizing her,
and she got such good care,
and she ended up needing more, like
she needed nursing home care,
actually, at some point.
But it was okay.
She ended up thanking us.
So that's been our time, Paul.
We see that.
I know you see that, Javier.
I do.
Thanking us then for making
the intervention.
And that was going to be my
punchline for the families are often
afraid they're being cruel.
Usually, not always.
But as I think we all know on
the back end, when the outcome has
been at least somewhat
positive, they're grateful.
And often the person
themselves who was involuntarily.
That's what I mean.
Yeah.
Is grateful, too.
Not always again, but often.
Yeah.
The other thing that happens and.
And I write about this in the book.
I have chapters at the end.
On involuntary treatment.
And my brother used to say to
me, because I, I.
Years later, when I was using
the leap approach with him, I would
apologize for calling 91 1.
I'd apologize for talking to
the doctor in the ER to get him admitted
against his will.
And I apologize.
I'm really sorry I did this to you.
Maybe I was wrong to do this,
but I did this because I love you.
And what he said to me was, I
know that he used to call me Javi.
I know that, Javi.
And he, more than once, he
gave me a hug, and he says, I know
you think you're doing the
right thing, even though you're not.
I know you really.
So he knew I was coming from a
place of love, even though we disagreed
on.
On what I was doing, you know?
Yeah.
And I think that resonates
with you all over the place, which
is why I just adore you.
And did you.
You understand that it's all about.
I just like you a lot.
You like Sorry, Paul, but yeah.
Well, you know, I kind of was
starting to adore Paul.
I mean, I don't know.
Sorry, Tracy, go ahead.
Like, you.
You.
You're caring that you get it.
Like, I love other people that
get it, because we don't see lots
of people sometimes in this
field that really get it and understand
the importance of the
relationship and caring.
And I want to do one more
quote from you if it's okay, because
I love this, too.
You were talking about, if you
want someone to seriously consider
your point of view, be certain
he feels you have seriously considered
his.
And I feel like you're all
about that.
And I've learned.
I personally learned so much
from you and continue to learn from
you and will share your wisdom
with everybody I know.
And we cannot thank you enough
for sharing life with us today.
And we really appreciate you.
Yeah.
Thank you for doing so much
for so many people and for being
our guest today.
And let's thank my brother
Henry, too, because without him,
none of this would have happened.
Yeah.
Yeah.
Thanks so much, guys.
Henry, thank you.
Great to see you.
Bye, now.
Thank you.
Thanks, Sam.