|
Rachel Loewy, PhD. - Guest
Rachel Loewy is a clinical psychologist currently working as a Professor of Psychiatry at the University of California, San Francisco. Along with teaching, Rachel has developed clinical programs to diagnose and treat early psychosis, and has led many research studies, primarily focused on early identification and intervention in schizophrenia. Currently, she is a co-investigator on a research project dedicated to building a California early psychosis network that would input thousands of patients' data into one network hoping to create a better system that allows for improved intervention effort. Alongside her research, Rachel has many publications regarding her work that have all been compiled at https://profiles.ucsf.edu/rachel.loewy. These publications focus on various studies regarding schizophrenia and psychosis, such as evidence-based practices for early intervention in psychosis particularly in community settings. |
|
W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Dr. Keith Sutton: (00:22)
Welcome to Therapy on the Cutting Edge, a podcast for therapist who want to be up to date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area and the Director of the Institute for the Advancement of Psychotherapy. Today, I'll be speaking with Rachel Loewy, Ph.D, a psychologist currently working as a Professor of Psychiatry at the University of California, San Francisco. Along with teaching, Rachel has developed clinical programs to diagnose and treat early psychosis and has led many research studies, primarily focused on early identification and intervention in schizophrenia. Currently, she is co-investigator on her research product dedicated to building a California early psychosis network that would input thousands of patients data into one network, hoping to create a better system that allows for improved intervention effort alongside her research. Rachel has many publications regarding her work and these publications focus on various studies regarding schizophrenia and psychosis, such as evidence-based for early intervention and psychosis, particularly in community settings. Let's listen to the interview. Well, hi, Rachel. Welcome. Thank you for coming today.
Dr. Rachel Loewy: (01:31)
Thank you.
Dr. Keith Sutton: (01:33)
So, I reached out to you because of your work in the field of working with schizophrenia and psychosis and particularly the prodromal work that is being done, UCSF's research and so on in the bay area here. I particularly worked at a program, my first practicum actually, with folks that were in a day treatment program that had psychosis schizophrenia. And it's not a major area of my practice, but I'm really interested in kind of, you know, what's been going on in the field lately. And I think that particularly that experience has been really helpful to me as sometimes I've got clients coming in and I'm seeing little signs of things, or I've got a teenager who's maybe, you know, having auditory hallucinations and trying to suss out kind of what's going on there. Before we even get to that part I'd also love to hear, you know, folks kind of, how they got to doing what they're doing and kind of their evolution of their work or their thinking or so on. So yeah, welcome.
Dr. Rachel Loewy: (02:34)
Thank you. Thank you. Yeah, so actually, so I've been doing both research and clinical work and program development in the field of early psycho. We'll call it my whole career. I'm a clinical psychologist by training and I am now a professor in the department of psychiatry at UCSF. And I actually got started in a similar way to what you described. I was an undergrad looking for opportunities in research and I fortuitous there was a flyer about personality, a personality study. I had no idea. I thought that was interesting. It turned out to be schizotypal personality disorder in adolescent. As a very early definition of what we now call either the progrom or the clinical high risk syndrome. And I'll describe the differences between those. So I was both seeing these teenagers with a very low level quasi psychotic symptoms and also working on a project with people, with schizophrenia in boarding care.
Dr. Rachel Loewy: (03:48)
And the difference to me of trying to understand how does this kid who really just has a little bit of something going on, but in otherwise it seems like they have the world in front of them. And then working with patients who were really impaired, who weren't able to live independently. I just thought, well, wait, how do we get from A to B isn't there something we can do? There has to be. And so I really got hooked on the idea of prevention and early intervention, and it just so happen that in that period of time is when this area of the field was just starting. And so my career kind of grew along with the field. So the first definition of this clinical high risk syndrome was defined in a series of papers in 1996. It was really, you know, for a century, people have been thinking about some sort of way to identify people who have a psychotic episode, but it was the first time researchers were really able to focus on it in a way that they could define it. And the distinction between the prodrome and this clinical high risk syndrome is that technically you can only define a prodrome after you know someone has definitely developed the psychotic disorder. It can only be done retrospectively, right? So, this is prospective, we're trying to identify low level symptoms that might develop into a psychotic episode. And obviously we hope they don't, that we are able to intervene. So it's considered a clinical high risk for psychosis syndrome.
Dr. Rachel Loewy: (05:40)
So there is actually a definition of it embedded in your DSM. If you look really closely under the psychotic disorder section, it made it into DSM five as an example of an other specified psychotic disorder.
Dr. Keith Sutton: (06:02)
Mm.
Dr. Rachel Loewy: (06:03)
So if you look in there, it describes what is basically the definition we use in the field and in research. So it's not its own separate diagnosis quite yet, but it's an example, that's sort of how they suck it in.
Dr. Keith Sutton: (06:18)
Yeah. I'm not familiar with that. Can you tell me about what the symptoms are of that clinical high risk syndrome?
Dr. Rachel Loewy: (06:26)
Yeah. Most people aren't and no one is really aware unless you happen to do this work that is buried in there. So there are a few different possible syndrome, but the primary one is based on what we call sub-threshold psychotic symptoms. The distinction there for us is 100% conviction that the experience is real. I'll give you some examples. So it's the difference between someone saying there's a voice talking to me, it scares me, I don't know what it is, I wonder if it's real. So there's still some reality testing around it versus there's been several talking to me. I have to do what he says. Yeah. You can't convince me otherwise. So it's a subtle threshold, you know, you have to place it somewhere. That's become the definition.
Dr. Keith Sutton: (07:26)
And I remember the, I think the terms were ego dystonic or ego syntonic, whether they kind of knew that it was separate from themselves, or it felt like the delusion or the hallucinations or something was real.
Dr. Rachel Loewy: (07:43)
Yeah. It's similar. It's slightly different than that distinction. Cause it can also be sometimes these delusions or hallucinations are positive experiences for people. They're not all negative. I might believe that I have superhuman powers, I might be really excited about that. So, you know, it's slightly different where it's just this level of conviction that it's real, no flexibility. So the clinical high risk syndrome includes sub-threshold hallucinations or delusions or possibly disorganized communication. But to be honest, that is a symptom that tends to develop much later. And really, if you're noticing seriously disorganized communication, I'm willing to bet the person is actually already having a fully psychotic episode. Sometimes it's just that the person can't share their internal experience and that may be the only thing you can really identify
Dr. Keith Sutton: (08:54)
Yeah.
Dr. Rachel Loewy: (08:55)
Or doesn't share.
Dr. Keith Sutton: (08:57)
Yeah.
Dr. Rachel Loewy: (08:58)
So the idea would be, there are these low level symptoms, and I'll give you some more examples, that are happening at least weekly over the course of a month for a certain amount of time, it gets a little technical. And the idea is there has to be distress or impairment associated with it, just like everything else, right, when it comes to psychiatric disorders. So this is what I describe as the difference between an experience and symptom. So actually psychotic like experiences at a low level, infrequently, are extremely common. They're more common in adolescence. Part of it has to do with the later stage of brain development in adolescence. Right? Everyone has either heard their name called, you were sure that was your name.
Dr. Keith Sutton: (09:54)
Sure.
Dr. Rachel Loewy: (09:57)
Right. All of us can hallucinate if we have not enough sleep. Right. If we are deprived of sensory input, you know, there's certain things that happen. And I like to remind people of that because there is a way we can other psychosis. And I think that's part of what you were talking about. A lot of people in private practice rarely come across.
Dr. Keith Sutton: (10:27)
Yes.
Dr. Rachel Loewy: (10:28)
Psychotic disorder, really they're focused on treating something else so we can feel like, oh wait, this is something else I'm not equipped to handle this. This is something scary. And I hear it from kids. I'll call them. Cause it's mostly teenagers a lot. They say, you know, I was talking to my therapist and I mentioned the voices and I saw the look on her face and I never mentioned it again. So I think we have to be careful as providers, you know, care about our patients. It's understandable that that might feel like, oh no, this is a little more serious than I thought. And you're worried, but it's also then buying into the idea that having a psychotic disorder means this person is never gonna function well. That this person is going to have this terrible outcome and that's not true. Actually, not true anymore.
Dr. Keith Sutton: (11:21)
Are people worried that they could be dangerous?
Dr. Rachel Loewy: (11:22)
Yes, exactly. Right. Unpredictable. This now what's the risk to me or to this person right now. It's actually true that the risk of violence is much, much higher to be experienced by the person with psychosis then to be acted out by that person. But you know, what gets played up in the press is the times when it's someone who is violent and has psychosis.
Dr. Keith Sutton: (11:58)
And I think too, a therapist that's not maybe familiar, has never worked with anybody with this experience, yeah, they might, like you're saying they might kind of freak out and be like, oh, what's my risk here? What's gonna happen? Or this can't be helped or so on. And you get scared, like you're saying, and possibly give that message to the client. Like, Ooh, you can't really talk about that or don't go there.
Dr. Rachel Loewy: (12:19):
Right. Inadvertently, you know, I'm saying this and it's really a problem with training. The problem with training is that in most training programs, of all kinds of backgrounds for clinicians, the only time people work with someone with psychosis is on an inpatient unit, right? Or in a community mental health setting where they have a lot of other problems besides psychosis. So that's our impression. One of the greatest things for me is when trainees work in our early psychosis and they get to see people recover and it's fantastic and it's absolutely possible. So I have seen plenty of people with a first episode of psychosis, not just this early high risk prodrome piece, go back to school, go back to work. I have people that I see who are fully functioning, have high level jobs, and sometimes have psychotic episodes.
Dr. Keith Sutton: (13:29)
I don't know how true this is, but somebody had told me at one point a third of people were remitting on their own. A third of people, the medication was effective and they were able to return to functioning. And then a third of folks, the medication wasn't really being helpful and it was more of a chronic struggle.
Dr. Rachel Loewy: (13:51)
Yeah, that's exactly right. And that's been traditionally what's happened. The difference in now is that there is an intervention model called coordinated specialty care. That is sort of like wraparound services taking every evidence based approach to bring it together specifically for first episode psychosis patients. But it's also being used with people in this clinical high risk phase. There's one thing that's important to be clear about, antipsychotic medication is not recommended during the prodromal stage. There have been several trials, It does nothing.
Dr. Keith Sutton: (14:33)
Oh, interesting.
Dr. Rachel Loewy: (14:33)
You know, that give people a lot of side effects. It's unfortunate. I think a lot of us were very hope that if you could give a very low dose antipsychotic that might be preventive, it does not look like it. What is helpful in preventing the transition to a full psychotic episode is CBT for psychosis.
Dr. Keith Sutton: (14:52)
Oh, interesting.
Dr. Rachel Loewy: (14:52)
And there have been a number of trials around the world showing that. So, the model, I can get into some details on that, but the model overall includes appropriate medication management. Obviously the high risk kids, depression, anxiety, whatever else goes along with it, none of them have just some low level psychotic symptoms. Right? There's always a lot of other co-morbidities, both because a lot of emerging disorders in adolescence, the severe version of them can have some psychotic like symptoms along with it, and maybe that's always never gonna be
Dr. Keith Sutton: (15:33)
Like depression with psychosis.
Dr. Rachel Loewy: (15:36)
Right. Or they could be heading in the direction of a fully psychotic episode. And I wanna also mention the reason that we talk about it as a high risk syndrome is that only up to a quarter of people will develop a psychotic disorder within two and a half years.
Dr. Keith Sutton: (15:57)
So interesting.
Dr. Rachel Loewy: (16:00)
A quarter is obviously much higher than the general population.
Dr. Keith Sutton: (16:04)
Sure.
Dr. Rachel Loewy: (16:05)
But pre quarters don't and that's really important to remember. We don't know yet. We know there are some details, you know, that we can put to try to predict a little bit better, but honestly we don't know. One caveat is that it would be unethical to not give people treatment at all. So we don't know how treatment is impacting those outcomes.
Dr. Keith Sutton: (16:32)
Yeah.
Dr. Rachel Loewy: (16:33)
We're not gonna say you can't get therapy.
Dr. Keith Sutton: (16:35)
I'm wondering too, I mean, I've had a number of teenagers over the years that had some auditory hallucinations, although weren't really that bothered by them. And it was kind of hard to sort out a little bit and oftentimes, the psychiatrist, we're kind of not like let's let it wait or so on. I was just wondering about how common or uncommon something like that is?
Dr. Rachel Loewy: (17:04)
Yeah. I would say it's much more common than people think.
Dr. Keith Sutton: (17:08)
Yeah.
Dr. Rachel Loewy: (17:09)
Right. I mean, maybe you have seen more of it right in your practice. But, like I said, there is actually very common, you know, 20% of adults have had a full psychotic experience again, I'll say experience.
Dr. Rachel Loewy: (17:24)
So the lower level stuff can be even more common. We start to be concerned when it becomes more frequent. Sort of like anything else, the frequency of it, the impact of it. But like you said, if it doesn't bother them, I'm much less worried. If it's upsetting to them, if they're very focussed on it, if it starts to get in the way of school, relationship, anything else, right. Then it's a little more concerning if they start to be unsure whether it is or isn't their own mind.
Dr. Keith Sutton: (18:01)
Yeah.
Dr. Rachel Loewy: (18:05)
If they're clear, this is my mind playing tricks on me, that's all it is, okay. But if they start having specific ideas of something else it might be, so it's a delusional explanation that starts showing up. Well, I've wondered if it's because you know, the FBI's really interested in me. That's obviously gonna say, okay, let's explore this a little more.
Dr. Keith Sutton: (18:31)
Definitely. Now with the CBT, I haven't learned the model, but I, from a little bit of my understanding, I think from researching a little bit, oftentimes if there is that kind of knowledge that this is separate from me, that oftentimes then we're almost treating it like an intrusive thought or so on. And that kind of shifting the relationship, or I also do a lot of O C D work. So that kind of idea of that rather than like, oh no, I had this thought or I heard this voice, or I had this intrusive piece rather than getting scared and, oh what's wrong with me or so on , kind of knowing that's what that is over there. And that I don't necessarily have to have an anxiety reaction to it and can kind of manage it in the way I think about those symptoms. Can you tell me a little bit about how the CBT is maybe a little in addition to the typical CBT?
Dr. Rachel Loewy: (19:27)
Yeah. I think that's a great example of how it can work, right. None of the things on strategies I'm gonna talk about are gonna be surprising if you know CBT for depression, anxiety, something else. Right. It does build off of those same ideas. So we might use in exactly the same way. You might ask them to rate their conviction on a scale, zero to how sure are you that this is external to you? What are the reasons for, and against it, what's the evidence that you're using. And then examining the evidence the same way you would think about a depressive thought.
Dr. Rachel Loewy: (20:12)
There's a lot of behavioral experimentation too. That's not just cognitive. So an example might be a kid says, you know, whenever I go out in the neighborhood, people are staring at me. I wonder if they can tell what I'm thinking. Okay, Yeah. You talk to them a bit, you find out, well, every time they go out, they pull their hoodie really low over their head. They're looking at other people, maybe they're doing some things that could be encouraging those reactions and they're unaware of it. So you might say, all right, next time, can you try pulling your hoodie back a little bit, can you try to see then what the experience is like for you? So you can also do behavioral experiments.
Dr. Keith Sutton: (20:57)
Oh, good, good.
Dr. Rachel Loewy: (20:59)
A little, you know, some other clinical pearls, if it's helpful to folks, one I really like is for people who often experience that they're not in control of these thoughts. So you think of it as an intrusive thought. So the voices, they're talking to me and no, I don't have any control. They just come at me so you can work with them in session to see if they can try to increase the thought. Rather than trying to stop them, try to increase them in loudness, intensity, whatever it is. And if people can, that's some evidence that actually they can influence them, which then you can flip.
Dr. Keith Sutton: (21:45)
Okay. Great. And especially as we're talking a bit about teenagers here, but I'm sure also with adults, how about the role of the family?
Dr. Rachel Loewy: (22:00)
I've been talking about the individual treatment, but the coordinate specialty care model includes medication management, individual therapy, two other really important components are supported education and employment, so that you're really focused on getting people back into school and work either functioning better in school or work or getting back into school or work as soon as possible.
Dr. Keith Sutton: (22:25)
Yeah.
Dr. Rachel Loewy: (22:26)
That's one piece just before I get to the family. This hits at late adolescents, early adulthood. So when kids fall off the track, as I can kind of say, it's so much harder to get back after several years than it is, if you can help keep them engaged right away. So that's a big focus.
Dr. Keith Sutton: (22:52)
Okay.
Dr. Rachel Loewy: (22:52)
And then the family piece is incredibly important. So number one is psycho-education. If you think parents aren't sure what's going on when their teenager is depressed, try when they're having psychotic symptoms.
Dr. Keith Sutton: (23:09)
All right.
Dr. Rachel Loewy: (23:11)
Understanding negative symptoms, that this is not willful behavior, that the kid is not, you know, doing their homework because they're having cognitive problems or they're withdrawing socially, you know, understanding what's causing all of that. One example that I give is let's imagine your neighbor has a 16 year old son who has cancer and what would you do?
Dr. Keith Sutton: (23:47)
Oh, yeah. I mean, I would ask 'em if they need any help, any support, maybe make 'em dinner, something they could heat up or these kind of things. And just try to kind of give them extra help if they need to lighten their load or emotionally support them.
Dr. Rachel Loewy: (24:07)
Exactly. Right. Now, imagine that same family has a 16 year old son in the hospital with schizophrenia.
Dr. Rachel Loewy: (24:17)
What happens, right?
Dr. Keith Sutton: (24:18)
Yeah. I would wanna do the same things, but yeah. I imagine a lot of people get scared or like, oh, they don't wanna talk about it. Or they kind of keep away or they think, oh, this kid's crazy or something and dangerous or something like that. They kind of lose their social support.
Dr. Rachel Loewy: (24:34)
Exactly. They lose it just at the moment they really need it.
Dr. Keith Sutton: (24:38)
Yeah.
Dr. Rachel Loewy: (24:39)
So part of it is supporting the families in a way that can help them. They need supports going through it as well as the education about what's going on, why it's happening. People have all sorts of ideas about that. Sometimes for families, because there is a strong genetic component, there was someone that they knew, an aunt and uncle, a parent, someone who had inevitably a very bad course. So maybe they saw someone or heard of them being institutionalized and they're terrified that was gonna happen to their kids. So there's also a lot of education around what can be different now with early intervention.
Dr. Keith Sutton: (25:23)
Good. Yeah. Cause that makes sense. Cause if somebody was in that two thirds that got better, they might not be aware of that uncle or great aunt or something like that but they are aware of maybe the one that committed suicide or something like that, or was hospitalized. So the reference points are the worst case scenarios.
Dr. Rachel Loewy: (25:46)
Exactly, exactly. And then for a lot of young adults, the challenges are that adult systems of care are not very good at supporting transition age youth in the context of their family. So parents often feel completely excluded, you know, they're 18.
Dr. Keith Sutton: (26:07)
Yeah.
Dr. Rachel Loewy: (26:08):
They may not be able to get access to information, the person may, as part of their delusion, believe something about the family so that they say no when they're actively psychotic, they don't want that information to be shared. And so we work very hard to try to develop those connections and support and teach parents how to interact with the system, which is unfortunate that we have to do that. But you know, they can share any information they want, even if someone can't share it back. Those kinds of things.
Dr. Keith Sutton: (26:43)
Well, I know that when I was in my practicum experience that a lot of the folks that were in a boarding care were getting their meds regularly and were actually doing fairly well and kind of stabilizing and moving out. Whereas a lot of the other folks that were either living on their own or sometimes, living with family members, were struggling and the medication wasn't going kind of according to plan and were relapsing. And so one of the things I was thinking of was like, it would be great to bring the families in to help them understand. Although the program was said we don't do that, we only do the individual work, we don't work with the families. So it's such a huge resource that was getting kinda left out.
Dr. Rachel Loewy: (27:27)
Unfortunately, that's still the case. I think you're absolutely right. This is the context they're living in. And if the cognitive impairments that go along with psychosis include problems with attention problems, with memory, even if someone wants to be taking that, it's very hard for them to handle that on their own. So they often need family support. If that family member doesn't think they need medication, or there's conflict around it, and they're not sure to handle it, then It can be a big impediment to recovery.
Dr. Keith Sutton: (28:04)
Yeah. I'm wondering, can you speak to medication? And I know that at least since I've worked with more of these clients that there's been some advances in the field regarding medication.
Dr. Rachel Loewy: (28:19)
There have. I'll describe this as two groups, there's those who have had their first episode or are in their first episode versus the clinical high risk. That's an important distinction that doesn't always get made. In terms of the medication, with a first episode, a big piece of what we do is start low and go slow. So unfortunately when people are in the hospital they're often on very high doses of an antipsychotic meant to mostly sedate them and try to get them to be able to be released as quickly as possible. That's our system and how it works. What happens is sometimes people are then maintained on those very high doses and outpatient psychiatrists may not want to reduce them. And there are terrible side effects. So people are very sedated, they can gain an incredible amount of weight, develop all sorts of physical health risk factors. And really it's about recognizing that they can be on a much lower dose if you have psychosocial support. And so that's where the rest of the team comes in. If you have therapy, if you have family support, if you have someone helping them get back to school and work, that's what allows it to happen.
Dr. Rachel Loewy: (29:41):
Another piece is the use of long acting, injectable, anti narcotics. Sometimes people think those should be reserved for someone later down the line, if oral medications aren't working, but actually they can be incredibly helpful as they can for any one who has a hard time remembering. We all forget to take our medications.
Dr. Keith Sutton: (30:06)
Every day.
Dr. Rachel Loewy: (30:07):
Right. And so, you know, I think this is where a lot of pharmacology is going in general, right. There are, you know, people want a birth control option, right? It doesn't mean I have to remember to take a pill every day. Well, the same thing is true for an anti psychotic so actually some people can do really well, but all they need is a monthly injection that takes so much off the board.
Dr. Keith Sutton: (30:29)
Yeah. And is that monthly injection kind of as effective as some of the medications that are taken on a daily basis?
Dr. Rachel Loewy: (30:36)
Oh, definitely. I mean it's actually the same. It's just a different mode of administration of the same one. So you might be on Risperidone orally and then you can switch to the injectable version, which is usually how people will do it. They'll put them on the oral version of the exact medication to make sure that that's working for them and then go to the injectable form.
Dr. Keith Sutton: (30:58)
Titrate to find the right dosage and then go to that long acting you. And actually I'm interested too, has there been any, I'm sure there's been studies on, you know, decreasing the psychotic episodes or two also, I know a large part of our homeless population, especially in San Francisco, we have a lot of folks that are struggling with homelessness. Oftentimes a lot of folks that struggle with psychosis or schizophrenia end up homeless. I was just interested too, of like, does that affect folks being able to maintain housing or so on being on a monthly injectable? Or daily med while living on the streets or whatever it might be.
Dr. Rachel Loewy: (31:41)
Yeah. So there's two things there that I think are important. One is how do we prevent homelessness and becoming unhoused, right? And then how do we help people once they are? So a lot of the early intervention work is around exactly this. How do you have a kid who's maybe couch surfing, not quite on the street yet, but at a very tenuous point and help them so that you can maybe prevent some of those outcomes. So there's that piece. And then long acting injectable antipsychotics have been very helpful for people in reducing relapse. And then of course, if you're not relapsing, you're able to maintain a job. If you keep having to go to the hospital, it's really hard to keep your job. Things like that. So yeah. Their outcomes are much better, so it's a great option that actually does not get offered as much as it should. And I'm actually working on that. We're looking at, even in the early psychosis programs, trying to support them to, offer that to people. More, and you probably won't be surprised that there are some disparities and equity issues about who gets offered one.
Dr. Keith Sutton: (32:55)
Well, that's what I was wondering too. I mean, there's gotta be a whole socioeconomic status kind of aspect, cultural, racial, you know, kind of pieces that also play in. And I think too, are these expensive? Are these hard to get,?I mean, again, often somebody who might be experiencing psychosis, hospitalized, hard to keep a job, hard to keep their housing, then they don't have money for maybe some of the medical care that they need or so on. So it almost becomes whether you're starting off from a position of difficulty or privilege that I imagine kind of, it might snowball down that way too.
Dr. Rachel Loewy: (33:40)
Yeah. I mean, it's hard not to get into a whole debate about for-profit healthcare, but-
Dr. Keith Sutton: (33:49)
Well, that's the other thing too. It's not really so profitable to make and improve these medications too. I imagine cuz this is not a population that's spending a lot on medication or a system that's willing probably to pay for.
Dr. Rachel Loewy: (34:03)
Well, the system is. So if you have Medical actually, usually you have access to a number of these on formulary and there are options for undocumented folks who don't have, the clinics kind of have to work out those relationships. So a lot of the county systems try to work with this, but yes, it probably is much easier for someone who's on a commercial insurance and going into say a medical center like UCSF or something, right? They're gonna have much more access.
Dr. Keith Sutton: (34:38)
Yeah. So we've got the, you were kind of talking about this model, the coordinated specialty care model, so there's one aspect, that's the medication, there's the other aspect that's kind of helping them keep on track with school, with work, and then there's the other piece around the family. And is there any additional pieces to that? And of course the therapy and so on.
Dr. Rachel Loewy: (35:08)
There's case management, right. In whatever way that's needed. And then the big piece is that this is all an integrated team. This is not separated out. This is a single team. They meet weekly and talk about every single case. Caseloads are kept lower so that there is the capacity to work with someone when people come in and maybe at first they're in a lot of crisis and they need more time and support. You know, this is not a one hour of outpatient treatment a week kind of program. It's not a day treatment thing either. It's more like an intensive somewhere between, you know, regular outpatient and intensive outpatient.
Dr. Keith Sutton: (35:53)
Got it.
Dr. Rachel Loewy: (35:54)
It's also collaborative in nature. So it's really important that the person chooses, which of these elements they want to engage in, what are their goals? And that's the focus, right? This is this distinction. So collaborative decision making is about what do they want, what they want, what everyone wants. They want to do well in school have a job. They like having a girlfriend, you know, whatever, right? And sometimes our goals as providers may feel like we want people to not hear voices anymore, right? We think about symptoms. And so it's really shifting it so that it's thinking about what are their goals. That's what's gonna help people engage and move towards what they want for themselves.
Dr. Keith Sutton: (36:40)
Yeah. Increasing-
Dr. Rachel Loewy: (36:41)
And it's competitive employment. Sorry, go ahead.
Dr. Keith Sutton: (36:44)
Yeah. I was gonna say increasing the functioning. I interviewed Scott Miller, who developed an outcome measure, and it looks at functioning, how is the person doing. And he was saying we don't look at symptoms because somebody can still be having hallucinations or so on, but be doing well and working and happy and so on. So it's not, we don't necessarily have to go straight at the symptoms in that situation. I was thinking about too, you were talking earlier about the level that the person is kind of aware around the conviction level. And I was wondering about, I imagine some of the more difficult situations are where there's a higher level of conviction that this is true, the FBI's after me or so on.
Dr. Keith Sutton: (37:29)
I was also thinking too, that I know a lot of substance abuse oftentimes happens as a person's trying to deal with that. And I know that I think there's some risk factors for folks that have some predisposition, sometimes marijuana can sometimes be a part of some of the first breaks, and just wondering if you could speak to some of that. Cause I think some people thinking like, gosh, can we even work with this person if they're, you know, or like, you're not supposed to necessarily challenge the illusion or so on because that's kind of gonna be somewhere you're just gonna get stuck, trying to explain the FBI is not following you or so on.
Dr. Rachel Loewy: (38:10)
Yeah. So the substance use question in cannabis in particular is really important to address. And then we can also talk about how do you work with the delusion rather than against it, cause that also is important. So the first piece is that yes, the substance use is gonna be very common and it can be tricky to pull apart what is happening when the person is high in using versus when they're not. So we do a very detailed evaluation to get a sense of that. Yeah. Obviously someone using meth can be absolutely psychotic for quite a long time after they stop using and it's really just because of the meth, It's not going to continue. But you don't know that in a 19 year old where it's just starting, you can't tell yet. So we do of course encourage harm reduction, less use. But we will absolutely work with people as long as they're able to come into the program and engage with us, we meet people where they are.
Dr. Keith Sutton: (39:19)
Sure, sure.
Dr. Rachel Loewy: (39:21)
The cannabis piece is important because a lot of people don't realize the risks involved. They think of that as it's legal now, relatively, I'm not too worried. Yeah. My kid smokes weed. Okay, fine. You know, that's not so bad, but for some people who have the genetic predisposition and we don't know who that is because it's not a simple gene, it's a variety of them. We don't even know which ones. There's no genetic tests. So nobody can really know who is at risk genetically. If they have that risk and they use cannabis heavily, especially for heavier use younger ages, it increases the time to developing psychosis.
Dr. Rachel Loewy: (40:19)
The jury is a little out on whether it is causing the psychosis and that they wouldn't have developed otherwise, because again, you can't do control trial that way. But we definitely know that for people who already have psychosis or have psychotic like symptoms, use makes it much worse. So there's a lot of this evidence you can sort of pull together to see it's not a good idea. Especially the thing that's very worrisome is the concentration of THC that is in a lot of cannabis that people are using now. And so something I'd like to remind people is the impact of substances like that on a developing brain are so different than an adult brain and our frontal lobe doesn't finish developing until about age 25. So we're not just talking 16 year olds. A 40 or 50 year old person who is smoking daily, It has a different risk of a 16 year old or even a 22 year old.
Dr. Rachel Loewy: (41:32)
That people need to think about. And it's very worrisome and actually I think a lot of us have been waiting to see how the epidemiological data look and whether we're actually seeing an increase in psychotic disorders.
Dr. Keith Sutton: (41:53)
Well, I know too, kids that are using before age 15 are five times more likely to develop addiction. So that timing of when use occurs has a lot of different effect, definitely.
Dr. Rachel Loewy: (42:09)
That exactly right. Yep. Same here.
Dr. Keith Sutton: (42:11)
And how about when folks have very strong attachment to delusions or conviction or so on? I'm also thinking of, I read the therapy with intimidating cases by Dick Fisch and the MRI folks down there and kind of using some paradoxal, somebody come in says, oh this session is being recorded by the FBI, and instead of challenging it, he says, oh, they can't do that, let's find it. And starts dumping out things from the desk and then looking all over. And the person's like, no, no, no. And then eventually they're like, oh, let's just talk about my mom or something like that. Kind of getting beyond the delusion and the back and forth around that or so on. But I think that's more a theoretical kind of example, but yeah.
Dr. Rachel Loewy: (43:02)
So I mean, in the traditional sense of arguing with the person, no. First of all, would you ever do that with any other patient?
Dr. Keith Sutton: (43:15)
Yeah, right?
Dr. Rachel Loewy: (43:16)
Right. So if you think about it, cause this is again where people think like, oh, psychosis is this other thing somehow. And it's like you would never do that with someone with any other kind of issue coming in. So of course that's not gonna help here. You can always align with the emotion, right? Wow, that be really scary. Because you can understand if you really thought people were out to kill you you'd be terrified.
Dr. Keith Sutton: (43:43)
Yeah.
Dr. Rachel Loewy: (43:44)
I wouldn't sleep either, that's really scary. So you can validate the emotion without having to agree with or disagree. So you can separate that
Dr. Keith Sutton: (44:01)
That kinda joining with the emotion.
Dr. Rachel Loewy: (44:03)
Exactly. So that's one strategy, to separate those out. And often it's the distress and the impairment around it that you need to work with first. So that helps that way. And then you can get to the point where as I gave the examples before you can sort of say, I'm not sure if it's happening because how could I know? I don't know, you're telling me, okay, It could be that's possible. I don't know. Would you be interested in us trying to figure it out together? And so sort of that curious dance around then starting to look at what's the evidence as I described before and what helps sway them one way or the other. So, like anything else you have to join first before you can start to explore in a collaborative way.
Dr. Keith Sutton: (45:03)
Yeah, definitely.
Dr. Rachel Loewy: (45:04)
But that's also something that's very hard for family members. Your kid comes and tells you something that sounds crazy. And a parent says, no, no, no, no, you don't have to worry about that, that's not true. Which actually doesn't help entirely, even though it's intended to be reassuring. So that's a lot of the family pieces, helping. How the heck do you know your kid believes this? How do you talk to them about it?
Dr. Keith Sutton: (45:36)
Well, I imagine too, oftentimes working with families and helping the parents to understand that if the kids feel like they understand, then oftentimes they're much more open to their influence or what they have to say. So oftentimes starting with that and I think that's, like you're saying, I'm recalling a client that I worked with who said I'm being followed or so on. And I was like, oh my gosh, are they here? And I looked out my blinds cuz I was like if I were in that situation, I'd be pretty terrified and kind of matching that experience. And then kind of saying like, wow, are you really scared? That kind of empathic conjecture to kind of be able to join and then kind of go from there cuz if the client doesn't feel like I get it and understand or I don't understand, then it's hard to move forward from there at all.
Dr. Rachel Loewy: (46:22)
Exactly. Exactly. And that's again, I mean, that's great that you did that and it is, like I said, it's really similar to how you work with anyone. So it's kind of, I encourage clinicians to kind of, keep their regular clinical skills hat on, it doesn't mean you throw it out. It's all the same principles and I think the idea of seeing it as either an intrusive thought or an extreme distortion helps a lot. People then feel more comfortable in how you might work with that.
Dr. Keith Sutton: (46:54)
Wanted to touch on expressed emotion in some of the research around that and families or also anything else that you wanna cover before we run out today. I'm interested in this cause one of my major groundings is in family systems work and particularly a lot of family systems work grew out of working where there was psychosis or schizophrenia and the person would be in the hospital, they would stabilize, be doing well and then they'd go home and things would kind of fall apart again. And so they even were bringing the families into the hospital and trying to understand, of course, unfortunately some of that went very negative with the schizophrenic mother and these kind of things and became apologizing and blaming. But I think that the family is of such a resource, as we're talking about earlier, and if they have some psycho-education, if they understand more and so on. But I know that there's the research around expressed emotion, which I don't really love that term because expressing emotions is not necessarily a bad thing, but it's kind of the three main components of high levels of criticalness hostility and emotional over involvement and the higher the levels of more relationship to relapse with schizophrenia or substance abuse of OCD or many different mental health conditions. Can you speak to any of that stuff?
Dr. Rachel Loewy: (48:16)
I'm actually really glad you brought that up because I think that the expressed emotion literature did a lot of damage in our field. There's two studies that I think are really helpful. One actually looked at in the minute dyadic interactions between a young person or a young adult with psychosis and the family member. And what they found was that it was an interaction. So it's not that the family just has this negative trait. It's that the development of the disorder over time has led to a lot of distress that then comes out in these ways. So what they would see is that the young person would express a symptom and then the parent would come back with a little bit of some component of expressed emotion, criticism, hostility, whatever, and then they would each escalate.
Dr. Keith Sutton: (49:21)
There's like a pattern of interactions that kind of became a habitual pattern that kind of fed off each other rather than something that's occurs within the parent or something.
Dr. Rachel Loewy: (49:31)
Exactly. And what they have also found is that in first episode samples there are much lower rates of high expressed emotion than in families where someone has been living at home and had the disorder for two decades also supporting this idea. So I think that just helps frame it. Part of the way we talk about it is yes, stress increases symptoms. Plain and simple, wherever that source of stress is. So stress in the family, high conflict criticism, hostility, negativity, yeah, increased symptoms. So addressing that interaction, right? Again, if parents understand why they're doing it and how they can help in other ways, that makes a big difference. So that's important. Like you said, the schizophrenic mother, which is this awful idea, you know what parent isn't gonna feel horribly guilty. And I hear parents come up with all kinds of things. You know, I didn't let him play on the soccer team, he wanted to be on that. Cause this, I mean, there's so much parental guilt that somehow this is their fault. That's actually an active area that we have to address is helping face that feeling. Yeah. And, and educate them that that's not true.
Dr. Keith Sutton: (51:00)
Well, and fueling that criticism or hostility or emotional over involvement is the fear and helplessness and particularly like, you're even saying, some shame. Like, did I do something wrong or so on and as trying to help and then feeling like nothing's helping, oftentimes people will get very frustrated and blaming or so on. And so it, you know, putting it into that context, it makes sense within the dynamic that might occur, especially if their child is struggling to recover or continuing to have difficulties or things like that. It might feel so outta control.
Dr. Rachel Loewy: (51:39)
Absolutely. And for a lot of family members, I've seen parents have to quit their jobs in order to devote time to taking care of a kid and helping support them. There's financial implications, like we said, they lose other supports. It's not that different from any serious medical condition that a kid has in the way it affects the family. But again, taking the pressure off the parents and their reaction, understanding the drivers of the stress on the system. That can lead to those interactions.
Dr. Keith Sutton: (52:16)
Right. And to wrap us up, any advice that you have for clinicians who maybe aren't as familiar with this, and they're seeing some things with their client, you know, there's maybe some voices, there's maybe some kind of things that are like, Hmm, this seems like a delusion and this is kind of beyond just a worry thought. What's the next step if they're not as familiar to kind of try and figure out what's going on here? I've got your program, so I oftentimes will send, if I've got a situation to kind of get some evaluation. But yeah, I would love to hear what might be helpful to clinicians.
Dr. Rachel Loewy: (52:48)
Yeah. That's exactly it. Consult, consult consult. Fortunately, due to several funding streams, nationally, there are more and more of these early psychosis programs. I co-founded several in the bay area with community partners. So they are open in counties. There are some at university settings, so pretty much they're expanding all over the country. I'll recommend if people are interested, there's a website, it's strong365.org
Dr. Rachel Loewy: (53:26)
And there's lots of great information there for people with psychosis, family members, providers, but also they keep a map with a tracker of all the programs across the country. So anywhere you are, you can look and I would say find your local one, you call. And people are often, even if they might not be appropriate for the program, happy to try to consult a bit because this is a complex differential diagnosis. It definitely requires an expert eye. Hopefully that expertise is growing. We're working now on a number of these programs around the state to strengthen them to start new ones if counties don't have them. With the idea, our goal is to have this kinda treatment be available for all Californians.
Dr. Keith Sutton: (54:21)
That be great. Wonderful. Well, thank you so much for your time. I really appreciate it. This is all so helpful and just valuable for me and hopefully valuable for other clinicians keeping up to date on what's going on in the field related to this subject. So thank you so much for coming in.
Dr. Rachel Loewy: (54:38)
Thank you for having me. I am always happy to share some of this with folks who are working out in the field who can't possibly keep up with with every new, small area. But this is one that is so important if people can help identify it early.
Dr. Keith Sutton: (54:54)
Yeah. Great. Well, thank you so much. Take care.
Dr. Rachel Loewy: (54:59):
Thank you.
Dr. Keith Sutton: (55:00)
Bye. Thank you for joining us. If you're wanting to use this podcast or continuing education credits, please go to our website at therapyonthecuttingedge.com. Our podcast is brought to you by the Institute of the Advancement of Psychotherapy, providing in-person and remote therapy in the San Francisco Bay Area. IAP provides training for licensed clinicians through our in-person and online programs, as well as our treatment for children, adolescents, families, couples, and individual adults. The for more information go to sfiap.com or call 415-617-5932. Also, we really appreciate feedback. And if you have something you're interested in something that's on the cutting edge of the field of therapy, and think clinicians should know about it, send us an email or call us. We're always looking for the advancements in the field of psychotherapy to help in creating lasting changes for our clients.
Welcome to Therapy on the Cutting Edge, a podcast for therapist who want to be up to date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area and the Director of the Institute for the Advancement of Psychotherapy. Today, I'll be speaking with Rachel Loewy, Ph.D, a psychologist currently working as a Professor of Psychiatry at the University of California, San Francisco. Along with teaching, Rachel has developed clinical programs to diagnose and treat early psychosis and has led many research studies, primarily focused on early identification and intervention in schizophrenia. Currently, she is co-investigator on her research product dedicated to building a California early psychosis network that would input thousands of patients data into one network, hoping to create a better system that allows for improved intervention effort alongside her research. Rachel has many publications regarding her work and these publications focus on various studies regarding schizophrenia and psychosis, such as evidence-based for early intervention and psychosis, particularly in community settings. Let's listen to the interview. Well, hi, Rachel. Welcome. Thank you for coming today.
Dr. Rachel Loewy: (01:31)
Thank you.
Dr. Keith Sutton: (01:33)
So, I reached out to you because of your work in the field of working with schizophrenia and psychosis and particularly the prodromal work that is being done, UCSF's research and so on in the bay area here. I particularly worked at a program, my first practicum actually, with folks that were in a day treatment program that had psychosis schizophrenia. And it's not a major area of my practice, but I'm really interested in kind of, you know, what's been going on in the field lately. And I think that particularly that experience has been really helpful to me as sometimes I've got clients coming in and I'm seeing little signs of things, or I've got a teenager who's maybe, you know, having auditory hallucinations and trying to suss out kind of what's going on there. Before we even get to that part I'd also love to hear, you know, folks kind of, how they got to doing what they're doing and kind of their evolution of their work or their thinking or so on. So yeah, welcome.
Dr. Rachel Loewy: (02:34)
Thank you. Thank you. Yeah, so actually, so I've been doing both research and clinical work and program development in the field of early psycho. We'll call it my whole career. I'm a clinical psychologist by training and I am now a professor in the department of psychiatry at UCSF. And I actually got started in a similar way to what you described. I was an undergrad looking for opportunities in research and I fortuitous there was a flyer about personality, a personality study. I had no idea. I thought that was interesting. It turned out to be schizotypal personality disorder in adolescent. As a very early definition of what we now call either the progrom or the clinical high risk syndrome. And I'll describe the differences between those. So I was both seeing these teenagers with a very low level quasi psychotic symptoms and also working on a project with people, with schizophrenia in boarding care.
Dr. Rachel Loewy: (03:48)
And the difference to me of trying to understand how does this kid who really just has a little bit of something going on, but in otherwise it seems like they have the world in front of them. And then working with patients who were really impaired, who weren't able to live independently. I just thought, well, wait, how do we get from A to B isn't there something we can do? There has to be. And so I really got hooked on the idea of prevention and early intervention, and it just so happen that in that period of time is when this area of the field was just starting. And so my career kind of grew along with the field. So the first definition of this clinical high risk syndrome was defined in a series of papers in 1996. It was really, you know, for a century, people have been thinking about some sort of way to identify people who have a psychotic episode, but it was the first time researchers were really able to focus on it in a way that they could define it. And the distinction between the prodrome and this clinical high risk syndrome is that technically you can only define a prodrome after you know someone has definitely developed the psychotic disorder. It can only be done retrospectively, right? So, this is prospective, we're trying to identify low level symptoms that might develop into a psychotic episode. And obviously we hope they don't, that we are able to intervene. So it's considered a clinical high risk for psychosis syndrome.
Dr. Rachel Loewy: (05:40)
So there is actually a definition of it embedded in your DSM. If you look really closely under the psychotic disorder section, it made it into DSM five as an example of an other specified psychotic disorder.
Dr. Keith Sutton: (06:02)
Mm.
Dr. Rachel Loewy: (06:03)
So if you look in there, it describes what is basically the definition we use in the field and in research. So it's not its own separate diagnosis quite yet, but it's an example, that's sort of how they suck it in.
Dr. Keith Sutton: (06:18)
Yeah. I'm not familiar with that. Can you tell me about what the symptoms are of that clinical high risk syndrome?
Dr. Rachel Loewy: (06:26)
Yeah. Most people aren't and no one is really aware unless you happen to do this work that is buried in there. So there are a few different possible syndrome, but the primary one is based on what we call sub-threshold psychotic symptoms. The distinction there for us is 100% conviction that the experience is real. I'll give you some examples. So it's the difference between someone saying there's a voice talking to me, it scares me, I don't know what it is, I wonder if it's real. So there's still some reality testing around it versus there's been several talking to me. I have to do what he says. Yeah. You can't convince me otherwise. So it's a subtle threshold, you know, you have to place it somewhere. That's become the definition.
Dr. Keith Sutton: (07:26)
And I remember the, I think the terms were ego dystonic or ego syntonic, whether they kind of knew that it was separate from themselves, or it felt like the delusion or the hallucinations or something was real.
Dr. Rachel Loewy: (07:43)
Yeah. It's similar. It's slightly different than that distinction. Cause it can also be sometimes these delusions or hallucinations are positive experiences for people. They're not all negative. I might believe that I have superhuman powers, I might be really excited about that. So, you know, it's slightly different where it's just this level of conviction that it's real, no flexibility. So the clinical high risk syndrome includes sub-threshold hallucinations or delusions or possibly disorganized communication. But to be honest, that is a symptom that tends to develop much later. And really, if you're noticing seriously disorganized communication, I'm willing to bet the person is actually already having a fully psychotic episode. Sometimes it's just that the person can't share their internal experience and that may be the only thing you can really identify
Dr. Keith Sutton: (08:54)
Yeah.
Dr. Rachel Loewy: (08:55)
Or doesn't share.
Dr. Keith Sutton: (08:57)
Yeah.
Dr. Rachel Loewy: (08:58)
So the idea would be, there are these low level symptoms, and I'll give you some more examples, that are happening at least weekly over the course of a month for a certain amount of time, it gets a little technical. And the idea is there has to be distress or impairment associated with it, just like everything else, right, when it comes to psychiatric disorders. So this is what I describe as the difference between an experience and symptom. So actually psychotic like experiences at a low level, infrequently, are extremely common. They're more common in adolescence. Part of it has to do with the later stage of brain development in adolescence. Right? Everyone has either heard their name called, you were sure that was your name.
Dr. Keith Sutton: (09:54)
Sure.
Dr. Rachel Loewy: (09:57)
Right. All of us can hallucinate if we have not enough sleep. Right. If we are deprived of sensory input, you know, there's certain things that happen. And I like to remind people of that because there is a way we can other psychosis. And I think that's part of what you were talking about. A lot of people in private practice rarely come across.
Dr. Keith Sutton: (10:27)
Yes.
Dr. Rachel Loewy: (10:28)
Psychotic disorder, really they're focused on treating something else so we can feel like, oh wait, this is something else I'm not equipped to handle this. This is something scary. And I hear it from kids. I'll call them. Cause it's mostly teenagers a lot. They say, you know, I was talking to my therapist and I mentioned the voices and I saw the look on her face and I never mentioned it again. So I think we have to be careful as providers, you know, care about our patients. It's understandable that that might feel like, oh no, this is a little more serious than I thought. And you're worried, but it's also then buying into the idea that having a psychotic disorder means this person is never gonna function well. That this person is going to have this terrible outcome and that's not true. Actually, not true anymore.
Dr. Keith Sutton: (11:21)
Are people worried that they could be dangerous?
Dr. Rachel Loewy: (11:22)
Yes, exactly. Right. Unpredictable. This now what's the risk to me or to this person right now. It's actually true that the risk of violence is much, much higher to be experienced by the person with psychosis then to be acted out by that person. But you know, what gets played up in the press is the times when it's someone who is violent and has psychosis.
Dr. Keith Sutton: (11:58)
And I think too, a therapist that's not maybe familiar, has never worked with anybody with this experience, yeah, they might, like you're saying they might kind of freak out and be like, oh, what's my risk here? What's gonna happen? Or this can't be helped or so on. And you get scared, like you're saying, and possibly give that message to the client. Like, Ooh, you can't really talk about that or don't go there.
Dr. Rachel Loewy: (12:19):
Right. Inadvertently, you know, I'm saying this and it's really a problem with training. The problem with training is that in most training programs, of all kinds of backgrounds for clinicians, the only time people work with someone with psychosis is on an inpatient unit, right? Or in a community mental health setting where they have a lot of other problems besides psychosis. So that's our impression. One of the greatest things for me is when trainees work in our early psychosis and they get to see people recover and it's fantastic and it's absolutely possible. So I have seen plenty of people with a first episode of psychosis, not just this early high risk prodrome piece, go back to school, go back to work. I have people that I see who are fully functioning, have high level jobs, and sometimes have psychotic episodes.
Dr. Keith Sutton: (13:29)
I don't know how true this is, but somebody had told me at one point a third of people were remitting on their own. A third of people, the medication was effective and they were able to return to functioning. And then a third of folks, the medication wasn't really being helpful and it was more of a chronic struggle.
Dr. Rachel Loewy: (13:51)
Yeah, that's exactly right. And that's been traditionally what's happened. The difference in now is that there is an intervention model called coordinated specialty care. That is sort of like wraparound services taking every evidence based approach to bring it together specifically for first episode psychosis patients. But it's also being used with people in this clinical high risk phase. There's one thing that's important to be clear about, antipsychotic medication is not recommended during the prodromal stage. There have been several trials, It does nothing.
Dr. Keith Sutton: (14:33)
Oh, interesting.
Dr. Rachel Loewy: (14:33)
You know, that give people a lot of side effects. It's unfortunate. I think a lot of us were very hope that if you could give a very low dose antipsychotic that might be preventive, it does not look like it. What is helpful in preventing the transition to a full psychotic episode is CBT for psychosis.
Dr. Keith Sutton: (14:52)
Oh, interesting.
Dr. Rachel Loewy: (14:52)
And there have been a number of trials around the world showing that. So, the model, I can get into some details on that, but the model overall includes appropriate medication management. Obviously the high risk kids, depression, anxiety, whatever else goes along with it, none of them have just some low level psychotic symptoms. Right? There's always a lot of other co-morbidities, both because a lot of emerging disorders in adolescence, the severe version of them can have some psychotic like symptoms along with it, and maybe that's always never gonna be
Dr. Keith Sutton: (15:33)
Like depression with psychosis.
Dr. Rachel Loewy: (15:36)
Right. Or they could be heading in the direction of a fully psychotic episode. And I wanna also mention the reason that we talk about it as a high risk syndrome is that only up to a quarter of people will develop a psychotic disorder within two and a half years.
Dr. Keith Sutton: (15:57)
So interesting.
Dr. Rachel Loewy: (16:00)
A quarter is obviously much higher than the general population.
Dr. Keith Sutton: (16:04)
Sure.
Dr. Rachel Loewy: (16:05)
But pre quarters don't and that's really important to remember. We don't know yet. We know there are some details, you know, that we can put to try to predict a little bit better, but honestly we don't know. One caveat is that it would be unethical to not give people treatment at all. So we don't know how treatment is impacting those outcomes.
Dr. Keith Sutton: (16:32)
Yeah.
Dr. Rachel Loewy: (16:33)
We're not gonna say you can't get therapy.
Dr. Keith Sutton: (16:35)
I'm wondering too, I mean, I've had a number of teenagers over the years that had some auditory hallucinations, although weren't really that bothered by them. And it was kind of hard to sort out a little bit and oftentimes, the psychiatrist, we're kind of not like let's let it wait or so on. I was just wondering about how common or uncommon something like that is?
Dr. Rachel Loewy: (17:04)
Yeah. I would say it's much more common than people think.
Dr. Keith Sutton: (17:08)
Yeah.
Dr. Rachel Loewy: (17:09)
Right. I mean, maybe you have seen more of it right in your practice. But, like I said, there is actually very common, you know, 20% of adults have had a full psychotic experience again, I'll say experience.
Dr. Rachel Loewy: (17:24)
So the lower level stuff can be even more common. We start to be concerned when it becomes more frequent. Sort of like anything else, the frequency of it, the impact of it. But like you said, if it doesn't bother them, I'm much less worried. If it's upsetting to them, if they're very focussed on it, if it starts to get in the way of school, relationship, anything else, right. Then it's a little more concerning if they start to be unsure whether it is or isn't their own mind.
Dr. Keith Sutton: (18:01)
Yeah.
Dr. Rachel Loewy: (18:05)
If they're clear, this is my mind playing tricks on me, that's all it is, okay. But if they start having specific ideas of something else it might be, so it's a delusional explanation that starts showing up. Well, I've wondered if it's because you know, the FBI's really interested in me. That's obviously gonna say, okay, let's explore this a little more.
Dr. Keith Sutton: (18:31)
Definitely. Now with the CBT, I haven't learned the model, but I, from a little bit of my understanding, I think from researching a little bit, oftentimes if there is that kind of knowledge that this is separate from me, that oftentimes then we're almost treating it like an intrusive thought or so on. And that kind of shifting the relationship, or I also do a lot of O C D work. So that kind of idea of that rather than like, oh no, I had this thought or I heard this voice, or I had this intrusive piece rather than getting scared and, oh what's wrong with me or so on , kind of knowing that's what that is over there. And that I don't necessarily have to have an anxiety reaction to it and can kind of manage it in the way I think about those symptoms. Can you tell me a little bit about how the CBT is maybe a little in addition to the typical CBT?
Dr. Rachel Loewy: (19:27)
Yeah. I think that's a great example of how it can work, right. None of the things on strategies I'm gonna talk about are gonna be surprising if you know CBT for depression, anxiety, something else. Right. It does build off of those same ideas. So we might use in exactly the same way. You might ask them to rate their conviction on a scale, zero to how sure are you that this is external to you? What are the reasons for, and against it, what's the evidence that you're using. And then examining the evidence the same way you would think about a depressive thought.
Dr. Rachel Loewy: (20:12)
There's a lot of behavioral experimentation too. That's not just cognitive. So an example might be a kid says, you know, whenever I go out in the neighborhood, people are staring at me. I wonder if they can tell what I'm thinking. Okay, Yeah. You talk to them a bit, you find out, well, every time they go out, they pull their hoodie really low over their head. They're looking at other people, maybe they're doing some things that could be encouraging those reactions and they're unaware of it. So you might say, all right, next time, can you try pulling your hoodie back a little bit, can you try to see then what the experience is like for you? So you can also do behavioral experiments.
Dr. Keith Sutton: (20:57)
Oh, good, good.
Dr. Rachel Loewy: (20:59)
A little, you know, some other clinical pearls, if it's helpful to folks, one I really like is for people who often experience that they're not in control of these thoughts. So you think of it as an intrusive thought. So the voices, they're talking to me and no, I don't have any control. They just come at me so you can work with them in session to see if they can try to increase the thought. Rather than trying to stop them, try to increase them in loudness, intensity, whatever it is. And if people can, that's some evidence that actually they can influence them, which then you can flip.
Dr. Keith Sutton: (21:45)
Okay. Great. And especially as we're talking a bit about teenagers here, but I'm sure also with adults, how about the role of the family?
Dr. Rachel Loewy: (22:00)
I've been talking about the individual treatment, but the coordinate specialty care model includes medication management, individual therapy, two other really important components are supported education and employment, so that you're really focused on getting people back into school and work either functioning better in school or work or getting back into school or work as soon as possible.
Dr. Keith Sutton: (22:25)
Yeah.
Dr. Rachel Loewy: (22:26)
That's one piece just before I get to the family. This hits at late adolescents, early adulthood. So when kids fall off the track, as I can kind of say, it's so much harder to get back after several years than it is, if you can help keep them engaged right away. So that's a big focus.
Dr. Keith Sutton: (22:52)
Okay.
Dr. Rachel Loewy: (22:52)
And then the family piece is incredibly important. So number one is psycho-education. If you think parents aren't sure what's going on when their teenager is depressed, try when they're having psychotic symptoms.
Dr. Keith Sutton: (23:09)
All right.
Dr. Rachel Loewy: (23:11)
Understanding negative symptoms, that this is not willful behavior, that the kid is not, you know, doing their homework because they're having cognitive problems or they're withdrawing socially, you know, understanding what's causing all of that. One example that I give is let's imagine your neighbor has a 16 year old son who has cancer and what would you do?
Dr. Keith Sutton: (23:47)
Oh, yeah. I mean, I would ask 'em if they need any help, any support, maybe make 'em dinner, something they could heat up or these kind of things. And just try to kind of give them extra help if they need to lighten their load or emotionally support them.
Dr. Rachel Loewy: (24:07)
Exactly. Right. Now, imagine that same family has a 16 year old son in the hospital with schizophrenia.
Dr. Rachel Loewy: (24:17)
What happens, right?
Dr. Keith Sutton: (24:18)
Yeah. I would wanna do the same things, but yeah. I imagine a lot of people get scared or like, oh, they don't wanna talk about it. Or they kind of keep away or they think, oh, this kid's crazy or something and dangerous or something like that. They kind of lose their social support.
Dr. Rachel Loewy: (24:34)
Exactly. They lose it just at the moment they really need it.
Dr. Keith Sutton: (24:38)
Yeah.
Dr. Rachel Loewy: (24:39)
So part of it is supporting the families in a way that can help them. They need supports going through it as well as the education about what's going on, why it's happening. People have all sorts of ideas about that. Sometimes for families, because there is a strong genetic component, there was someone that they knew, an aunt and uncle, a parent, someone who had inevitably a very bad course. So maybe they saw someone or heard of them being institutionalized and they're terrified that was gonna happen to their kids. So there's also a lot of education around what can be different now with early intervention.
Dr. Keith Sutton: (25:23)
Good. Yeah. Cause that makes sense. Cause if somebody was in that two thirds that got better, they might not be aware of that uncle or great aunt or something like that but they are aware of maybe the one that committed suicide or something like that, or was hospitalized. So the reference points are the worst case scenarios.
Dr. Rachel Loewy: (25:46)
Exactly, exactly. And then for a lot of young adults, the challenges are that adult systems of care are not very good at supporting transition age youth in the context of their family. So parents often feel completely excluded, you know, they're 18.
Dr. Keith Sutton: (26:07)
Yeah.
Dr. Rachel Loewy: (26:08):
They may not be able to get access to information, the person may, as part of their delusion, believe something about the family so that they say no when they're actively psychotic, they don't want that information to be shared. And so we work very hard to try to develop those connections and support and teach parents how to interact with the system, which is unfortunate that we have to do that. But you know, they can share any information they want, even if someone can't share it back. Those kinds of things.
Dr. Keith Sutton: (26:43)
Well, I know that when I was in my practicum experience that a lot of the folks that were in a boarding care were getting their meds regularly and were actually doing fairly well and kind of stabilizing and moving out. Whereas a lot of the other folks that were either living on their own or sometimes, living with family members, were struggling and the medication wasn't going kind of according to plan and were relapsing. And so one of the things I was thinking of was like, it would be great to bring the families in to help them understand. Although the program was said we don't do that, we only do the individual work, we don't work with the families. So it's such a huge resource that was getting kinda left out.
Dr. Rachel Loewy: (27:27)
Unfortunately, that's still the case. I think you're absolutely right. This is the context they're living in. And if the cognitive impairments that go along with psychosis include problems with attention problems, with memory, even if someone wants to be taking that, it's very hard for them to handle that on their own. So they often need family support. If that family member doesn't think they need medication, or there's conflict around it, and they're not sure to handle it, then It can be a big impediment to recovery.
Dr. Keith Sutton: (28:04)
Yeah. I'm wondering, can you speak to medication? And I know that at least since I've worked with more of these clients that there's been some advances in the field regarding medication.
Dr. Rachel Loewy: (28:19)
There have. I'll describe this as two groups, there's those who have had their first episode or are in their first episode versus the clinical high risk. That's an important distinction that doesn't always get made. In terms of the medication, with a first episode, a big piece of what we do is start low and go slow. So unfortunately when people are in the hospital they're often on very high doses of an antipsychotic meant to mostly sedate them and try to get them to be able to be released as quickly as possible. That's our system and how it works. What happens is sometimes people are then maintained on those very high doses and outpatient psychiatrists may not want to reduce them. And there are terrible side effects. So people are very sedated, they can gain an incredible amount of weight, develop all sorts of physical health risk factors. And really it's about recognizing that they can be on a much lower dose if you have psychosocial support. And so that's where the rest of the team comes in. If you have therapy, if you have family support, if you have someone helping them get back to school and work, that's what allows it to happen.
Dr. Rachel Loewy: (29:41):
Another piece is the use of long acting, injectable, anti narcotics. Sometimes people think those should be reserved for someone later down the line, if oral medications aren't working, but actually they can be incredibly helpful as they can for any one who has a hard time remembering. We all forget to take our medications.
Dr. Keith Sutton: (30:06)
Every day.
Dr. Rachel Loewy: (30:07):
Right. And so, you know, I think this is where a lot of pharmacology is going in general, right. There are, you know, people want a birth control option, right? It doesn't mean I have to remember to take a pill every day. Well, the same thing is true for an anti psychotic so actually some people can do really well, but all they need is a monthly injection that takes so much off the board.
Dr. Keith Sutton: (30:29)
Yeah. And is that monthly injection kind of as effective as some of the medications that are taken on a daily basis?
Dr. Rachel Loewy: (30:36)
Oh, definitely. I mean it's actually the same. It's just a different mode of administration of the same one. So you might be on Risperidone orally and then you can switch to the injectable version, which is usually how people will do it. They'll put them on the oral version of the exact medication to make sure that that's working for them and then go to the injectable form.
Dr. Keith Sutton: (30:58)
Titrate to find the right dosage and then go to that long acting you. And actually I'm interested too, has there been any, I'm sure there's been studies on, you know, decreasing the psychotic episodes or two also, I know a large part of our homeless population, especially in San Francisco, we have a lot of folks that are struggling with homelessness. Oftentimes a lot of folks that struggle with psychosis or schizophrenia end up homeless. I was just interested too, of like, does that affect folks being able to maintain housing or so on being on a monthly injectable? Or daily med while living on the streets or whatever it might be.
Dr. Rachel Loewy: (31:41)
Yeah. So there's two things there that I think are important. One is how do we prevent homelessness and becoming unhoused, right? And then how do we help people once they are? So a lot of the early intervention work is around exactly this. How do you have a kid who's maybe couch surfing, not quite on the street yet, but at a very tenuous point and help them so that you can maybe prevent some of those outcomes. So there's that piece. And then long acting injectable antipsychotics have been very helpful for people in reducing relapse. And then of course, if you're not relapsing, you're able to maintain a job. If you keep having to go to the hospital, it's really hard to keep your job. Things like that. So yeah. Their outcomes are much better, so it's a great option that actually does not get offered as much as it should. And I'm actually working on that. We're looking at, even in the early psychosis programs, trying to support them to, offer that to people. More, and you probably won't be surprised that there are some disparities and equity issues about who gets offered one.
Dr. Keith Sutton: (32:55)
Well, that's what I was wondering too. I mean, there's gotta be a whole socioeconomic status kind of aspect, cultural, racial, you know, kind of pieces that also play in. And I think too, are these expensive? Are these hard to get,?I mean, again, often somebody who might be experiencing psychosis, hospitalized, hard to keep a job, hard to keep their housing, then they don't have money for maybe some of the medical care that they need or so on. So it almost becomes whether you're starting off from a position of difficulty or privilege that I imagine kind of, it might snowball down that way too.
Dr. Rachel Loewy: (33:40)
Yeah. I mean, it's hard not to get into a whole debate about for-profit healthcare, but-
Dr. Keith Sutton: (33:49)
Well, that's the other thing too. It's not really so profitable to make and improve these medications too. I imagine cuz this is not a population that's spending a lot on medication or a system that's willing probably to pay for.
Dr. Rachel Loewy: (34:03)
Well, the system is. So if you have Medical actually, usually you have access to a number of these on formulary and there are options for undocumented folks who don't have, the clinics kind of have to work out those relationships. So a lot of the county systems try to work with this, but yes, it probably is much easier for someone who's on a commercial insurance and going into say a medical center like UCSF or something, right? They're gonna have much more access.
Dr. Keith Sutton: (34:38)
Yeah. So we've got the, you were kind of talking about this model, the coordinated specialty care model, so there's one aspect, that's the medication, there's the other aspect that's kind of helping them keep on track with school, with work, and then there's the other piece around the family. And is there any additional pieces to that? And of course the therapy and so on.
Dr. Rachel Loewy: (35:08)
There's case management, right. In whatever way that's needed. And then the big piece is that this is all an integrated team. This is not separated out. This is a single team. They meet weekly and talk about every single case. Caseloads are kept lower so that there is the capacity to work with someone when people come in and maybe at first they're in a lot of crisis and they need more time and support. You know, this is not a one hour of outpatient treatment a week kind of program. It's not a day treatment thing either. It's more like an intensive somewhere between, you know, regular outpatient and intensive outpatient.
Dr. Keith Sutton: (35:53)
Got it.
Dr. Rachel Loewy: (35:54)
It's also collaborative in nature. So it's really important that the person chooses, which of these elements they want to engage in, what are their goals? And that's the focus, right? This is this distinction. So collaborative decision making is about what do they want, what they want, what everyone wants. They want to do well in school have a job. They like having a girlfriend, you know, whatever, right? And sometimes our goals as providers may feel like we want people to not hear voices anymore, right? We think about symptoms. And so it's really shifting it so that it's thinking about what are their goals. That's what's gonna help people engage and move towards what they want for themselves.
Dr. Keith Sutton: (36:40)
Yeah. Increasing-
Dr. Rachel Loewy: (36:41)
And it's competitive employment. Sorry, go ahead.
Dr. Keith Sutton: (36:44)
Yeah. I was gonna say increasing the functioning. I interviewed Scott Miller, who developed an outcome measure, and it looks at functioning, how is the person doing. And he was saying we don't look at symptoms because somebody can still be having hallucinations or so on, but be doing well and working and happy and so on. So it's not, we don't necessarily have to go straight at the symptoms in that situation. I was thinking about too, you were talking earlier about the level that the person is kind of aware around the conviction level. And I was wondering about, I imagine some of the more difficult situations are where there's a higher level of conviction that this is true, the FBI's after me or so on.
Dr. Keith Sutton: (37:29)
I was also thinking too, that I know a lot of substance abuse oftentimes happens as a person's trying to deal with that. And I know that I think there's some risk factors for folks that have some predisposition, sometimes marijuana can sometimes be a part of some of the first breaks, and just wondering if you could speak to some of that. Cause I think some people thinking like, gosh, can we even work with this person if they're, you know, or like, you're not supposed to necessarily challenge the illusion or so on because that's kind of gonna be somewhere you're just gonna get stuck, trying to explain the FBI is not following you or so on.
Dr. Rachel Loewy: (38:10)
Yeah. So the substance use question in cannabis in particular is really important to address. And then we can also talk about how do you work with the delusion rather than against it, cause that also is important. So the first piece is that yes, the substance use is gonna be very common and it can be tricky to pull apart what is happening when the person is high in using versus when they're not. So we do a very detailed evaluation to get a sense of that. Yeah. Obviously someone using meth can be absolutely psychotic for quite a long time after they stop using and it's really just because of the meth, It's not going to continue. But you don't know that in a 19 year old where it's just starting, you can't tell yet. So we do of course encourage harm reduction, less use. But we will absolutely work with people as long as they're able to come into the program and engage with us, we meet people where they are.
Dr. Keith Sutton: (39:19)
Sure, sure.
Dr. Rachel Loewy: (39:21)
The cannabis piece is important because a lot of people don't realize the risks involved. They think of that as it's legal now, relatively, I'm not too worried. Yeah. My kid smokes weed. Okay, fine. You know, that's not so bad, but for some people who have the genetic predisposition and we don't know who that is because it's not a simple gene, it's a variety of them. We don't even know which ones. There's no genetic tests. So nobody can really know who is at risk genetically. If they have that risk and they use cannabis heavily, especially for heavier use younger ages, it increases the time to developing psychosis.
Dr. Rachel Loewy: (40:19)
The jury is a little out on whether it is causing the psychosis and that they wouldn't have developed otherwise, because again, you can't do control trial that way. But we definitely know that for people who already have psychosis or have psychotic like symptoms, use makes it much worse. So there's a lot of this evidence you can sort of pull together to see it's not a good idea. Especially the thing that's very worrisome is the concentration of THC that is in a lot of cannabis that people are using now. And so something I'd like to remind people is the impact of substances like that on a developing brain are so different than an adult brain and our frontal lobe doesn't finish developing until about age 25. So we're not just talking 16 year olds. A 40 or 50 year old person who is smoking daily, It has a different risk of a 16 year old or even a 22 year old.
Dr. Rachel Loewy: (41:32)
That people need to think about. And it's very worrisome and actually I think a lot of us have been waiting to see how the epidemiological data look and whether we're actually seeing an increase in psychotic disorders.
Dr. Keith Sutton: (41:53)
Well, I know too, kids that are using before age 15 are five times more likely to develop addiction. So that timing of when use occurs has a lot of different effect, definitely.
Dr. Rachel Loewy: (42:09)
That exactly right. Yep. Same here.
Dr. Keith Sutton: (42:11)
And how about when folks have very strong attachment to delusions or conviction or so on? I'm also thinking of, I read the therapy with intimidating cases by Dick Fisch and the MRI folks down there and kind of using some paradoxal, somebody come in says, oh this session is being recorded by the FBI, and instead of challenging it, he says, oh, they can't do that, let's find it. And starts dumping out things from the desk and then looking all over. And the person's like, no, no, no. And then eventually they're like, oh, let's just talk about my mom or something like that. Kind of getting beyond the delusion and the back and forth around that or so on. But I think that's more a theoretical kind of example, but yeah.
Dr. Rachel Loewy: (43:02)
So I mean, in the traditional sense of arguing with the person, no. First of all, would you ever do that with any other patient?
Dr. Keith Sutton: (43:15)
Yeah, right?
Dr. Rachel Loewy: (43:16)
Right. So if you think about it, cause this is again where people think like, oh, psychosis is this other thing somehow. And it's like you would never do that with someone with any other kind of issue coming in. So of course that's not gonna help here. You can always align with the emotion, right? Wow, that be really scary. Because you can understand if you really thought people were out to kill you you'd be terrified.
Dr. Keith Sutton: (43:43)
Yeah.
Dr. Rachel Loewy: (43:44)
I wouldn't sleep either, that's really scary. So you can validate the emotion without having to agree with or disagree. So you can separate that
Dr. Keith Sutton: (44:01)
That kinda joining with the emotion.
Dr. Rachel Loewy: (44:03)
Exactly. So that's one strategy, to separate those out. And often it's the distress and the impairment around it that you need to work with first. So that helps that way. And then you can get to the point where as I gave the examples before you can sort of say, I'm not sure if it's happening because how could I know? I don't know, you're telling me, okay, It could be that's possible. I don't know. Would you be interested in us trying to figure it out together? And so sort of that curious dance around then starting to look at what's the evidence as I described before and what helps sway them one way or the other. So, like anything else you have to join first before you can start to explore in a collaborative way.
Dr. Keith Sutton: (45:03)
Yeah, definitely.
Dr. Rachel Loewy: (45:04)
But that's also something that's very hard for family members. Your kid comes and tells you something that sounds crazy. And a parent says, no, no, no, no, you don't have to worry about that, that's not true. Which actually doesn't help entirely, even though it's intended to be reassuring. So that's a lot of the family pieces, helping. How the heck do you know your kid believes this? How do you talk to them about it?
Dr. Keith Sutton: (45:36)
Well, I imagine too, oftentimes working with families and helping the parents to understand that if the kids feel like they understand, then oftentimes they're much more open to their influence or what they have to say. So oftentimes starting with that and I think that's, like you're saying, I'm recalling a client that I worked with who said I'm being followed or so on. And I was like, oh my gosh, are they here? And I looked out my blinds cuz I was like if I were in that situation, I'd be pretty terrified and kind of matching that experience. And then kind of saying like, wow, are you really scared? That kind of empathic conjecture to kind of be able to join and then kind of go from there cuz if the client doesn't feel like I get it and understand or I don't understand, then it's hard to move forward from there at all.
Dr. Rachel Loewy: (46:22)
Exactly. Exactly. And that's again, I mean, that's great that you did that and it is, like I said, it's really similar to how you work with anyone. So it's kind of, I encourage clinicians to kind of, keep their regular clinical skills hat on, it doesn't mean you throw it out. It's all the same principles and I think the idea of seeing it as either an intrusive thought or an extreme distortion helps a lot. People then feel more comfortable in how you might work with that.
Dr. Keith Sutton: (46:54)
Wanted to touch on expressed emotion in some of the research around that and families or also anything else that you wanna cover before we run out today. I'm interested in this cause one of my major groundings is in family systems work and particularly a lot of family systems work grew out of working where there was psychosis or schizophrenia and the person would be in the hospital, they would stabilize, be doing well and then they'd go home and things would kind of fall apart again. And so they even were bringing the families into the hospital and trying to understand, of course, unfortunately some of that went very negative with the schizophrenic mother and these kind of things and became apologizing and blaming. But I think that the family is of such a resource, as we're talking about earlier, and if they have some psycho-education, if they understand more and so on. But I know that there's the research around expressed emotion, which I don't really love that term because expressing emotions is not necessarily a bad thing, but it's kind of the three main components of high levels of criticalness hostility and emotional over involvement and the higher the levels of more relationship to relapse with schizophrenia or substance abuse of OCD or many different mental health conditions. Can you speak to any of that stuff?
Dr. Rachel Loewy: (48:16)
I'm actually really glad you brought that up because I think that the expressed emotion literature did a lot of damage in our field. There's two studies that I think are really helpful. One actually looked at in the minute dyadic interactions between a young person or a young adult with psychosis and the family member. And what they found was that it was an interaction. So it's not that the family just has this negative trait. It's that the development of the disorder over time has led to a lot of distress that then comes out in these ways. So what they would see is that the young person would express a symptom and then the parent would come back with a little bit of some component of expressed emotion, criticism, hostility, whatever, and then they would each escalate.
Dr. Keith Sutton: (49:21)
There's like a pattern of interactions that kind of became a habitual pattern that kind of fed off each other rather than something that's occurs within the parent or something.
Dr. Rachel Loewy: (49:31)
Exactly. And what they have also found is that in first episode samples there are much lower rates of high expressed emotion than in families where someone has been living at home and had the disorder for two decades also supporting this idea. So I think that just helps frame it. Part of the way we talk about it is yes, stress increases symptoms. Plain and simple, wherever that source of stress is. So stress in the family, high conflict criticism, hostility, negativity, yeah, increased symptoms. So addressing that interaction, right? Again, if parents understand why they're doing it and how they can help in other ways, that makes a big difference. So that's important. Like you said, the schizophrenic mother, which is this awful idea, you know what parent isn't gonna feel horribly guilty. And I hear parents come up with all kinds of things. You know, I didn't let him play on the soccer team, he wanted to be on that. Cause this, I mean, there's so much parental guilt that somehow this is their fault. That's actually an active area that we have to address is helping face that feeling. Yeah. And, and educate them that that's not true.
Dr. Keith Sutton: (51:00)
Well, and fueling that criticism or hostility or emotional over involvement is the fear and helplessness and particularly like, you're even saying, some shame. Like, did I do something wrong or so on and as trying to help and then feeling like nothing's helping, oftentimes people will get very frustrated and blaming or so on. And so it, you know, putting it into that context, it makes sense within the dynamic that might occur, especially if their child is struggling to recover or continuing to have difficulties or things like that. It might feel so outta control.
Dr. Rachel Loewy: (51:39)
Absolutely. And for a lot of family members, I've seen parents have to quit their jobs in order to devote time to taking care of a kid and helping support them. There's financial implications, like we said, they lose other supports. It's not that different from any serious medical condition that a kid has in the way it affects the family. But again, taking the pressure off the parents and their reaction, understanding the drivers of the stress on the system. That can lead to those interactions.
Dr. Keith Sutton: (52:16)
Right. And to wrap us up, any advice that you have for clinicians who maybe aren't as familiar with this, and they're seeing some things with their client, you know, there's maybe some voices, there's maybe some kind of things that are like, Hmm, this seems like a delusion and this is kind of beyond just a worry thought. What's the next step if they're not as familiar to kind of try and figure out what's going on here? I've got your program, so I oftentimes will send, if I've got a situation to kind of get some evaluation. But yeah, I would love to hear what might be helpful to clinicians.
Dr. Rachel Loewy: (52:48)
Yeah. That's exactly it. Consult, consult consult. Fortunately, due to several funding streams, nationally, there are more and more of these early psychosis programs. I co-founded several in the bay area with community partners. So they are open in counties. There are some at university settings, so pretty much they're expanding all over the country. I'll recommend if people are interested, there's a website, it's strong365.org
Dr. Rachel Loewy: (53:26)
And there's lots of great information there for people with psychosis, family members, providers, but also they keep a map with a tracker of all the programs across the country. So anywhere you are, you can look and I would say find your local one, you call. And people are often, even if they might not be appropriate for the program, happy to try to consult a bit because this is a complex differential diagnosis. It definitely requires an expert eye. Hopefully that expertise is growing. We're working now on a number of these programs around the state to strengthen them to start new ones if counties don't have them. With the idea, our goal is to have this kinda treatment be available for all Californians.
Dr. Keith Sutton: (54:21)
That be great. Wonderful. Well, thank you so much for your time. I really appreciate it. This is all so helpful and just valuable for me and hopefully valuable for other clinicians keeping up to date on what's going on in the field related to this subject. So thank you so much for coming in.
Dr. Rachel Loewy: (54:38)
Thank you for having me. I am always happy to share some of this with folks who are working out in the field who can't possibly keep up with with every new, small area. But this is one that is so important if people can help identify it early.
Dr. Keith Sutton: (54:54)
Yeah. Great. Well, thank you so much. Take care.
Dr. Rachel Loewy: (54:59):
Thank you.
Dr. Keith Sutton: (55:00)
Bye. Thank you for joining us. If you're wanting to use this podcast or continuing education credits, please go to our website at therapyonthecuttingedge.com. Our podcast is brought to you by the Institute of the Advancement of Psychotherapy, providing in-person and remote therapy in the San Francisco Bay Area. IAP provides training for licensed clinicians through our in-person and online programs, as well as our treatment for children, adolescents, families, couples, and individual adults. The for more information go to sfiap.com or call 415-617-5932. Also, we really appreciate feedback. And if you have something you're interested in something that's on the cutting edge of the field of therapy, and think clinicians should know about it, send us an email or call us. We're always looking for the advancements in the field of psychotherapy to help in creating lasting changes for our clients.