How to Understand and Treat Psychosis: An interview with Maggie Mullen, LCSW
Curt and Katie interview Maggie Mullen, LCSW, a national trainer on culturally responsive, evidence-based care for psychotic spectrum disorders. We talk with Maggie about their anti-racist and disability justice framework of psychosis, understanding psychosis on a spectrum, what to do when psychosis enters the treatment picture, assessment of psychosis, and treatment using Dialectical Behavior Therapy (DBT). We also talk about how society defines “normal” and pathology, exploring cultural differences in these definitions.
Click here to scroll to the podcast transcript.
Click here to scroll to the podcast transcript.
Interview with Maggie Mullen, LCSW
Maggie Mullen, LCSW (they/them) is a clinical social worker, national trainer, community activist, and author of The Dialectical Behavior Therapy Skills Workbook for Psychosis. Maggie specializes in culturally responsive, evidence-based care for psychotic spectrum disorders, trauma and PTSD, the LBGTQ+ community, and formerly incarcerated people. As a training director at Kaiser Permanente, they take great pride in mentoring, training, and supervising the next generation of social workers. You can find them online at http://www.maggiemullen.com
In this podcast episode we talk about looking at psychosis differently
We started the conversation on psychosis when we were looking at conspiracy theories. We know that folks who believe in conspiracy theories and those who have a diagnosis of psychosis are different, but knew that we needed a deeper dive into how to understand and treat psychosis. We dig deeply into this conversation in this week’s podcast episode:
Maggie Mullen’s anti-racist and disability justice framework of psychosis
“People with psychosis [are] being overly institutionalized… over medicated or highly focused on medication as the sole treatment. And particularly for our… black, indigenous, and folks of color experiencing psychosis, and people who are being shot and killed by police… when they’re out responding to their symptoms in a public way, or being incarcerated and not receiving treatment.”
- Maggie came from a community organizing background
- Inequity and lack of resources for people who experience chronic psychosis
- The focus on medication rather than other forms of treatment for psychosis
- BIPOC individuals being shot by police when psychosis shows up in a public space
“Psychotic spectrum” versus the segregation of psychosis as “other”
“We are often the least prepared to deal with our most acute clients”
- The continued segregation of psychotic disorders
- Cultural considerations when determining what is psychosis or other types of experiences
- The lack of inclusion of psychosis in the research
- Psychosis is not “other” but is actually a spectrum of behaviors and are very common
- The symptoms of psychosis are not constant, they fluctuate for every individual
- The importance of following the model and voices of the disability justice movement
- Including education on the treatment for psychosis, rather than allowing therapists to opt out
- Folks with psychosis are often not included in the research, which needs to change
What to do when psychosis comes into the treatment picture for our clients
“The reality is there are wonderful outcomes, I think, for people with psychosis, when we look at it from a different perspective. Which is to say – what if some of the work might be on changing your symptoms themselves? But what if part of the work is actually on accepting your experiences so that you can just experience less stress with them?”
- We need more training on psychosis to feel confident
- Normalizing the experience of psychosis
- Helping to make peace with psychotic symptoms (i.e., making friends with the voices) to decrease distress
- Looking at treatments beyond medication
- How to identify psychosis and assess for impact and impairment
- The myth that all elements of psychosis are distressing and bad
Why Maggie Mullen is using Dialectical Behavior Therapy (DBT) to treat psychosis
“People with psychosis deal with emotion dysregulation, actually more so than the average person…that’s where we know DBT is really effective”
- We frequently underestimate the ability to help folks with psychosis
- Using DBT skills for emotion regulation concerns that frequently come up in psychosis
- Psychosis and PTSD oftentimes occur together and aren’t always diagnosed
- Trauma can influence the onset of psychosis AND psychosis can be traumatic
- Maggie’s pilot program with DBT for psychosis
- The concrete and straight forward nature of DBT skills make them very accessible
Understanding psychosis differently, including the cultural differences of what is “normal”
- How to identify what is “real” and what is psychosis
- How do you define what is normal for someone?
- What do we decide what we pathologize?
- Breaking up the binary of normal or not normal – reframing as “experience”
- The importance of understanding what is negatively impacting the client and how to keep clients safe
- Take the lead of your client and trust that they know themselves best
- The tension between taking the lead of the client and mandates and requirements as a therapist
The Dialectical Behavior Therapy Skills Workbook for Psychosis by Maggie Mullen, LCSW
- Maggie wrote a book to democratize DBT skills
- Using DBT, but making the skills more concrete and accessible
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Who we are:
Curt Widhalm, LMFT
Curt Widhalm is in private practice in the Los Angeles area. He is the cofounder of the Therapy Reimagined conference, an Adjunct Professor at Pepperdine University and CSUN, a former Subject Matter Expert for the California Board of Behavioral Sciences, former CFO of the California Association of Marriage and Family Therapists, and a loving husband and father. He is 1/2 great person, 1/2 provocateur, and 1/2 geek, in that order. He dabbles in the dark art of making “dad jokes” and usually has a half-empty cup of coffee somewhere nearby. Learn more at: http://www.curtwidhalm.com
Katie Vernoy, LMFT
Katie Vernoy is a Licensed Marriage and Family Therapist, coach, and consultant supporting leaders, visionaries, executives, and helping professionals to create sustainable careers. Katie, with Curt, has developed workshops and a conference, Therapy Reimagined, to support therapists navigating through the modern challenges of this profession. Katie is also a former President of the California Association of Marriage and Family Therapists. In her spare time, Katie is secretly siphoning off Curt’s youthful energy, so that she can take over the world. Learn more at: http://www.katievernoy.com
A Quick Note:
Our opinions are our own. We are only speaking for ourselves – except when we speak for each other, or over each other. We’re working on it.
Our guests are also only speaking for themselves and have their own opinions. We aren’t trying to take their voice, and no one speaks for us either. Mostly because they don’t want to, but hey.
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Music by Crystal Grooms Mangano http://www.crystalmangano.com/
Transcript for this episode of the Modern Therapist’s Survival Guide podcast (Autogenerated):
Curt Widhalm 00:00
This episode of the Modern Therapist’s Survival Guide is sponsored by Buying Time
Katie Vernoy 00:04
Buying Time has a full team of virtual assistants with a wide variety of skill sets to support your business. From basic admin support customer service and email management to marketing and bookkeeping, they’ve got you covered. Don’t know where to start, check out the system’s inventory checklist, which helps business owners figure out what they don’t want to do anymore and get those delegated ASAP. You can find that checklist at buying time. llc.com forward slash systems stash checklist.
Curt Widhalm 00:31
Listen at the end of the episode for more information.
You’re listening to the modern therapist survival guide where therapists live, breed and practice as human beings to support you as a whole person and a therapist. Here are your hosts, Curt Widhalm and Katie Vernoy.
Curt Widhalm 00:49
Welcome back modern therapist. This is the modern therapist Survival Guide. I’m Curt Widhalm with Katie Vernoy. And this is the podcast for therapists about all sorts of stuff and just my continued ability or inability to introduce episodes well here but
Katie Vernoy 01:06
Curt Widhalm 01:07
Recently, we had an episode on conspiracy theories. We very, very briefly talked about the difference between people who are following conspiracy theories and psychosis. We did an almost barely adequate job of talking about it and decided that we needed to follow up with somebody could who could help us talk about psychosis a little bit more deeply. And so we have a guest today, Maggie Mullen LCSW w. And they are a fantastic resource when it comes to working with psychosis and very glad to have them with us here today. So thank you very much, Maggie, for joining us.
Maggie Mullen 01:49
Thanks so much for having me, Curt. And Katie.
Katie Vernoy 01:51
So glad to have you here. Like I told you before we got started, we needed somebody to talk about psychosis saw that you had sent in a little pitch to us. And we’re like, oh my gosh, this is perfect. We’re so excited. And I can’t wait to kind of get to meet you here on the podcast. But let’s, let’s have everyone meet you and say what we always say to all our guests, who are you? And what are you putting out to the world.
Maggie Mullen 02:12
As Curt mentioned, Maggie Mullen, LCSW I use they them pronouns. And I am an author and trainer. And what I am working right now to put out into the world is an anti racist and disability justice approach to working with people experiencing psychosis that really focuses on centering their experiences and needs. And one of the ways that I’m really going about that right now is by offering DBT informed treatment to people who are struggling with psychotic spectrum disorders like schizophrenia, schizoaffective, disorder, bipolar disorder, etc.
Curt Widhalm 02:43
You get into this work, that a lot of therapists have their own stories that just what’s your story as far as getting into working with psychosis, and really having this level of passion for it?
Maggie Mullen 02:59
So I come from a community organizing background, right, a lot of the work that I was doing before grad school was really centered around how do we bring communities together to fight for change. And I chose a path of social work, because I really wanted to have the opportunity to do both that macro kind of bigger level practice, but also help individuals because I was somebody who was able to connect with people pretty well and really enjoyed that part of the work. And as I was in grad school, learning more about mental health and kind of being in that part of the field, the thing I kept seeing over and over again, was the inequity and really lack of resources for people who are experiencing psychosis in a chronic way. And the way that, you know, that kind of shows up and at least at US, US society is, you know, seen people with psychosis being overly institutionalized, you know, really over medicated or highly focused on medication as the sole treatment. And particularly for our, you know, black indigenous and folks of color experiencing psychosis, and people who are being shot and killed by police, right when they’re out of responding to their symptoms in a public way, or being incarcerated and not receiving treatment. And for me, that just felt like a call to action to say, I want to get involved in this area that really needs to be expanded. And I think one additional piece is if you look at almost any piece of literature in our field, right? So if you’re like nerd like me, you want to go and do research about something. If you look into almost any psychotherapy treatment, you’ll see that there’s a rule out for participants who experienced psychosis. And that’s really widespread across almost all therapies. And I find this odd because the same type of like what we used to call delusional beliefs we now call distressing beliefs or distorted beliefs, those same types of things happen in other diagnoses, right? We see this in eating disorders, right? People who have such distorted beliefs about their bodies to the point that they’re willing to, you know, encounter significant health issues in order to engage in certain behaviors, right or even with depression, right, where we have distorted beliefs about your self worth to the point that you’re willing to hurt yourself. but we don’t exclude people so aggressively from treatment as we do with psychosis. And for me, that’s really kind of a question that I kept coming on grad school, like, why this group? Why are we segregating them in this kind of way that’s leading to, you know, high rates of suicide, high rates of incarceration, all those things that I mentioned before, that are just poor quality of life issues for these folks.
Curt Widhalm 05:20
So to ask maybe an obvious question here. Why, why what have you found out and asking this big question, what is our system have against psychosis? Is it fear from treatment professionals in the past? I’m sure that you’ve come up with some at least explanatory answers here.
Maggie Mullen 05:41
Yeah, there’s not one right answer, I think is part of this, right. Like, if we went back really far in history, one of the things that we would see is that across cultures, right, there are really different approaches to psychosis, right? We see in a lot of indigenous cultures, the idea that people with psychosis are actually, you know, accessing other states of reality, and that scene is a strength, right? And something that’s really valued, right, like people who are medicine are healers. And we don’t see that particularly in white society in the US, right, where we’re really have kind of more colon colonized mindset. But I think a lot of this comes from fear, right? Just the idea that I don’t understand maybe what’s happening to this person, they’re behaving in a way that’s, you know, erratic in my eyes, when it can’t really get into their, you know, headspace and understand what they’re experiencing. And I think that’s part of how our field is responded, because if we look back at Dr. Aaron Beck, right, the creator of CBT, who just passed recently, he was doing trials of CBT, with people with psychosis back in 1950s. And for some reason, and I don’t know all the reasons why his research kind of stopped around that point, right, kind of hit a dead end. And then we just kind of started offering these things to people with more like depression, anxiety, etc. I think part of this is just again, that fear that you mentioned, Curt, more than anything, unfortunately,
Katie Vernoy 05:45
when we look at this, there are folks who try to exclude psychosis from their practices, especially private practices. But we can’t always exclude it. Right? Like there are times when it comes into our office, we’ve an established relationship with the client, and we can’t always exclude and I’m not saying that we should always exclude it. I think that’s part of the problem. But when we don’t when we actually start working with psychosis, because it is so… I don’t even know what the right word is…kind of fringe, maybe to our profession. I mean, I even think about I know you do DBT for psychosis, I’ve talked with DBT centers that say if they have psychosis, they shouldn’t be doing DBT. I mean, like, there’s, there seems like there’s not really guidance, when whether you invite or exclude psychosis, when it shows up in your office, it seems like there’s there’s an opportunity for us to really do it wrong. And so I mean, typically, we asked what a therapist get wrong. So I guess I’m asking that question. But I, I’m trying to sort out kind of even how to get to the correct question, because it seems like part of what we get wrong as we exclude these folks from our practice. But if they show up, I imagine there’s stuff that we’re really getting wrong in the room and in the treatment planning.
Maggie Mullen 08:18
Yeah, I think part of this is that combination of we need clinicians to have more training across the board and treating psychosis. And again, I think with these newer wave therapies, like CBT, for psychosis, act for psychosis, more DBT skills kind of approach that are really emerging as very strong in the literature and really effective for people. And that are offered, but just not I think, in a very widespread way, again, at least in the US. And so I think part of it is we need clinicians with more training, so they feel more competent. And I think part of where we get things wrong, is that we think of psychosis as like these people over there, right? We kind of again, like you said, kind of put them in like a box segregated in some way. And the way that we really approach psychosis now in a kind of more modern or progressive sense, is that there’s really a spectrum of psychosis. Right. On one end of the spectrum, we see people with less distressing less bothersome experiences of psychosis. And that for like, for me, for example, that looks like I’m on call for my work every once in a while, and I My phone has to be on 24/7 because I might be calling the emergency room to do an evaluation. And what will happen to me occasionally is I will think I hear my phone rang, and I will look down and I’ll see no miss call, right? And I’ll like say to my partner like hey, did you see Did you hear my phone ring? And they’re like, No, that’s an experience of an auditory hallucination, right. I’ve just had experience of psychosis. And on the other side of the spectrum, we have more of these distressing chronic life impairing experiences like psychosis that are more common for people who get diagnosed with schizoaffective sorta are psychotic spectrum disorder of some kind. And people who experienced those diagnoses fluctuate on the scale in the same way, right? That they are doing better at certain points, or their symptoms are not as distressing, etc. And part of the reason we frame it in this way now is to normalize the experience of psychosis that at some point, almost all of us will have some experience of psychosis. And I think when we look at it from that perspective, it feels less scary to approach psychosis. And I think also it can instill some hope that I think a lot of therapists don’t have when they work with psychosis, right? We feel like, it feels hopeless, nothing’s going to change, things are not going to get better. But we get training, I think and experience in that way. And the reality is there are wonderful outcomes, I think, for people with psychosis, when we look at it from a different perspective, which is to say, what if some of the work might be on changing your symptoms themselves? But what if part of the work is actually on acccepting your experiences so that you can just experience less stress with them? Right, so how do I make friends with my voices? So they don’t bother me in the same way? Or how do I have to, like, do education with somebody’s loved ones and families or societies to accommodate the fact that this person may need to, you know, do certain things to manage their psychotic symptoms, right. And that’s just a normal part of their experience, rather than a pathologized experience. So I think these are ways as therapists that we have been getting things wrong historically. But we also know that there’s plenty of ways that we can shift that with training with education, to make ourselves feel more confident doing this work
Curt Widhalm 11:37
The longer that we do this podcast more than I recognize that maybe my graduate training was not the greatest. And I’m trying to recall back to the way that we were educated on it. And it just seems to have been like one class in like the the psychopathology class that was just kind of, here’s defining what it is. And if you ever end up working on it, then you’ll get trained at your site. And it really kind of allowed for opting out of even having to learn about it. And my experience across time has been that it still shows up in my office that clients still present with this kind of stuff. Where do you see, you know, if my experience is really bad, where do you see graduate education needing to go as far as removing some of this fear or other ring of psychotic spectrum as a thing that needs to be feared?
Maggie Mullen 12:43
I think it starts with following the model and the experiences of the Disability Justice Movement, right, I think the thing that we can do first and foremost, is bring in the voices of people who experience psychosis themselves, right, have this lived experience, into our education or classroom settings. Because it’s one way that we, I think, with any kind of stigma, right, that’s out there is that through more dialogue and experience with people who are living with this, you know, whether we call it condition or experience or whatever, the more comfortable we get with it, the more normal it becomes to us. And so I think it’s starting there and in the education and kind of classroom settings to reduce that kind of othering. And then, in addition to that piece, I think, again, it’s the part of actively including, and teaching the treatments for folks with psychosis, and not acting like we can opt out of it. I think one thing I find, with therapists, not across the board, but oftentimes, is that we are often the least prepared to deal with our most acute clients, right? So we are often trained really well to work with people with, you know, garden variety, depression and anxiety adjustment issues, etc. The word Well, exactly right. And we don’t get a lot of trained, I think that is very quality for people who are chronically struggling and dealing with things that are acute and very difficult for them very distressing. And I think that’s part of where our education and our schools needs to change is to shift away from, you know, exclusive treatment of worried well, and really integrate the bigger spectrum of mental health and well being overall,
Curt Widhalm 14:20
to maybe even further add to this is not necessarily treating psychosis as something that just needs to be medicated away, which has been historically just kind of where well, you ship them to a psychiatrist, and that’ll take care of the voices.
Maggie Mullen 14:38
Absolutely. Yeah, I hear that even for my colleagues, right, who work in my clinic have the idea that like psychosis is actually easy to work with because it’s on the psychiatrist right to do that work. It’s not really on us. We’re just chasing them around getting them on medication. But as you’ve probably experienced in doing any of this work yourselves, many people with psychosis struggle with medications as an intervention, right? That can be life changing. For a lot of people, and for other folks, the side effects that come with them, you know, are so impairing that they’re like, I don’t want to do this right or, or I’m scared to do this or whatever it is because they can really change your life, your health outcomes, and even just the longevity of your life. So when we rely exclusively on that stuff, it really denies people the ability to build a life worth living, but isn’t just, you know, kind of circled around medications as the only treatment
Katie Vernoy 15:26
Well, even in and how you’re talking about psychosis, it just really puts a different flavor of it for me with this whole idea of a spectrum of psychosis. And to me, I mean, if we’re really looking at auditory hallucinations, like hearing the phone ring, but it hasn’t really wrong, or, or even, you know, kind of some of these really distorted thoughts that come up and these delusional beliefs that we have about ourselves that happen in, you know, even kind of garden variety, depression and anxiety, it seems like assessing psychosis would actually be much more complicated. If we’re really looking at the full spectrum of the experience. What is your advice as far as identifying, you know, kind of what, what requires or what would be helped by this knowledge around psychosis?
Maggie Mullen 16:16
Can you answer a different way, Katie?
Katie Vernoy 16:19
Yeah, I guess I’m just asking, basically, how do you assess psychosis when it’s not kind of this florid psychosis? How do you how do you actually assess psychosis with this idea of a spectrum of psychosis and psychotic experience?
Maggie Mullen 16:38
I think it’s really dependent on the level of distress and impairment and causes in somebody’s life. Right? Like with all things, when I think about if you’re doing really good assessment for any mental health issue, and psychosis is no exception. It’s like, how is this interfering with your goals? And the things you want to be doing with your values, your ability to do what you love? How is this in terms of the emotional side of it, right? Like, how much distress how much upset is this causing you, etc. And getting a really clear picture from clients around those pieces, I think can tell us whether we what level of intervention we need to kind of do. Because again, I think one thing that providers often do is we also kind of do the other extreme, which is to assume that if you have any experience of psychosis, it is distressing, and it’s bad, right? Like we need to get rid of it. And I think a lot of people who have lived experience of psychosis will tell you, I actually find that there’s some very comforting parts of my psychosis, right? Like, maybe I hear the voice of my mom talking to me who passed away or some other loved one, right, or, you know, something that can feel like it’s just reassuring to them. And so when we need to when we’re doing these assessments, we want to also be integrated in what’s the problem and what’s actually quite adaptive and works for your life instead,
Curt Widhalm 17:51
So why DBT for psychosis
Maggie Mullen 17:54
So in thinking back to the part about like, where researchers and mental health people got it wrong. So for a long time, providers assumed that people with psychosis didn’t experience emotions in the same way as people who were maybe more neurotypical because they weren’t expressing their emotions through their effect or their body language, right. And a lot of that has to do with negative symptoms, which are part of that spectrum of psychosis. And what we now know is that people with psychosis deal with emotion dysregulation, actually more so than the average person, right? So they’re dealing with overwhelming emotions, that are sometimes triggered by their symptoms, right. So if you have a critical voice telling you, you’re a bad person, that’s going to cause emotion dysregulation, we’re going to get emotional, sure, and kind of the cycle that can happen where then you might experience more psychosis, right? More symptoms, because of an increase in emotions, so kind of becomes a cycle. And what we know to be true is that people then cope with that emotion dysregulation the same way that somebody with, you know, BPD, who’s in treatment for DBT, like do which is self harming suicide attempts, substance use, etc. And so that’s where we know DBT is really effective, right, based on both the literature, the research, but people’s lived experience around it. And so the idea with how we use DBT skills, and I say DBT skills, because we’re taking an informed treatment approach, we’re not necessarily doing a full DBT treatment program, although that is appropriate for some people with psychosis. We’re thinking, let’s break that cycle of again, emotions and symptoms kind of escalating each other by using something like distress tolerance skill, or an emotion regulation skill or mindfulness to help break things up and help reduce your distress.
Katie Vernoy 19:44
It seems to be completely logical that that would be the case like and my experience of working with some clients that had different different diagnoses on the spectrum of psychosis, and I also in my experience, if in any way was was aware of oftentimes trauma histories as well as is that? Is that relevant to this conversation?
Maggie Mullen 20:09
Absolutely. Yeah. Thanks for bringing it up. So one thing that I think is, or I don’t think I know is very common amongst people with psychotic spectrum disorders is PTSD. So not just experiences of trauma, but experiences of trauma that are continuing to impact our life in a really significant way. And right now, we think about a third of people with schizophrenia have PTSD, which is a very high number. We actually think it’s probably higher, though, because clinicians tend to not assess for PTSD very commonly. And clients don’t tend to also report those symptoms very actively when they’re not asked. So when we think about, again, what clinicians might be missing, it’s important that we assess for that and, and part of how we think about trauma with psychosis is that it’s really common for people with a psychotic spectrum disorder to have, you know, childhood trauma, so some kind of trauma from growing up. That might be one of the contributing stress factors in the development of psychosis over time. And we also know the experiences associated with experiencing psychosis are traumatic, right. So for example, we talked about the idea of like being incarcerated or being taken by the police in handcuffs to go to the hospital, right, that’s a traumatizing experience for a lot of people, particularly for people of color. We also have, you know, being mistreated in hospitals kind of being warehoused there for long periods of time. And then certainly just the experience of psychosis itself, right, when you’re just oriented and you’re, you know, kind of separated from reality that can be really scary for people, right, we might do things that are out of character for ourselves. So trauma is a common experience, I think, for people with psychosis. And secondarily, there’s really great treatment for people experiencing PTSD who also have a psychotic spectrum disorder. But it’s really uncommon for providers to offer it because of fear, I think, again, to what we were talking about earlier. And we know, I think more so part of what we see the literature and research changing is that we are including more people with psychosis and studies now than we used to before. So for example, we see a lot of the new prolonged exposure, which is, you know, one of the gold standards for treatment of PTSD, that if somebody has relatively well controlled psychosis, so they might experience some active psychosis, but it may just not cause strong levels of distress. They’re a great candidate for PTSD treatment. And same thing for cognitive processing therapy or CPT as well.
Curt Widhalm 22:31
Over the couple 100 episodes or so that we’ve done, we’ve had plenty of guests who come in and speak very well about their their target populations. But I don’t think that we’ve had people like you who’ve actually piloted programs that back up that this is just beyond kind of the here’s something that I’ve experienced a lot in my office and done well with, can you talk about what you saw as an opportunity with the program that you piloted?
Maggie Mullen 23:00
Sure, so I was trained as a DBT clinician, that’s like my bread and butter as a therapist and working in a fully intensively trained DBT program. And I like live and breathe DBT, like, I am one of those DBT nerds that you hear about in grad school. And I think I felt like I was working, you know, as a DBT therapist, but also working a lot with people with psychosis in a in a kind of a treatment program. And there was this weird separation where we saw like, these two worlds being again, just very disparate, and not a lot offered between them necessarily, even though again, for people with borderline personality disorder who are really well treated by DBT. A lot of them actually experienced psychosis as part of their symptoms. And so what I did, essentially, with the encouragement of my colleagues was to say, why don’t we just try to offer some of these skills to our clients and see how they do with them, see if they’re practical enough, if they’re concrete enough, which is, you know, important for people who might be experiencing chronic psychosis to be able to use them. And I really did this in conjunction with cognitive behavioral therapy for psychosis, right. CBT for psychosis has a really strong evidence base. And so I felt like, let’s address this cognitive piece that CBT is really good at, but also integrated behavioral piece of DBT. And our clients loved it. Like it was actually kind of overwhelming the response that we received, as well as the outcome studies that we were doing around clients talking about how they were using those skills, and what that what that was shifting in their life, essentially, to feel like, not only do I know how to shift my thinking, but I can do something differently about it. And the thing about DBT skills that maybe no one will tell you is they’re very straightforward, right? There are a lot of things people are already doing. Right? So self soothing, right? Many of us self soothe in many different ways, right? we distract ourselves, right? We use all of these skills, I think in many adaptive ways. And part of the work I think of integrating DBT skills is saying, Okay, do that intentionally now, right like don’t just Do it as a background thing, but like think about what do I actually need right now that I’m feeling distressed? Because of the voices I’m hearing? You know, do we need to practice? You know, tip, right, which is a common skill in DBT when somebody is really distressed? Or do we want to practice opposite action here, because you’re feeling some unjustified emotions, for example, and really just getting people to practice those in a more active way.
Katie Vernoy 25:20
I guess I keep going back to this notion that psychosis is not something that is separate, although I think there are programs where folks end up that are separate, like a day treatment program, those types of things, but oftentimes, even in those programs, it’s folks that have had pretty intense emotions, intense suicidality, you know, there’s, there’s a reason that they’re there, it’s doesn’t always mean that every single person in these day treatment programs have psychosis. But regardless, I think that the, the thing that I keep coming back to is this idea around looking at psychosis differently. And when we do that, it opens up all these other treatment options, because we look at as folks who have this element, and not “them”, when you were talking about the way that other cultures look at psychosis, and the ways that folks who are having some of these experiences are, are seen as whether it’s a medicine person, or someone that has insight in a different way. Or there’s, there’s different things where, you know, people are in touch with different parts of reality. I think about religion in the United States, and the similarities with that, and how people will hear God, they’ll they’ll, you know, they’ll see signs, there’s, there’s a lot of things where there are pieces of things that are kind of acceptable, and culturally appropriate. And there are things that are seen as other and I’m just curious, because you talk about kind of your your background and the way that you’re perceiving psychosis, and it seems like it would be very hard. And maybe this is what I was trying to get to earlier with the assessment question, but it seems like it’s very hard to identify, in some cases, what is real? And what is psychosis? And so the question I have is, again, kind of like, how do we sort through that? How do we sort through? Is this a cultural experience? I mean, I think earlier, you said it was more around, you know, kind of distress. But sometimes having these things that are culturally appropriate are very distressing, you know, you get messages from God, or you get messages from other sources that are very distressing to you. And so how to how do you grapple with that when you’re really trying to honor the experience of the person and sorting through whether it’s psychosis or whether it’s something else?
Maggie Mullen 27:48
I think one of the questions that you’re kind of getting at is the question of like, how do you define what’s normal for somebody?
Katie Vernoy 27:55
Maggie Mullen 27:56
Yeah. And I, this is a question. I think that is when we like really backtrack as mental health professionals to the idea of like, what do we pathologize? And what do we consider normal? It’s really hard to do our jobs to some extent, because the DSM is, right, kind of almost based on the idea that there are certain things that are not normal. But
Katie Vernoy 28:17
Maggie Mullen 28:17
normal is really relative, right, based on culture based on history based on so many different parts of our experience. So it’s, it’s a little bit hard to answer that question, because it’s a real philosophical one, in a way.
Katie Vernoy 28:28
Maggie Mullen 28:28
I think that is what informs our approaches, different providers is like, where do we come from? And our background of how we approach this type of stuff, again, of the idea of like, is there anything that’s normal. And so I think when I see like this disability justice pushing around this piece, that’s the part that really aims to sort of break up that binary of normal or not normal and say, like, this is all just experience. And again, the part that becomes how we assess things as clinicians is when somebody tells us this is a problem for me, or this isn’t normal for me, right? Or this is scaring me, for example. And that’s when we treat things with that kind of lens. It’s complex. I think, in many ways, though, because for example, if I have somebody who is experiencing mania, they’re not going to tell me something as a problem, oftentimes, right, you know, kind of, again, is a kind of generalization. When people experience mania, oftentimes, they feel amazing, right? They feel very on top of the world, not all the time, but for many folks. And they don’t want an intervention at that point. And the thing that I’m always weighing right is the idea of, can you be safe at this point, right? Like art, what kinds of risks are you taking, for example? And what are ways that like, I need to intervene to help you just live your best life but take more of a harm reduction approach here, right like to keep you on track so that you’re doing okay, the least amount of harm happens. But it’s I think it’s very tricky because so much of this stuff is relative and I honestly don’t know if I have a great answer to Your question because of how murky things get around this piece. And so I think maybe my best advice around it is to say, take the lead of your client and know that they know themselves best and will inform you if something’s an issue.
Katie Vernoy 30:12
Yeah, yeah, I think the the thought process that I’ve heard a number of different times and in my travels and learning about psychosis, is being able to inhabit the world where your client is, and then kind of slowly assess what is real and not real with the client from the clients perspective. And, and to me, I feel like that can be very, very challenging, because I think there’s so much bias that comes into how we perceive the world that it’s can be hard to truly take the lead of the client, do you have advice on how to how to do that when when it’s not like, Oh, you have a different opinion for me, but it’s like, Oh, your, your reality is different than mine.
Maggie Mullen 30:54
It’s tough. It’s really, it can be very challenging, because again, we have two different systems of training, right. So like, I have my beliefs around strengths based approach, following the lead of the client, like they are the expert on their own life that we get. And then there are things like being a mandated reporter, right, and like, needing to assess for risk and safety and things that my agency requires. And those are often at odds with each other, I think with a psychosis with the idea that I approach that really, by trying to be as transparent as possible with my clients coming into treatment around what their experience might be like, and maybe the way that I’m documenting things in my notes, right, and like trying to more educate them and say, Okay, so your doctor is going to talk about your delusions, your ideas of reference, etc. Here’s what that means. Now, what’s the language that you and I are going to use to describe that type of stuff that is affirming to you, and that is recognizing your experience as unique? And I try to take a bit of that perspective around all of this, because I think we can’t necessarily fight the existing system. We have without I think, like working around it in that kind of way. So I don’t know if that answers your question. Exactly, Katie,
Katie Vernoy 32:07
Yeah, no, that totally answers my question. Thank you.
Curt Widhalm 32:09
And I think your last couple of answers have really demonstrated why the DBT approach to psychosis fits so naturally, yeah. And I think is where your book probably just came very naturally in this whole process.
Maggie Mullen 32:27
It did it well. And I’ll tell you, I didn’t start out to write a book. Because I don’t know, I didn’t ever think of myself as somebody who’s a writer, or even frankly, like training. But I got recruited to write a book because I was doing something it was a bit more innovative in this approach to working with psychosis. And the funny part is, one of the things that came up really frequently, just as kind of an aside is getting messages about people with psychosis don’t read, right? There isn’t a market for this. And it first of all, that’s, that’s very discriminatory. Yeah, for lack of a better term wrong. It’s awful. And I think part of the reason people assume that A is because of stigma, and you know, wrong beliefs about people with psychosis, but also because there are literally aren’t any other books written for people that are self help books for somebody with psychosis. And, you know, we have a wonderful books on the market for loved ones, or families or mental health providers working with psychosis, but almost nothing that is geared for the experience of somebody with a psychotic spectrum disorder to say, you take control of your own experience, right, you get to be educated and learn and be offered skills. And I think in particular, with psychosis, the other thing that we know is that most people with psychosis don’t get mental health treatment, right, they don’t either have access to it, they don’t want it or they don’t have providers who are, you know, competent in providing, as we talked about before. And so this book, obviously, is not a substitute for therapy. But it’s a way to really, I think, democratize these skills to say, I want to get these out to you in a form of offering that’s less than $20. And so I always encourage people to seek treatment as part of that book. But this is just one way to kind of get that message out there. So that’s part of kind of the journey that led me to writing the book is just wanting to make sure people had access to these skills one way or the other, essentially,
Katie Vernoy 34:16
are there differences and how DBT skills are used when you are learned when you have psychosis as part of the the makeup.
Maggie Mullen 34:25
So the actual skills themselves are really identical to Marsha Linehan’s work, right. And I really respect her work. And for me, I did not want to stray away from what the model is because the model is really effective. We’re seeing more research now around full DBT treatment programs serving people with psychosis, but that’s still kind of emerging literature. And Marsha Linehan, and her book actually even talks a bit about that. But to go back to your question, I think, part of what we do need to do when we’re kind of, you know, adapting or kind of shifting. The way we teach DBT skills for these clients is to do a few things. One is to make them really concrete. so that there’s just really straightforward information, there’s not a lot of psychological jargon, right? Things that are just very straightforward. We also want to make sure that whatever we’re offering is accessible. Because, you know, as we talked about a little bit before, you know, rates have been on, you know, for example, like SSI, so like being on a fixed income are really high amongst people with psychosis. So people don’t have a lot of money. A lot of folks are marginally housed don’t have stable housing or food access. And so we want to make things that are really accessible, right? You know, there’s a DBT skill about going on a brief vacation, for example, we have to talk about, what does that actually practically look like in the life of somebody who has who’s getting 700 ollars? a month, right? Like, what does that look like? So we want to adapt the examples to actually be a reflection of their personal experience as part of that as well. But otherwise, I think the skills really kind of match on well to the experience of psychosis.
Curt Widhalm 35:53
We’ve mentioned your book a couple of times, I think it’s fair for us to actually name it. So dialectical behavior therapy skills, workbook for psychosis. We’ll put a link to that in our show notes. But where else can people find out about you and the work that you’re doing?
Maggie Mullen 36:12
So first is my website, which is Maggie mullen.com. I’m on Instagram. I’m working on building that following. It’s Maggie Mullen, LCSW W there. And those are the main pieces you can contact me and reach me my direct contact information is there. I really am trying right now to put the work out again of this more progressive approach to treating psychosis into the world and doing a lot of consulting and training with agencies. So that’s definitely something that I’m always excited about doing with new folks.
Curt Widhalm 36:40
And we will include links to Maggie’s websites and Instagram handle over in our show notes. You can find those at MTS g podcast.com. And you can follow our social media come and let us know about your experiences and getting trained or poorly trained in working with psychosis. Come in and be a part of our Facebook community, the modern therapist group, and until next time, I’m Curt Widhalm with Katie Vernoy And Maggie Mullen.
Katie Vernoy 37:10
Thanks again to our sponsor, Buying Time
Curt Widhalm 37:12
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Katie Vernoy 37:41
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