Mental Healthcare Inequality

Watch Dr. McFadden discuss “Mental Healthcare Inequality” on YouTube: https://youtu.be/twDbWUGmgQ4

In this video, I review a chapter from “Mind Matters: A Resource Guide to Psychiatry for Black Communities.” The book is brilliant, but I selected a chapter for review that is especially pertinent today: Dr. Malaika Berkeley’s chapter on Racism and Inequalities in Mental Health.

Dr. Berkeley educates the reader on healthcare inequalities by definition and by example. Healthcare inequalities are, simply put, differences in health and healthcare. Minorities (including African Americans, Hispanic Americans, American Indians, Asian Americans, and Native Hawaiians) have a greater incidence of diabetes, cancer, heart disease, substance abuse, and infant deaths. They die at an earlier age from these ailments. They have less access to quality health care, and less access to ANY health care. And even when factors such as age, social standing, wealth, location, language, gender, sexual identity and orientation are controlled, these inequalities persist.

Dr. Berkeley gives specifics about disparities in African American vs. white patients. For instance, black patients are twice as likely to be diagnosed with diabetes than white patients. She goes on to talk specifically about inequalities in mental health care, including how African American patients are more likely to leave treatment after the first visit. This is a particularly devastating statistic to me. In my training as a psychiatrist, a central tenant was taught by every single supervisor I had.
“The goal of the initial session is to ensure a second session occurs.” The lack of follow up after session one goes against this basic truism of clinical psychiatry.

Another disturbing fact shared by Dr. Berkeley is regarding inferior treatment of depression. Only 27% of African Americans were prescribed antidepressants when first diagnosed with depression compared to 44% of Caucasians. In my practice, and in discussions with other health care providers, it is EDUCATION that boosts the percentage of patients receiving optimal care and follow up. While it not stated by Dr. Berkeley, TO ME this fact suggests inadequate time and education with the African American patients.

Dr. Berkeley addresses the helplessness people experience when faced with these facts. She acknowledges that by reading the chapter (or even this review!) you are doing something about it. Find out where you or your loved ones can go for help. Use the resources that are available and help a loved one take the first step to seek treatment.

Racism

In my practice, I follow the leadership and guidance of both the AMA (American Medical Association) and the APA (American Psychiatric Association).

I will ask my colleagues, students, and patients how they have been affected by racism and how they are doing. I will listen to their responses.

I monitor the COVID Racial Data Tracker. I reflect on what that data means. I will continue to educate myself as best I can. I will try to make a difference.

The REAL Dangers of Stimulants

Here is the link to my YouTube video on ADHD and Likeability: https://youtu.be/JaSaL2dwcIA

Psychostimulants are powerful and effective medications. However, stimulants also have significant risks. Unfortunately, popular media focuses on the risks of abuse and diversion. Abuse can mean taking the medication for the purpose of intoxicaiton. Diversion can mean obtaining the medication to sell it.

However, for well-intentioned people, the risks are quite different. I review the most common I see in my practice, including:

  1. Adverse affects (for instance: tics, tremors, palpitations, irritability, insomnia, headaches, dry-mouth, and changes in blood pressure and heart rate)
  2. Trying to “cheat” sleep
  3. Fueling bad habits
  4. Accellerating self-critical or anxious thoughts.

And about good habits….here is one idea for staying fit at home. SpinMama Castro does live spin classes on Facebook, but invites you to use whatever equipment you have!

https://www.facebook.com/profile.php?id=100007538236705

Relax in 6 seconds!

Here is the YouTube link to my instructional video on the 6 second relaxation: https://youtu.be/Q4Az4XlkYjw

This is a technique taught to me almost 20 years ago by Linda Shrier, Ph.D. a volunteer faculty at my residency program. She described it as an “induction.” The technique both decreases physiologic tension, and increases your suggestibility. In other words, you relax and are willing to listen to a SUGGESTION you give yourself.

  1. Sit with hands on thighs
  2. Deep breath in and hold
  3. Close eyes
  4. Think “Alert Mind, Calm Body”*
  5. Begin to slowly exhale
  6. Feel the tension leave your jaw and tongue
  7. Feel a wave of heaviness and warmth in your hands, then your feet
  8. Smile inwardly
  9. Open your eyes

*The SUGGESTION is the mantra from step 4. This suggestion can be changed to whatever you like! I recommend people experiment to find their own best statement.

I like this technique because it is fast, and can be done anywhere. It can even be adapted if you are standing; just try putting you hands on your hips or in your pockets.

If you enjoyed the video, please Like and Subscribe! I will be back this weekend with a thought about CoronaVirus, and how to take “as needed” medications. Keep smiling!

ADHD and Likeability

Here is the link to my YouTube video on ADHD and Likeability: https://youtu.be/MIHhv3mwJz4

Most of us know the popularly defined symptoms of ADHD – inattention, hyperactivity, and impulsiveness. These symptoms are a good starting place but tell a small fraction of the story.

In my practice, I use a different set of starting criteria: rejection sensitivity, interest-based attention, and emotional hyperarousal. Dr. William Dodson provided this rubric in an article from 2019. Thinking about ADHD in these terms helps me connect more with my patients. It also resonates more with them when they reflect on the narrative of their lives. Perhaps most importantly, it provides the beginning of a call to action; a way of thinking about ADHD that helps the patient improve their lives by doing more than just taking a medication.

Certainly, the medications play a significant role for many people. Adjustments to other lifestyle issues do too: nutrition and use of supplements, exercise, sleep, and certain “brain games” go a long way. But most of the people who come into my office want more than this. They want an even more 360 degree approach. I will never forget the moment, when one of my patients looked at me through tears, eyes glittering with anger, and said “I want to go to war with this. I want to defeat it completely.” Since that moment, I have developed a more complete program to address ADHD. Today, I will discuss the concept of Likeability.

Let’s go back for a moment to the “new” ADHD definition. The Interest Based Attention can make it hard for a person to listen in a conversation. It can also make it hard to pick up on non-verbal cues, the social subtleties, the subtext of an interaction. The Emotional Hyperarousal can lead to blurting out of turn, or have such strong emotional reactions that it becomes too hard to stay in a constructive conversation. THEN, the rejection sensitivity kicks in. The person feels SO betrayed, or unloved, and they cannot bounce back into the flow of the discussion. Another social opportunity lost.

Depressing, right? Imagine if this was a COMMON outcome of your interpersonal interactions – you are just starting to get a sense of how destructive untreated ADHD can be. It is NOT just an academic issue.

So, how do I begin to address this with people?
First, they have to buy into the idea that they can grow. That there are such things as social skills. I’ll say, “Do you know THAT GUY who everyone seems to like at a party, or THAT GIRL that everyone knows and gets along with at work?” They have a skill, and you can develop it too. Then, I ask if they believe that there can be more happening in a conversation than a simple transcript of the conversation would show. I’ll usually give the example of picking up on the fact that someone is bluffing in poker – you can TELL without even knowing their cards!!!
I have them do reflections on likeability. What makes you likeable – what do people say about your strengths? Then, the more unpleasant questions: What makes you less likable? Where do you get in trouble socially? I tell them that no one likes to think about social interactions as an economic exchange, but that unconsciously people know when the social scales get out of balance.
“You’re EXTRA” the kids say now-a-days. When I was young it was “high maintenance.” My parents would have said a person was “too much.” HOWEVER, when a person is more likable, others are more willing to tolerate some of the imbalance. EXTRA becomes “fun and quirky.” TOO MUCH becomes absentminded but brilliant. HIGH MAINTENANCE becomes “high energy.”

So, what traits to we work on? In my experience, the traits with the highest return on investment are: RELIABLE – return calls and texts. Show up. TRUTHFUL – be honest, it makes people feel valued….BUT KIND – will your comment make a person feel good or bad? IS there a way to say it that could make it kind? CHEERFUL – smile more! Laugh! Find humor, make a joke.

I hope this was helpful! My goal is to educate and hopefully improve someone’s life. If you enjoyed the video please hit that LIKE button on YouTube and SUBSCRIBE, and share it with someone!

I’ll be back by Monday with a new video.

Integration, From 'A Course In Happiness'

This post is a summary of my YouTube post on the concept of Integration from Dr. Mardi Horowitz’s book “A Course In Happiness.” Here is the link to the video: https://youtu.be/vryPtI8w3D0

Dr. Horowitz’s book is an action-packed thriller! He works his way through 3 “levels of self-understanding”: Integration, Intimacy, and Integrity.

Integrity is the foundation of the recipe for happiness. Self-esteem, coping skills and your ability to pursue happiness all depend on integration. Integration takes into account the best and worst parts of you, your rational and irrational thoughts, your self-defeating behaviors and over-reactions. It depends on your ability to examine regrettable actions and missed opportunities from the past, and your ability to plan for a long-range future. It demands a review of your goals to see if they are mutually exclusive, and a capacity to prioritize your dreams. You need to avoid ending reflections with potential catastrophic outcomes. Accept compromise and remember that achievements don’t always turn out as expected. Finally, the process is ongoing.

Dr. Horowitz focuses on four skill sets to build Integration: Introspection, Focused Thinking, Mastering Stress, and Decentering.

Dr. Horowitz’s approach is based on the importance of a “configurational formulation.” He believes that an individual’s psyche is complex, and a continuous reduction of the ambiguity of this complexity is necessary. Each of the steps of the analysis of this formulation will be done multiple times. You will need to reflect on your symptoms, states of mind, obstacles, relationships (including with yourself), and refine your planning and self-treatment.

In my practice, Integration is a nearly universal starting point. At the initial meeting, I encourage a person to tell me about the different parts of themselves, their “inner lives” as the analyst Salman Akhtar would say. Some people have trouble accepting that parts of their minds are irrational, and even worse, that at times those parts are running the show! Some are too ashamed to confront the darkest parts of themselves and need to find courage and get support to do so. It can take a while before some realize that a “fact” of their lives is, actually, an over-reaction. Therefore, Integration requires frequent revisiting over the course of a therapeutic relationship.

Of the four skills that Dr. Horowitz’s mentions, Introspection is the skill that seems to require the most coaching. People mostly grasp the parts of themselves – you could probably pause this video right now and make a list of what you have, what you do, and what your “soul” or “spirit” is. But the PROCESS of Introspection takes some practice. He describes 4 elements: 1. Prep work must be done, including a clear and fresh mind, all thoughts and feelings being welcome without ruminating on self-criticism, prepare for short and long term thinking and resist insisting on solutions. 2. Next, be specific about a topic, and develop a list of pros, cons, and what ifs. 3. Have perspective – observe your physical and mental states and your self concepts. 4. Then, learn when to stop the process.

In my experience, people need to be reminded most of three elements of successful introspection. First, their mind’s environment needs to be fresh. They need to avoid self criticism during reflection. Second, They need to pick a specific topic to generate thoughts about. Thoughts need to be more pros/cons and what ifs than solutions. Finally, this work is not easy! A person needs to know when to stop. I suggest a start time of 10 minutes.

Thank you to Dr. Horowitz for allowing me to review and teach from two of his books. You can find a written review of his book “Formulation as a Basis for Planning Psychotherapy Treatment” on July 8, 2019 on my blog.

Dreams and Covid-19

Here is the link to my YouTube video on Dreams and Covid-19: https://youtu.be/6ffoXWQGgcU

Multiple media outlets (LA Times, NY Post, Vox) report more people experiencing vivid dreams. Social distancing, abandonment and illness are some of the common themes.

So, what is going on?

In my practice since the inception of social distancing in March, I have had more people reporting dreams. Even people who are not in talk therapy, but just having a medication check appointment have asked about their dreams. Some refer to my analytic couch, asking “This makes you a Freudian, right? So a couple nights ago, I had a ragger of a nightmare…”

What do therapists REALLY do with dreams? In some ways, the song Silent Lucidity (written by lead guitarist Chris DeMarco of Queensryche) says it most eloquently:

So here it is, another chance Wide awake you face the day Your dream is over…. or has it just begun?

As Freud said “Dreams are the royal road to the unconscious.” Charels Brenner said that no other phenomenon give people as much access to the unconscious working of their mind.

Because dreams are so powerful and personal, a good therapist needs to earn your trust and take their time to interpret dreams with you. Ideally, you both will return to dreams over the course of multiple sessions.

Why do dream work in therapy? It becomes a way for you to develop the skills of ongoing self-inquiry.

How do you interpret a dream?

  1. Reflect on the dream, and as you think it through see if there are any details you forgot.
  2. Remember what happened in your life the day before and the morning after.
  3. Consider that you are the scriptwriter, and you have motivations to use symbolic disguises in your dream. Remind, your dream can’t be too upsetting, otherwise you’d wake up!
  4. See what your associations are – your mental connections - to the dream.
  5. Think about what is MISSING from the dream.
  6. Focus on the FEELING of the dream.

If you do this, you may have insights about your wishes, fears and conflicts. You may learn about how you developed certain style of dealing with stress, or the patterns in which you relate to others…or yourself.

The two most common connections my people have been making with the CoronaDreams are: trauma and reworking of trauma, and conflict and wish fulfillment.

From my point of view, the CoronaDreams have two frequent themes:

  1. The traumas have often been about early loss of a loved one, or social isolation associated with bullying. Many of my patients have, paradoxically, had some “wish fulfillment” upon awaking. And they have, as Chris DeMarco would have said, “another chance to face the day.” Their loved ones and they are healthy, or at least managing. They are alone, but with a partner or family, or are a call or “Zoom” away from connecting with someone they care about.
  2. The conflicts have frequently been about erotic intimacy. The mystery created by distraction from the outside world is gone. There is less “separateness” with sexual partners if they are sheltering together. Ester Perel, in Mating in Captivity, talks about how mystery and separateness are critically important elements of sustaining erotic desire in a committed relationship. Based on this, I think that couples have a real opportunity during this time. Exploring how to truly accept, listen to, be patient with, play and flirt with your partner instead of just “scoring” are some activities to practice. Those don’t sound like bad things to practice, right?

YouTube Video - Accurate and Inaccurate Diagnosis

Here is my video on Common Diagnotic Errors: https://youtu.be/8JtMLwFsDsE

A brief overview: Why discuss the diagnostic process? I think that knowing about the diagnostic process can help you have confidence that you and your doctor or therapist have a solid foundation to work on. This discussion is be specifically about diagnosis in outpatient clinics and offices. I found many articles for the most common misdiagnoses in MH with simple Google and Google Scholar searches. Overall, the most frequently cited diagnoses on the 25 or so sites I looked at were: ADHD, Bipolar Disorder, Substance Use, PTSD and Personality Disorders.

I have noticed four common errors made in mental health diagnosis.

  1. A provider gets stuck in a rut. A diagnosis takes on a special meaning for them, or they are “marketed” by advertizing, often from the pharmaceutical industry.
  2. A couple of details don’t fit and get ignored or forgotten. Please see Katherine’s Story “A Correct Diagnosis” in the Personal Stories section on the NAMI website. https://www.nami.org/Personal-Stories/A-Correct-Diagnosis
  3. The ailment gets broken down into separate problems instead of seen as big picture. In psychiatry, this often happens when the focus is on too many quantitative measure, and not enough focus on development, environment, and identity.
  4. Associated physiologic symptoms are not investigated with physical exam, blood work, or even a check up with a primary care doctor.

How do I try to be accurate in diagnosis?

  1. Use some quantitative measures.
  2. Complete a well-rounded Bio-Psycho-Social assessment.
  3. Make diagnosis an ongoing discussion, so I don’t miss anything the patient is concerned about. That also gives the patient the opportunity to bring up data that may have initially been too difficult to discuss at first, or that they hadn’t initially considered.
  4. Review our results, taking into account that sub-optimal response MAY BE because of an inaccurate diagnosis.
  5. Keep an ongoing, functional formulation. This allows for us to add data and refine the diagnosis, even if treatment is going well.
  6. Take my Continuing Medical Education seriously

Stay safe, keep following precautions with social distancing, handwashing, and droplet precautions. Keep smiling!

YouTube Videos - Self-Scheduling and Positive Responses to CoVid19

Here is a link to my first YouTube video, “Mental Health and Coronavirus” https://youtu.be/HCtH6TYyhhw

Please subscribe! I intend to create a new video each week.

A brief summary: A March, 2020 poll conducted by the American Psychiatric Association (https://www.psychiatry.org/newsroom/news-releases/new-poll-covid-19-impacting-mental-well-being-americans-feeling-anxious-especially-for-loved-ones-older-adults-are-less-anxious) reported that 48% of Americans are anxious about getting coronavirus, 40% are anxious about serious illness and death, and 62% are anxious about the possibiility of loved ones getting the virus. Trouble sleeping, use of substances, fights with loved ones and trouble concentrating are the most commonly reported behavioral impacts. Most media outlets have turned their attention to the negatives people are experiecing during this time.

My approach to psychotherapy is partly based on the belief that elements of health and illness are experienced together. Here are the themes of health and wellness that I have heard from my patients:

  1. An opportunity to return to the tried and true basics of their treatment plans. May people have used this time as an opportunity to remember the specifics of how they make healthy decisions, have clear thoughts, and enhance their emotional regulation. They have been pleased to see that these fundamentals are working despite this enormous change in the reality of the world.
  2. A chance to improve communications with their loved ones. Accepting the “we are stuck in this together” has led to efforts of both parties to try again with difficult subjects. Two guidelines I suggest are Habermaas’ “Ideal Speech Situation” and “Crucial Conversations” by Switzler, Grenny and McMillan.
  3. A reenergizing of their efforts with public health and social distancing. Especially for sensitive people who are pro-social, and people who want to make a positive difference, it has been hard for them to feel like they aren’t helping. They remember that following the public health restrictions are practicing droplet precaution guidelines IS helping society! And smilling helps too.

Viruses hate smiles.

Here is the link to my second YouTube video, “Self Scheduling During Covid-19”: https://youtu.be/0iKXPO5PVg4

The most common stumbling block of self scheduling is self criticism. It is hard! Don’t make it about “willpower” or some character flaw…it is just difficult.

The five pillars of succeeding at creating your own schedule?

  1. Prioritize responsibilities and dreams
  2. Be arbitrary
  3. Be bold
  4. Make adjustments
  5. Review results

Fee Reduction for Patients Affected by COVID-19

The negative impact of Coronavirus is touching us all. However, each person’s experience is unique and much be considered.

If your income has been affected, I can reduce the fee of your next follow up appointment with me. We can discuss the details when we meet, or before if necessary.

See the post below for my current policy on Coronavirus and my practice: https://www.robertmcfaddenmd.com/blog/covid19

Please enjoy some pictures of Spring. Try to smile!

Magnolia

In Bloom

Shamrock Plant Celebrating St. Patrick's Day

Dwarf Cherry Blossom - Day

Dwarf Cherry Blossom - Night