Psychiatry

Trans Psychiatrist Answers – What the Public Needs to Know About Queer and Genderqueer People.

/ Jame A. Agapoff, MD, MS (she/they) / 2 Comments

Queer and genderqueer people have a long history of stigmatization and discrimination.

A little over 50 years ago, psychiatrist John E. Fryer had to where a disguise and use an alias at an APA conference to discuss being gay. He had to do this out of fear of being fired or worse, having his professional license attacked.

It would take almost another decade for homosexuality to be depathologized in the DSM of mental disorders. Up until then, homosexuality was considered a sexual disorder. Even after homosexuality was depathologized, pathological theories and treatments around homosexuality remained.  Queer children were forced to undergo inhumane forms of conversion therapy in the name of science. Now we know that being gay, queer, or homosexual is about WHO YOU LOVE. Queer identities are not sexual or socially appropriated, and they never were.

But social contagion is often the erroneous argument behind every don’t say gay bill and book ban. This concept is utterly preposterous and without any evidence, yet it still remains, and such unscientific and bigoted ideas continue to be legislated upon, negatively impacting the lives of queer people, and queer kids today.

Transgender and Gender Diverse People are equally misunderstood. While being queer is about who you love, being genderqueer is about WHO YOU ARE.

Gender diversity like homosexuality has also long been sexualized by the researchers and the greater medical community. This has led to largely debunked and poorly supported sexualized models of gender diversity such as autogynophilia.

It’s only been in the last decade that the DSM has depathologized gender identity and recognized gender diversity as inherent facet of human diversity. Despite this, genderqueer people are often called “groomers” and legislated against just for being themselves. It’s utterly appalling and sad, and as a society everyone needs to know that being trans, non-binary, or genderqueer is not sexual. It never has been.

The impact of being sexualized in media and in the medical literature has a significant impact on the psyches of trans people. Because they are forced to hide their exceptional gender qualities, they sometimes express their authentic gender through sexual fantasy or acts. Freud believed that dreams and sexual fantasies represented attempts by the unconscious to resolve a wish or conflict. The wish was repressed by the ego due to shame/guilt or because it represented something unaccepted by society (Freud, 1899; Schept, 2007). This is commonly seen in early transition but diminishes as individuals proceed in their transition and become their authentic selves.

As a psychiatrist, a transgender person, and a human being I implore all of you to open your hearts to queer and genderqueer people. All we want is to be ourselves free of discrimination. We can’t do this without you.

Be an ally. Be an upstander. And stand up against discrimination in all its forms.

Therapeutic Silence

/ Jame A. Agapoff, MD, MS (she/they) / Leave a comment

Language and voice are a unique characteristic or our human condition. From our births, we are encouraged to speak and taught to express our needs, emotions, and thoughts through words. This becomes so natural many of us forget the subtle non-verbal forms of expression each of us use everyday.

When most people think of therapy, they think of ‘talk therapy.’ Learning to name emotions and verbalize mental states is an important first step in working with a therapist. I am confident in saying that the progress of therapy is made primarily through an oral discourse; but, at times, our words may also be a deflection from the truth.

Resistance in therapy is the conscious or subconscious act of opposing therapeutic recommendations. In terms of communication, this may involve forming an excuse for why the intervention can’t be done, changing the subject, or even avoiding the subject all together. Spotting resistance is important but so is how to respond to it. Confrontation too early in treatment may result in the loss of a therapeutic alliance. Therefore, this may be a good time for therapeutic silence.

Therapeutic silence is an active process. It involves listening and observing. Sometimes, the process can be uncomfortable for a client and their therapist. For example, an anxious patient may attempt to engage their therapist in idle chatter to avoid something that is bothering them. The therapist, on the other hand, may internalize the patient’s anxiety and try to dissipate it through more idle chatter. A more skilled provider may simply stay silent and only introject to comment on the patient’s behavior or provide gentle redirection to the therapeutic work. Sometimes, it may involve staying mostly silent through most of the session. This can be helpful, for example, if someone is experiencing a grief reaction.

There are many ways to learn therapeutic silence or a practice of active listening. This is a common practice learned in mindfulness meditation. Through a practice of quieting one’s own mind, one develops a calmer, more relaxed, and less reactive mental state conducive for observation and listening. This skill can be further refined through silent retreat or other forms of mind training.

Human communication, like human emotion, is complex. What is said can be as important as what is not said, and sometimes what is said means nothing at all. Therapeutic silence can help us all understand each other better, and respond in a meaningful way that facilitates growth. Sometimes, the best response is no response at all.

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Holding the Anxiety of Others

/ Jame A. Agapoff, MD, MS (she/they) / 1 Comment

Sometimes, when I’m asked what makes a good psychiatrist, I reply, “A good psychiatrist can hold their patient’s anxiety.” This useful skill can be helpful in leadership and other disciplines. Let me explain.

When a patient walks into my office, they might be sad, angry, or experiencing other strong emotions that they display in the session. They may introject these feelings or project them outward. In some cases they are directed to me.

To hold the anxieties of others first requires us to be present and aware of our own feelings. The other person’s feelings are not our own. This is important to recognize because it is easy to appropriate another’s feeling or react to them in a defensive manner.

For example, imagine someone is upset or angry, and suddenly they direct those frustrations toward you. It would be easy to react defensively or in kind. This type of response is rarely, if ever, a helpful response for either party.

The better path is to acknowledge the emotions or concerns of the other person and to hold those feelings for them without judgement. This may involve simply listening or being supportive in a non-affirming manner.

Take for example a mother who’s child is throwing a fit. Getting angry with the child only escalates the situation. On the other hand, staying calm, speaking with firm kindness, and modeling appropriate behavior and responses, create the space for positive mirroring and change.

Thus, in a way, good psychiatrists are like good parents. They hold their patients’ anxieties, react in a neutral but caring manner, and support the growth of their patients. If a psychiatrist can do this, I think even Winnicott would say they are “good enough .” 😉

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How COVID-19 May Ultimately lmprove Mental Health Access for Rural and Underserved Communities

/ Jame A. Agapoff, MD, MS (she/they) / Leave a comment

1 in 5. That is the number of persons with a mental health or substance use disorder. Of those, only 40% seek help. A major barrier is access to psychiatrists and other qualified mental health professionals.

According to one statistic, there was approximately 31,000 psychiatrists actively practicing in the U.S. in 2018. The U.S. population in 2018 was approximately 237 million. Rural counties often suffer from the greatest shortage in psychiatric care with 60% of U.S. counties and 80% of rural counties having zero psychiatrists.

Of those psychiatrists who are actively practicing, 60% are over the age of 55. This makes psychiatry one of the “oldest” specialties.

COVID-19 has had a significant impact on mental health. Between 2019-2021 the average number of persons reporting symptoms of anxiety or depressive disorders rose from 11 to 41 percent. Young persons, essential workers, and minority communities of color have been most impacted with higher rates of suicide and substance use.

So what tools do psychiatrists have now that didn’t exist before COVID-19?

Prior to the pandemic, state licensing boards required physicians to hold licenses in each state they saw patients. This requirement was relaxed under COVID-19.

Reimbursement has also changed. Prior to COVID-19, federal regulators restricted how and when telemedicine could be reimbursed. Right now, because of the pandemic, video visits are being reimbursed equally to face-to-face visits.

Telephone appointments have also changed. Prior to COVID-19 doctors were rarely paid for telephonic appointments. Now they do, and many patients, especially those who don’t have video capabilities and have to travel long distances for face-to-face visits, appreciate this flexibility.

Another rule that has been relaxed during COVID-19 relates to prescribing. Under the Ryan Haight Act, physicians were unable to prescribe controlled substances via telehealth without a prior face-to-face encounter. During COVID-19, psychiatrists and other providers could offer these medications after a telemedicine encounter. This is especially important in the treatment of opioid use disorders where buprenorphine is the mainstay of treatment.

COVID-19 has had a significant toll on health care workers and the patients they treat. Out from this tragedy have arisen expanded ways psychiatrists can prescribe and offer services to patients in rural and underserved communities. I agree with other mental health professionals in advocacy to keep these changes in place after the pandemic ends. This is one way we can help address the shortage of psychiatrists and the needs of all those who have been impacted by COVID-19.

References:

Lubell, Jennifer. A call to make four telehealth provisions permanent. Clinical Psychiatry News. Vol. 48: No. 12.

Inside America’s Psychiatrist Shortage
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Mental Health & Policing

/ Jame A. Agapoff, MD, MS (she/they) / 2 Comments

As a psychiatrist, the death of George Floyd exposed more than systemic racism within our justice system. It exposed serious flaws in how we manage community mental health crisis.

Based on the testimony of expert witnesses during the Derek Chauvin trial, George Floyd likely suffered from a substance use disorder. He may have also suffered from other mental health conditions. It is unclear whether George ever received or was offered treatment for those conditions. Given what we know about underserved minority communities, the chances are that mental health services were scarce, and police were the first responders to mental health emergencies.  

In the U.S., most mental health emergencies are handled by police, who lack the training and expertise necessary to deescalate and properly manage these patients. Calls to “defund the police,” are more about funding mental health and social resources than truly defunding policing. People with serious mental illness are rarely violent, and few families want a police intervention when a member of the family is suffering from a mental health emergency.

Part of the problem can be traced all the way back to this deinstitionalization of the mentally ill, which was done without any thought to how communities would support, treat, house, and manage persons with severe mental illness. For many of these patients, the hospital was their home, and they lacked the insight, skills, and wherewithal to function in society without a high level of support. I’ve personally worked in jails filled with patients who would be better served in a hospital setting. This is a Faustian bargain if there ever was one.  

 Making police the first responders to mental health emergencies is a recipe for disaster, and we have the bad outcomes to prove it. Each of us shares a part of this shame, but I think there are a few models worth adopting that might help improve outcomes.

The CAHOOT’s (Crisis Assistance Helping Out on the Streets) model operates on two-person teams consisting of a medic and a caseworker who are first-responders to mental health emergencies. CAHOOT’s teams are psychiatrically trained to use de-escalation tactics and other methods to manage emergency calls. In 2017, Eugene, OR, the CAHOOTs team managed about 17% of all police calls on a fraction of the budget (2.1 million vs. 90 million a year). Other cities are hoping to adopt similar models to CAHOOTs. The unifying principle of these models are simple: mental health emergencies should be handled by mental health professionals.

The death of George Floyd is a tragedy that should not be forgotten. It is incumbent on a compassionate and just society to provide safe and meaningful interventions for their most vulnerable persons. This starts with innovation and investment in new, evidence-based systems that address systemic racism, homelessness, and severe mental illness. How we manage community mental health crisis is within our power to change. It’s time for us to make the right choice.

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Choose Integrated Care

/ Jame A. Agapoff, MD, MS (she/they) / Leave a comment

In my previous post, I talk about the difference between psychiatrists and other mental health professionals. I also introduce the topic of the biopsychosocial formulation, which is the psychiatrist’s tool to formulate the psychological, social, and biological determinants of an individual’s psychopathology.

The biopsychosocial formulation integrates the different dimensions of human life to give us a clear picture of the predisposing, precipitating, perpetuating, and protective factors underlying a person’s illness. The psychiatrist is the only mental health professional with the expertise to treat all these dimensions; however, even psychiatrists do better if they belong to an integrated team of providers.

In integrated care models, providers share information and work together to deliver high-quality treatment. Systems like the VA and Kaiser are integrated, along with many other health care systems. I personally recommend integrated care systems to all my friends and family.

Some clinics/systems may be integrated but not have psychiatrists. This may be alright, so long as the available providers can fulfill all the needs of the biopsychosocial formulation. For example, mental health nurse practitioners can prescribe medications and treat the biological components of disease; social workers can address social dimensions of illness; and, psychologists can examine and treat psychological needs. Ideally, these providers, along with primary care, should be working together as a team.

These are difficult times for all of us. It is natural to feel more anxious or depressed. If these feelings are impacting your daily function, it may be helpful to talk to somebody. Your primary care doctor may be the first person to ask about therapy and treatment resources. They may have embedded mental health professionals in their clinic who can provide support and help. Remember, if possible, choose care that is integrated.

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The Expertise of a Psychiatrist

/ Jame A. Agapoff, MD, MS (she/they) / 1 Comment

During these difficult times, mental health symptoms are on the rise. Some may be considering re-engaging with mental health, while others may be considering getting help for the first time. Many people are unaware of some of the differences between psychologists, psychiatrists, and therapists/counselors. This short blog series will explore some of these differences to help you make an informed decision about your care.

Counselors/Therapists: Anybody can call themselves a counselor or therapist. That doesn’t mean they are all bad. I work with several Licensed Clinical Social Workers (LCSWs) who are very good at therapy. They also bring in the expertise of social work, which can help navigate difficult family problems. LCSWs can add specialized training and certificates to their degrees, making them proficient in family counseling, addiction counseling, trauma counseling, etc. LCSWs typically have Master’s Degrees. Many other providers who call themselves therapists or counselors do not have advanced degrees. They may have certificates for specific therapies like LCSWs. Botton line: if someone calls themself a therapist or a counselor, I think it’s important to know their credentials.

Psychologists: Psychologists are Master’s or Doctoral level practitioners who specialize in non-pharmacologic treatments, specifically the evidence-based treatments. There are two doctoral-level tracks a psychologist can take: Ph.D. or PsyD. For the sake of this post, just note that Ph.D. programs are often considered more rigorous and research-based, and PsyD programs are more clinically based. If your provider is licensed, you know they meet a general standard of knowledge to practice in that state.

Because of their doctoral-level training, psychologists are doctors, but they aren’t medical doctors who hold advanced medical degrees (either M.D.s or D.O.s). This means that they can’t prescribe medicine. Depending on your needs, it’s essential to know this distinction before you make an appointment.

Psychiatrists: A psychiatrist is a medical doctor (M.D. or D.O.) who has completed a 4-year residency training program in psychiatry. After residency, some psychiatrists further specialize in areas like child psychiatry or addiction psychiatric, which requires additional years of training (a fellowship).

In the U.S., medical degree programs are highly selective and regulated under the Association of American Medical Colleges (M.D. Programs), or the Commission on Osteopathic College Accreditation of the American Osteopathic Association (D.O. Programs). This is also true of psychiatric residency programs that are accredited by The Accreditation Council for Graduate Medical Education (ACGME). If your doctor is a psychiatrist, he/she would have graduated from both medical school and residency.

A Board Certified Psychiatrist is a psychiatrist who has taken the additional step of taking an all day-knowledge test demonstrating expertise in the field and maintains his knowledge through a series of learning activities to ensure he is up to date on all the latest medical information. If a psychiatrist tells you he is “board eligible,” it just means he can take the boards.

Psychiatrists bring together clinical expertise, research, and medical knowledge. For each patient, we complete a biopsychosocial formulation, which synthesizes psychological, social, and biological factors of disease. We then formulate which factors are predisposing, precipitating, and perpetuating. This then forms the basis of our treatment plan and recommendations.

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Confronting the Negative Within

/ Jame A. Agapoff, MD, MS (she/they) / Leave a comment

 

Human beings are prone to accent the negative over the positive. As we have evolved, negativity bias may have given us a biological advantage to avoid dangers in our environment; however, in the modern world, negativity bias can significantly impact our perceptions of ourselves and the world around us, leading to depression, decreased productivity, and relationship discord.

In a very interesting study of newlyweds, Gottman et al. postulated that it takes five “positive” interactions for every one “negative” interaction to maintain a happy relationship. Consider how this 5:1 rule might impact other situations in your life.

In depression, negativity bias strongly affects mood and blinds us to the goodness in our lives. Awareness of our negativity bias is the first step to overcoming it. Positive psychology teaches us that a daily practice of gratitude can temper our negativity bias and lead to greater happiness.

Two simple ways of practicing daily gratitude include gratitude journaling and gratitude meditation. Gratitude journaling involves writing out things you are grateful for in your life. For example, I may write about my health, my pets, my home, my family, my job, my friends, etc. As I write, I consider how these things enrich my life. Another way to practice gratitude is to simply sit (preferably in a quiet place without distractions) and consciously reflect the positive things in your life. Personally, I find it helpful to visualize these things as I reflect on them.

The two practices I have outlined above may seem simplistic, but they can have a profound impact on reducing our negativity bias and lead to greater happiness. The more we focus on the light at the end of the tunnel the less aware we are of the darkness around us.

I am grateful for all my readers.

References:

Gottman, J. M., Coan, J., Carrere, S., & Swanson, C. (1998). Predicting marital happiness and stability from newlywed interactions. Journal of Marriage and the Family, 5-22.

Rozin, P., & Royzman, E. B. (2001). Negativity bias, negativity dominance, and contagion. Personality and social psychology review, 5(4), 296-320.

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Loneliness…The Silent Killer

/ Jame A. Agapoff, MD, MS (she/they) / 1 Comment

You may find this surprising, but loneliness may be a bigger public health risk than obesity, smoking, or alcoholism. Yes, loneliness. According to one meta study by Brigham Young University social isolation increases your risk of death by 30%, with individual study estimates as high as 60%. This is equivalent to someone who smokes about 15 cigarettes a day or life span decrease of almost 8 years. Wow!

In my psychiatric practice, I treat many patient whose primary complaint could be described as social isolation. This is different than objective isolation but the two are often interrelated. These individuals are more likely to express hopeless thoughts, which are correlated with suicidal thinking.

But the effects of loneliness are not only psychological. Being lonely can have profound physical effects. Loneliness places the body in a chronic stress state. Chronic stress has been shown to lower the immune system and lead to high blood pressure, heart disease, obesity and diabetes.

Healing loneliness is within all our grasps. The first step is considering people you might know who may become lonely. For example, someone who recently lost a loved one, who might be going through a break-up, an individual who lives alone, or someone showing signs of loneliness even though they have social context.  Simply sharing your time with these persons can have a profound impact on their mental and physical well being. You don’t need to be doctor to heal others–you only have to be human.

References:

https://www.forbes.com/sites/quora/2017/01/18/loneliness-might-be-a-bigger-health-risk-than-smoking-or-obesity/#4bf5904525d1

The power and prevalence of loneliness

https://time.com/3747784/loneliness-mortality/

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