Delivering a Hopeful, Recovery-Oriented Schizophrenia Diagnosis

Announcer:
You’re listening to On the Frontlines of Schizophrenia on ReachMD. And now, here’s your host, Dr. Alexandria May.  

Dr. May:
This is On the Frontlines of Schizophrenia on ReachMD, and I'm Dr. Alexandria May. Joining me to share best practices for delivering a hopeful, recovery-oriented schizophrenia diagnosis to patients and their families is Dr. Apurva Bhatt. She's a child, adolescent, and adult psychiatrist, and a Clinical Assistant Professor in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine. Dr. Bhatt, welcome to the program.

Dr. Bhatt:
Thanks for having me here.

Dr. May:
To start us off, Dr. Bhatt, why does the way we deliver a schizophrenia diagnosis matter so much when it comes to long-term outcomes?

Dr. Bhatt:
This is a really important question to be asking ourselves. So one thing is that when individuals are coming into care, and for a first episode of psychosis related to schizophrenia, it can be a really stressful time. It can be confusing; there can be a lot of emotions that family members, support persons, and the individual are navigating as they are getting that first diagnosis.

It can also be scary; the ways in which schizophrenia is portrayed in the media, in medical school, or in other medical healthcare training programs aren't always in a positive light, which is not actually accurate. You know, the majority of individuals living with this can live lives that are fulfilling, rich, and connected in pursuit of their goals or where they are achieving their goals.

And so when you're delivering that diagnosis for that first time, it's important to provide accurate examples of that hope so that the person doesn't feel so crushed by the experience, and so they can see the light at the end of that tunnel. And when people believe in that recovery-oriented mindset, it can really impact their long-term outcomes because they're not shutting down from the diagnosis or their family members aren't shutting down from the diagnosis.

Dr. May:
So given that our initial approach carries that much weight, can you share some principles or mindset shifts we can adopt to bring a more recovery-oriented tone into these conversations?

Dr. Bhatt:
Absolutely. I think the first step is to—whoever is delivering the diagnosis, so the healthcare provider—check yourself and your biases. We all come into this work with some level of biases, especially psychiatrists, because the nature of psychiatry training is that we are frontloaded with a lot of inpatient experiences in the ER or inside the hospital oftentimes where people are in crisis. And so we are seeing individuals repeatedly who are probably at the worst of their illness, and we rarely get opportunities to see the other side of it and to see folks that are doing really well on the outpatient side who are honestly just coasting with their lives and focused on their goals. And what that can do is create a bias in our mind that anyone experiencing psychosis or schizophrenia is going to have a really rough course of it, and that's just not true.

So I think the first step is to, as a provider, acknowledge that, to reflect on your own training experiences, and then try to find opportunities to see the other side and to see accurate examples of recovery or people who have experienced meaningful recovery.

Dr. May:
And based on your experience, what practical strategies or language cues help make a diagnosis of schizophrenia more accessible and less overwhelming for patients and families?

Dr. Bhatt:
The healthcare provider holds that hope, right? So going into that encounter, I'm going to be talking about the diagnosis, what we think is going on, and then talking about treatment options. I first check in on how everyone in the room is doing and just do an emotional check-in. How are folks feeling? If there's anxiety, validate that and then explain that, okay, I'm going to break down this session. Usually it's a 60-minute session that I allocate for these educational sessions or the feedback session, and I explain to them I'm going to talk about the diagnosis—why I think this diagnosis maps onto your experiences, but of course, things can change over time. And then talking about treatment options.

And I deliver that first line of, "based on everything that I've observed and all the records that we've reviewed, we think it's schizophrenia. And guess what? Many people living with this actually can live great lives where they are able to pursue their goals as long as they engage in the treatment supports that are most useful to them in suppressing the illness or managing it. And many individuals learn to live alongside these experiences." So framing the very beginning of that session in that way can then soften the anxiety response that many will experience when you're delivering that diagnosis.

And then when you're talking about treatment modalities, it's really important to take a very holistic, multimodal approach. Yes, medications can be useful. Yes, therapy can be helpful, but also talking about every other part of their life, right? Diet, lifestyle, supporting the family members or siblings, and making sure that the people in their life who matter to them understand this and can support that individual as well.

And then it's also about centering the person's values and things that are important to them. Make sure that anytime we're talking about treatment modalities that we know at the beginning what matters to this person and then emphasizing that our goal together is to make it so that this illness doesn't get in the way as much of your day-to-day living so that you are able to pursue what matters to you. So when you're talking about it in that way, you are assuming that this person's life has not ended with this diagnosis, right? That they have something to look forward to and work towards, and I think that's really important.

Dr. May:
For those just tuning in, you're listening to On the Frontlines of Schizophrenia on ReachMD. I'm Dr. Alexandria May, and I'm speaking with Dr. Apurva Bhatt about how we can instill hope and promote recovery when delivering a schizophrenia diagnosis.

Now, if we continue to focus on external support systems, Dr. Bhatt, many patients are surrounded by family members during this time. So how do you navigate different reactions, especially across generations when delivering this diagnosis?

Dr. Bhatt:
It's very individualized per the family system that's in front of me. I think the first thing that I really try to do in my evaluation, if I have time, is to understand the lore of this family, right? Understand what has happened across generations. What are the different sociopolitical events that they were exposed to? What are the potential traumas that the family might have experienced? Are there other family members living with schizophrenia, and what was their experience like observing their family members and supporting that family member? When we're able, as the provider, to understand that, we can then help navigate around that and help the family process that their loved one, who is my patient, may have a different outcome or a better outcome because they're coming into care, and they have access to potentially more things. So I think it's really important to understand that family's background and to really be humble. Don’t assume that the way that you view things diagnostically or treatment wise is the right way. Sometimes that can contribute to too much conflict.

The other thing that I'll mention is that with some family members of the patient, there may be intergenerational differences, right? If they are immigrants, a child of immigrants, or if they're from the US but there are just generational differences in how mental health is conceptualized, your job will be to bridge that gap to help bring them closer together in terms of their understanding of what's going on. Trying to model the language that the service user, patient, or family members are using rather than sticking to your Western model language can really help bridge that gap. So I think that's really important.

And then validate all perspectives in the room. The individual who has lived-experience of psychosis will have their perspective and so will their family members. There are two processes of acceptance happening. One is in the individual receiving treatment, but the other is in their support system, whether it's their spouse, parents, or siblings, and they will go at different paces, and it's okay for that process. You have to allow them to go through that process, so just be there for them alongside their journey and try to offer support in the best way that you can in a humble way.

Dr. May:
And we also know that stigma around psychosis is still deeply entrenched even within the healthcare system, but how can hopeful diagnostic practices help shift those narratives, both at the individual and the systems level?

Dr. Bhatt:
This is such an important thing, and it's the piece that I think really crushes me still as a provider working in the outpatient side. A lot of the young people that I work with who live with schizophrenia or schizoaffective disorder get sick sometimes. They have medical things going on that they need care for, and I have seen the ways in which other specialties handle it. It's like their medical brain turns off when they're encountering one of my young people who has a real medical condition that needs to be properly evaluated. And I think it's just really important to acknowledge that one, yes, psychosis can be at the forefront of why someone is coming in for an appointment, but it's not always the reason, right? They could still have other medical things going on. I think that is one way in which stigma really impacts my young people, especially if they're going in for diagnostic evaluation of some other medical condition.

I think the other thing that really matters is understanding that a majority of these individuals are not aggressive; they're not dangerous. In fact, many of them are more likely to be victims of violence. And when a lot of my young people go in for other healthcare appointments, I do see that there's maybe this fear and then that then impacts them getting proper care. And so it's a challenge that I hope to change over time.

When I give lectures to medical students, I bring some of my young people who have volunteered and who are really passionate about using their voice. And these young people shift the narrative much more so than anything I say. The medical students have shared that having this young person share their experience about what it's been like—what they would've wanted doctors or other healthcare providers to know about living with psychosis and the things that they did well and maybe the opportunities for improvement.

Dr. May:
That's awesome. That's so innovative of you to bring in patients to give that example. Before we wrap up Dr. Bhatt, are there any final takeaways you'd like to leave our listeners with who might be looking to bring more compassion and clarity into these pivotal diagnostic moments?

Dr. Bhatt:
Absolutely. If you are in a position where you are the one delivering this diagnosis, I think first and foremost, slow down that interaction. Allot enough time to the individual and their family members to explain what this is. Use visuals—have a board or have things printed out that explain or support what you're sharing verbally because not everyone is going to be able to intake the information verbally. Make sure that when you are first giving that diagnosis that you instill hope. Make sure that you don't scare the family or that young person. There are good treatments available for folks, and meaningful recovery is achievable for many people. And then make sure that you break down the diagnosis, talk about treatment options, and offer the family and the individual opportunities to ask questions.

And then, like I said, show them accurate examples of what it's like to live with this. There's a bunch of individuals now on Instagram sharing their story, and I think they're great advocates who are showing that accurate example of what the recovery journey is. So I encourage folks to check them out. There's @schizophrenichippie, @schizophrenic.nyc, and @schizokitzo. Those are my three favorites. I think they do a great job of sharing accurate examples of what it's like to live with psychosis and schizophrenia.

Dr. May:
As those final takeaways bring us to the end of today's program, I want to thank my guest, Dr. Apurva Bhatt, for joining me to share her thoughts on how we can navigate the delivery of a recovery-oriented schizophrenia diagnosis. Dr. Bhatt, it was wonderful speaking with you today.

Dr. Bhatt:
Thanks so much for having me.

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