Welcome back to Analyze Scripts, where a psychiatrist and a therapist analyze what Hollywood gets right and wrong about mental health. Today, we are thrilled to be joined by Dr. Tobias Wasser, a forensic psychiatrist from Yale University, in analyzing the 2010 film "Shutter Island." Dr. Wasser explains how forensic psychiatry bridges the gap between the criminal justice and mental health care systems. He describes what it's really like to work on a forensic psychiatry unit and compares his experience to that depicted in the film. We also ask him to explain the difference between competency to stand trial and the NGRI (not guilty by reason of insanity) plea. He also shares his opinions about our favorite narcissistic psychopaths - Joe Goldberg, Logan Roy, and Tom Wambsgans. We learned a ton and hope you enjoy!

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[00:00] Dr. Katrina Furey: Our channel.

[00:10] Portia Pendleton: Hi, I'm Dr. Katrina Fury, a psychiatrist. And I'm Portia Pendleton, a licensed clinical social worker. And this is Analyze Scripts, a podcast where two shrinks analyze the depiction of mental health in movies and TV shows. Our hope is that you learn some legit info about mental health while feeling like you're chatting with your girlfriend. There is so much misinformation out there, and it drives us nuts. And if someday we pay off our student loans or land a sponsorship, like with a lay flat airline or a major beauty brand, even better. So sit back, relax, grab some popcorn and your DSM Five and enjoy. Welcome back to Analyze scripts. Portia and I are super excited to be joined today by Dr. Tobias Wasser, who is an associate professor of psychiatry at the Yale School of Medicine. He completed all of his psychiatry training at Yale, including the psychiatry Residency program and two fellowships in forensic psychiatry and public psychiatry. He currently serves as the Deputy medical Director for Community and Forensic Psychiatry for Yale New Haven Hospital and the Assistant Chair for Program development in the Yale Psychiatry department. He's previously held leadership roles in Yale psychiatry residency program and for five years served as the chief medical officer of Connecticut's State Forensic Hospital. And most importantly, he was my chief resident for a whole day at the very beginning of my intern year. So welcome, Tobias. Thank you so much for coming and joining us today.

[01:46] Dr. Katrina Furey: Hi, thank you so much for having me.

[01:49] Portia Pendleton: So interestingly. I'm sure you don't remember this, Tobias, but I remember my very first day of psychiatry residency. I was on the inpatient psych unit. You were observing me do, I think, like, my very first interview as a resident, and I was interviewing a patient with a psychotic disorder. I don't think I'd ever really interviewed someone with one of those before. And afterwards you told me something that has stuck with me ever since, and I think is really pertinent to this movie you were telling me. And you were so nice in the way that you would tell me this criticism, but it's very kind. You were saying, you did a great job, but when you're listening to someone talk about their delusions, try really hard not to nod as they're talking. It's like a very natural thing to do. But if you're nodding, you're kind of confirming for them, like, yeah, this is true. This is true. What a perfect sort of clinical pearl to think about as we talk about Shutter Island today, right?

[02:53] Dr. Katrina Furey: Well, you're right that I don't totally remember saying that to you, but I guess maybe it'll make you feel better to know you're not the only individual to whom I've given that feedback.

[03:05] Portia Pendleton: Good.

[03:06] Dr. Katrina Furey: It is a common aspect of people learning how to practice psychiatry and mental health. So as you said, I think it's a natural reaction. So clearly it helped you.

[03:17] Portia Pendleton: I'm glad it's but I just like that sort of popped in my mind as I rewatched the movie today, knowing you join us because in this movie, they do this whole weird experiment, right? And so I think before we dive in and really pick your brain on what it's like to be a forensic psychiatrist and what you think about this movie, portia is going to give us just a really quick rundown of the plot.

[03:43] Dr. Tobias Wasser: So the movie came out in 2013 by Martin Scorsese, all star cast, all star director. We have Teddy Daniels, who is played by Leonardo DiCaprio. And then we have Chuck, played by Mark Rafalo. And so we see these two people kind of heading to this island where there's apparently this mental institution where the criminally insane are being held. And it opens up with vomiting, which we talk about this a lot.

[04:12] Portia Pendleton: I was like, great, portia hates vomiting.

[04:16] Dr. Tobias Wasser: And so they are going to kind of investigate someone who's missing.

[04:20] Portia Pendleton: And they are state marshals.

[04:23] Dr. Tobias Wasser: Yes, marshals. And so you kind of see them exploring the island. It looks really scary. And there's a few different kind of living arrangements, it seems like. One where more, I would say, like, peaceful patients are housed. And then another one that feels really gross and dirty and more jail like. And the movie does take place in 1954. So it's like post World War II, which I think is interesting with the differences in how we treat mental health. So we kind of see them investigating this crime or this person who's missing, as we have some questions of Teddy's mental status. So he has these migraines. There's some flashbacks to his time during World War II at some concentration camps. Really, really traumatic, it seems like some experiences that he's had. And then also these kind of flashbacks to this family, but then to this other wife without kids. And it's confusing. So I was kind of confused watching it at first. And then we see him kind of continuing to investigate and believe that there are these inhumane trials going on or.

[05:41] Portia Pendleton: Clinical trials or like experimentation, almost experimentations.

[05:46] Dr. Tobias Wasser: Kind of going on that we see, and he doesn't find any. And so the movie kind of arcs all of a sudden to where I initially thought, so this was the first time that I saw it, that he was being kind of like, pushed into insanity, quote, unquote. He was being given some medications. All of a sudden there's this part where it's like, well, have you been eating the food? Have you been taking medications from them? Have you been smoking your own cigarettes? And he starts to kind of feel.

[06:14] Portia Pendleton: Like he was poisoned or something.

[06:15] Dr. Tobias Wasser: Yeah. And so then all of a sudden, we find out that he is the test subject of this really immersive. I don't want to say well done, but well done.

[06:30] Portia Pendleton: Well executed.

[06:31] Dr. Tobias Wasser: Maybe set up for him in order to help his psychosis or delusions in order to kind of have him kind.

[06:40] Portia Pendleton: Of come back, snap out of it.

[06:41] Dr. Tobias Wasser: Which is his wife killed his three children and then he killed her.

[06:46] Portia Pendleton: And so he is actually a patient.

[06:48] Dr. Tobias Wasser: To make someone potentially have a psychotic break or experience some psychosis. So I will say that I'm probably going to take a little bit of a backseat to this episode. I think the only experience I have with psychosis is, like, drug induced. So it's not my poor kid. I don't think I've ever interviewed or come across a patient with non drug induced psychosis. So that's kind of the story of the movie. And I think it leaves off with two questions. Did they trick him? And that was a whole trick to kind of get him to stay there, or was he really a patient?

[07:23] Portia Pendleton: Yeah, I think he was the 67th patient that he was looking for the whole time. And then at the very end, I felt like the whole premise, once you figured out what was going on, was they were trying to restore his sanity once and for all with this elaborate hoax in hopes that he could avoid a lobotomy. Right? And then at the very end, you see him sort of slip back into his delusional way of thinking and go off to get the lobotomy. And I think actually he knew what he was doing. I think he sort of didn't actually slip back into that delusional frame of mind. I think he finally realized what had happened and didn't want to live with it. So it was really fascinating movie. I always love Leonardo DiCaprio, especially with a Boston accent. I'm just like, anytime. But one thing that hit me right away was just like, there's like this big, scary mental hospital in the middle of the ocean where you can't get to and we're going to play this big scary music, and there's rocks everywhere, and there's like, police everywhere. And just like this. It reminded me of Alcatraz in San Francisco, which was just a jail, I believe, not a forensic psych hospital. But I was just like, oh, my God. Just like, yeah. It's like, oh, God.

[08:39] Dr. Katrina Furey: Yeah.

[08:39] Portia Pendleton: The mentally we're so scary. It just really right away really knocked you over with that intensity. What did you think, Tobias, about sort of the way they started off.

[08:51] Dr. Katrina Furey: Yeah. So I think you're right about the ending. I saw Capri a really extreme form of denial, almost like choosing an extreme form of denial that once he knew what he had done, he didn't want to live with it anymore, and choosing surgical interventions to try to keep that out of his mind as far as the depiction of what the place looks like. So I definitely think you're right. It played into all of our worst stigmas about psychiatric hospitals. It's criminally insane and this scary island in the middle of nowhere, and that it has to be surrounded by miles and miles of water to prevent anyone from escaping. And I think also, Portia, your point about this is post night. This is in the 1950s, and so it's a very different understanding of what mental illness is at the time in any case. But I'll say as someone who, as Katrina you mentioned in the brief bio, someone who spent many years running a current forensic hospital, it's a very different experience than how it's been depicted in the movie. I think we often imagine these really horrible, scary places. And I will say there are aspects of it that align with my experience. But for the most part, we've come a long way in the 50 years. If that's what it really was like 70 years ago, we've come a long way. But I definitely agree that it was trying to really I think it was trying to immerse the viewer in experience of being terrified. And I think it succeeded in that.

[10:26] Portia Pendleton: Yes, it did. So what parts of it sort of matched with your experience working in a modern day forensic hospital?

[10:33] Dr. Katrina Furey: Yeah, so I think part of it is what Portia alluded to with this idea that there might be different parts of the hospital. So that continues to be true today. So not all forensic hospitals are like this, but many of them will have what we call different services. So in Connecticut, for example, the hospital that I was a chief medical officer for, for five years, we did have two different services. We had what we called a maximum security service, which was for patients who are at a higher risk for violence or who may have engaged in more violent behavior before they came to the hospital or currently were engaging in unsafe behaviors. And that is more like a synthesis between a typical hospital or typical psychiatric hospital and a correctional setting. At least on the one in Connecticut. The walls are cinder block and in order to get in, you have to go through multiple layers of security and double locking doors. We call a Sally Port, like you're entering a prison facility. So there are layers of security to it that are similar, and the structure is somewhat similar. When you get on the unit, though, it looks more as opposed to in the movie where people are in jail cells and they're locked up, and it really looks like a jail facility. Once you actually get into the physical space where the patients are living, it's more like an inpatient unit. People have bedrooms, they don't have cells, they don't have bars on the doors. They can enter and exit as they wish. There are group rooms in which therapeutic activities occur. There's a shared dining space, there's television. So there are some aspects that are similar, but hopefully it's a little bit more humane when you actually get onto the unit. The one in Connecticut is a much older facility. It was built in 1970. So actually not long after this movie supposedly takes place. And there are a couple of much more modern facilities that have been built, one in Washington, DC. And one in Missouri, that are really picturesque, very aesthetically pleasing. They really focus on things that are supposed to enhance individual recovery, like access to natural light spaces and all those things. So the more modern facilities have really come a long, long way and they look nicer than some typical psychiatric hospitals. Not for forensic patients. And then the other aspect is going to say, so there is a second service, again, even in our own hospital, for safer patients, patients who have engaged in less serious violence, but for some reason have engaged in some kind of behavior that got them involved with the criminal justice system. And they require psychiatric treatment. And those settings, at least in Connecticut, looks much more like a typical hospital that you'd expect. And those patients actually are given grounds privileges. They can walk the ground, sort of like we saw in the movie, that they can walk around.

[13:17] Portia Pendleton: Are they handcuffed like we saw in the movie? People would be like in shackles, walking around, but like their feet shackled up.

[13:26] Dr. Katrina Furey: That's a great question. So no, they're not modern day because there's been so much emphasis on patients rights and advocacy movements for all patients, not just these kinds of patients. And maybe I should just take a step back to define what does it mean to be a forensic patient. So forensic really refers to in mental health or in psychiatry. It's talking about the intersection of psychiatry and the law. So when we talk about forensic hospitals or forensic patients, sort of like in the movie, they are typically places where individuals who've been found not guilty by reason of insanity. So they've committed a crime. They've pledged what's anecdotally called, colloquially called the insanity defense, meaning that they're saying they're not criminally responsible for their actions because at the time of the crime, they either didn't appreciate that what they were doing was wrong or they couldn't control their behavior because of a mental illness. They're found not guilty by reason of insanity, which is a horrible stigmatizing moniker, but it's still what we call it. And then they're sent for long term psychiatric treatment in a hospital setting.

[14:30] Portia Pendleton: And then is the goal. We just released an episode about the movie side effects. I don't know if you ever saw that movie, it's also an older movie, but in that movie it seemed like the goal was to restore the character who was found not guilty by reason of insanity to sanity, so then she could go back to them, be tried. Does that actually happen?

[14:56] Dr. Katrina Furey: Yes, that's a great question. It's kind of mixing two different topics in forensics, like two different populations. So we do have the one group who is what I just described, not guilty by visa and sanity. We have a second group of individuals who are found not competent to stand trial, which similar but is different. So being found not competent to stand trial. So for all of us, if we are accused of a crime, we're all presumed or assumed to be competent. Meaning you understand what's going on in court. For some individuals with mental illness or cognitive disorders, they're not able or intellectual disabilities, they're not competent as a result of their capacities. And so if they're not able to understand what's going on in court, they don't know what a judge is, what a lawyer is, or they have delusions that the court is out to get them and they're paranoid about it or because of an intellectual disability, they're just not able to effectively understand what's happening. Or maybe because of mood instability, they're so upset and get so upset so easily and angry and yelling and screaming. They can't really work. A lawyer, they're a court hearing. Those are all reasons somebody might be found not competent to stand in trial.

[16:09] Portia Pendleton: Got it.

[16:10] Dr. Katrina Furey: And that's very much like on here and now at the time you're supposed to show up to court, you will get what's going on.

[16:17] Portia Pendleton: Got it.

[16:17] Dr. Katrina Furey: Whereas the insanity defense is much more about when you did the thing right.

[16:23] Portia Pendleton: Okay, so for this second group, this.

[16:26] Dr. Katrina Furey: Not competent group, it would be more like what you were talking about with Sideways, where they might also come to our hospital and they're going to be sent there for treatment and we're going to try to restore them. So we're going to try to make them better so that they can go back to court and deal with their charges. And that might be through getting medications, group therapies and just education about the court system. Sometimes there's an educational deficit and then we try to send them back so they can deal with their charges. The other group we talked about, the insanity defense, folks, we are trying to make them better, but they're not going to go back and face their charges. They've already been found not guilty and their trial is over.

[17:06] Portia Pendleton: Got it.

[17:07] Dr. Katrina Furey: Now we're just going to re.

[17:10] Portia Pendleton: Got it. That makes a lot of sense. Portia we've been talking about that for weeks. We're discovering and doing this podcast that a lot of the shows we watch and that other people are asking us to cover involve narcissists and psychopaths. This keeps coming up. Yeah, apparently fascinating.

[17:33] Dr. Tobias Wasser: I think also we see, which I think is an interesting shift. In the movie, Dr. Kauley makes a comment that sanity is not a choice. And then also if you treat a patient with respect, you can reach them. So I think that's kind of like the shift into more current times with respecting patients and having them understand what's happening and having a right to choose maybe different medication trials or therapies and stuff like that. And I think that's great and wonderful and it seemed like what he was doing at the time was really kind of like shocking and out there.

[18:07] Portia Pendleton: Right.

[18:08] Dr. Tobias Wasser: And you even see Teddy the Marshall like being angry. Some of these patients are being treated well or, you know, they're not just.

[18:18] Portia Pendleton: Being, um, so cool, like they're being believed. Right. I'm so curious to biased to hear your views about the forensic psychiatrist they depict who is played by Ben Kingsley, dr. Collie. I did write down a couple of quotes that either he said, I think he said them that I actually thought were pretty lovely. So at one point he was sort of telling Teddy Leonardo DiCaprio's character like what they do at Ashcliffe and he said something like this is the moral fusion between law and order and clinical care. And I thought like, well, that's kind of a lovely description of or definition of forensic psychiatry. And then I really appreciated when Dr. Collie would correct the marshals, when they would refer to the patients as prisoners. And he kept saying they're patients, they're patients. And I think Teddy at one point is like, how can you even treat them like knowing these awful things that they've done? And he said something like I treat the patients, not their victims, I'm not the one here to judge. And I just thought like, wow, I don't know. What are your thoughts about his character Tobias and the depiction of him and the other psychiatrists? All of which I'll just point out were old white men, which is accurate probably for the think.

[19:42] Dr. Katrina Furey: You have picked up on some really lovely quotes and some themes in this that I also aligned with, noticed as being really interesting and as you're saying, portion of the time probably were very progressive. And now I think I wouldn't say they're mainstream, but I think they really what's reflected in this is a lot of the tensions that we do see in the practice of modern forensic days, modern day forensic psychiatry that even now working in these facilities. So we've come a long way since the 1950s and there have been this enormous movement around patients rights and giving them the right to choose what does it mean to accept or refuse medication, what abilities do you have to have to be able to do that? Just because you've been committed to a hospital doesn't mean you can be forced to take medications necessarily. And all the things you're saying about in a forensic hospital, about calling them patients, not prisoners, thinking about their illness and their symptoms rather than the criminal behavior they're accused of or been convicted of. And yet we struggle with this all the time still all day working in these facilities. You often find this tension between how he described the law and order and the clinical care you hope for, that the mental health clinician will be the ones really advocating for the treatment component, that they're going to want to think about the person and their illness. Many of these individuals have been horribly traumatized and see an enormous amount of comorbidity in terms of histories of physical, emotional and sexual trauma in their youth that leads them then to enact this kind of behavior when they're older or it's not surprising to any of us. And so we try to get our staff who are demonstrated, like orderlies or the police officers or security guards, whatever they are, to help them understand that these patients are people and that yes, they may have done something really horrible, but that's not what we're going to define them by. But it's still really a struggle and it really falls on those of us who are providing the care or leadership roles in these institutions to keep holding on to that moralistic value and try to keep advancing things forward. And I often found that in these environments, you often see some amount of regression by the staff, meaning that they start to act in more primitive and earlier ways because it can be an unsafe environment. There is more aggression in these environments than the typical mental health setting. And when people start to feel unsafe, they start to regress into these earlier states of being. And so you'll see more interest in punishment than maybe clinical care. They want the patients to have consequences.

[22:18] Portia Pendleton: When they do that right, or sometimes.

[22:21] Dr. Katrina Furey: They'Ll refer to them by their crime as opposed to by their name or their diagnosis. They're just a murderer, they're just a rapist, something horrible like that. And so it takes a lot of work and a lot of effort to continue to hold the line and to not be drawn into that because I think it's kind of a natural human proclivity and it taxes all of us. But it's also our responsibility when you work in these settings to try to keep holding on to that. The role I had running the hospital for the patients, particularly the individuals who have been found not guilty by reason of insanity, they had to have mandatory public hearings every two years in terms to monitor their progress. And if there was ever an effort to try to move them from the hospital to the community and this happens, every state handles it differently. But every state has some process where either the court or a quasi judicial body, like in Connecticut, we have this separate board. It's kind of like a synthesis between a mental health it's sort of like a mental health parole board, essentially, that these folks, as they move through the system to less and less restrictive environments. And whenever you have to have these hearings, families will come, and they have the opportunity, or they have the opportunity at least to give victim statements, the victim themselves or the family of the victim. And it was heart wrenching. It was really awful to hear and really difficult to many of them have been horribly traumatized by what happened to them or their family members. And as difficult and uncomfortable as it was, it was extremely important, I know for myself and others who work in that environment to hear that for two reasons. One, because I think you don't. As much as we're focused on the patients and wanting to get them better, I think as opposed to how the movie depicts it, where it's I don't think about the other things. I just think about this. We have to at least consider that. I mean, one, because it affects their risk, their initial behavior, even if they were really ill at the time they committed some horrific act, we know that's the riskiest thing potentially they could do, right? If they became ill again, if they medicine or they were out of treatment, that could happen again. And so we have to account for that. The second thing is you can become a little too myopic if all you think about is the patient. There has to be some consideration for the impact of this on the community, both just as a human and if you're trying to advocate that this person returns to the community. And that's probably the biggest reason, is if you advocate that this person returns to the community, this is a reflection of what they might experience in the community. The victims will be there, the family of the victims or other victims who have been suffered at the hands of other individuals. And so the patient has to be ready to manage that, and you have to help the patient to be ready to manage that. And so you can't entirely turn a blind eye to it and just say, oh, that's something that happens out there. Because if the goal is to help the patient get back to out there, you want them to be prepared to what that's going to be like. So I think it's extremely difficult. I don't want to pretend like it's easy, but I think it's a really important part of doing this type of work.

[25:33] Portia Pendleton: This sounds like a really hard job.

[25:37] Dr. Katrina Furey: It's not an easy job.

[25:38] Portia Pendleton: It sounds really hard. Like just thinking about not just being the psychiatrist for patients like this. I think some would argue these might be like the sickest of the sick, but then also managing the whole team, treating them, who every team member brings in their own experiences. And so they're also probably getting triggered by different things, as we all are right in this line of work. And then thinking about the community at large, I'm just thinking like, gosh, that sounds like a lot of pressure to be the one, I guess at the end of the day to decide like, okay, yes, I think you're ready to reintegrate, or no, I don't know if I could do that. It sounds really hard.

[26:23] Dr. Katrina Furey: It's really tough. And I think raising a couple of points. One is the community. No community wants these individuals in their community. There actually was a New York Times Magazine article back in, I think, either 2017 or 2018, where they interviewed folks who run these types of hospitals all over the country because they talked about the fact that it's so hard to get patients out of the hospital because nobody wants a former arsonist to be their next door neighbor.

[26:50] Portia Pendleton: Right?

[26:51] Dr. Katrina Furey: Arsonist with schizophrenia. I mean, doesn't that sound really inviting that you want to move next door and not to be I don't want to be overly stigmatizing. Maybe that's how people in the community experience this. The other aspect of it that you talk about, the experience of staff who have been traumatized, and so part of it is, as you are saying, they may have had trauma in their own lives that might be triggering when they do this work. As much as I don't want to propagate the idea that individuals mental illness are violent, they're much more likely to be the victims of violence and the perpetrators of violence. But when you have enclosed environments dedicated for individuals who have been accused of crimes, many of who engaged in violent behavior, there is an increased risk of violence in those environments. And some of these staff members will become they will be harmed, of course, their work. And that, of course, can be very traumatizing. And then the final pieces in these environments, the patients tend to stay there for much longer than at a usual hospital. So, I mean, typical, if someone has to go to the psychiatric hospital, they're there maybe seven to 14 days. For our patients, the shortest period of time they're there is usually 60 to 90 days, and the longest is two decades.

[28:02] Portia Pendleton: Wow.

[28:03] Dr. Katrina Furey: People will be there for very long periods of time. And to incentivize, particularly general healthcare workers to work in these environments, they're usually part of unions that are through the state. They have really good benefits, and so they work there for long periods of time. And so you can only imagine the kinds of relationships and dynamics that evolve over the course of years with employees with their own history of trauma, most well trained in managing personality disorders, your psychopaths, your narcissist, your borderline personality disorders, and then you've got those individuals living in an enclosed environment for a decade. It's fraught with all sorts of drama and trauma.

[28:40] Portia Pendleton: Drama and trauma, yeah, for sure. One thing we wanted to ask you, Tobias, is are you able to comment at all about what are the common diagnoses you see or the most common diagnoses you tend to see? Because I think, just like you said, it's really important to us also that in releasing these podcast episodes, that we keep getting the message out there that people with mental illness are so much more likely to be victims of crimes rather than perpetrators of crimes. And yet a lot of these shows depict these raging psychopathic narcissistic. People who are hurting everyone all around them. So I'm just curious if you're able to comment on that or if that was something you noticed in doing this work.

[29:30] Dr. Katrina Furey: Yeah, so I think this is very much a generalization based on data, statistics or anything, but generally you tend, for the most part to see two kinds of kind of diagnostic profiles. So I think on the one hand, you tend to see individuals who have some kind of a psychotic and or genetic illness schizophrenia, schizoaffective disorder, bipolar disorder with psychotic features. Sometimes they become depressed with psychosis, but mostly it's more in the kind of bipolar and psychotic rain. And their illness is untreated. Either it's been unrecognized or it has been. But they've got off medication for a long period of time. And because of their severe symptoms, their severe mood and psychotic symptoms, they develop either delusional beliefs or they hear voices tell them to do violent things, and then they end up engaging in some kind of risky or violent behavior, whether that's directly being harmful, physical assault, sexual assault, setting a fire, something of that nature. That's kind of one large diagnostic group we tend to see. The second tends to be much more, actually, unfortunately, you said you don't have experience with this, but it tends to actually be probably people you might have been more likely to see, which are individuals who have severe personality disorders and then may or may not develop some. They're usually using substances and may or may not develop a substance induced psychosis. So they're typically, as I was saying, really people with some kind of antisocial personality disorder, which means that they disregard the rights of others. They don't care about rules. They're really only out for themselves. They usually have a heavy dose of narcissism. And then you see a fair number of individuals with borderline personality disorders with this relationship instability and all sorts of other things. You add some substances on top of that, whether it's alcohol, marijuana, coffee, opiates, whatever it might be. And then sometimes they start to develop psychop psychosis or extreme mood instability. And with that group so with the first group we talked about who has a more classic psychotic, manic illness, they actually tend to do it because once they get to the hospital, they get treatment. We know how to treat that group, right? Medicines we have that are tried and true, therapies we have that are tried and true. And they actually tend to get out of the hospital sooner if they're willing to kind of go along with the treatment program. The second group is enormously difficult to treat. And as you guys will know, we certainly don't have medicines because usually what happens is, once they're in the hospital, they're not using illicit substances. So that psychotic or manic illness, dissipates, and all we're left with is the personality disorder, and we don't have medicines to treat it. Our therapies are intermittently or variably effective, depending. Particularly, we don't really have much for antisocial, right? We're a little better with borderline antisocial. But then they're also in these contained environments which are full of law and worship, just like described in the OB. And these individuals don't tend to they don't like it.

[32:39] Portia Pendleton: Lots of rules and law being told.

[32:41] Dr. Katrina Furey: What to do and long term relationships with either their peers or staff who keep showing up every single day. So those individuals are really challenging for the staff, and they're really challenging to reintegrate into the environment.

[32:57] Portia Pendleton: Do you come across a fair amount of malingering?

[33:01] Dr. Katrina Furey: So you do. Where you tend to see more malingering, you tend to see a lot of malingering in those. Not a lot, I should say we see more for the most part, there is not a lot of malingering, but we do see it probably more than other environments. And when we tend to see it, it tends to be in those individuals who not the insanity defense folks, but those people who are found not competent to stand trial. So again, every state is different, but in most states, the legal regulations are essentially that if you're not competent to stand trial, you cannot be tried for your crime, because the courts place this emphasis on human dignity, essentially. And so the idea is, if you're not mentally sound, how can we try you for a crime if you don't understand what's going on? Work effectively to your lawyer. So it depends on the state, but if you're not able to be competent or restored to your competence, you may never face your charges. And so how that's dealt with is different. You may end up in a psychiatric hospital, you may not, but most of those people won't face their crime. And so there's a number of individuals, whether their crimes are significant or more minor, who essentially think, can I fake crazy?

[34:15] Portia Pendleton: Can I fake crazy in order to.

[34:16] Dr. Katrina Furey: Get out of facing my crime and dealing with the consequences. So we do see that more than most things, and most of hospitals like this employ psychologists who can do psychological testing and screen for malinkering as a way of trying to help us substitute that out. That's a big part of the assessment we do, especially if we suspect that somebody might be faking it more than might be faking it, period.

[34:39] Portia Pendleton: When you're getting ready to discharge patients from these forensic hospitals, are there specific community clinics or places that you sort of go to who can sort of do you get to collaborate with them after the patient leaves to sort of make sure they're okay or their check ins. Or if they start to unravel, they can sort of quickly come back into treatment. Or is that just like a fantasy I'm creating in my head?

[35:05] Dr. Katrina Furey: No, you're not far off. So again, my experience is here in the state of Connecticut. So here we tend to work with our state mental health department and almost all the patients receive treatment at community mental health centers that are part of the state mental health system.

[35:20] Portia Pendleton: Okay.

[35:22] Dr. Katrina Furey: They work with those folks and because it's so hard to get them to the community, there are usually prolonged transition periods where they're meeting their community clinicians while they're still at the hospital. They're beginning they have transitional visits if they're going to be in some kind of they're almost always living in some kind of supervised setting, whether it's a supervised apartment or a group home or something. And so they do transitional visits before they actually leave the hospital. And they may spend months, maybe even up to a year, just engaged in a transition process before they actually go and leave the hospital. And then usually in most states, there's some mechanism for bringing us back to the hospital if they're not doing well. So there's a concept called conditional release, which is the idea that they can be released to the hospital, but it's conditional on their safety, good behavior or whatever you want to say. And it can be both. That's why it's conditional if there's some safety related concern and they can be brought back to the hospital.

[36:22] Portia Pendleton: I see. Okay. Wouldn't this be nice for almost everyone needing inpatient psychiatric care to just have more time getting treatment and then have this nice transition period? And it just seems like such a better model overall. And I wonder if that's what it used to be like back in the day where people would not just get two days of treatment and then be discharged.

[36:45] Dr. Katrina Furey: I think in a world that's less driven by insurance reimbursement, this probably was I don't know that quite this extreme, but I imagine this was the model. And I do think as so much of our health care is now decided by what will be paid for and not paid for, we've really gotten away from this. And I think not everybody needs this, but many individuals for whom they could benefit from this kind of care. And part of what's talked about in public entities, state, county funded institutions, is this idea that kind of like the allocation of resources really depends on what the law requires you to do. And so there's always a limited fund of resources in any state, county, whatever. And so where you shift your resources is what's required. So like, for example, Connecticut is not one of them. But most states have some form of involuntary outpatient commitment for individuals who need to be they're chronically ill, chronically dangerous, and they want something like what you're describing, which is a way to bring them into the hospital quickly if they're not doing well in the community.

[37:47] Portia Pendleton: I think New York has something like that, right? Where if you're not complying with your injectable antipsychotic or something.

[37:55] Dr. Katrina Furey: Exactly, yeah. So New York actually 46 of the 50 states have laws like this but New York was one of the first, called Kendra's Law. North Carolina was an early adopter of this as well. They've done the most research on it, and there's some evidence that it works. But the major concerns with laws like this one is that it tends to be overly representative of minoritized individuals, people who are black, brown, Hispanic, from low socionomic status, that we tend to see more of those individuals. And so there's a significant concern that's been raised that these ideas are built on racist practices and structures, and so it's inappropriately used in those populations too often. The second concern that's often raised, which I think is where I was going before, was that because there's a limited pot or pool of resources, when you construct laws like what I'm describing, for involuntary outpatient commitment, it requires the public entity to give the resources to those individuals usually at the loss of the resources for other individuals who aren't engaging in those same behaviors but might equally benefit from them. Because you're going to kind of shift your focus to whatever you have to do, and whatever you don't have to do, you're less likely to do.

[39:12] Portia Pendleton: That makes a lot of sense. I also feel like that could be really used against patients in an icky way. It's so hard. It's like I understand it, but then it just feels like it could be really coercive.

[39:26] Dr. Katrina Furey: Yeah, it's not the same, but it's a little similar to when you have patients if you're caring for individuals who are on probation. And then there's this polls as well. Your probation officer is not going to like it if you don't show up. I'm going to call them again. I think it's like this well intended effort to try to keep the person engaged in treatment and engaged and using the interventions that you think will keep them safe and well and out of trouble. But it's really manipulative kind of co opting the purpose of treatment, which ought to be for treatment, and we ought to be giving people a choice. And if they want to participate, great. And if they don't, they may have consequences for those choices, but it's not our responsibility as mental health providers to be enacting those consequences. And that's often the challenge that people find themselves in, that somehow they get drawn into that in a well intended but kind of inappropriately administered way.

[40:18] Portia Pendleton: Yeah.

[40:18] Dr. Tobias Wasser: And I want motivational interviewing gone wrong, helping them explore the potential consequences and what that might be like versus I'm going to call them myself.

[40:31] Portia Pendleton: It reminds me when I threaten to call Santa Claus on my children when they won't just get dressed in the morning. So Tobias, do you have any criticisms about this movie and the way anything was portrayed? Or I guess on the flip side, did they get anything really right that you really liked?

[41:01] Dr. Katrina Furey: I found myself really struggling with the ending. When you find out that this whole thing has been kind of an elaborate and effort to lean into the delusions. I think back to your anecdote.

[41:17] Dr. Tobias Wasser: There was a part of me that.

[41:18] Dr. Katrina Furey: You don't know why.

[41:19] Portia Pendleton: Right. What are you doing? I learned this my very first day of training.

[41:25] Dr. Katrina Furey: Yeah. And then you don't want to trick your patients. That's not a way of engendering trust and all these things. And then there was another part of me that thought, like, this is really interesting. Would this work? Is there any chance that trying to align with the patient in some way could be effective? I think I reached a conclusion. No, I don't think so. I don't think we want to. It's a tightrope walk, as we probably talked about that fateful day. I think you want to help the patient feel supported without reinforcing that the beliefs that you think are symptoms of an illness are actually happening.

[42:02] Portia Pendleton: Right.

[42:03] Dr. Katrina Furey: I think that it wasn't surprising to me, I guess, given that this was supposed to be such a novel, progressive treatment model, that they would try to enact this on Shutter Island. But I found myself troubled by it, ultimately.

[42:20] Portia Pendleton: And I couldn't believe it was his psychiatrist who was, like, the other Marshall. Right. Like Mark Ruffalo's character. Like, for a while, I kept thinking, like, was Mark Ruffalo like a hallucination? Was that his part of his mind that was still sane in some ways? And then when it comes out that that's actually the psychiatrist they all said was on vacation, I was like, how do you do that? How is he ever going to trust you again?

[42:47] Dr. Tobias Wasser: Yeah.

[42:48] Portia Pendleton: What did you think about when they were all having their scotch at the end of their night, like, in their big, fancy velvet chairs and thrilling their mustaches? And that one psychiatrist kept saying, I feel like I want to use this in social conversation. Somehow he kept looking at Teddy and going, you have great defense mechanisms. Do you remember that? Wow, these are great defense. But it was like an underhanded comment. I don't know.

[43:15] Dr. Katrina Furey: Was that not part of your training?

[43:17] Portia Pendleton: No, I missed that part. I must have been on maternity leave.

[43:23] Dr. Katrina Furey: Yeah. I just thought it was so stereotypical of psychiatrists. Who knows? Maybe that is what really happened in the 50s. But it was just this kind of idea of the old boys club, and let's sit around and be very sophisticated and talk about our analytics theory right.

[43:42] Portia Pendleton: And judge and analyze everyone. Right. I feel like I think we all probably get this in social situations, like when you're just trying to make friends or whatever, and people hear your psychiatrist and everyone gets so nervous, and they're like, oh, are you analyzing me now? But I think movies like this sort of perpetuate that when these people are analyzing everyone so quickly. One thing that I wanted to touch on was Michelle Williams's character. I forget her name, but she was basically Teddy Daniels's wife. And she did end up, it seems like well, she did end up killing their three children. And I just wanted to bring it up because it reminds me of postpartum psychosis, which has been in the news lately. And as a reproductive psychiatrist, anytime I can talk about this and sort of just get some info out there, I like to, because it is the most severe complication of childbirth. I mean, mental health complications like depression, anxiety, OCD are the most common complication of childbirth beyond any physical complication. And then postpartum psychosis is the most severe and also the most rare. And if you develop postpartum depression or anxiety, that does not increase your risk for having postpartum psychosis. These are two separate disease pathways. So I see a lot of women in my practice who have had postpartum depression or anxiety, especially lately, I think, with what's being said in the news, who get really scared that if they want to have a baby, does that mean that they could lose their mind, so to speak? So this condition occurs in one to two out of every thousand births. So, again, super rare. About 40% of women have the baby blues after delivering a baby. That's just where you feel like you're on an emotional roller coaster, and it's awful, but it's totally normal. And then about ten to 15% develop postpartum depression, anxiety, OCD. And then, again, one to two out of 1000. I can't do that fraction in my head, but very rare to get postpartum psychosis. Again, I feel like I don't think that's what this character was experiencing because her children look too old. I don't think there was a baby involved. Usually, postpartum psychosis develops in hours to weeks after delivery, so that first, like, two to four weeks is really critical to be monitoring someone. A lot of times, women who develop this condition, you'll have symptoms of hallucinations, hearing or seeing things that aren't there, delusional lines of thinking that aren't in line with the broader cultural beliefs that you're growing up in. And a lot of times, unfortunately, these delusional thoughts are directed toward the baby. You think, like, the baby is possessed by a demon. The only way of helping them is by killing them, for example. Something like that. So the rates of suicide infanticide are really high. Sadly, I think there's like a 4% risk of suicide and around the same for infanticide. And that's incredibly sad. In this movie, it seems like the children were older. So again, postpartum psychosis would develop really early or up to a year. A lot of times, women with this condition end up having an underlying bipolar disorder. So, again, if you have a history of bipolar disorder, you really want to be monitored carefully. Again, it's still rare, but it could happen. But I feel like, if I remember correctly in the movie, the kids were older, so it makes me wonder if the mom had depression with psychotic features or a personality disorder. We don't really know. We don't really get to know anything about her. But I couldn't watch it this time. I had to fast forward through those scenes near the end. It was, like, way too much for me to watch. I don't know about you guys. Yeah.

[47:35] Dr. Tobias Wasser: They had said in the movie and using their words at the time that his wife was insane and a manic depressive. Suicidal tendencies was how they described her to him when he was kind of.

[47:48] Portia Pendleton: Coming out of right. So maybe she had some kind of bipolar disorder or schizoaffective disorder or something.

[47:58] Dr. Tobias Wasser: And I think, too, I was just, like, reflecting on his trauma in the war and then coming home and kind of finding his children deceased. And then his wife kind of really flippant about it. And I think that could make a lot of people react the way he did with killing her in that moment. Emotions are so high because I was thinking it's like, why did he end up here? I might be way off here. I don't know at all. He was there not because of the crime of killing his wife, but because of his then, like, delusion after because I feel like you could kill someone and you go to jail versus, like, a forensic hospital.

[48:48] Portia Pendleton: Maybe he was found not guilty by reason of insanity because they were saying maybe have happened.

[48:53] Dr. Tobias Wasser: I'm assuming then for him to end up on that island versus, like, a jail.

[48:57] Portia Pendleton: Right? No, I think you're right. And I think I wrote down when the team kept talking about Rachel Solano, the brunette woman who allegedly went missing, I felt like if you rewatched it, you could hear their thoughts about Teddy, right? Like, as they're all part of this big hoax. I think they're actually, like, talking to Teddy, and they said something about how the greatest obstacle to recovery is the inability to face what she's done. And I feel like that was him. And I think, like you said earlier, Tobias, it really speaks to is he delusional or an extreme denial? And we kind of saw that foundation laid. I thought with all the flashbacks to war and that he clearly had PTSD, looks like he developed an alcohol use disorder, and then this happened. Why wouldn't he still be using his excellent defense mechanisms to stay in this world of denial? Is there anything else you want to mention before we ask you your thoughts about some of our other favorite psychopaths?

[50:09] Dr. Katrina Furey: No. I hate you guys at all. I welcome your psychopath.

[50:16] Portia Pendleton: So you have seen the show. You right. At least some of it.

[50:20] Dr. Katrina Furey: Yes. I've seen the first couple of seasons.

[50:22] Portia Pendleton: I'm so jealous whenever I meet someone who isn't caught up because it's so good, and, like, season three and four are so good. So we're dying to know your thoughts about Joe Goldberg?

[50:36] Dr. Katrina Furey: Yeah. And I've heard some of your guys discussions about this, about the episode, the seasons. I have seen that he is such an interesting sociopath.

[50:48] Portia Pendleton: Right.

[50:48] Dr. Katrina Furey: He's got this level of compassion in him that you just don't typically see. And it's confusing. I mean, like his relationship, like with.

[50:59] Portia Pendleton: Paco, the little boy.

[51:01] Dr. Katrina Furey: Exactly. Neighbor boy. Clearly there's some projection identification there, but there are just ways in which he clearly connects exactly in a way that you don't typically get. It makes it almost feel not real. But in my experience working with individuals with social personality disorder, and even the ones who would be identified as sociopaths, I've never come across somebody like that before. You tend to see much more callousness, much more narcissism, self directed interest. And he clearly has plenty of callousness and self directed interest and erotic fantasies and all sorts of other things. But I think that's the part to me that's most notable because it humanizes the character in a way that you almost root for him.

[51:52] Portia Pendleton: Right.

[51:53] Dr. Katrina Furey: Dominique, sociopathic, right?

[51:56] Portia Pendleton: Yeah. What do you think about Logan Roy? Do you watch Succession?

[52:06] Dr. Katrina Furey: I'm just thinking about this in anticipation of today and I guess are you guys convinced that he's a sociopath or a psychopath? I think he's an extreme narcissist, doesn't care about other people. I don't know that he purposely tries to harm me. To me, I view his character pathology as all being about himself and a way of fulfilling his own needs, seeing himself as more important than anybody else. I don't see him necessarily as like I guess he doesn't care about the rules, but it just all seems so self serving. So maybe I'm drawing the lines of distinctions that don't exist, but I don't know what you guys think.

[52:47] Portia Pendleton: I still think he's very, like a malignant narcissist. However, I could maybe be convinced that this was a very intense, complex PTSD and developments of putting his own needs first to survive in a trauma informed kind of way based on the way he was brought up. Like, he doesn't know any better, but then he just does stuff to the kid, to his kids who are adults, but I always call them kids that just feel so icky and like to his grandson, and maybe he's going to poison them or not, where then I'm just like.

[53:25] Dr. Katrina Furey: Yeah, that's fair. Poisoning of the children.

[53:31] Portia Pendleton: That'S usually not cool. What do you think about that?

[53:35] Dr. Tobias Wasser: Is that also learned?

[53:37] Portia Pendleton: Right?

[53:38] Dr. Tobias Wasser: This is how he was hit, or this is how you make a man, or this is how you make someone who's self sufficient views at times like Kendall and specifically, it feels like Kendall is really soft, right. Not hard enough, not like a killer. And I don't know, it's like almost his disappointment in that, because he is, but it's like he was raised that way. I think it is confusing. I mean, a lot of trauma always there seems to be. But does he love does he feel good when he hurts them because he hurts them, or does he not think about it, or does he feel like he's helping them? I don't know.

[54:23] Portia Pendleton: Right.

[54:25] Dr. Katrina Furey: I think I can see that, and I guess I've seen it more as maybe an adaptive behavior. I think that based on the difficult life experiences that we learned recently that he had and upbringing, the challenges he had to overcome, I think both. He literally had to overcome a lot. And it seems like there's this learned aspect that espousing a machado and a machismo. Like, this is the way that you're big and you're tough and you got to get through life to get over these things. And he does some horrible things, but usually it's to achieve some personal, self serving end.

[54:59] Portia Pendleton: Usually the reason, not because he's, like, getting off on hurting someone else.

[55:04] Dr. Katrina Furey: Yeah. Again. I don't pretend to fully understand logan Roy. It doesn't seem like he hurts for the sake of hurting. He seems to hurt as a means to the end of his own success and survival.

[55:16] Portia Pendleton: Right? Yeah. Right. What do you think about Tom?

[55:20] Dr. Katrina Furey: He's, like, slimy and slithery and will do whatever he has to do to anybody in order to get to that ultimate goal. And it's hard to know. He probably is probably born that way, whatever. But it does seem like it stems differently from this deep seated insecurity about his upbringing and always wanting something grand and great and wanting to feel grand and great. And it seems like he hopes that if he can be in the presence of greatness, then he will be great, and then he will ascend to greatness, and he'll finally, basically, finally convince Mommy to love him.

[55:53] Dr. Tobias Wasser: I had the wool over my eyes for him until recently.

[55:57] Portia Pendleton: That's okay, portia. You have a pure heart. You have a pure heart. Got to watch out. People like him will get you like it for real. Thank you so much, Tobias. This is super helpful. So thanks for listening to another episode of Analyze Scripts. You can find us on Instagram at Analyze scripts. You can find us on TikTok at Analyze Scripts podcast and stay tuned for our next episode, and we'll see you next Monday. Bye. This podcast and its contents are a copyright of Analyzed Scripts. All rights reserved. Any redistribution or reproduction of part or all of the contents in any form is prohibited. Unless you want to share it with your friends and rate review and subscribe, that's fine. All stories and characters discussed are fictional in nature. No identification with actual persons, living or deceased places, buildings, or products is intended or should be inferred. This podcast is for entertainment purposes only. The podcast and its contents do not constitute professional mental health or medical advice. Listeners might consider consulting a mental health provider if they need assistance with any mental health problems. Or concerns. As always, please call 911 or go directly to your nearest emergency room for any psychiatric emergencies. Thanks for listening and see you next time.

[57:29] Dr. Katrina Furey: Our channel.

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