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Reflections on my Pathway to CBT for Psychosis: From John Hinkley to Montana and Back Again…

I’m writing this blog post as I sit in my temporary rental house, quarantined, in Missoula, MT, where my husband and I are spending the semester as visiting professors at the University of Montana.

And while Montana is quite a different place than Boston, where I usually live and work, this experience comes at a very special time in my professional life. I was a graduate student at UM in the Department of Psychology, and I earned my MA and Doctoral degrees in clinical psychology here. Our return to this town and to this university marked exactly 20 years since the time I first arrived to begin my initial year of clinical psych graduate training. And what better way to honor the anniversary of starting my career as a psychologist then to take a few minutes to reflect upon the somewhat winding pathway that got me to this place, literally (back to Montana) and figuratively (fully immersed in CBTp research, clinical work, training, consultation, and supervision).

But my professional story really begins in Washington, DC. It was one of those incredibly hot, humid summer days that DC is known for, and I was between my sophomore and junior year of college, a Psychology major (naturally) at American University. Because our school was located in the nation’s capital where there was a richness of opportunities within international relations, finance, and politics, there was a heavy emphasis on students having internships in the city in order to gain practical experience. While I was deeply interested in pursuing an advanced degree in psychology, I wasn’t sure what I wanted to focus on specifically. Plus, I had picked one of the hottest summer days of the year to head into the Psych Department office to look into what was at the time an enormous three-ring binder that contained all of the available mental health volunteer opportunities in the area. Given the weather and its (un-positive) effect on my mood, I realized it probably wasn’t the best day for me to be doing this search, but here I was. In frustration, I quickly flung open the giant binder and out onto my lap fell a small leaflet of paper: “Volunteer Internship Opportunity Available at the Renowned St. Elizabeth’s Hospital: For Interested Psychology Students.” Good enough, I thought, and I grabbed the paper and left.

I ended up volunteering at St. Elizabeth’s for almost 2 ½ years before I graduated. I helped out in several of the inpatient units, but spent a good portion of my time working in the hospital library, helping patients find (very limited) resources, check out (old, in poor condition) books, and so forth. It was there that I met John Hinkley, a man diagnosed with schizophrenia, who infamously shot Ronald Reagan and some of his staff. As information came out that Mr. Hinkley had a series of high-conviction, inaccurate beliefs about his relationship with the actor Jodie Foster, as well as command auditory hallucinations driving his behavior, this incident was, unsurprisingly, widely covered in the media for years. And also unsurprisingly, highly- sensationalized, adding to the already-acute stigma that people with psychosis were experiencing. At the time of my internship, Mr. Hinkley had been at St. E’s for about 8 years following his conviction and sentencing. He came to the library frequently to check out a new pile of books, or sit and read at one of the tables. We exchanged just a few words each time he was there – a greeting, sometimes a little small talk – but that was really the extent of our relationship. And yet, my time interacting with him (and at St. Elizabeth’s in general), impacted me profoundly and had a tremendous influence on the trajectory of my career. During the time I worked there, and afterwards, I thought about him a great deal --languishing away in that gloomy hospital, without adequate resources, lacking any sort of meaningful activity, real psychotherapy, or skills training to occupy his time productively, to help him with the distress his psychotic symptoms caused, or to move him toward his personal goals as a human being.

What if there had been someone trained appropriately to talk with him about his upsetting beliefs, to really try to understand what had gone on in his earlier life to put him in this predicament and maintain and exacerbate these symptoms --to see the whole picture of the person and all the past trauma, struggles, and resiliency within him? What if there had been a clinician who had helped him reduce the urgency to act on these thoughts and auditory hallucinations, to challenge the content of the bullying voices, who aided him in developing the ability to look at alternative explanations for his beliefs, and who taught him tools to manage his distress? If these things had been explored, what could have been prevented in terms of the danger to the White House, the fear that Jodie Foster likely experienced, and the needless ongoing public stigma around the propensity of violent behavior in those with psychosis and schizophrenia? Not to mention Mr. Hinkley’s (and his family’s) own quality of life.

I didn’t know at the time that what I was thinking about around this was actually an intervention called CBT for Psychosis of course, but I knew I wanted to learn more about everything related to psychosis and its treatment. This was my path, I had decided.

So I went through graduate school at UM, focused on social skills training research and clinical work for schizophrenia, and the beginnings of more general CBT education (CBT for Psychosis training wasn’t quite yet a thing back then). I started going to ABCT, joined the Serious Mental Illness SIG, attended as many trainings and workshops and read as many books as I could about CBT for Psychosis (and additional empirically-supported interventions for schizophrenia and other serious psychiatric conditions). Matched at a great CBT- and CBTp-based internship (UCSD), followed by a CBTp-related postdoc at Mass General Hospital, then faculty positions focused on the adaptation, evaluation, and dissemination of CBTp interventions from then on.

All along, I’ve thought about my time at St. Elizabeth’s often over the years. With the clinical trials I’ve worked on, the treatment developments and tweaks; the relationships with my clients; while teaching and training of groups of clinicians; and with the many therapy sessions I listen to and provide feedback on – highlighting for me time and time again what these small but meaningful CBTp interactions can do to change or better the course of someone’s life with psychosis, the people close to them, and those in the greater radius of that person’s existence.

It’s probably not lost on anyone reading this how much this covid-19 pandemic is shining an unflattering light on the complexities and shortcomings of our mental health system. And that can make it feel even harder to keep doing what we are trying to do for the advancement of empirically-supported psychosocial treatments for our clients and their families.

But coming back to the memories and events of what got us interested in helping people with psychosis in the first place, and remembering where and how our career trajectory began, can offer a good deal of comfort, re-affirmation, and motivation to move forward every day to help improve people’s lives via CBTp.

What we’ve seen posted in the internet, pasted in our emails, and printed in the newspapers rings true: We’re All In This Together.

What was your pathway or trajectory to interest in helping people with psychosis? To your work in CBT for Psychosis? Please share your experiences on the NACBTp bulletin board

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