Hi, Dr. Malsberg. I see you're in the office today. Am I allowed to mention that? We don't have video on this podcast.
Oops, sorry. That's okay. We'll make do. The audio might not be as good because we're in the office, but it should be tolerable.
Yeah, well, you got a lot of diplomas, it looks like, behind you. I hope they're all yours.
Not a single one is mine.
Well, it's nice to borrow office once in a while.
So what are we talking about? I haven't even picked up my diploma from residency. Are you serious? No. Legally, I'm not sure if I- You really got to pick that up.
It is important in the future. It doesn't seem like it is, but it is.
Yeah, we'll deal with that later. Right away. So yeah, last time we talked, well, we started planning to talk about forensic psychiatry, and then we stayed on topic more so with agents of treatment and then some comments on involuntary commitment and thinking about it. I think we're gonna do the same thing today where we're trying to start with what forensic is. And I have a feeling we're gonna find one subject that we stick with.
Did we already talk about what forensic is? Quick recap, forensic psychiatry is not correctional psychiatry. Forensic psychiatry is the application of psychiatric expertise and knowledge to legal questions. But I guess what I wanted to talk about was what I've learned from practicing as a forensic psychiatrist, which is probably more important to most people. And probably the main one that we didn't get to last time is that in forensic psychiatry, you are basically an independent expert.
At least you're supposed to be. Not everyone necessarily operates that way. But your job is to give advice and to lend expertise to in a pretty much neutral fashion rather than putting weight on the scales in one direction or another. That's the platonic ideal. And I would say that it's important in clinical psychiatry to feel and think the same way when it comes to working with patients.
Yeah, it is such... I really have no idea what it is a forensic psychiatrist does day to day. My biggest exposure, funnily enough, is... Do you remember the Amber Heard-Johnny Depp trial?
Yeah.
That psychiatrist who... To me, if... It felt so silly what he was doing. From my perspective, which is comically uninformed in regards to forensics and the legal system. He was saying because the person had risk factors for narcissism, that he has narcissistic personality disorder, which puts him at a higher risk for interpersonal violence. To me, it felt like, I don't know, slapstick psychiatry being used for legal matters.
So, you know, that's interesting. That kind of... presses on my other point. And there's a saying that, I mean, it's certainly not my saying, but when I think about the practice of psychiatry and forensic psychiatry, I like to remember every idiot can have an opinion. Okay, and that's a good example of someone giving an opinion that maybe wasn't so good. Now, the caveat here is I didn't actually follow that.
I only heard about it secondhand. But one thing to keep in mind when you look at high profile televised cases, and experts. This is just a suspicion on my part. I don't think for the most part, reputable experts of any stripe, any specialty will sign on to such high profile cases because the risk benefit is so poor. OK, if you want to just make money, you can just take some kind of a high stakes civil case that no one's ever heard of where there's many millions of dollars on the line.
OK. But putting your name and your face out there on some single case that could potentially ruin your reputation, the risk benefit is not theirs. I get the feeling that only relatively feckless experts show up on those high profile cases, though I saw a little bit of depth expert who seemed to be pretty good.
um yeah i guess that's the part that confuses me um you know because i guess so much of psychiatry is subjective we don't really know much about anything i know maybe i'm just being a little bit too nihilistic in regards to uh how much we know about psychiatry but um you know there's such a difference between using psychiatric knowledge to help a person versus using psychiatric knowledge to make a judgment on right and wrong and whether or how long someone should be locked up like those are very very very different things and it's scary with my understanding of how little we know about psychiatry having that influence uh legal matters
Yeah, I mean, I think that's an extremely salient critique of how legalists and legislatures have chosen to use medical expertise for social policy and for all kinds of judgments. That's kind of a separate discussion, maybe. But I would just say that broadly what I mean by every idiot can have an opinion and that you're an independent adviser. is that because psychiatry is so fuzzy, it's especially important that forensic and general psychiatrists know exactly what is based in science, what is based in clinical experience, and what is not.
Because if we try to apply our field in a reckless way, in a way that doesn't make much sense, that's further discrediting our already easily discreditable field.
Yeah. And, you know, one thing that's I guess I'm not sure if most people are aware of this, like if I wanted to, I could. find a provider to give me any diagnosis i wanted to tomorrow i know it sounds silly but so as someone with no you know psychiatric diagnosis i could find someone and depending on how i bent the facts uh could almost guarantee i could get you any and opposite diagnosis possible tomorrow if desired that's right which is scary with regards which is i mean like you know for individual treatment that's My opinion on that doesn't matter that much.
But for legal matters, to me, that's kind of odd.
I think it matters more for individual treatment. I mean, these are everyday people's lives. People are coming in. They have ideas, correct or not, about their problem. They want that problem fixed. You know, it's the difference between years of disability, impairment and distress and getting better or at least reasonably better than they used to be when they were suffering in a matter of months. The difference can be that stark, I think, if you're practicing correctly.
And so that's what I mean when I say remember your role and remember your limits. And when you give an opinion, when you have a conclusion, a clinical conclusion for a patient, you better have that on a good basis that you can explain to a neutral audience. And they would look at it and say, hey, you know what? That makes sense to me. Okay. Instead of thinking, exactly how did you get from A to B to C to D, the way that you were feeling when you saw the Depth V Herd expert work, right?
You're like, what exactly is going on there? The premises are weak. There's no logical connections between the conclusions. Okay. And so if any idiot can have an opinion and you're any idiot as a clinician, then I hope that you can actually lay out the facts For a patient that you can draw the facts out of the patient and then make some connections with the patient in a way that they can go like, you know what, you're not just any idiot.
I agree with that opinion. So that's what I mean when I'm emphasizing that psychiatry is really even in clinical work about independent advising and proving that your opinion has any worth.
Yeah, and I guess I've always had this illusion that, I don't know, when it comes to legal cases, you can find a psychiatrist to get you any of those diagnoses. So I guess I imagine that lawyers are going to have psychiatrists that they know are reliable. So I guess as an independent advisor, is there not a particular pressure to give a certain diagnosis? I don't even know what the behind-the-scenes look like.
When you're called in, what is it...
Yeah, I can speak a little bit about that. My impression anyway, in my personal experience, is that there aren't really so many people who are just outright hired guns. People who detect knowingly what the attorney wants in terms of opinion and gives it. I think that there are just more and less talented evaluators and there are more and less... resistant to social pressure evaluators. Okay. So if you want an expert who will sit there and nod and listen to anything the evaluee says, I have space aliens in my head.
They torment me day and night and that's why I killed him. Wow, this guy has psychosis. You can find that expert because they're out there working and they can still get work because if you want that kind of opinion, you can go get it. But if you want someone that actually makes a full analysis of the case and weighs the alternative options and looks at the evidence for that and shows you why one seems to stand out against the rest as the most likely, you can find those experts too.
And in the end, it does rely upon... the S. legal system being adversary, right? One side wants to do one thing. The other side should want to do the exact opposite. And so it relies on if this side produces a really bad opinion, then the other side should read it and go like, you know what? I'm not buying it. I'm going to get my own expert. So there is only so much utility to bad opinions.
And Over time, if you're a forensic psychologist or a psychiatrist and you're not reliable, people are going to find out. They're going to know. I bet there are ones that don't know they're not reliable, but everyone else knows.
Now, I don't want to come off as anti-psychiatry, but the thing that worries me is that the paradigms of psychiatry sometimes aren't particularly good. There are trends and the beliefs that are currently in psychiatry to me are missing the I don't know, the truth isn't the word, but they're... I guess what I'm saying is there's such major trends in that, like, you know, ADHD is all the rage.
And then you have complex PTSD is all the rage. And, you know, 10 years ago, it was something different. And 10 years before that, it was something different. Like, these things feel like trends. So... How are they influencing the legal thing? Like, I guess when I said earlier that it doesn't matter for clinical care, it's like the trends come and go. But making a decision like the legal system is supposed to be getting at the truth and what's occurring.
So it's you can't just follow trends. And I guess I have a tough time with understanding that. I don't know. That was weird.
I don't think that's strange at all. I think that's a very rational question. concern. First of all, I guess I'm not so sure the function of a judicial system is to get to the truth. I think the function of a judicial system is to resolve disputes first and foremost. You know, we hope we get to the truth. We try. I don't think we should delude ourselves in any walk of human life.
This is more a philosophical statement about humanity in general. I don't think we have fundamental access to the truth. We just try our best. Why? do trends happen and how do they impact societies well we're not free of that there's always going to be trends you know we've got the trend of trauma we've got the trend of bdhd we've got the previous trend of bipolar right uh there's not much that can be done about that um i would say that in the legal system in the us uh we at least have the benefit of tradition you know uh precedent and And properly run systems, that tradition, that precedent and the people who know it and feel and think about it and act accordingly are a guardrail against trends and are guardrails against attempts to do things in a new way that are not appropriate.
That doesn't always happen. Right. But it is something that's possible. And when you don't have that knowledge and intent to follow traditions, you can run into problems. I'm reminded of a case out of Oklahoma. Now, the insanity defense. traditionally excludes antisocial personality disorder. Everyone who has been trained appropriately and understands fundamentally why the insanity defense exists and who it applies to knows that it cannot apply to antisocial personality disorder because antisocial personality disorder is essentially criminality.
And the purpose of the insanity defense is to excuse someone because they were not acting due to criminality, but because of some other qualifying mental disorder. Well, apparently in Oklahoma, they did not have enough experts or people of knowledge on one case to be aware of that. And there was a guy who got he qualified under some ruling for the insanity defense under antisocial personality. OK, completely inappropriate.
So, you know, what actually happened was, well, I don't think they could undo that, but they did end up having to put into the law, the written law. Excluding antisocial personality disorder, where in many other states and locations, it was the experts and, you know, the legalists just knew that it was not qualifying.
Yeah, it's quite silly that they were able to be determined not to be responsible because I mean, if you use the antisocial personality as essentially, you know, there's a criminal personality in some sense. Like, it's so ridiculous that they were able to get off because they're a criminal. Yes.
Yeah. So things bad things happen. Life is imperfect. You know, we just try our best.
Can you explain to me what the, sorry, the insanity defense, like when it applies and who it applies to?
Okay. You know, you're catching me off guard here on all my slides, but essentially there is a traditional rule starting from England where it was, you can be found not guilty by reason of insanity and If you don't understand what you were doing, OK, and or or you don't understand that it was right or wrong. OK, so you don't understand the wrongfulness or the nature and quality is the specific language they use.
And that then the reason why you don't understand has to be because of a mental illness, not because of your personality. So if you're a psychopath, antisocial and you don't understand right from wrong because you don't care, doesn't qualify. That was the framework for a long time. There have been attempts to get a little bit more granular and also to loosen it. There was a movement to make it so that if your behaviors at the time of the crime were the product of a mental illness, then you could qualify for an insanity defense.
They've tried to do that too. This is effectively what is happening in California for many cases because of some new laws. Okay. There's also things like you can qualify for an insanity defense if you couldn't control your actions due to a mental illness. Well, how do you determine that? It's very hard to determine. Okay. And then in the other direction, there are some states like, I believe, Kansas perhaps, and perhaps Arizona, can't remember off the top of my head, where they say you have to be unable to understand what you were doing.
It's not enough to be unable to understand the wrongfulness. So that's a higher bar. You have to be more mentally ill in order to not even understand what you were doing compared to the right and wrong. In California, the wrongfulness was further separated out into legal versus moral. That as long as you didn't understand the moral wrongfulness, That qualified, even if you could understand the legal wrong.
Even if you knew it was illegal, as long as you thought it was morally right due to your mental illness or you couldn't understand it was morally wrong, that qualified.
One thing I struggle with is, yeah, when I first heard this however many years ago, I thought like, you know, we're talking about some schizophrenic patient who, you know, is fully psychotic, has no idea what they're doing and commits a crime. Then when I see now that I'm on the other side of training, the line between how much is the result of a mental illness is so blurry.
You know, I'm thinking of like bipolar patients that like, yes, what they're doing is the result of a manic process, but there's still awareness. For example, you know, there's celebrities that from my viewpoint, I think could be determined to be manic or hypomanic but um you know the question of whether or not they're responsible for what they're doing is to be something that would be impossible to answer um even though i think that it's a contributing factor i don't i guess it's it's a lot blurrier than just like someone does or doesn't have awareness and another aspect that's confused me um is you know let's say someone in terms of uh you know even moral culpability uh someone someone with a mental illness chooses not to take medications and then commits a crime that they don't take their medications which almost inevitably is going to result in them not having uh the ability to judge right and wrong.
Um, but they still made the choice not to take the medications. What would their responsibility be? I know those are, uh, a lot of high level stuff, but any, any thoughts on that kind of thing?
Well, there's a rapid fire. It was several. I think at the outset, what I would emphasize is that the actual classical insanity defense is, is extremely rare. Okay, it's extremely rare. So most cases don't go to the insanity defense. It's just the outcome is not necessarily favorable for a lot of people, and the specific rules around the classical insanity defense are so particular that if you're in an area where you have at least some uh prudent and qualified experts it will only go to the classical situation that you're thinking of okay since it's a cognitive test about not understanding what they were doing or right from wrong it does require a pretty high level of mental illness at the time of the crime to qualify OK, let's put that in front.
Separate to that, though, is the tendency for society in general to misunderstand mental illness and its effects on the ability for people to make decisions. and how our personality and our decision-making at every step can impact the course of the illness. So I think that latter issue is really what you're more referring to when you're thinking about whether someone is responsible. Because insanity defense is not about responsibility.
The insanity defense is just, is this person a criminal or are they dangerous because of a mental illness? And if they're dangerous because of a mental illness, even if they're responsible, they're not responsible in the same way. And so we should give them treatment. That's the point of Insanity Defense. Right. Traditionally, it was hard to get released. In fact, it's an indefinite commitment in some areas, most areas, I think.
And it's an option to you don't have to plead insanity. You can accept your term limited prison sentence where you'll be released eventually on probation or parole, which in some cases will be shorter than if you take the insanity defense. But I guess the bigger warning then is we have to get complicated and we have to be nuanced when we think about overall personal responsibility and how it interplays with mental illness.
But I will say that personally, I do think East Coasters are maybe a little bit too stringent in terms of assigning the ability to choose to people in certain mental states. Can you say more about that? I don't know. I think there's I'm reminded of I can't even remember the content of it. I think I was a medical student in training on the East Coast and there was some talk about.
how to treat addiction and just and I'm talking about a room psychiatrist, not senior psychiatrist, certainly junior psychiatrist. But the attitude was very kind of like, well, screw them. Why would we give them MAT at all? You know, this was many years ago. They were very anti treatment, in my opinion. And maybe we go too far on the West Coast. I don't want to I don't know what to tell you.
But I guess what I would say is It makes sense to me why a lot of people would not choose to take medications because they suck, even though they help. Right. There's a lot of side effects. And also, I think that psychiatrists and the mental health system do a very, very, very bad job explaining to people exactly how and why they should be taking medications. Number one.
That goes back to what I was saying about every idiot has an opinion. You have to make your opinion intelligible to the patient. OK. And then the other half of it is. If we're going to hold people responsible for what they do, if we are capable of detecting their level of mental illness, then I think as a society, we have a obligation to detect early on when someone's mental illness makes them unable to actually make a rational decision about treatment.
And then we have to intervene, but we don't. So in a way, in the US, we kind of have the worst of both worlds, right? We give people the freedom to essentially damage their brain, and then we punish them once they've acted because they've damaged their brain.
Freedom.
Yeah. Yeah.
Yeah, this is pretty heavy stuff. Us two idiots are certainly not getting any answers today. Going back to other lessons, what are other... Lessons from the chapters of forensic psyche you got for us.
So, by the way, you mentioned, I don't know what the day-to-day life of a forensic psychiatrist looks like. I would say, at least from criminal, the most common evaluation is competency to stand trial. That's when somebody gets charged with a crime, and most of the time they have their first interaction with their public defender, and the public defender interacts with the guy, and they think... Something's wrong here.
This guy's not making sense, doesn't seem to understand what's going on. Okay. And so they refer them for competency to stand trial evaluation. That's basically determining whether or not, if due to a mental illness, the person cannot rationally assist their attorney in finding the case or understand what's going on in the courtroom. Okay. That is the bread and butter of forensic psychiatry for criminal forensics. Why is that an important experience?
Clinically, I would say it's because you access this group of patients that would otherwise never be seen in a clinic or a hospital in a lot of cases. There is this whole section of humanity that is just mentally ill enough to exist in society most of the time without having to go to a clinic or hospital. Yet also that may land them in some trouble with the law.
So you can see some very subtle psychopathology that you wouldn't ever know what exists unless you do things like competency evaluations repeatedly, because outpatient today is voluntary so they have to have insight to some degree or they have to have a family that has the insight for them right and inpatient is most of the united states now extremely high bar to get an involuntary hold right So you begin to see subtle patients.
On top of that, you also see people who are malingering. Everyone knows about that. But more importantly, you can see patients who are dissimulating health. So these subtle patients with subtle mood and psychotic disorders, low insight, they often do not want to be found as mentally ill, even if would have a much better outcome in their case if they were found to be mentally ill they hate the stigma and they will actively try to suppress and deny any aspect of mental illness this is very different than the person who presents to a outpatient right and then it's also different from evaluating an inpatient because the ones on inpatient are so acute and you have collateral reports that tell you a lot about why they got brought to the hospital So it teaches you a lot in terms of how subtle mental illness can be, how subacute it can be, and how it can exist and smolder for months to years.
And also, you begin to develop techniques and sort of a way to observe subtle manifestations of psychopathology.
Dissimulating is a funny word. So it's really opposite ends of the spectrum. You have malingering, which patients are feigning mental illness for secondary gain. Now you have the opposite. It's alter ego patients who have mental illness but are actively covering it up. Let's start with the malingering patient and then we'll get to the dissimulating patient.
Malingering is like too big of a topic, I think. Yeah. and it's also too rare personally i think it's too rare in most cases for clinical settings dissimulation i think is actually something that you tend to see in patients of psychotic disorders who are being brought in by family now the traditional way to manage that is to get collateral contacts, right? Now, this is going to be more relevant, I think, to emergency rooms where you can't get collateral contacts.
But essentially, the best way to detect any kind of issues with someone who's dissimulating is to try to hold a prolonged conversation that has nothing or very little to do with evaluating for specific symptoms. OK, this is actually a good approach to look for malingering as well. But what you're doing is that you're just talking and you're going to talk about people's lives, what they've done, what's their day like, what's bothering them, anything stressing you out, anyone bullying or harassing you.
Just talk. And as you talk, you're trying to develop rapport and you're simultaneously observing closely in your mental status exam. And just do that. And as you do that, look for subtle things that they mention in order to pick at it a little bit. This is very similar to psychoanalytic psychotherapy technique. You notice little signs, little bits that seem important, and you say, tell me more about that.
That's it. open-ended questions, no closed-ended questions, no structured interview. You simply get the patient talking. And when you get anyone talking, that lowers the ability to produce some kind of a specific presentation, right? Whether that's a presentation that is sick or having a lot of symptoms or whether that's a presentation that is extremely well. And unfortunately, this also requires you to do it for a long time.
The ability for people to keep up a front gets harder and harder as time goes on. And that is the general approach. You unfortunately just need to talk to people. You want to talk to them about things that seem unrelated and you want to rely on your mental status exam rather than relying on the output statements of the patient around you.
Yeah, and I think, you know, you're talking about this in regards to assessing out a dissimulating patient, but I think what you're describing is helpful. Like, I like to have that be an aspect of almost all my intake appointments is, you know, not getting canned response, not like trying to talk separate from symptoms, trying to... do your own assessment without, you know, when you're talking about particular symptoms or you're asking questions that are clearly looking for particular answers, it anchors patients into certain ways of responding that might be not, won't be giving you the same information of just an open-ended conversation, which is more of like a Rorschach in terms of like what's going on in their brain.
Exactly.
So what are the sort of things that, you know, you mentioned like, as you do it more, you kind of pick up on subtle signs or things that sound a little bit odd. Can you maybe give us a few examples or things that like, what it would look like or what patients say or what happens when you do try to go into them?
Well, I can give you kind of a really remarkable one. I think I mentioned it in a previous episode briefly, maybe the psychosis episode. But let's take an example of a guy who says he has no mental illness and he doesn't hear voices, et cetera, et cetera. I don't have any delusions. I'm just here for no reason. This is in the jail. OK. And. I'm aware that that's what he's been saying to people over and over.
Nonetheless, he continues to say and act and decide in very bizarre ways when interacting with his attorney. Well, do I go in and do I start saying hello? I'm here to evaluate you for a mental illness. Do you hear voices? Do you see anything other people can't see? No? Well, I guess you don't have psychosis. No, I don't do that, right? So I just talked to him.
So what was going on before you came here? What was your life like? Where do you usually live? What kind of things do you like to do for fun? And then as you do that, suddenly, because if something is important to you, it will come out. You will talk about it if you're just having a conversation. Suddenly, he started saying, you know, it's just really annoying because my neighbors were causing me a lot of problems.
I said, your neighbors? What was going on? He's like, yeah, you know, one of them would just stand in front of my door all the time and encourage me to have gay sex. I couldn't believe it. Okay, so if you go directly for the questions, you're not going to be able to get subtle information. If you simply ask about experiences and have people elaborate on their experiences, then you'll be able to get the actual information that you need.
So to that end, you were mentioning, since it's useful for clinical treatment, I agree. I would say for any intake or any time that you're assessing for a specific diagnosis, don't ask your structured interview questions or the DSM criteria. for at least the first 20% of your interview. Just rely on what's been going on. What's it like? Tell me more. I'm reminded of a question that is a favorite of, I can't remember his name.
He's a great trainer for interpersonal psychotherapy. One question he likes is, what was that like for you? And that's what we're trying to get when we interview. When they tell us about something, I want to know, what was that like for you? Tell me more about it. Paint me a picture of it. What was going on? That's going to get you far more information that's salient clinically than if you close off and frame the interview with specific questions, as you mentioned.
Yeah, it's comical how different of an interview, like what you see, depending on like how the questions are asked and in what way, you know, like you would see all the time of, you know, a resident, you go to start an interview with a resident and they go up to the patient and they go like, are you being suicidal? And then that's going to activate defenses. It's going to activate certain types of responses.
And it's going to put the person in a certain mindset to answer in particular ways. And a lot of times, if you come up and you don't go directly towards the thing that they know wants to be talked about and that you're not the psychiatrist assessing xyz uh you can actually make an assessment on how they're doing how they're thinking what their life is like uh that's not like just guided by their defenses or what they're trying to portray um yeah you know that kind of reminds me of
another point that i have um that i feel like forensic psychiatry lends towards and so that you can read into the primary sources or the law yourself. You don't have to rely on secondary sources. When we're interviewing in that way, what we're basically doing is we're trying to get to the primary source and the primary source is the patient's own recollection of their experiences. rather than their summary of their experiences through specific questions.
Not, was your energy low? Yes. But what happened when you tried to do things day to day? What were your activities like? right, getting to the primary source. And this applies not just to patient interviewing. If you're not sure about a regulation in psychiatry, if you're not sure about diagnosis or a medication, go to the most primary source that you can and read it yourself. And apply your knowledge.
And if you can't make sense of it, then you can bring that to colleagues and supervisors and learn more about it. Right. And primary sources can be anything from a FDA package insert to the original studies that they use to approve those medications or, you know, just anything really just the text of the DSM, for example.
right uh instead of you know i think i'm going to ask the same question i asked earlier other signs of you know you're talking about the dissimulating patient um what are other things that kind of tick you off that uh there's something else
going on as in what people are saying is not the same as what's going on underneath yeah i think i guess we're going to go Yeah, what's important is also the story, right? You're talking to someone in front of you, but we don't want to just know what's going on today or in the last couple of months. We need to know how did this person get here?
And what was their life like? So I think forensic work and evaluation of people of either low insight or low willingness to disclose their actual experiences or just impaired memory of their actual experiences happens a lot in mood disorders, psychotic disorders and substance use disorders. You need to try to flesh out and paint a timeline, a picture of what has happened before and how they got here.
And so I think you began to really value the psychosocial assessment, looking into their school, when they graduated, what work they did, any gaps in their work and their school, what's the longest job they could hold on to, what have their relationships been like? All that stuff can show you a lot more about course of illness and personality functioning than you could ever get by asking structured questions about DSM criteria.
And that's really important. I will find that sometimes even, um, instead of inquiring directly about symptoms, uh, once I sort of get a little bit of a clinical suspicion about what we're working with, I will actually focus most of the first interview on psychosocial stuff. Okay. You're going to got a lot of data out of that. That's important.
Yeah. What you're saying actually, like in the emergency room, something that was helpful for me was, um, The most important thing isn't knowing all the diagnoses, all the criteria. In terms of this thing, when I'm talking to a patient, the ability to have a picture in my head of what happened and why they're there, or just some sort of story that is somewhat coherent. is to me like the the first thing you need to do is just have a ability to visualize and under like have a a narrative that makes some sort of sense and whenever there's a question of like i can't quite uh um make sense of these two facts uh like in in my assessment in terms of how i'm asking questions is i'll sometimes even verbalize like you know you're saying this uh you're giving me one word answers i kind of just want a picture of what what was going on how you ended up here Um, and it's, it's a, it's a helpful guiding principle of like, until I get that picture, I'm not, I'm not walking away from the interview.
Um, you know, obviously it's not always the case when you have violent or agitated patients, but, uh, early on, like I, you know, asked my 10 checklist questions and walk away and then said, you know, they denied SI, they, they denied depression. Um, you know, that's all I got. And it's like, well, there's no, there's no visual, there's no story. So, um, just kind of sitting down in the interview until I have a story that can make some sort of sense is just a helpful guiding principle in interviews.
Yeah, a lot of life and most of psychiatry, I would say, is storytelling or story making. I don't mean telling fiction, you know, but I do mean stringing together facts to make a coherent narrative about what has happened, why and what's going to happen if certain things occur. And I guess we should go back there then to talking about that's how you make your opinion worth anything.
Right. It doesn't matter. Let's say you were magically some kind of a futuristic robot that could detect with 100 percent certainty whatever medical problem someone has when they walk into the door and you just tell them that. OK, why would they believe you? They're not going to believe the magic robot story. You know, you need to gather enough information together with the patient to string it together into a story that they're going to accept.
And in forensics, you have to also be a good writer. You have to be able to write that story down in a concise way that if someone reads it, they'll be like, well, I get it. Okay. But in the practice of clinical psychiatry, it's not your written work that matters. You can be very brief with your notes. It's your talking. You have to be able to have a dialogue and put narrative together.
When you mentioned, you know, the dissimulating patient, and there's something I kind of wanted you to get to, but especially with psychosis, often there's a weird feeling I get when there's psychosis, even when objectively like everything's being answered correctly or somewhat correctly. Um, and I have a tough time putting into words what the experience is. It just, it feels like something's off. Um, you know, I think like we in psychiatry, we call it like, you know, honing your, your counter transference or honing, um, you know, like in every experience with a patient, you're, assessing your internal responses trying to do it objectively in that like
listening to the third ear in some literature
Yeah, or, you know, a patient's telling me a story that if a friend told me, I would be upset, and I noticed that I'm getting angry, and trying to be curious about it, right? Like, I don't say to myself, like, hey, like, Dr. Malzberg, you can't be angry with a patient, like, you have to be curious and say, I wonder why that is. And the reason could be, you know, in terms of what we learn with counter transference, it could be because it's reminding me of something in my past that makes me angry and It's not inappropriate because I think all feelings are never appropriate or inappropriate.
I'm not going to go that far, but you know the gist of what I'm saying. But that it's hitting on something from my past that is making me angry that wouldn't be necessarily dictated by what the patient's doing. Or there could be information within the interaction as to why I'm feeling that way.
Yeah, you know, it's hard to separate that out. I think it's very true that the countertransference feelings can be mostly or even entirely the product of the clinician rather than the patient. But you're touching on something important there, at least for the assessment of psychosis. And that feeling of the uncanny oddness, fear, confusion, I think is a normal response. And it's not one coming solely from the clinician most of the time in genuine psychotic disorders.
It's that there are a lot of little micro expressions and the absence of many small social cues. and ways of relating and interacting in people who are suffering from acute psychosis that you automatically pick up on. Now, I think a lot of people don't necessarily pay as much attention to that because the way it has been conceptualized in the DSM is extremely broad. Okay. It's pretty much covered by negative symptoms of psychosis, which has tons of categories under it.
and also by thought disorganization, which again has tons of categories under it. So I think that feeling of the uncanny, I don't know if everyone gets that when talking to someone with acute psychosis, but it's based off of data in front of you. And so even if your individual response can be unique or outsized in terms of your internal emotional feelings, those feelings, the countertransference, are being provoked by something objectively identifiable.
So how do you get better with that? I would encourage that clinicians carefully observe different types of patients and compare them to each other. If you happen to be, for example, in an open milieu inpatient or emergency room, you can even watch different patients with different diagnoses interact with staff. OK, look at all the things, little mannerisms, lack of mannerisms, facial expressions, eye contact, minor things. OK, you will probably pick up on subtle differences.
There is an ethical rule. against making any specific diagnoses of public figures without the assessment. Okay. But I am reminded at least for mental status exam purposes, you don't need to, um, make any conclusions from it, but are you familiar with, uh, Jordan, the producer for, uh, he's one of the producers of the Conan O'Brien show and Conan O'Brien, they have, uh, many different videos of them interacting.
Yes, I really like those videos.
Yeah, I love those videos. So I first saw those videos, of course, because they've been at it for a long time when I had no training at all. Right. As a psychiatrist. And, you know, Jordan's a weird guy. He just comes off as weird, and you're not really sure why, okay? But I feel like as the years have passed and as I've honed and become even involuntary in my mental status exam, you can see some stark differences.
So pick any Jordan and Conan video and just do a mental status exam for both of them and look at the differences because you can't find two more different people in one video, I think, most of the time.
So, yeah, you're talking about, you know, the uncanny feeling. And it's picking up on small, incorrect micro or missing micro expressions or maybe not even micro.
Yeah.
And it induces a feeling. I mean, yeah, can you... Now, the definition of uncanny is something that's close. I mean, I'm going to butcher this because I'm doing something that's close to what it should be, but it's slightly off. And because it's slightly off, it actually disturbs us more than if it was very off. Is that... I mean,
I don't know if that's a dictionary definition of uncanny, but that does refer to the uncanny valley. Yeah, I guess that's what I'm referring to in terms of human like things. Yeah, I mean, maybe there's something to that. I think you're I haven't put that together. I should have. But I'm not saying that, you know, psychotic people are non human at all. But yeah, they're just some parts of the normal human social interaction are being impaired by the acute psychotic process.
And humans tend to detect that. Um, There's just something a little bit different. And some people are also different at baseline from a neurodevelopmental disorder. I feel like the feeling is different with those people. But yes, it's just there are certain things. Watch someone and everyone's different. There are some people who are more socially animated, expressive, interactive, and there are people who are less. Just watch differences in regular people, non-clinical populations, and then observe how people of certain diagnoses tend to interact.
This is still relevant even to things like major depression, right? Someone with a melancholic, traditional, more biological, depressive episode, they're going to act very differently than someone whose depression comes from things like trauma or personality.
Yeah, I guess you're right. I was talking about the uncanny valley, which to put that into better words, it's like the psychological and aesthetic relationship between an object's degree of resemblance to a human being and the emotional response to an object. So if something is like doesn't resemble a human object at all, it doesn't give us an uncomfortable feeling. If something is close to it, but just slightly off, it gives us a very uncomfortable feeling.
An example would be like a zombie, which is close to a human being, but a little bit off. So it gives us an uncomfortable experience. And I guess in here, I'm not saying, like, as you mentioned, I'm not saying psychotic people aren't human. I'm just saying it's off the normal human experience, like normal human emotions or expressions.
It's out of the usual range. And again, there are plenty of people without psychosis who are out of the usual range, too. Everyone's unique. There's a normal range of human functioning. But you just have to incorporate any differences from the norm that you can detect when you're doing a medical evaluation. That's the whole practice of medicine. We're detecting what changes from the apparent norm and whether or not it should be treated if it's a problem at all.
That's what we're trying to do. Yeah. Yeah.
Yeah, I guess, you know, thinking about this out loud, when someone is, you know, on the more psychotic range and it's more apparent and they're not trying to dissimulate it, my countertransference, and Nancy McWilliams writes about this a little bit, is almost like maternal. Like I feel like protective and I feel like I want to help them in some regards. And then as you move along the valley and it gets closer to closer to like they're able to come off seemingly normal that's when i get a more uncomfortable uh or confused uh feeling inside me yeah and i i hope our use of
uncanny and we've been repeating it but I hope that's not contributing to any stigma. I really feel that for psychotic and bipolar disorders, as a society, we've been incorrectly conceptualizing these conditions as psychological. They're not psychological. These are brain disorders. These are issues where people have more or less a normal range of human brain disorders. personality functioning for some time. You can pick at certain differences because of genetic trends probably, but it's an onset of a brain disorder that is more or less now correctable, at least partially with medication.
That's not a psychological problem to me.
Yeah, and I'm glad you bring that up because it's sometimes, yeah, when you're talking about this stuff, it's easy or it's difficult to think of how I'm coming off objectively because, you know, from my perspective, I'm not trying to say anything particularly dehumanizing, but it's, you know, we're so baked in this stuff that it's sometimes hard to get an outside perspective of how I sound.
Yeah. Generally speaking... I would not be terribly afraid of anyone except for the anti-socials.
All right. I think this is, you know, if we can start winding things down. Anything else you want to cap us off with?
No, I just think even if you're not going to practice forensics, having a mindset of going into your clinical practice as if you're practicing forensics is helpful. And I don't mean trying to get fancy or trying to catch people out. What I mean is making your assessment and opinions intelligible to the average reasonable person. And that average reasonable person may be your patient. Or it may be an independent observer, but if you're not going to be able to make sense to, let's say somebody's grandma, uh, if you can't tell that story to somebody's grandma who with no mental health training and they're like, yeah, that makes sense.
Then you might need to adjust something about how you form stories and tell them to your patients.
Yeah, and you mentioned some people learn these things to be able to have a gotcha or be able to catch. Let me just say that it is not cool to be that person who is cynical and distrustful. I was always bothered by the intern who's like, oh, they're just malingering. And it's like, well, put into words, verbalize. If you can't give me a full assessment as to why you think that and you think that it's cool to just not trust everyone and be cynical, I don't think you're cool.
Yeah, because it's easy to do that. You know, we have lost stress in the medical field. You know, it takes a long time to get there. There's some bad personalities in the system. And so I think it's very easy to act out, you know, put your aggression towards colleagues, patients,
yourself.
That's a trap. You know, it's not a good way to live. So just be careful.
It should be something you should be fighting against, not warmly welcoming the becoming cynical or having gotcha moments. It's easy, but it's much more rewarding to be a thoughtful, non-cynical provider.
Well, I think that's our time. Like and subscribe, comment, share, whatever.
That does nothing. I think it does something.
I think some people have been commenting. That was very nice of them. I'm only crying in the shower 25% of the time now. My shower scale has decreased.
You saying like, comment, subscribe, doesn't do anything. What we need to do is talk about the emotional impact it has on you when they don't. comment, like, and subscribe.
No, we just got to manipulate the algorithm.
All right.
I'll see you next time. All right.