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Pathways To Spirit is hosted by Dr. Troy Melendez and Dr. Nate Velez of Journey to Recovery, offering an inside look at the people, practices, and purpose behind a culturally grounded approach to healing from addiction. Through conversations with the Journey to Recovery team, the podcast explores the program’s history, its new facility, and the clinical and cultural principles that guide their work. Pathways To Spirit provides a welcoming space to learn how Community, culture, and connection support the recovery journey, and how this program is shaping a path toward wellness and a deeper sense of spirit.
Welcome to Pathways to Spirit. Our journey today seeks to honor the sacred land, revered teachings, and ancestral wisdom that guide us through the path of mental health wellness and holistic recovery. Together, we'll explore the stories of strength, healing, hope, embracing the clinical techniques and cultural foundations that remind us we are never alone on this sacred journey toward wellness and a strong personal connection to spirit. Welcome back to Pathways to Spirit. I'm your host, Doctor.
Troy:Troy Melendez, and you are flying solo with me today. I'm going to talk a little bit about psychosis and substance use disorders, and some similarities between the two, specifically around a condition known as Anosognosia. Anosognosia is a condition whereby individuals experience symptoms of a larger disorder, but don't really understand that they have a condition themselves. It's a neurological lack of insight, and it's a major barrier for substance use disorder treatment, because it prevents an individual from recognizing that they have a substance use problem or a psychiatric disorder, It also prevents them from recognizing that their behavior causes negative consequences, and this can drastically hinder treatment, initiation, and continuation. I want to talk a little bit about psychosis and substance abuse before we jump into the Anosognosia condition, as well as how do we work with individuals that suffer from these illnesses and don't have the insight to recognize that they need treatment or don't want treatment as a result of that.
Troy:We got to start out by recognizing that everyone's story and journey is unique. How we experience or process the same events may differ. A lot of that has to do with the way that we experience reality is in reference to what we've experienced before. If we've gone through experiences where maybe people's emotions were higher and there was a lot of conflict, we can either be really sensitive conflict in the future or we may be really accepting of conflict or seek that out in the future. So it not only has to do with what we've experienced in the past, but how we've experienced that.
Troy:No two individuals have had exactly the same experience, and so there's always going to be a slight disconnect in terms of how we experience things. We understand where people with different perspectives are coming from without adopting that perspective ourselves. Our natural tendency might be to tell somebody that their experience isn't right or is problematic. All that really does, especially in initial interactions with folks that you care about that are suffering from any types of disorders, is it pushes them away. It It creates a barrier where there's maybe a lack of trust is developed or they just don't feel comfortable interacting with somebody that sees their situation so differently.
Troy:When we recognize that all of our experiences in life are going to be very subjective to who we are, we can better understand an individual that might be suffering from conditions that cause them to see the world in a very different way. In understanding psychosis, psychosis is the experience of a loss of contact with reality that's not part of the person's cultural or religious beliefs. A person experiencing psychosis may not know which of their feelings and thoughts are real. When we're interacting with somebody that has symptoms of psychosis, we have to understand that this is an individual that is experiencing these things. They may not know why they're experiencing them.
Troy:We don't know if this experience is upsetting or it's just normal for them. It's really important for us to sit back and allow them to explain this stuff to us, which is hard to do because when somebody's telling you, Hey, I hear voices or angels talk to me or demons torment me, I mean that justifiably causes some upset for us. We'll have a reaction of, We want to just tell them that that's not real and they don't need to believe that, and you know, in an attempt to offer some relief. Really what that does is it just creates a barrier between us and the individual that is either reaching out to us for help or we're trying to get them to get some help beyond us. Psychosis is not a diagnosis in itself.
Troy:It's a collection of symptoms, hallucinations, delusions. It's signs of an underlying condition, which may include a psychiatric illness, severe stress, substance use, or other medical issues. If psychosis symptoms are persistent, this usually leads to an underlying disorder diagnosis, typically schizophrenia, bipolar with psychotic features, or major depressive disorder with psychotic features. These beliefs are often felt as an unfounded fear or suspicion. Delusional beliefs do not change when a person is given facts that show that they are false.
Troy:They still retain those beliefs, they just gather the information that you don't believe what they believe. And so, when we're dealing with hallucinations and delusions, we have to understand that the individual is experiencing that as reality. Even if we can understand that, hey, that's extra to reality, that's not what I see here, Because a lot of times a psychotic person or a person dealing with psychosis will explain to you something that's happening right in front of them, and you can see that that's not happening right in front of the two of you. It's going to be difficult to You don't necessarily endorse what they're seeing, but you don't challenge it because of the fact that that challenge can create a barrier to further conversation, further understanding, and eventually getting some assistance for the person. Now there are some myths around psychosis.
Troy:Because psychosis and symptoms of psychosis are so upsetting to people, they're so out of the ordinary for us, we sometimes make the assumption that a person experiencing psychosis is dangerous. In fact, it doesn't necessarily make them dangerous. A person that experiences psychosis will be confused, will be frightened, they'll be vulnerable. Some will have mood swings and become agitated. Most times people experiencing psychosis try to stay away from other people.
Troy:They're much more likely to harm themselves than another person. That's why it's really important to get treatment right away to keep these people safe. Another myth is that once a person experiences psychosis, they're going to be in that state forever. The reality of this is, is that about a fourth of the people who experience a first episode of psychosis recover completely and never experience psychosis again. Now the other seventy five percent may go on to lead relatively productive lives and be able to create some structure in their lives and will occasionally experience a flare up in these symptoms.
Troy:With proper treatment and proper counseling and a good structure, a lot of times these individuals can anticipate these episodes coming on and they're able to reach out for more help, maybe control the situation with medication. In some cases people voluntarily check themselves in because they know, Hey, this is going to get really dark for me. This is going to get really difficult and I need to be in a safe environment where I'm not going to be prone to reach out to unhealthy things to help me cope with what's going on here. About half of the people that experience psychosis do very well with medication and treatment, There's about a fourth of the people that experience psychosis that are going to need more intensive ongoing care. It's really not the dire consequences that a lot of us think it is, you know, on first glance at looking at somebody that's experiencing such severe symptoms.
Troy:Only about one in four actually need real intensive long term care, and so with proper treatment and medication, a lot of people can go on to just live their lives and be in a good place and manage these symptoms. So we'll look a little bit at hallucinations. Hallucinations can include auditory hallucinations, hearing voices. A lot of those times those voices are very critical. They'll tell a person that they're worthless, that people around them can't be trusted, or sometimes they tell them that the individual has superpowers.
Troy:Then in some cases, these voices can encourage somebody to harm themselves or harm another person. Other hallucinations can happen in the visual sense, seeing bright colorful lights, there may just be flashes. From time to time people can interpret it, some of these extra visual perceptions as religious figures. People believe that they're in touch with God or Jesus and other things or people that aren't there. Seeing things that are common in your cultural or religious traditions are not considered hallucinations.
Troy:It's really important when we're talking about these extra perceptions that we have, to really understand that our perception and our ability to perceive goes far beyond our five physical senses. That within our five physical senses, there's even some tempering of those senses. We don't see all that there is to see. If we take light for instance, the light spectrum, ultraviolet light and infrared light and all these different types of light, our brain filters those out so that we can see. If we could see all types of light, we wouldn't be able to see it all.
Troy:There'd be too much interference there. We only see about a hundredth of a percent of the visible or of the total light spectrum is visible to us. Same thing with auditory. We see about 1% of the total auditory spectrum and same reason, if we could hear high frequencies or low frequencies, we wouldn't be able to communicate. There'd be too much interference.
Troy:I've always kind of taken the approach that when people are seeing or hearing things that maybe there's just something that's not working right with their filter, that maybe a little bit extra gets in and because we understand things in reference to what we've experienced before, they don't really have a context to understand these extra things that they see or extra things they hear, and so they put it in the context of what they know. A lot of times it's religious based and they'll attribute it to angels or demons, and so it's understanding that we can have these auditory and these visual hallucinations. There's also tasting or olfactory, smelling something that's not there. The taste or the smell, a lot of times is unpleasant and they get really triggered by this unpleasant smell or this irritation in their tasting. This is mostly common in psychosis caused by a medical condition more so than a mental illness.
Troy:Then there are tactile hallucinations as well, feeling like someone's touching you or there's bugs under your skin or other tactile situations. We see this a lot in substance use disorders and people that are experiencing psychosis as a result of their substance use. We see it most commonly at Journey to Recovery in our folks that are suffering from methamphetamine addiction. The chemicals that are used to create methamphetamine today are much more powerful than the chemicals that were used even five years ago, and we're seeing a large uptick in folks that are experiencing meth induced psychosis. A lot times we have folks come in to detox, they're experiencing psychosis, and with some time and stabilization those symptoms of psychosis go away.
Troy:Some of them can linger and we address those in counseling, but a lot of times these are temporary situations when substance involved. Next, talk a little bit about delusions. Common delusions are delusions of paranoia, the belief that someone or the proverbial they are out to get them. The person might believe, for example, that their tap water has been poisoned, or that people are listening to their thoughts, or there's people that are watching their house. These are very common delusions of paranoia.
Troy:There's also delusions of reference, that it's a belief that an event or an item holds a special meaning for them. A person may believe that celebrity on TV is sending them special messages, or that there's messages that are being conveyed when they open the Bible and they find inspiration or they find direction within that. Delusions of grandeur are also very common, the belief that they are an important figure. They may take a figure from history. It might be a religious figure like Jesus Christ, it might be a political figure like Abraham Lincoln or Napoleon.
Troy:The person believes that they have these superpowers, sometimes like the ability to fly or tell the future. And so this can be very upsetting to folks that are hearing this from another individual, but it's a very common aspect of delusions that people will experience. There's also delusions of control, the belief that their mind is being controlled by outside forces. A lot of times they believe this is space aliens or the government or different radio waves. Sometimes a person will have both delusions and hallucinations.
Troy:A person may believe that there are that people with red eyes are evil, or a person may then start to see red eyes when they look at their loved ones and become very frightened of their family. And so there's that's a delusion that's also paired up with a hallucination that can make situation much more difficult to engage and work through. Other signs of psychosis that we'll see is disorganized thinking and disorganized speech. Folks have difficulty organizing their thoughts. A lot of times they'll speak incoherently incoherently or they'll engage in tangential thinking, which is jumping from one topic to the next with no real segue or relevant information that ties those two topics together.
Troy:We'll see disorganized behavior, folks will act in odd ways. One of the common signs of this is they neglect their hygiene and withdraw from social interactions. A lot of times we'll see folks that'll engage in just bizarre movements for no reason. Then other symptoms that we can see of delusions is anxiety, depression, paranoia and confusion. So these are really important things to consider when you're interacting with somebody that may be dealing with psychosis.
Troy:So how do we support them? This is, you know, it's a simple way but it's not easy to do. Above all, we want to be respectful. We want to be non judgmental and take an approach that doesn't categorize them or diagnose them. We just want to be listening to what their experience is.
Troy:It's important to be direct when speaking about delusions or voices or psychosis and understand that speaking about these things does not reinforce their belief. We can talk about them, we can ask them questions about their experiences, how they feel when they're experiencing these things. Do they feel that these voices or these individuals that they may be perceiving are helpful to them or are they out to hurt them? An individual will likely shut down if they perceive that you don't believe them in any way, or that you're judging them. Direct and empathic reflection is the best approach.
Troy:We're just mirroring back to them what they're saying to us to demonstrate that we understand. Our goal is to reduce distress, not to rid them of the voices or delusion, not to make them seem able to see what's real for us, but to just reduce their distress, normalize their experience that they're having, and believe them. Know, you don't have to see it to believe it, and believing that they're seeing that doesn't endorse that those things are actually happening. An important thing to consider when we're approaching folks is their ability to perceive what's going on with them. A lot of times, they're aware of these situations that happen, but they're not always aware that it's actually an underlying disorder.
Troy:There's a condition known as Anosognosia, and it's a common symptom of certain mental illnesses, and it's very difficult to understand for those that never experienced it. Relative. Anosognosia is relative. Self awareness can vary over time, allowing a person to acknowledge that their illness is there at times, and sometimes they're not able to acknowledge that at all. Again, it's not important for us to convince someone that they're suffering from or experiencing disordered behavior or they are they're experiencing behavior that's diagnosable.
Troy:What's important for us is we want to help them to reduce their distress because the distress is what's going to lead somebody to use substances, to run away from people, to seclude themselves, or to consider harming themselves. So We want to be able to engage that person in a way that helps us to build trust. The prevalence and risk associated with Anosognosia indicates that about thirty percent of people with schizophrenia and about twenty percent of people with bipolar disorder experienced this severe lack of awareness in their diagnosis. Now the numbers aren't as concrete when it comes to substance use disorder, but it's very prevalent in a substance use disorder. Now, we don't know if it comes mostly from an inability to have that awareness or if it's just we're ignoring that because it doesn't If I think about how disordered my behavior is in terms of my drug use, then I have to accept that I need to stop my drug use.
Troy:A lot of folks will avoid that, acknowledging that when they're dealing with a substance use disorder. So we'll often see folks start to rationalize. They'll generate seemingly logical but fundamentally flawed explanations to justify their substance use. It may be I'm treating a pain disorder or I'm trying to heal from trauma or certain substances can help me get through my day. Rational understanding of, Oh yeah, that would help, but it's a lack of acknowledging that there's significant negative results or consequences of those behaviors.
Troy:Folks will also minimize, downplay the frequency or the quantity or the effects of their drug or alcohol use. Then most commonly we get pretty defensive responses. Individuals become agitated, they don't want to discuss their addiction issues, they'll often mistake their symptoms for conscious denial, or these defensive responses. That brings up an important part to acknowledge here, is that anosognosia and denial, they look similar to folks interacting with individuals that are engaged in this, but they function very differently. Denial is a psychological defense mechanism where a person consciously or sometimes subconsciously subconsciously rejects an unpleasant reality to avoid the emotional pain.
Troy:I don't want to accept that I have a disorder because that's going to cause me to realize that I need help, I need to stop certain behaviors that are soothing to me, and that desire to avoid that emotional pain comes out in denial behaviors. Where Anosognosia is a physiological deficit that results from actual changes in brain function, most typically in our frontal lobe. Because it's a neurological impairment, individuals with Anosognosia genuinely believe that they're not sick. Our brain is susceptible to changes based on experiences that we have. When we have an experience repeatedly, our brain, our neurological pathways will change to accommodate that belief or that practice that may be outside of the norm for most people.
Troy:So it's understandable that in this condition of Anosognosia, the individual just really doesn't have the capacity to understand that they're not able to see underlying causes of these symptoms. When we see this in recovery, the individuals that suffer from a substance use disorder and Anosognosia experience a worsening in their clinical outcomes because they actively avoid treatment, or they relapse after a short period of treatment. Some of them may be convinced that, Hey, I have this under control. I understand my substance use. I'm just going to minimize it.
Troy:Addressing this requires very specialized non confrontational communication strategies that focus on building trust rather than forcing the person to admit that they have a problem. Again, you can see we're avoiding that need to diagnose or that need to label or that need to say, Hey, there's something wrong with you. It's really more of building a relationship based on trust, based on communication that's going to help this individual to move through this experience. Also in the context of addiction, Anosognosia is not just simply psychological denial, as we've spoken about previously, but it's a biological consequence of the neuroplastic changes in the brain. You literally are creating pathways in the brain through these behaviors, and so this chronic substance use can alter our prefrontal cortex.
Troy:This is the area of our brain that's responsible for our self monitoring, for our judgment, and our emotional regulation. This physiological impairment prevents the brain from accurately assessing the negative consequences of substance abuse. They're literally not able to see how their substance use can be dangerous, is destructive to their family or their job or their ability to just you know, in a society in calm and non confrontational way. So we want to help people to get to a place where they can see that the symptoms are creating difficulties for them and that will motivate them to seek further treatment. You might be asking yourself right now, that's a lot of information, how do I do this?
Troy:Where do I even start with this? There's a book that was written by a man named Javier Amador. He wrote a book about his experiences with his brother that was dealing with psychotic symptoms. The book's called, I'm Not Sick and I Don't Need Help. In that book, Javier chronicles his experiences growing up with his brother and then his experiences with his brother as he's starting to experience these symptoms of psychosis.
Troy:Through this book, he developed what's called the LEAP model, L E A P. The LEAP model is just an approach for working with individuals that are experiencing psychosis, substance use disorders, and or Anosognosia in combination with that. While individuals with these severe mental health conditions may perceive life differently, the LEAP approach really emphasizes the importance of respecting and acknowledging their reality. We don't want to convince them that their reality is wrong. Even if they're open to that, that, yeah, I understand these are different things and maybe not everybody sees them and these are causing problems for me.
Troy:If we're trying to convince them that what their experiences is not real, there will come a time where they will push back from us because they're continuing to experience these things and they understand that we don't believe them. You don't need somebody to admit that they are sick to help them to connect with help and improve their symptoms. The LEAP model stands for listen, empathize, agree, and partner. This is a way that we can help to create that trusting relationship and develop strong communication with an individual that's experiencing these symptoms without pushing them away. When we listen, we want to listen with only one goal, and our goal is understanding the other person's point of view.
Troy:Then we want to reflect that understanding back to them. What you're telling me is you hear voices that tell you that you're Jesus, and because you're Jesus, you want help the world. Is that what you're telling me? Now that's not, you can't be Jesus, that's just crazy, you're not gonna help everybody in the world. I'm not saying any of that.
Troy:I'm just reflecting back to them. This is what you've told me. We can then a lot of times follow-up those statements with, know, is this correct? Is this what you meant to tell me? You know, am I understanding you?
Troy:Effective listening involves us sitting back, listening to frustrations, listening to fears and hopes and dreams of the other person, and just repeating your understanding of what's been said. You can use effective listening to stop offering your opinion or advice, because our opinion, our advice is just not going to mesh with where a person's coming from in the early stages of this. This may be something we can engage in later in the process, but right now we just want to listen in order to understand. As we empathize with another, we do that in order to identify with their feelings, their thoughts, and their attitudes, and to convey our empathy to the person that we care for, we can acknowledge that their delusional beliefs might be frightening, and their desire to prove that they're not sick or that they wish to avoid treatment. We're just reflecting that back.
Troy:We don't want to challenge them that, Well, don't think I'm sick and I don't want to go to treatment. We can explore the reasons, Well, why don't you think you're sick? Or, Why wouldn't you want to go to treatment? We can do this through a process of motivational interviewing, where we help people to kind of see, hey, there's you don't want to go to treatment, but you don't really have a place to stay. You keep staying with friends and they boot you out for various reasons.
Troy:Do you think that it might have something to do? We can do that as we are trying to help the person in treatment so that they can gain a better understanding of what their condition is and how to improve that. The A in LEAP is agree. When you're facing somebody who's rigidly holding onto irrational beliefs, there's nothing to be gained by disagreeing with them. We want to reach an agreement, and in order to do this we will start by just limiting our discussion to problems or symptoms perceived by the person that you work with.
Troy:Not our opinion, not our advice, not, you know, Hey, I saw somebody else that dealt with this and here's what they did. We want to review the advantages and the disadvantages of treatment with them and reflect back to them the perceived benefits and if need be to agree to disagree on some things. That, Hey, I just don't see it that same way, but I respect your view, your ability to see that. Then finally the P is in partnering. When we share the same goals, we can work together instead of being at odds, even when our perception of this situation is very different.
Troy:You can partner by moving towards goals that you both agree can be worked on together. We can also partner by agreeing on goals that challenge the person you care for to step outside of their comfort zone, but they're still within their ability to achieve. We want to use these methods of interacting with our loved ones to shift the focus from arguments and education and disapproval towards an emotional connection, validating feelings, expressing care and concern without imposing your own agenda. This approach allows us to facilitate dialogue, which is so important. Having a person understand that they have a place to be heard, and that they're going to be believed, and this helps to promote problem solving and collaboration.
Troy:If somebody that's dealing with these severe symptoms knows that, Hey, this is a friendly individual that doesn't challenge me, doesn't tell me I'm sick, doesn't tell me there's something wrong with me, they're going to be more apt to come to us in those times when they need extra assistance. That'll help us to build strong relationships that are very much needed on that path to recovery. I'm really hoping that folks were able to get something out of this brief description. This is certainly a lot more to this approach, and there's a lot more to understanding psychosis, and anosognosia, and substance use disorders, and how they all go together. I mentioned the book, if you're interested in reading more about Javier Amador's experience.
Troy:The book is I'm Not Sick and I Don't Need Help. You can find that on Amazon and really anywhere where you can get books. Then there's a companion to that which is learning the LEAP model. If you're interested more in the LEAP model, the LEAP Institute's website is leapinstitute.org. So leapinstitute.org.
Troy:Hopefully through this experience you're able to define and identify the symptoms of psychosis, explain Anosognosia, and outline these elements of the LEAP model. We encourage you to reach out, either to JTR or our outpatient behavioral health at River People Health Center. If you've got more interest in this, or if have you a loved one that you're concerned about, come on in and get some consultation about how to engage in this particular approach. I hope you found this enlightening and helpful, and I hope you're able to go on and have a fabulous weekend. Be well, folks.
Troy:Thank you. Thank you for joining us on Pathways to Spirit. Remember, within our traditions and our spirit lies connection, support, love, and hope. Let us walk forward together, honoring our paths and supporting one another on the journey toward physical, emotional, and spiritual health and wholeness. Until next time, may the spirits of the ancestors guide you, and may you find peace, healing, and renewal in every step along your journey.