Transcript of Talking Heads with Dr. Noosha Niv – Episode 1
Family Matters: Transforming Schizophrenia Care
Announcer: This is Talking Heads. Explore the latest in research and policy about serious mental health disorders with Dr. Niv.
Dr. Niv: Well, hello. Today’s guest is Dr. Shirley Glynn. Dr. Glynn is a clinical research psychologist at the VA Greater Los Angeles Healthcare System in West Los Angeles and a research psychologist at the UCLA Sumal Institute of Neuroscience and Human Behavior. Her research is primarily on psychosocial interventions, most especially family intervention supported employment and social skills training to support recovery from schizophrenia and other psychotic illnesses for the past few decades. Is that right? Um and on a personal note she is a wonderful mentor and a dear friend and welcome Shirley. Thank you so much for joining me.
Dr. Glynn: Thank you.
Dr. Niv: I wanted to start off by asking you what led you to psychology and then more specifically to focus on schizophrenia and psychosis.
Dr. Glynn: I’ve had a few pivotal experiences in my life. There’s been a lot of serious psychiatric illness in my family and when I think of some things like I can remember being five or six years old and going to visit a family member at a state hospital and they could come outside for a picnic and I have a very vivid memory of being there and seeing what that was like a little bit. It was a little frightening for a little kid but also I love the person who was hospitalized.
Dr. Niv: And you were five you said. five or six.
Dr. Glynn: I think it was a great aunt and she helped raise me um when she was doing well. And throughout the much of the rest of my life, other people in my family started getting ill. And I thought to myself, I want to do something because when they would got ill, nobody really helped us very much. And there were a lot of kids involved and nobody was helping the kids. And I thought to myself, I really want to make a change. in this. I want to understand mental illness better, particularly psychosis. I want to help people with psychosis, but I want to help their families too. And the particular thing that happened to me, much of the illness, though not by any means all of it, was my mother. And the thing about my mother is she could get very, very ill, very psychotic, very troubled. And she also had periods where she was wonderful and raised five kids, um, got a part-time job so I could go to college. and made it to all the PTA meetings and it was very important to her to be a good mother and a good provider as it was with my father. And so it was this peculiar thing where this really called to me and I really wanted to help families. But I also believed in my bones people with these illnesses could have rich full lives. She had a full marriage with a lot of kids and so that gave me hope doing this. I never was particularly despairing. So it was those combinations of things. I was afraid of psychology. So, when I went to college, I decided that I’d like to help people but not get too close. So, I decided to go into urban planning.
Dr. Niv: I didn’t know that about you.
Dr. Glynn: And I did that for a couple of years and then I sort of sidled up to psychology and said, “Oh, this is kind of cool.” But the school I was at didn’t have a good psychology program. So, I dropped out for a year and then came back and um just found a life calling, which I know sounds trit, but is really true for me.
Dr. Niv: Given your experience, I think that makes a lot of sense.
Dr. Glynn: It was important to me.
Dr. Niv: You you mentioned that there wasn’t really help for your family when you’re when they were going through all this. What would have been helpful at the time?5
Dr. Glynn: Well, I think if anybody would have even noticed, there are a bunch of kids who are kind of frightened. Fortunately, I did have a couple teachers who took me under their wing, which was great, but there wasn’t anybody in the mental health community. I can remember my father always wanted my mother to sign into the hospital. He never wanted to put her on a commitment if she could. And we used to bring her to the hospital and she would sign in Jesus or something else on the sheets and they’d rip it up and have to have her sign again.
Dr. Niv: She would sign in with her name as
Dr. Glynn: Yeah. She would sign in as Jesus and the admissions. So, and and they saw so obviously they knew that was a family there,
Dr. Niv: right?
Dr. Glynn: And yet no one ever came and said, you know, what’s happening with those kids? Is anybody helping them, talking to them or anything? Now, this was 50 years ago and things have changed a lot. I think that just somebody acknowledging us, somebody reassuring us, somebody telling us that it would likely be okay. Can’t promise everything, but you know that chances were she was going to be able to come home and be with us and take care of us again and stuff, which she did. She always used to say a story when she was in the hospital that nurses would say to her, “Mrs. Glynn, you got five kids at home. You got to get it together.” And and it helped her. She did, you know. So, um, so I think just acknowledging us and educating us, letting us be a little fearful, but reassuring us, that would have helped.
Dr. Niv: That would have helped. And it happens not as often as we’d like it to, but happens more now.
Dr. Glynn: Yes, definitely.
Dr. Niv: You have seen significant changes in how families are viewed in both the ideology
Dr. Glynn: definitely
Dr. Niv: of the disorder as well as treatment.
Dr. Glynn: Yes.
Dr. Niv: What’s been your experience with that? If you could talk about both of those.
Dr. Glynn: Yeah. It’s funny. One of the really special special moments of my life is when I got to graduate school, I happened to run into two colleagues and one of them was Kim user who’s well published in this area and the three of us took a course together in family therapy and we decided to write the ultimate family therapy program for people with schizophrenia and their families and so I began reading and again so this would have been like 40 years ago began reading about all about expressed emotion and the beginning of like Ian Foon’s work and this was all just coming out and we actually designed a program without knowing much about their work that mirrored it in some ways what we thought were best practices. And so and then I saw training in it, you know, I started seeking training like in clubhouse model places where people were actually trying to hold shots and do things. I did some work at Thresholds in Chicago. Worked in a home where mothers were living with psychosis and were raising their children and really sort of tried to help with that and learn about that. And it just became a focus for me. to try to see what was happening which was some combination of having a lot of hope, giving people skills and acknowledging their support system was critical but needed support too.
Dr. Niv: Um, you mentioned expressed emotion.
Dr. Glynn: Yes.
Dr. Niv: And when you were studying it, can you describe what that is?
Dr. Glynn: Sure. There was this famous sociologist George Brown who was around in the 50s in the UK when people started getting released from hospitals and living going home. But what he found was some people did better going to what we would think of as boarding cares, nice boarding cares. And he and he was sort of fascinated. Why are they doing better there than they were at their homes? And he began to talk with family members and realize that some families are really able to manage manage helping a loved one with serious psychiatric illness very very well. Perhaps temperament. Perhaps they’re educated, they’ve educated themselves more. Perhaps they’re just a little more able to roll with the punches. But in any case, some families can manage and not be sort of critical or tense or so worried about the person with illness that they’re prompting and nagging them all the time. If they’re prompting and nagging them all the time, that became known as I expressed emotion. Whereas that more capacity to be a little laid-back and not so critical and not so nagging would be considered what we call low expressed emotion.
Dr. Niv: It happens that in western cultures expressed emotion high expressed emotion is common.
Dr. Glynn: So that’s like criticism and nagging.
Dr. Niv: I I think of it as nagging. Okay?
Dr. Glynn: You know people who why don’t you get a job? Why don’t you go take a shower? Why you know when somebody may be really having a very hard time functioning. very easy for a family member to do. I’ve done it myself, but it can be kind of noxious for the person who’s really struggling with a lot of internal stimulus. So, there were a group of people both in the UK and in America who started developing programs to help relatives reduce their amount of expressed emotion. Basically, by providing education on expectations, trying to get the stopping to pathologize the ill loved ones behavior and um often teaching communication and problem solving skills. The interventions tested in the research projects were very effective in reducing relapse over a 2 to 5ear period among people who participated in them. I should make one point when you’re trying to assess expressed devotion it’s done at the time someone is very symptomatic. So typically the way this was done was somebody was hospitalized And then a researcher would say, “Could I talk to you about your family member?” And they would interview them using a structured interview for about an hour. And so it’s really something you measure at the time when somebody’s really having a symptom exacerbation. And it’s a strong predictor of outcome 9 months later.
Dr. Niv: So when these families are in a high stress moment, how family members react to it at that moment,
Dr. Glynn: right? And we think it probably reflects to some extent how they interact with the CL. with the with the person with the illness.
Dr. Niv: Um there are some data to suggest that and if we can help families cope and not feel so isolated. I mean I always think think about when there’s serious mental illness in your family and when there’s physical illness. I mean in the neighborhood I grew up in if somebody had a heart attack or death or a horrible accident, you know, the neighbors would all come in and bring potluck and be nice and I’ll say a prayer and all that kind of stuff. meal plans delivery. Yeah.
Dr. Glynn: Yeah. Exactly. When somebody had mental illness, I mean, everybody steps back, it’s a rare person who understands it well enough to say, “What can I do for you?”
Dr. Niv: That’s a special person.
Dr. Glynn: And so, we’re just trying to increase the likelihood of that.
Dr. Niv: So, reducing the stigma.
Dr. Glynn: Yeah.
Dr. Niv: You know, when you think about families, I remember in grad school the whole concept of the schizophrenic mother and
Dr. Glynn: Right.
Dr. Niv: Can can you describe where that was and where we’ve moved? since
Dr. Glynn: yeah I mean there have been in the 40s and the 50s there were several clinical researchers who I’m sure meant the best who were trying to understand what the ideology of schizophrenia was and there was some recognition of biology and some recognition of social determinance but most of it was about something with the person and their family had gone on a ride.
Dr. Glynn: There was the schizophrenic mother who may have been both wanting the person to individuate but not let them and that was then made famous and even more clarified in Gregory Bates and stuff on the double bind theory and they would hospitalize whole families up in PaloAlto to look for what was called communication deviance. See it must be happening that the families are giving the the ill relative double messages. I love you but saying it with a grimace or I’m happy for you but clearly not enthusiastic about it. And these were all thought of as ways that schizophrenia was perhaps caused or exacerbated. Now I think we don’t really have much data to support any of those models. But what we did have not so much that these things cause the disorder because I don’t think they do. We don’t have any sense that before when I mentioned expressed emotion that that caused schizophrenia at all. But what we do think is people can react, loved ones can react to a psychotic episode in ways that are helpful or in ways that may increase the stress. And we know the importance of expressed emotion holds true in bipolar illness as well.
Dr. Niv: Depression, a multitude of psychiatric illnesses,
Dr. Glynn: these are all disorders that people are tend to be exacerbated when there’s stress and uncomfortable family conversations can cause stress. Now the other thing I want to say though and then I promise to let you talk is that I want to have a lot of charity for the family members. It is not easy to be the parent of someone developing a psychosis. It is not easy to love someone that be your partner or your mother or your sibling and see all the struggles they’re having. You want to hold on to all their strength, which are great, but you see their struggles. It’s not surprising that you would start nagging them. Please go take your shower,14
Dr. Niv: right?
Dr. Glynn: You know, please take your medication. I mean, it’s normative, but unfortunately, it can backfire.
Dr. Niv: The initial part of that when people learn what’s going on, there there’s a grief period, isn’t there?
Dr. Glynn: I think so. Yes. Grief and mourning. And some people have written that really the idea particularly I think of parenting someone with serious psychiatric illness is basically prolonged grief
Dr. Niv: you know because unless you’re lucky and things really come around you know there’s always going to be a little sense of I wish it had been different I I was hoping my loved one could perhaps accomplish more in traditional terms than they’ve been able to15
Dr. Glynn: right
Dr. Niv: so I absolutely think grief is part of it and what’s really tricky I think is that for those of us in the field, it’s useful when we see people conjointly so we see whoever is ill and whoever loves them, you know, together, whoever is experiencing these problems. But often times, family members need a place where they can also say on their own, I I’m so sad. I I hate to see my loved ones suffer. I wanted a different life for them. Whatever it is,
Dr. Glynn: right?
Dr. Niv: And that’s hard to do in a family. context,16
Dr. Glynn: right? Because it can come off as criticism if there when really it’s mourning.
Dr. Niv: Exactly. And that takes a skillful clinician to sort of manage, I think.
Dr. Niv: Would would you usually see those family members on their own for processing that to some extent?
Dr. Glynn: Yeah. You know, I have a private practice and I see a lot of people can join me and a lot of people I see just the person living with the psychiatric illness and then I see family members alone as well. It sort of depends on what people want. And I have clients who are basically I have people living with psychiatric illness who would like nothing better than for me to talk to their families and see if I can help them. And you know, if I can, I do.
Dr. Niv: Okay. But speaking of treatment, the attitudes towards including families in treatment have significantly shifted over the last 15 years or so. It seems like such a big change. What are you seeing?
Dr. Glynn: Well, our society, rightly so, puts a premium on autonomy. People making their own decisions about their lives about mastery and self-direction. And that’s really important in our society. The challenge we have is sometimes people have a very hard time taking care of themselves. That can be a physical problem or that can be a mental health problem, you know. So, there are times where that’s a complicated uh situation. So, sometimes you have people who really aren’t able to care for themselves and their families are trying to get them help and can’t get them help.
Dr. Niv: Can’t can’t get them help because it’s not available in their
Dr. Glynn: or or the person doesn’t want it. The person doesn’t think there’s a problem. Both. But a lot of times, if you approach it, if you’re lucky enough to approach approach it with sensitivity and really sort of almost think that you’re going to have a place for the person living with the psychiatric illness to grow, but you also want to garner and shore up their support. That that can often be a viable model. And that’s sort of what we try to do when I do trainings that we want family members to be seen as allies of the person with the mental health challenges and to both be able to support that person to some extent emotionally often although sometimes instrumentally and that the then the treatment program should be supporting both of them.
Dr. Glynn: So I think there’s more openness to involving families in care. I mean it’s like for example when I first started doing hospital work you know there was that whole thing about you can’t confirm or deny somebody’s been hospitalized. Right.
Dr. Niv: They would never do that for a heart attack. You know, if if your partner has a heart attack, they can’t get you there fast enough.
Dr. Glynn: Yeah. We we’re not going to tell you if your husband had a heart attack.
Dr. Niv: Exactly. But slowly it’s changing now. If you look at HIPPA laws, actually HIPPA allows you to talk to family members. If you think it’s um for the best interests of the consumer, the patient, the person with the challenges, unless they’ve told you, definitely don’t. And I think there There’s also a willingness for staff to recognize, you know, what I always say to people is it’s a figure ground problem. We sort of see ourselves as the figure in a therapy relationship, but the reality is we’re kind of the ground and it’s the family member who’s likely to be there most of the time. And let’s face it, for most of us, the people we know the longest in our lives are our siblings.
Dr. Niv: So, shooting them aside,
Dr. Glynn: not good plan.
Dr. Niv: It what is the point? right?
Dr. Glynn: You know what is the point? I do think there’s more openness although there’s still room to grow on that
Dr. Niv: and when you say that you mean from healthcare systems and clinicians
Dr. Glynn: I think systems I think systems and I think one of the things you know there’s been a big effort now to develop first episode psychosis programs and you know the challenge there is people with disorders that end up getting diagnosed on the schizophrenia spectrum um They’re often in their late teens and early 20s. Their jobs aren’t to individuate. Their jobs are to leave home in our society. Not every society, but our society.
Dr. Niv: Western.
Dr. Glynn: Yeah. And and and now we’re sort of saying to them or they’re realizing, I need to be a little dependent. You know, I’m dependent on my family. I can’t leave home, but man, I hate this dependence.
Dr. Niv: So, the thing I’m going to do is say, you can’t talk to my family members, to the staff, because that way I have some privacy and individuation
Dr. Glynn: some autonomy and decision making and
Dr. Niv: makes perfect sense but works often works against the person. So we need to get more skillful at helping people evaluate that. Sure there are some situations where avoidance and distance are best. Not every family it’s great by any means but we have to understand that for many people it is their family who’s going to be the carer of last resort.
Dr. Niv: Right? And involving families doesn’t mean fully participating in therapy, right?
Dr. Glynn: No. I always say to clients I’m working with, I mean, I just did this last week. This is someone whom I’ve been seeing in therapy for a while. And what I try to do when people are living together, and I actually think this is a best practice myself, is if if you have somebody with a serious psychiatric illness who’s living with somebody else, a family member, perhaps even a close friend, but a family member, a partner, whatever. I like to have I call family meetings which we have maybe every couple months and we talk about how things are going. I always want to draw out strengths you know what’s going well what’s you know what can we be proud of what are things that are happening that are worrisome as well and I think a reasonable clinician a seasoned clinician can manage what might seem like a boundary problem. Now the other way you could do it is you can have two people do it. You could have one person do the family meetings and somebody else doing the therapy. But, you know, there aren’t often all that well-trained people just floating around ready to go23
Dr. Niv: to work with families with SMI. Yeah.
Dr. Glynn: Yeah. And you’re right. And working with serious psychiatric illness. So, that can be hard, but that’s what I mean. And in preparing for that meeting, I can say to somebody, are there topics you don’t want to be brought up? You know, I say I can’t control what your folks bring up, but I don’t necessarily have to say you’re using cannabis and they don’t know. Right. We can set some boundaries around what it’s talked about,
Dr. Niv: which is a common thing. Yeah. But we can still talk about how you’re going to solve particular problems. How are they going to do the fastest so you can go back to school?24
Dr. Glynn: They want you to drive. Do they really understand? Are they totally in on yes, they feel safe with you driving? Let’s talk about this. You know, those kinds of things.
Dr. Niv: You you touched on this a little bit earlier and this like friction between um civil liberties.
Dr. Glynn: Yeah.
Dr. Niv: For people with these disorders and the family’s frustration with the person who either doesn’t recognize there’s a problem or refuses to get treatment. And for a lot of family members, they kind of hit
Dr. Glynn: they hit the wall.
Dr. Niv: It’s just what do they do, right? They they become really despondent. I I’m sure you’ve had this where we have people family members say, “I have to kick him out. He’s going to become homeless.”25
Dr. Glynn: It’s really hard. You know, I I was telling somebody uh last week, you know, we have, you know, this idea of sort of tough love, you know, and that we can use tough love and and that will help shape people up. And I always remember, for those of you who are as old as I am, that George uh McGovern wrote a biography after he had obviously lost the presidency several years after. And he talks about he had a daughter who suffered a lot from very serious depression and substance use. And the daughter went into rehab in and out, in and out. And finally the the professionals said, “You really got to have tough love here. You really have to.” And so they did and they kicked her out again. They wouldn’t take her back and she froze to death leaving a bar.
Dr. Niv: Oh, that’s heartbreaking.
Dr. Glynn: It’s a horrible story and it has stuck with me all this time. I I mean, I understand why they did it. We sort of think people are going to hit bottom, but there’s a group of people, and I think they’re disproportionately in the group of people with serious mental illness that they can die before they hit bottom. And not that I would ever say a family should tolerate violence in their home or aggression or anything. I’m not saying that at all. But I think that it’s such a fine line and you really want to try to get some consultation at that point. if not before, you know, to really sort of think about what your options are and are there any other ways to go. Um, it can be very hard. I mean, I’ve helped families, you know, buy RVs so their loved one can sit on live on the property but not in the house,27
Dr. Niv: right?
Dr. Glynn: Or, you know, work hard to get them section 8 housing. I It’s not for me to judge because these are horrible dilemmas. Really horrible dilemmas.
Dr. Niv: It’s a heartbreaking decision. It’s not like these family members are making these decisions lightly by any means.
Dr. Glynn: Very much so. Very much so. And I can’t say what anybody else should do except to really understand that many of these people with these illnesses really have significant challenges in developing the kinds of lives they would like to have.
Dr. Niv: And it’s not as easy as well go look for a place to live or go get a job, right? We know they they are lacking the cognitive skills to do these things.
Dr. Glynn: That’s really important. That’s a very important point.
Dr. Niv: So, how how can a family member help in that regard while you know staying cognizant of these challenges?
Dr. Glynn: Well, you know, one thing I try to do when I work with families is speaking to a point what you just made. We often think of schizophrenia and bipolar illness and serious depression. You know, we know what the symptoms are, whatever. We can go to the DSM5. What we often don’t fully appreciate is the challenges some of these disorders cause, residual problems people have with cognition. And people often get benefits from medication. So, they’re no longer perhaps hearing voices or having unusual thoughts or distressing thoughts, but their cognition may be reasonably impaired. And by that, I mean, their attention, their memory, their concentration, their focus. And it’s easy to forget that. It’s really easy because a person looks the same. And maybe they’re even saying, “I’m not hearing voices anymore.” Which everyone is like, “Thank God,29
Dr. Niv: right?” That’s the really noticeable symptom,
Dr. Glynn: right? We’re back to normal. And we don’t necessarily understand there’s this residual stuff going on that may make it very hard for somebody to hold the job. May make it very hard for them to balance their checkbook, all these executive function kinds of things. And so I think one of the most important things family members can do is just remember that, you know, really just sort of remember. And one of the quick things I’ll say to family members is why don’t you see is your loved one watching any kind of media? Not so much video games, but are they watching anything on, you know, Netflix or whatever? Can they actually sit down and watch a show for half an hour, can they tell you what the story was? Can they read something, you know, on Yahoo and tell you what the story was? People often find they can’t really do that and it helps them sort of open their eyes a little bit. So, I think then we’re talking about helping people dig down, helping the person with the challenges dig down and find out what they want to do and then figuring out are there compensatory strategies we can teach. Are there workarounds? I mean, how are we going to help this person? And and then often people realize the person with living with the distressing symptoms realizes that they’re not performing as well as they might. So, they often have a lot of shame. That’s the other thing.
Dr. Niv: Internalized stigma. And between the cognition and the internalized stigma, it can be a heavy road. And if you can help a family member get that, I mean, really get your son, your daughter feels ashamed every time they go out that door. If that’s true, it’s not true for everybody, but if it’s true, and it seems to be true with many people with these problems, you can help people develop empathy, and that goes a long way.
Dr. Glynn: And and that’s where education really comes in, right?
Dr. Niv: Absolutely.
Dr. Glynn: These are core symptoms of this disorder. They’re not not being obstinate or lazy.
Dr. Niv: Exactly. It’s not a personality thing. Being open to learning about these kinds of things, it’s really helpful.
Dr. Glynn: Education can go a long way to understanding, being more empathetic. To switch gears a little bit, you mentioned these uh first episode programs. Can you talk more about those and what that means for people?
Dr. Glynn: Sure. We have a funny history in terms of in terms of thinking about prognosis and and now I’ll limit myself primarily to schizophrenia. um disorders. The original term for schizophrenia was dementia precox which was basically early dementia which was not a good thing. That poor prognosis that’s not a good thing. And the whole point was the way you could find out whether somebody had bipolar illness is they didn’t have this poor prognosis. They would get better whereas people with schizophrenia would not. So for many years we thought the prognosis was poor. And there were occasional places that would try to set up nice rest bits retreats real retreats where people would go and maybe they could heal. But generally that all those efforts got decimated and there was the state pit, the state hospital, general sense of hopelessness about these disorders. And we now know that even though bipolar illness often doesn’t look quite as people don’t often look quite as impaired, they often over time get more impaired. So the general notion was whether we’re talking about bipolar illness or schizophrenia, the outcome is going to bleak. But then medications came. Probably many of you know the general medications that we found to be effective were found serendipitously. It’s the sort of thing where somebody would have to have surgery, they give them a medication that we now consider to be an antipsychotic. And if they had a psychosis, when they woke up from the surgery, they were better. And they realized it was because of the medication that they had given them. So in the 50s, all these things, lithium came and chloromazine, thorazine. So there began to be hope that people would do better. Now you guys probably most of you have heard unfortunately there wasn’t funding to support people in the community in the way that we would like. And so even though people were getting discharged from hospitals and it was hopeful, it didn’t really go very far because there weren’t the supports in the community say in the 60s and 70s and 80s. But in the 1980s, Particularly in the UK and Canada and Australia in the 80s and early 90s, a bunch of psychologists and psychiatrists started saying, “We have behavioral techniques that work in other in to help people with anxiety and depression. What if we try to use some of them with people with more serious disorders, particularly people with psychosis, and just give them everything we have right when they get ill? Let’s find them right can they get ill and can we change the trajectory of their illness? So they did a bunch of studies and they could do them in places where there was universal health care where there were where there were you know if you will socialized medicine because the thing is the government could say to everybody seeing people with psychosis I want you to offer them a treatment program right when they get ill to try to improve their lives. It was hard to have a mechanism like that in the US. We There’s no way the government can make a bunch of psychiatrists do anything, but they could do it in the UK. So, they developed these programs and they’re typically called first episode psychosis program. Most only include people with schizophrenia. Some also include bipolar illness if they have psychosis. And the notion was if we give them family intervention and individual therapy and are really careful with medications and give them support to keep them in school, or go to work, what happens? Can we really give them that for a couple of years and see if they do better? So, a bunch of studies were done all over Europe, all looking really good in the ‘9s. Well, not all looking good, but 90% looking good. And so, around 2006, 2007, several of our colleagues at the National Institute of Mental Health said, “Let’s try this in the US. It’s going to be hard because we don’t have a bunch of psychiatrists. We could just say give somebody this medication or whatever, but we’re going to go out to community mental health centers and we’re going to ask them, are you curious and interested in working with us to see if we can do the same thing they do in the UK? What’s now called coordinated specialty care,32
Dr. Glynn: which again involves family therapy, support for education and getting people jobs, individual therapy to help them cope better with their illness, and target medication. So there were two studies done, two very large studies done to show that yes, in fact, if people can have access to that kind of care when they first get ill, they can have better outcomes. And first we looked at two-year outcomes and they were better. And now there we recently published on five year outcomes and they’re better. That doesn’t mean everybody does well. Sort of like cancer in so far as a lot of people are going to get better if they have the right treatment. Some people were not, but more people get better with this treatment than if they just got what you traditionally get at a community mental health center, what we call customary care,33
Dr. Niv: the medication.
Dr. Glynn: Yeah. Medication, a little bit of case management. I should say that what also what I said about the coordinated specialty care, two other important parts of it I think that we didn’t specify as well, but are critical we’ve come to understand. One is case management. to help you meet your needs. The other is peer support. Having the opportunity for people with these illnesses, these problems to be able to interact with other people who have these challenges and have been able to develop rich full lives and often now work at the community mental health centers to be models and partners in recovery.
Dr. Niv: Gives a lot of hope, doesn’t it?
Dr. Glynn: Yeah, very much so. Very much so. I don’t know what people will look like in 20 or 30 years. But, you know, it’s a nice bookend because I started out by saying, you know, I had hope just watching for my family members. But now that you see this, you know, sort of coming to fruition with if people have a lot of support, they can have good lives.
Dr. Niv: Yeah.
Dr. Glynn: I I always say some of the people I work with, whatever, patients, clients, there’s so many names and it’s so political. But in any case, I mean, a lot of them have great lives. They’re married with kids and have professional jobs and you know not everybody but35
Dr. Niv: that they’re doing well.
Dr. Glynn: I just want to encourage people to have hope. That’s what
Dr. Niv: that’s a great segue to a few questions from people um from a Facebook group and I have to throw them out there again kind of related to how we started this is what are some resources for educating children specifically about bipolar disorder?
Dr. Glynn: I I have to honestly say I don’t No. Uh, I don’t know specific resources for bipolar disorder. I wish I did. There a a colleague of ours, Michelle Sherman, she’s written a couple of books um for young people sort of more along the lines of so your family member has a mental illness that are written for younger people. So that’s typically where I go.
Dr. Niv: So this person is asking, “What should I do to deal with my husband’s delusions? When I tell him he’s wrong or that’s not true, he just gets mad at me.”
Dr. Glynn: Yes. Isn’t that the truth? Yeah. Boy, what I would say, I’m going to speak on two levels. One, one level is it doesn’t seem to be effective to try to talk people out of their delusions. Okay? I mean, if I tried to persuade you something that you believed very fiercely in we know from psychology the concept of reactants people only get firmer in their belief so we don’t encourage that what I would encourage is empathizing with the feeling so if somebody tells you I’m sure somebody’s following us or I don’t feel safe in this restaurant or whatever you could sort of say gosh that must be hard or that I’m sorry you’re anxious you know maybe we’ll get our dessert to go or whatever um so you’re speaking to the a effect, the emotion.
Dr. Niv: So you don’t have to believe what they’re saying or agree with what they’re saying.
Dr. Glynn: No, you’re agreeing to the feeling that it must give someone. So I would say that.
Dr. Niv: And next question. Can someone with schizophrenia work? And if so, how?
Dr. Glynn: Yes.
Dr. Niv: So that’s a big question.
Dr. Glynn: So people do. Um I mean I again I think that’s like saying can somebody with back pain work? Right. So what I would say is there’s a particular kind of intervention called supported employment and education. And the kind of subset that really seems to work well is called individual placement and support. That’s an evidence-based treatment program that basically helps people identify a job they would like to get or a school opportunity they’d like to have and then helps them in small steps to get it. Does it work with everybody? No. But it seems to be if you take a group of people who are not working and you follow them for two years who are at a community mental health center and have a serious psychiatric diagnosis about 75% of them will be able to get a job
Dr. Niv: if they participate in supportive.
Dr. Glynn: Yeah, they have to say they want a job. Good point. We’re not miracle workers, but if they want to get a job, 75% can. There’s a group that are not and we do have colleagues um Kim and Susan have actually written a a book on this called thinking skills for work which is actually how to help the people who don’t benefit from these traditional programs. So what I would say is look around in your community and see if there’s a supported employment and education program. Go to the community mental health center and if not the other place to go is Voke Rehab because they can often help people get shots.
Dr. Niv: All right, I know we just have a few minutes. How do I get help for someone that refuses it? and How do I get divorced if they don’t get the help?
Dr. Glynn: Well, I’m not a lawyer, so I’m not going to be able to offer any advice on the divorce thing, but I would say get a good therapist.
Dr. Niv: I I think they mean maybe like how do I communicate that, right?
Dr. Glynn: What I would say is this. What we think is worth trying is not to tell somebody you’ve got to get help, you’re deficient in some way, however nicely we’re saying that, but instead to really try to find out what the person wants. Do they want a better job? Do they want a better marriage? Do they want to be a better parent? What’s the positive thing that they would like sort of irrespective of their illness? And then say, well, that’s the thing you can work on. We could find a therapist, we could find a group, we could find something who will help you on that. And now you may be totally aware the person has all these other problems. Okay, totally totally get that. But the way we think we’ll work is by trying to engage somebody in a recovery goal that they have. And then sort of just aligning with that with regard to the divorce, what I would say is this. You know, we know divorce rates and serious psychiatric illness are high. It’s a very, very big decision. Obviously, you haven’t left yet because you’re asking the question. So, my heart really goes out to you. I would say, and I mean this in all serious, I hope you have your own therapist, your own support that you can sort of talk to, and it’s got to be the right person. It’s got to be someone who can appreciate that you married somebody hopefully because you cared a lot about them and they’re having trouble now and maybe you will have to leave. I mean, that happens. But not to make you feel ashamed because you’ve stayed as long as you have, because you tolerated what it takes to love somebody with a serious psychiatric illness. And it can be hard to find a clinician who can do that. So you got to look around.
Dr. Niv: because the clinicians might judge that relationship, right?
Dr. Glynn: Well, the clinicians I mean it’s easy to say in that kind of situation you should get out and perhaps you should. I can’t make any statement about that. But the very fact you’re asking the question probably means you haven’t totally left yet. because you’re trying to figure out how to how to make it work. So, you need a savvy therapist for your husband or wife, whatever it is, and for yourself. Okay? And like I say, my heart goes out to you. And if there are kids involved, think about what we’ve said today about making sure your children understand that even if their parent has problems, they still have wonderful things about them, too.
Dr. Niv: One last question. If you had your magic wand that could change anything in the field of psychosis other than just a straight up cure. What would you want to change?14
Dr. Glynn: I think one is, and I know this is controversial to say, I wish the medications worked better. I wish the side effects weren’t so bad. I mean, I know that brings in the whole thing about is this even an illness. I’m very cognizant I’ve used that term today, but I can live with it. I wish people didn’t put on weight and feel sluggish and all that. So, I think that And then I wish there were less stigma. I wish people felt like the world wanted to see them and be with them.
Dr. Niv: Thank you so much, Dr. Shirley Glynn. I really appreciate your time, and I can’t wait to have you back here with you and could talk about more things psychosis.
Dr. Glynn: It was lovely. Thank you very much.
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