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Combatting Agism in Behavioral Health with Dana Ebeling, PMHNP

Agism in Mental Health with Dana Ebeling, PMHNP

Agism in Mental Health
with Dana Ebeling, PMHNP

Dana Ebeling is a psychiatric nurse practitioner who advocates for better mental health care for aging and elderly and works with Heading a mental health provider with locations in Austin and Dallas-Fort Worth. 

 

With over 30 years of healthcare experience, including working as a medical director of a nursing home, her work has taught her the importance of resilience and valuing the unique life experiences of each individual. 

 

In this article, we explore Dana’s expertise in psychiatric care for the elderly, including the unique challenges faced by this population, supporting anxiety and depression especially when they cooccur with physical diagnoses, and the importance of collaboration between mental health professionals and primary care providers.

 

The heart she brings to care is coupled with a passion to ensure that mental health is not overlooked as people age. Good care of wellbeing and emotional landscape of a person’s life cannot be overshadowed by physical health, and Dana discusses how they go hand in hand. 

 

Resilience and Time

 

Dana has a deep appreciation for the resiliency of the elderly population. She believes that time on Earth and lived experiences shape who we are, and that the elderly have a unique perspective on life. The wisdom of her patients is something Dana felt blessed to witness when she started her career as a young nurse. 

 

To kick off the interview, Dana shared a story about one of her patients, a woman she calls Jewel, to illustrate this point:

 

“Jewel was one of the first patients I ever worked with as a young nurse. She suffered multiple fractures from a head-on motor vehicle accident. She was determined to get well and worked hard every day, despite chronic pain, nausea, fatigue. Yet, she was always so concerned about me, her nurse. ‘Was I working too much overtime?’ ‘Did my family need me at home?’ She was so kind and also so determined. She made a full recovery and was discharged to home.”

 

Dana noted that she would meet Jewel again over the years, as her husband became ill and he eventually passed away. Then, Jewel herself became ill and moved to a nursing home. Despite her own struggles, Jewel always focused on others. Dana shares one of their conversations:

 

“[Jewel and I] would sit together and chat about growing old, what it was like to give up your home and move to a nursing home, struggles with living with chronic illness and kidney disease. Yet, in all this, I noticed she continued to focus on others even as her own health was failing.”

 

When asked what she learned from this experience and what she wished more mental health care providers would consider to better serve the elderly, Dana went back to why she began to specialize in this area in the first place. 

 

Unique Challenges in Psychiatry and Therapy for the Elderly

In her experience as a nurse, Dana found mental health to be a crucial aspect of aging that is often overlooked. In fact, it was her experience as a medical director at a nursing facility, as well as her time spent in acute rehab facilities, that inspired her to seek the mental health route as the next phase of her career. 

 

“Mental health focuses on aging as a normal part of life. We can experience loss, trauma, symptoms of depression, anxiety at any age. Mental health professionals should value the individual, not the ‘age’.”

 

Dana stressed that an assumption of life experience, including adverse life experience, as part of the norm – in addition to physical illnesses often becoming more prevalence – the care aging patients are provided heavily focuses exclusively on their physical decline and often ignores their emotional wellbeing. 

 

This brings up one of the biggest challenges in mental health care for the elderly –  the increased prevalence of medical conditions and chronic illness in older adults. This requires providers to maintain close collaboration with other members of a patient’s medical team. Dana explained, “Often with aging, there is an increase in medical conditions that may require close collaboration and consideration when prescribing psychiatric medications.”

 

“Chronic illness and depression, and pain and depression are like bad marriages. It doesn’t mean these things aren’t linked, but that also doesn’t mean the depression shouldn’t be addressed for what it is – and that’s what’s important. We can’t chalk their depression up to ‘just getting old.’ We have to dig in and really get concerned about quality of life,” Dana suggested.

 

Generational Stigma

 

Dana also notes that there is often a stigma around mental health in older adults. She shared, “Mental health care providers need to consider that their patients may have grown up in a society where mental health was not discussed or considered at all.”

 

However, she did note that she has seen a shift in attitudes over her 30 years in healthcare, with adult children often encouraging their parents and grandparents to seek help.

Dana added, “I think the most important thing is to listen to their story, to be compassionate, and to meet them where they are at. It’s really about building that relationship, building that trust, and being a partner with them in their healthcare journey.”

 

In terms of specific approaches to working with older adults, Dana suggests taking the time to understand their cultural backgrounds and how that might impact their attitudes toward mental health. “There’s a lot of diversity and generational differences within the older adult population,” she says, “and it’s important to recognize that and to approach each person with an open mind and an open heart.”

 

Combating Agism in Healthcare and Mental Health Care

 

“I think ageism is fairly present across all medical disciplines in some capacity,” Dana shared. “Ageism is also prevalent in society. American culture tends to idolize the physically young and strong. Growing old is considered a weakness because, well, our bodies do age – but that doesn’t mean life is over. If you read stories by centenarians, you find commonalities like a continual interest in life, learning, socializing, and engaging in the community. A continued pursuit of life!”

 

Research confirms Dana’s findings too. In fact elderly populations living with mental health conditions report feeling age discrimination twice as often as their counterparts without mental illness.  Additionally studies have shown that people 60 years of age and older who have previously experienced agism are more likely to develop signs of negative mental health and more likely to experience depressive symptoms, and anxiety. 

They also may begin to anticipate agism occurring in their interactions which could impact the quality of relationship built with their providers – especially as advances in technology continue to change the delivery of care, and as provider shortages continue to stress and already pressured medical community. 


Continued education, research, and proactively seeking feedback can be helpful for providers to address any gaps in care or blindspots they may have when it comes to offering care to those in later stages of their life. Opportunities exist in virtual care as well including finding ways to support older patients as they navigate technology. Virtual care can improve access for those who live rurally or are less mobile, but the technology and care team support must be there as new systems are learned.

 

“This work is incredibly rewarding for healthcare providers. Working with patients who have wisdom and life experience is an honor. We should offer extra support, and consider it a privilege not only to provide care but also to learn from them,” Dana concluded.

 

Wise words, indeed.

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Blog depression Ketamine spravato Uncategorized

Who Is Not a Good Candidate for Ketamine Therapy?

Who is and is not a Good Candidate for Ketamine Treatment?

Ketamine treatment is a breakthrough for people who have not experienced relief from traditional modes of treatment or medications, or the effectiveness of these methods of care has diminished. Unlike traditionally prescribed medications which can take several weeks to show effectiveness, patients receiving ketamine often report a reduction in symptoms within the first few sessions.


Research shows that Ketamine  may be suitable for people with various mental health conditions such as depression, anxiety, PTSD, OCD, and chronic pain, who have not responded to traditional treatments such as therapy and antidepressant medications. Specifically, Ketamine treatment has shown promising results in treating treatment-resistant depression, suicidal thoughts, and chronic pain. FDA approved drug Spravato® is approved for the treatment of treatment-resistant depression, and has changes the lives of many who have received this line of care.


There are many reasons why a traditional medication may stop working, or is otherwise not suitable for someone with treatment-resistant depression, or chronic, long-standing stress disorders like anxiety, or PTSD. For example some patients cannot tolerate the side effects of traditional medications. However, it is important to note that each individual’s circumstances are unique, and it is recommended to consult with a qualified medical professional to determine if Ketamine treatment is a suitable option for their specific condition and medical history.


Ketamine and Spravato® are breakthroughs for many, but are not right for everyone.  In this article we look at some factors that may play into Ketamine candidacy and important safety considerations.  

Factors to Consider for Ketamine Candidates

It is important to consult with a qualified medical professional to determine if Ketamine treatment is appropriate for an individual’s treatment of depression, anxiety, or PTSD. At Heading we conduct an intervention treatment Q&A with a care coordinator as well as a 60 minute psychiatric consultation session to establish a personalized care plan and also to determine candidacy prior to a patient receiving treatment.

 

It’s important to note that candidacy works hand in hand with outcomes and patient goals. Both of these should be monitored continually through the process, and the process is not ‘one-and-done’. Prior to every in-center ketamine or Spravato® appointment several factors are monitored before treatment. Keeping optimal outcomes, and safety in mind patients have access to their care-team during treatment sessions, immediately after treatment sessions, and throughout the course of a treatment protocol. 

 

Ketamine is becoming more well known as an interventional treatment for depression and anxiety that have not responded well to other treatments. Ketamine offers rapid relief for many people, especially when other medications have not worked.

 

That said, the results for any depression treatment method are not the same across the board, because every patient’s individual needs are different. That’s why it is important that a mental health care-team always consider the best course of treatment for an individual.

 

As a patient considers ketamine treatment there are factors to keep in mind.

 

Ketamine may not be the right choice for someone if:

  1. They have uncontrolled high blood pressure or heart disease. Ketamine can cause an increase in blood pressure and heart rate, which is why it is important for prescribers and care teams to be aware of a patient’s cardiovascular health history prior to receiving treatment.

  2. A patient has a history of schizophrenia or schizoaffective disorders. Ketamine may have adverse side effects and worsen symptoms of these conditions.

  3. A patient has a history of substance abuse or addiction. Ketamine has the potential for abuse and care teams are careful to ensure that treatment will not trigger relapse. 

  4. They are pregnant or breastfeeding. There is limited research on the safety of ketamine use during pregnancy and breastfeeding, and it is not recommended.

  5. They have certain medical conditions, such as liver or kidney disease.

  6. They are unable to participate in the requirements for the protocol such as payments or co-pays, the time-investment is not suitable for that moment in life, or making arrangements for care such as getting a ride to a center if they are receiving treatment at a medical office or making time for the length of treatment is not feasible with their schedule. 

It’s also important to note that this is not an exhaustive list, and a thorough consultation under the direct care of a psychiatric medical professional is crucial.  Since the goal of ketamine therapy is to experience relief from long-standing and hard-to-treat mental health disorders, if the protocol isn’t working for a patient – that’s ok! There are always changes that can be made, and other treatments.  Personalized approaches including combination therapies, and a team of mental health care providers working together can make all the difference – as mental health care is not one-side-fits-all. 

Ketamine In Center Care and Safety

The two most important goals of determining candidacy are:

1) patient safety, and 

2) the best possible outcome for feeling better and healing.

 

 

Methods of receiving ketamine vary, and patient preference, insurance coverage, and access plays a large part into whether or not they seek treatment in a center, or through another means.  However, in-center treatments, under a doctor and medical team’s supervision, have added benefits to meet high standards for safety and outcomes.

 

 

“Patients receiving ketamine in a clinic or medical center receive an entire team of people who are supporting the best possible outcomes. Safety is, of course, paramount. Patients also take comfort in knowing that they have a medical team who can immediately make them more comfortable and answer any questions or concerns they may have in real-time. These are also the same medical professionals you will see time and time again. Developing therapeutic relationships requires trust, and building trust over time with your care team enhances the experience,” shared Dr. Arif Noorbaksh M.D. a leading psychiatrist at Heading who practices out of Dallas, Texas and offers virtual psychiatric services and medication management to patients statewide.

 

In addition to having medical professionals immediately available to monitor physical metrics before a treatment such as blood pressure and weight, some patients receiving Ketamine also feel more comfortable receiving treatment knowing that they are in a safe medical center with nurses and doctor’s just a few steps away as the medication takes effect.  Ketamine can induce a dissociative state, sometimes this is referred to as a ‘trip’, and the patient may feel out of body, like they are flying, or experiencing a range of sensations outside of their normal state of being.  In-center treatment options provide a patient with immediate options for assistance, and a team of medical professionals determining when a patient is ready and able to leave treatment. At Heading a ride to and from an appointment is required as it is not advised to drive or operate machinery until a patient has had a good night sleep after treatment. 

 

Thoughts When Considering Ketamine

  • Ketamine is an effective medication offering rapid relief for depression, but not everyone is a good candidate for treatment.
  • Safety is a top priority. Work with providers who offer thorough screenings and care throughout the process
  • Effectiveness is key. There’s no point in starting or continuing a treatment protocol if it is not proving to be effective. Select a psychiatry provider who will offer a holistic assessment of your needs, including honest feedback about whether or not Ketamine is a good choice for you, as well as what additional treatment protocols they might recommend such as additional medication options, lifestyle changes, or the addition of psychotherapy which can be important in both behavior change as well as integration of the Ketamine experience.
  • Consider your own personal preferences for set and setting. How would you feel in a center with medical professionals steps away versus another method?
  • Ask a lot of questions in your intake and consultations. No question is dumb or unnecessary. You deserve care coordinators and psychiatric professionals who take time to answer all your questions, and ensure your needs are being met throughout the process.
  • Become aware of insurance, payment, and coverage options. There may be expenses related to your care. Ask questions up front, and consider how investing in your mental health impacts your wellbeing and life overall.
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anxiety BIPOC Mental health Blog depression Provider wellness women's mental health

Care Insights: Multicultural Care for International Women in the U.S. with Asha Hussein

Care Insights: Multicultural Care for International Women in the U.S. with Asha Hussein, LPC

March 30, 2023

Having a Multicultural Approach

March is International Women’s Month, a time dedicated to place attention on all of the contributions that women have made and causes important to gender equity and equality. As the month comes to a close Heading took the time in this edition in Care Insights to speak with multicultural counselor and therapist, Asha Hussien.  Asha is a Licensed Professional Counselor at Heading who sees patients virtually across Austin, Dallas, and state-wide in Texas.  

 

 

While Asha offers excellent care to patients from all genders, ages, religions, identities, and backgrounds, she has a particular expertise in offering multicultural counseling to women, especially those who have migrated to the States.

 

 

Asha discusses her own experience being a trailblazer in her own family when she decided to seek therapy for herself, and pursue a career in counseling, and how the experience of therapy is different for her female patients whose culture, family heritage, or country of origin is not the U.S.  She also offers insights for therapists who want to improve their skills in multicultural counseling.

Acknowledging Cultural Perceptions of Mental Health

A cultural acceptance of going to therapy and mental health parity itself within the medicine and insurance is still relatively new in the United States. That said, more and more, the conversation around mental health is out of the shadows. Mental health diagnoses are increasingly being talked about more openly, and there are employer anti-discrimination protections in place for those suffering from mental illness. While there is still a long way to go, for those from  countries whose cultures are not as open to discussing mental health seeking therapy may come with additional shame, embarrassment, or concern about social or familial acceptance. Asha, who emigrated from Somalia, discusses the gap in cultural acceptance between the U.S. and her country of origin as the conversation opened. 

 

“I studied philosophy in college and no one, at least no Somali I knew, studied philosophy. I remember my aunt said ‘Asha people study science or math. What African have you ever met that does philosophy? How are you gonna use that in your life?’ And, so I’ve always been interested in social sciences about the human experience. That already had made me different in my community. But I’m happy that I did that because it showed me that there’s this bigger part that we don’t talk about as humans,” Asha began.

 

Asha Hussein reflected on her unique experience within her community.  After studying philosophy in college and prior to her career as a counselor Asha also worked as a teacher for a few years, specifically in an Islamic school, where she taught middle and high school students. She observed that many of her students struggled with suppressed emotions and parental issues, which often led them to act out in the classroom. Asha felt a deep connection to her students and empathized with their difficulties. She realized that the traditional rule-based system of teaching did not work for these students and eventually left the teaching profession.

 

Subsequently, Asha became an ESL instructor at a college, where she noticed that there was a significant need for mental health services not only within her own culture but also within Hispanic, Asian, and Arab cultures. 

 

“For young people, or younger families, often they’re the ones that come to America. Younger immigrants or asylum seekers often still have aging parents or extended family still struggling in their home country. So they become the beacon of hope for the whole family, and it’s a lot of pressure,” Asha offered. 

 

Overall, Asha’s unique experiences have given her insight into the importance of mental health services for marginalized communities, immigrants and asylum seekers. She also offered that for international women, the problems with seeking help are amplified. Asha explained, “In Somalia, before we came here, we dealt with war and with hunger. It’s a lot better now. But, dealing with the mental aftermath of the struggle is not really encouraged. As a matter of fact, it’s not even discussed. That ignites my passion for mental health, especially for international women. I want to make it as normal as possible, destigmatize it.”

 

She also shared, “Usually when I do talk to my community or other women who immigrated to the States, I tell them my own mental health story. For example, I was prescribed an antidepressant from my primary care provider, and I once told a woman from my community. She got scared for me, told me to throw it out and that it was addictive and harmful. But I don’t shy away from telling my own journey so other women from communities like mine don’t feel like they aren’t alone in their struggle, and they don’t feel isolated or ashamed or stigmatized.”

 

Helping Women Who Worry About Family Acceptance

“In many African cultures, and where I’m from [Somalia] it’s really looked down on even admitting that you have a mental health issue like postpartum depression or that you’ve been feeling depressed or anxious. Or, god forbid, something like bipolar disorder,” Asha explained.

 

“As a woman’s need increases the more she’s likely to be outright labeled: you are crazy. But, it’s not just name calling. If she’s ‘crazy’ people might keep their distance, and just hope that the woman won’t have an ‘episode’. And then the woman is scared that she will lose the acceptance of her family or be ostracized in her community.”

 

 

Psychology researchers argue that understanding cultural beliefs about mental health is especially important for immigrants, refugees and asylum-seekers, as there may be significant differences between dominant models of mental health and treatment in their home countries and those available in their host countries. There is a need for comprehensive investigation of the barriers to help-seeking such as financial resources and access. Experts also emphasized that taking into account perceptions of mental health and treatment is one of the principle barriers to overcome.

 

 

As an experienced mental health professional, Asha has encountered many clients struggling with mental health issues, but when she works with women from international backgrounds she knows the process may need to be slower. To demonstrate a common scenario of how the prospect of therapy could be particularly intimidating for a woman from another country, she shared a story about a patient from an Arab country whose husband was struggling to understand her struggles. “Her husband was so confused as to how to deal with the situation. From the way he was raised he feels that because she’s a mother and a wife it should be sufficient for her and enough to make her happy,” Asha explained.

 

 

However, Asha’s patient secretly felt purposeless and struggled with perfectionism, depression, and manic episodes. She felt she was failing because she didn’t feel completely fulfilled just being a wife and mother. Asha took on the role in therapy to remind her of her other qualities outside of being a mother and wife. “She had amazing qualities outside of being a mother, outside of being a wife, and I had to remind her of that,” Asha said. “So with clients like that, I really take it very, very slow. So that, that way, they can process their own pain, and feelings, and struggle.”

 

Asha noted that such situations often lead to secrecy and fear of divorce. However, her main focus is helping her clients prioritize their mental health. “For this client, she was definitely afraid that her husband would leave her. We had to sort through her priorities for feeling well and not hiding parts of herself without judgement. My client shared that her priority was to feel well, and so we started from there.” Asha said.

 

 

“This isn’t the case with every patient, but with her we knew that it wasn’t necessarily the case that her husband is going to leave. He just didn’t understand what was going on or how to help. The husbands aren’t therapists. They can’t know it all. And so once that becomes an understanding we could move forward. Eventually she started coming to sessions wearing makeup, with lists of the jobs she’d applied for, and ultimately got a job at Microsoft” Asha explained.

 

 

But the problems, Asha explained, are not solely with men not understanding women. In her experience Asha explained that women she’s treated who come from cultures in which gender roles are strongly cemented, pressure to hide things like postpartum depression, depression, or anxiety comes from extended family members too. 

 

Embracing Curiosity.

“Listen. And, listen more.”


When asked about what she would recommend other counselors do if they wish to have a richer multicultural approach Asha didn’t skip a beat, “I could talk all day about this topic, because it is so important.”


Her first piece of advice was for counselors to take a class and additional training to gain an overview of various cultures, taboos, and customs. 

Next, she said, “Listen, and listen more.”


The need to listen to understand the clients’ perspectives, expectations, and roles, especially gather information about their role as a woman in their culture – and their perception of these roles. Asha also reminded counselors to prioritize the client and always bring it back to them, “It’s so common for the women I see to start talking about their husbands, their husband’s needs, and his feelings.”


Instead of focusing on their husbands or their feelings Asha suggested this redirect, “We’re here to talk about what’s going on with you, not necessarily about your husband or his feelings. How do you feel?” 


She also cautioned against quick judgement of cultures, stating that each culture is unique and has its beauty. She said, “Just because it is patriarchal does not mean that culture is always bad or being harmful. It just means that’s their culture. So your job is not to judge.”


Asha stressed that understanding cultural differences and showing empathy and respect towards clients is crucial for establishing a comfortable and productive counseling relationship. She explained that even small things like direct eye contact could make some clients uncomfortable, so counselors should be mindful of such differences. She concluded, “You want to have insight into these things so that your patients feel comfortable with you. That’s always the first step, no matter who you’re seeing, right?”


Asha Hussein is a Licensed Professional Counselor who offers therapy to patients in Texas through Heading. Heading offers virtual therapy, virtual psychiatry, and in center Ketamine treatment in Austin and Dallas. To learn more about Asha visit her profile here. 

Categories
Blog depression Ketamine Provider spravato wellness women's mental health

Brain Change with Psychedelics

The Depressed Brain may Rewire with Psychedelics

March 29, 2023

Researchers are discovering more information about why psychedelics may improve the symptoms of depression, and it's not all about the 'trip'.

Some psychedelic drugs, such as psilocybin and MDMA, how promise in treating depression and post-traumatic stress disorder. They do this by encouraging the growth of new connections between neurons in the brain. This ability of the brain to make new connections is called plasticity. However, exactly how these drugs promote plasticity has been unclear.


It’s important to develop related drugs that can promote brain plasticity without causing ‘a trip’. 

Dr. David Olson and his research team from the University of California, Davis, have developed a sensor that can tell which drugs that attach to a receptor called 5-HT2AR in neurons have hallucinogenic properties and which do not. This study aims to figure out why only some of the drugs that bind to 5-HT2AR are capable of promoting brain plasticity. Brain plasticity refers to the brain’s ability to form new connections. Improved plasticity can help treat mental health disorders like depression and post-traumatic stress disorder.


Researchers discovered that a compound’s ability to enter a neuron and bind to receptors inside the cell determines how well it can promote the growth of dendritic spines. Dendritic spines are structures that help to connect neurons in the brain. The research team also found that clusters of the 5-HT2AR receptor could be found both inside and outside the neurons. The compounds that could bind to the receptors inside the neurons caused the dendritic spines to grow. But, the compounds that only bind to the receptors on the outer surface of neurons, such as serotonin, did not have the same effect.

When they used an electrical current to allow compounds like serotonin to enter neurons, the compounds promoted dendritic spine growth. Similar results were seen in neurons engineered to make a protein that can pull serotonin into cells. Neurons that took serotonin inside formed new dendritic spines. Neurons where serotonin could only bind to exterior 5-HT2ARs did not. When they tested this phenomenon in living brains of mice engineered to make a protein that can bring serotonin into neurons, the mice formed substantially more dendritic spines than in mice without the protein. The mice also showed improvements in a behavior test thought to be relevant to depression.


These results suggest that the 5-HT2ARs inside and outside of neurons activate different cell-signaling pathways. The researchers hope that these results will help develop better drugs that can safely activate the pathways for brain plasticity while avoiding hallucinogenic effects.


Interventional psychiatric treatments like Ketamine and Spravato® are already in use for depression including at Heading Health centers in Austin and Dallas. The addition of more psychedelic treatments, and understanding of each one’s particular best use is continuing to be researched with promising results offering hope that psychiatric researchers are moving closer to understanding how psychedelics can be safely administered for the rapid treatment of long-standing stress disorders. 

The research is now focusing on decoding the biological mechanisms behind how psychedelics can affect the brain and how the effects of these psychoactive drugs can be harnessed for therapeutic benefits. 


The research team is exploring the effects of psychedelics on the body’s serotonin, glutamate and dopamine systems, as well as their impact on the hypothalamic-pituitary-adrenal axis, which plays a key role in the body’s stress response. They hope that by understanding the underlying biology of these substances, they can develop more effective treatments to help people suffering from mental illness. In addition, they are also studying the potential of psychedelics to enhance cognitive performance, creativity and even spirituality. Ultimately, the researchers hope that by better understanding the biochemistry of psychedelics, they can develop more effective treatments to help people suffering from mental illness and even improve overall well-being.

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anxiety BIPOC Mental health Blog depression Provider wellness women's mental health

Care Insights: Why Team Approach Is Key in Treating BPD with Dr. Darren Fred and Andrea Marquez, LCSW

Why a Team Approach is Best for those with Long-standing and Complex Conditions like Borderline Personality Disorder with Dr. Darren Fred and Andrea Marquez, LCSW

March 21, 2023

Collaboration is Key

Diagnoses carry weight. They not only impact the patient’s own view and understanding of what they’re going through diagnosis can also influence care plans and treatment. Getting the diagnosis right is crucial, and when it comes to a diagnosis of borderline personality disorder finding specialized providers who collaborate on care improves outcomes. 

 

Outside of in-patient care where a patient experiences a dedicated team consistently working together on their case, outpatient practices with a team of psychiatrists and therapists who directly work together are less common. Given the known shortage of mental healthcare providers –  and additional shortage of providers who specialize in BPD –  collaboration between providers and providers who seek to develop an expertise in the care of people with a BPD diagnosis is needed. 

In this Care Insights we spoke with Dr. Darren Fred, a psychiatrist at Heading Health who treats patients across Texas through virtual psychiatry. We also heard from Andrea Marquez, LCSW a therapist at Heading Health who offers virtual therapy also for patients in Texas. Both Dr. Fred and Andrea Marquez have experience and expertise when it comes to caring for patients with trauma, and complex including Borderline Personality Disorder. They offer their insight into the diagnosis itself, why a direct, team approach offers superior care, and how having a practice that employs both prescribers and therapists can be a game changer for patients living with difficult-to-treat disorders.

 

“Collaboration in just about any work field is ideal, and that holds true in medicine and specialties such as behavioral health – especially with long-standing or difficult to treat conditions,” said Dr. Fred. 

 

Direct communication between therapists and psychiatrists working with patients with borderline personality disorder is beneficial in overcoming barriers to treatment, and potential missteps which may impede care. Stigmatization and marginalization of patients diagnosed with personality disorders has been studied as a significant obstacle in finding care, and finding providers on both the medical and therapeutic sides of care can be difficult.

Improving Mental Health Care Through Efficient Communication

“A team approach for managing patients with a borderline personality diagnosis is ideal and has many benefits for the patients,” started Dr. Fred. 

 

“The most obvious benefit is that both treatment parties, the therapist and the prescriber, work together to be on the same page when it comes to diagnosis and treatment.”

 

 

“I completely agree with Dr. Fred’s point of view,” offered Andrea.  “If you have a patient with an inaccurate diagnosis, or if it takes too much time to get information shared between providers, it affects a patient’s therapy experience, too. Misdiagnosis and delays in care means someone who is struggling waits even longer to experience the improvement in their symptoms that they need, or achieve goals they have for quality of life.”

 

 

Not only is ensuring that an agreed upon diagnosis is accurate and made clear between providers, Darren and Andrea pointed out how a team approach benefits the patients experience handling the logistics of care, can improve the provider’s knowledge of the patient’s case, and can motivate a patient to take a more active role in treatment itself.

 

Reducing Frustration for the Patient

“When a patient has a diagnosis that should be addressed through a combination of therapy and medication they will be attending a lot of appointments – which may seem obvious – but it can be overwhelming to juggle especially for people who are already dealing with significant struggles,” said Dr. Fred.

 

In my experience with both psychiatrists and therapists under one roof, regularly participating in provider meetings, and being able to send quick, secure messages to one another removes barriers and improves the patient outcome and experience.”

 

It’s not uncommon for a patient receiving mental health care to shuffle between several places. Often the everyday mechanisms of communications, paperwork, and scheduling that creates delays in care. Seemingly simple tasks such as patients signing release forms to be faxed to a separate medical office takes time. From there both providers have to try to align time between seeing patients to share notes. Minimizing the burden of these tasks accelerates treatment.

 

“In my private practice days, where I was a solo practitioner, it could be very difficult to get in touch with a psychiatry provider to consult on a patient – especially when it required connecting with a provider who had a lot of experience treating a patient with borderline personality disorder. I feel very fortunate that I work in a practice where a patient has a team. As a therapist, directly connecting to one of my patient’s prescribing providers is a normal part of operating.  In our practice here at Heading we message one another to collaborate on a patient’s care,” Andrea shared.

 

Spotting Common Misdiagnoses

When it comes to psychiatrists and therapists who specialize in personality disorders, collaboration can also help spot misdiagnosis and ensure appropriate treatment.

 

 

“Collaborating with other providers can also help address misdiagnosis. Patients with borderline personality disorder often have trauma histories, other diagnoses such as PTSD, and most often a mood disorder diagnosis,” explained Dr. Fred. “Unfortunately many patients will see one provider who gives them, for example, a bipolar mood disorder diagnosis. Then, another provider might tell them they do not have bipolar disorder but rather unipolar depression.  This can be frustrating and confusing for patients, especially when one provider is suggesting treatment specific for bipolar disorder, and the other is suggesting treatment specific for depression.”

 

 

Dr. Fred’s elaborated on the additional concerns that come with common misdiagnosis for borderline personality disorder noting that not only does that change the treatment protocol, but the medications prescribed may be simply ineffective, or worse, the patient may be prescribed a medication with many side effects, but never experience the intended relief due to not addressing the appropriate problem.

 

 

“Take for example a common diagnosis differential of depression or bipolar depression. From a prescriber standpoint these different diagnoses have huge ramifications,” Dr. Fred cautioned. “If a patient with borderline personality disorder is diagnosed with a co-occurring bipolar disorder, but does not actually have bipolar disorder, it can lead them down a road of being prescribed medications that may be more sedating, and have more intense side effects such as weight gain, or something more permanent like tardive dyskinesia – which is a complication from antipsychotic medications – and all the while their depressive symptoms are being undertreated, their mood is not improving, and the aren’t feeling better.”

 

 

“I completely agree with Dr. Fred’s point of view,” Andrea noted. “Bipolar Disorder is one of the most common mistakes we see on the psychotherapy side as well when it comes to borderline personality disorder and co-occurring diagnoses.  I have seen so many patients come in for therapy who are diagnosed with Bipolar Disorder and what they actually are managing is Depression, Anxiety, and/or complex PTSD and they also meet criteria for Borderline Personality Disorder.  

 

Empowering Patients Through a Team Approach

Prescriptions aren’t the only concern. Misdiagnosis also affects therapy too. Darren shared that the psychoeducation a patient has around their diagnosis influences the decisions they may, or may not, take in terms of their own care. Andrea agreed.


“Mood symptoms can be managed by medication but trauma needs a different lens,” shared Andrea.


When it comes to changing thoughts, behaviors, and ultimately feeling better patients who feel empowered to make change, and are encouraged to an active role in their care will have better outcomes.


“It’s not uncommon for a patient who has been struggling for a long time to assume they have no control of their behaviors especially if they are on medication and it’s not working as they thought it would.  Misdiagnosis delays a patient becoming empowered to make the positive changes necessary for them to live a more fulfilling life, and rely less on coping mechanisms that have painful consequences,” summarized Dr. Fred. 


With psychoeducation, appropriate diagnoses, and a team that collaborates the impact is not only the selection of more effective prescriptions and therapeutic techniques, it also inspires the patient to take an active role. To demonstrate how impactful a collaborative, specialized team can be for patients who have difficult and complex diagnosis,  Andrea went on to share this care story:


One of the most successful cases I have seen has been while working with the providers here at Heading.  A colleague of mine, a prescriber, and I were working with the same patient.  The prescriber noticed that the medications they had prescribed the patient were not working well and they looked at my notes and sent me a message to do a quick call.  


I was able to give my opinion that I did not see a cyclical pattern of symptoms but that there was a consistent set of issues causing chaos in her life that were causing acute stress symptoms that were insomnia, restlessness, intense emotions, impulsive temper outbursts and some self-medicating.  We discussed steps forward.


And a month later I was able to go back to the prescriber and share more revelations after working with the patient for another couple of weeks.  I was able to report that there might be some subclinical Bipolar Disorder symptoms there because of persistent cyclical sleep and mood changes that could not be explained because acute stress had subsided.  


We are still working with this patient and the patient has started asking us to share information they forgot to tell in an appointment or therapy session.  to tell one of us something and she would like the other to know.  Because they have a team, this patient has become more connected in their care and is taking an active role – which is wonderful!


Living with a complex mental health diagnosis, like borderline personality disorder, comes with a long list of symptoms and struggles that severely impact the quality of a person’s life and their relationships. Ensuring that the care team supporting a person’s journey is specialized, collaborative, and has easy access to clear communication not only makes the patient’s experience easier, it improves their ability to find healing. 


 People struggling with mental health disorders, and their loved ones, should feel confident in asking their doctor about how they approach care when it involves multiple providers.  Finding the right team of providers who make it a priority to maintain open communication and collaboration helps a patient achieve the best outcome possible.

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10 Helpful Facts About Ketamine Therapy

10 Helpful Facts About Ketamine for Depression and Anxiety

March 15, 2023

When it comes to feeling better it is understandable that people with treatment-resistant depression feel nothing will work. Ketamine is an option that is changing the story and offering hope.

Ketamine is a powerful drug that has been used in medical settings for decades, but it is now gaining attention for its potential to treat depression, anxiety, and PTSD. 

 

 

Here are 10 surprising facts about the drug that you should know. 

 

  • Ketamine is used in medical settings as an anesthetic, but it is also being used in psychiatric care as a treatment for depression, anxiety, and PTSD.
  • Ketamine is a dissociative anaesthetic that has psychedelic effects. It produces a feeling of altered consciousness and can cause hallucinations.
  • Research suggests that Ketamine positively impacts neuroplasticity, which is the ability of the brain to form new connections and reorganize itself. So, while the ‘trip’ may be all the buzz, the positive impact is has on brain connections overtime that is really exciting for patients who have experienced treatment resistance.
  • Ketamine is often used in combination with psychotherapy to help treat mental health conditions, and a therapist who is trained in offering care to patients in ketamine therapy can help patients process their treatment experiences and maximize its benefits.
  • Ketamine is generally considered safe but can cause side effects such as dizziness, nausea, and confusion. Seeking treatment within a center under medical supervision may be optimal as having a medical care team present to support treatment can both enhance safety and puts some patients at ease knowing if they are anxious about the experience.
  • Spravato® is a medication that is a variation of ketamine that has been FDA approved for treatment resistant depression. It is administered as a nasal spray.
  • Ketamine is not recommended for people with certain medical and psychiatric conditions, including heart disease and high blood pressure. This is why it is important to get a thorough consultation with a psychiatrist who specializes in this treatment, and can continually meet with you to monitor care.
  • Ketamine is not recommended for recreational use. 

Ketamine is an exciting area of research, and it has the potential to help many people who suffer from depression, anxiety, and PTSD. If you or someone you know is considering using Ketamine for mental health treatment, consider setting up a consult with Heading where you could receive ketamine or Spravato® treatment in our centers in Austin or Dallas-Forth Worth.

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Care Insights: Black Maternal Mental Health with Meghan Murchison

The Positive Impact of Therapy in Maternal Care with Meghan Murchison, LPC

February 24, 2023

Getting Therapists Involved in the Maternal Healthcare Conversation

In this edition of Care Insights we spoke with Meghan Murchison, a therapist with Heading Health who is based out of Houston, Texas.  Meghan’s passion for counseling started from a desire to reduce the stigma surrounding seeking therapy, especially for Black and BIPOC people. Now, Meghan says it is her journey as a mother that continues to fuel her passion to support people in finding mental wellness.  She offered insight from her own life as well as her professional expertise on the subject of maternal mental health, what she thinks is important for pregnant people to know, and how she feels therapists and doctors can do better when it comes to helping new mothers and parents thrive. 

 

“I have a passion for maternal mental health and focusing on women and the very broad spectrum of motherhood. My personal goal is to decrease the amount of deaths related to childbirth and post childbirth,” Meghan began.

Moms Need More Than Screenings

“I would like for us all to remove the stigma attached to postpartum depression, and how people have been solely categorized as having postpartum depression and not exploring other very real things like access to resources and support, PTSD after difficult pregnancies or traumatic births, OCD, anxiety, and even psychosis which can also occur during pregnancy and after childbirth,” she offered.

 

“After having a baby you go to doctor’s office and they do this little check-off list but I personally, as someone who completed the list and have clients who have completed the list,  I don’t feel that it is thorough enough. It’s a start, but we need to do more” Meghan noted.

 

“Physicians could do better in making sure that they partner with psychiatrists and partnering with therapists, and keep those referral pathways top of mind. Women should be getting help immediately, and preferably long before this 6 week checkup because finding a therapist after you’ve had a baby is probably the very last thing on your mind.” 

 

The checklist that Meghan is referring to is a screening that typically occurs while a woman or pregnant person is in the care of an OBGYN. The American College of Obstetrics and Gynocology recommends that doctors and providers screen postpartum for depression and anxiety. ACOG also recommends screenings occur before and during pregnancy to help ensure that comprehensive follow up also happens after birth as well. While screenings are common, studies have found that OBGYNs may need to do a better job ensuring referrals and resources make it to the patient. A 2020 study concluded that screening may not be enough, which echoed Meghan statement. Rather, increasing awareness and increasing resource availability seemed to be missing pieces to supporting the over 15% of postpartum people diagnosed with depression after birth. 

 

“Screenings just aren’t enough,” said Meghan.

 

When asked what therapists could be doing better, Meghan didn’t skip a beat.

 

“Expecting mothers need help and someone who listens. And it doesn’t matter if you have five kids, two kids, or it’s your first pregnancy, it is – to me – imperative that people receive therapy throughout the entire process of pregnancy, birth, and postpartum because it’s a reeling experience. Changes in your body physically and chemically. Changes in your work and social life. Changes in your relationship, and your sex life. And so many of the activities that you used to love may not be on the table any more, or at least for a while. Not to mention pregnancy can also be dangerous for some people. So it can be a scary time,” she said.

 

Advocacy and education seem to be missing pieces according to Meghan.  Very often people don’t seek out therapy until after there is a known problem, or someone in their life suggests it. While routine and regular physical checkups with a physician or midwife are involved in pregnancy healthcare, mental healthcare checkups with a licensed therapist are not considered routine. 

Improving Outcomes for Black Women

“Advocating for seeking therapy before and throughout pregnancy is something I would love to see for all moms, but I believe it is very important for Black mothers because there is still an inequity in Black maternal mortality rates,” Meghan noted when expanding on her desire for therapy to be considered more routine in prenatal care.

 

 

“Expecting moms, especially Black women, can benefit by having a therapist who helps them develop the skills necessary to advocate for their needs during pregnancy care. As a black woman, not only do I have to worry about the fact that my provider may not listen to me, or take my needs or wants into consideration because there is still a very real bias that exists in healthcare.”

 

 

Meghan discussed not only her professional experience witnessing Black women navigate difficult pregnancies, but she shared personal stories as well, “With my second child I was so afraid. I mean you’re already afraid as a mom. You’re just worrying about each day. Let me get this baby to the next day. Let me get this baby to the next week. Let me get this baby to the next month but then when you throw in  preeclampsia or gestational diabetes it raises the bar. I was so frantic because diabetes is already something that heavily affects the Black community.” 

 

 

Statistically Black women do experience more complications during pregnancy, higher maternal and infant mortality rates. While maternal mortality rate has experienced disappointing numbers in general over the last two decades, the gap for Black maternal mortality rates has increased and seems to have peaked during the pandemic.  Additionally, Black women report, on average, less satisfaction with their care, less trust in their providers, and a larger concern about bias among providers

 

 

“And ours is a community that already experiences a lot of disparity. For many Black women just securing a job with good benefits is a really big deal. So to be able to keep that job and keep that insurance often becomes the priority rather than really focusing on getting adequate rest and care.”

 

 

“My own pregnancy was very nerve-wracking and scary. But, luckily, I had a therapist that I’d been speaking with consistently. It made a huge difference in the way I approached my prenatal appointments, the questions I asked, and, how I spoke to my doctors. Just having someone who can help you feel more confident in every appointment can really improve the experience and the health of a pregnant person,” Meghan concluded.

Empowering The Expecting

“There is a huge opportunity for mental health providers to lean towards this community,” Meghan suggested.

 

Therapy for those experiencing pregnancy for the first time is shown to reduce rates of anxiety. Meghan proposes that it may also have a positive effect on how a person feels about the care they receive during pregnancy as well, and empower them to feel strong about the role they  play in the health of their pregnancy and new baby. 


“Therapy offers an outlet, as well, as a space of accountability,” Meghan explained.


Going to therapy is a bit like going to see a trainer in the gym. You learn the moves, and practice them, and you have a coach guiding you on how it’s done. Then you go work out on your own. In the early stages of pregnancy, those tips and guidance are essential, because everything is new. The outlet [of therapy]  can be very cathartic and it helps a woman feel like she’s not alone because of pregnancy and learn how to use her voice.”


Therapy is often thought of as a place to share feelings, or examine events and how they influence responses. Cognitive behavioral therapy, for example, helps patients recognize when a thinking pattern may be faulty and influences a behavior or reaction that is unhelpful, and it is a widely used therapeutic modality for anxiety and depression. However, therapy is not solely CBT. 


Therapy also can involve reframing a narrative, or belief system, about oneself, as well as coaching for a pregnant person who may be feeling intimidated by doctor’s appointments. Using a therapy session as a training ground to practice establishing boundaries, practice speaking up for themselves at appointments or during labor and childbirth, and discussing plans, fears and desires can be a outlet to process difficult emotions in a safe space. Additionally many therapists employ mindfulness techniques, and can offer education and practices that support nervous system regulation which can be helpful during moments of anxiety including birth itself. 


“I can share from my own experience that I had a doctor that solely focused on  having a safe delivery – and my birth preferences were not really part of the discussion. ‘Get the baby out safely’. That’s fair, but I wanted to enjoy my experience. I told my therapist that I was a little concerned that my doctor wasn’t not listening to me. My therapist was able to give me the feedback I needed. She told me ‘ok you have to be assertive and you have to tell her ‘this is what I need. Where can we meet in the middle?’ She also suggested I get a doula and encouraged me to write down a birth plan,” Meghan shared.  


“I heavily encourage talking about that birth plan with your therapist. Birth can be scary, but also it’s beautiful, and more times than not that mom and baby are both healthy. A therapist can help you focus on the positive potential outcomes too, especially when you’re feeling very anxious. So talking to your therapist is helpful in gathering those plans and empowering you to speak your truth.”


When considering her bottom line and what she hopes for the future, Meghan was clear.


“I personally believe that all Black women should know that they have a right to control their medical experience specifically. In birthing and caring for a child we have a history of pain, and a story that needs to change. Dating all the way back to slavery black women often had no autonomy over their experience as a mother, many times their children were ripped away from them or they spent all their time caring for other people’s children without being able to dedicate the same time caring for their own. And so I want black women to know that they are powerful, that this is their experience, and their experience only,” Meghan concluded. 


“If someone makes you feel bad about speaking up for yourself, then they are not the provider for you. They are not a support person for you. You have to find another support person and not to give up on finding that person or people who will help you make your birth the best possible experience for you and baby.

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Facts About Major Depression Everyone Should Know

Facts About Major Depression Everyone Should Know

February 22, 2023

Depression is a Leading Cause of Disability

With an estimated 300 million people suffering  worldwide, depression has become a leading cause of disability. The financial toll that depression takes on an individual furthers the difficulty individuals have in maintaining stable employment and adequately being able to receive treatment. Prolonged depression that is untreated or undertreated only serves to increase the problem leaving the individual, and their families not only with health concerns, but additional financial stress that comes from being on disability and concerns regarding on how to pay for treatment. 

Adults with Depression Have over a 60% Increase in Their Chance of Developing Heart Disease

When it comes to health it is clear that mental health plays a huge role. The two-way link between heart disease and depression is multifaceted. From the impact of prolonged stress on the nervous system stimulation, to inflammation, to the influence depression has on other lifestyle factors including movement, diet, and socialization, it is obvious that the physical body suffers when the mind suffers. Mental health is health, and must be a serious part of the conversation.

Suicide is the Fourth Leading Cause of Death in People 15-29

Depression can be lethal especially for young people. More than 700,000 people die by suicide every year. Not only do these deaths have tremendous ripple effects, they are completely preventable. Education, resources, access to personalized and more effective treatments, and reducing the stigma around mental health are all important components in suicide prevention. 

Combining Therapy with Medication Often Works Better Than One Treatment Alone.

When it comes to depression, many people consider taking medication, which can be effective in symptom reduction.  However, most people with major depression respond better to a combination approach that includes psychotherapy. Treatment that incorporates both top down and bottom up approaches seems to work. While medication is addressing symptoms physically, therapy can come in to help a person develop longer term coping strategies to better navigate stress.  Increasing access to in-network psychiatrists and therapists is key in increases access to care that improves outcomes. 

Some Studies Show 10%, and Others Up to 30% of People with Major Depression are Treatment Resistant

While SSRIs and combination therapy work for some, they don’t work for all. Be it side effects that become intolerable, or simply a medication that no longer works, treatment-resistant is a term that applies to someone that has tried multiple attempts at treatment (typically medication) and is still suffering. There are many theories as to why SSRIs don’t work or stop working. However, that does not mean there isn’t hope for those individuals. New treatments like psychedelic treatments, including Ketamine therapy, have shown rapid improvement of symptoms for those who have experienced treatment resistance.

 

 

There is a 2-Way Link Between Sleep Disorders and Major Depression.

Restful sleep supports the brain, and a healthy mind promotes good sleep. Those who experience sleeplessness and insomnia are more likely to experience major depression. Additionally those who have trouble sleeping may have less success with medication as well. A tired mind and body have a difficult time healing. Bottom line, those who are experiencing sleeplessness should be talking to their mental health care provider about it, and developing strategies to get more restful sleep, and providers should be proactively asking about and addressing sleep concerns.


Changing Medications is Common and Normal, as is Pursuing Alternative Treatments and Therapies, Such as Ketamine, rTMS, and Psychosocial Interventions

It is common for a medication that has worked for years to stop working for someone with depression, and this may be for a variety of reasons both biological and related to life events. For some, switching to a new medication works. However, for others, it does not. People who are treatment resistant, which generally mean they have tried and failed to find relief from traditionally prescribed medications, may be more inclined to seek interventional treatments. While treatment resistance is difficult to treat a significant number of people with treatment resistant depression who engage in other treatments such as Ketamine, repetitive transcranial magnetic stimulation, and psychosocial interventions do find some level of relief when traditionally prescribed medications stopped working. 

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Care Insights: Sex & Therapy with Jestina Franks, LPC-S, AASECT Certified Sex Therapist

Talking Sex & Therapy with Jestina Franks, Sex Therapist & LPC-S

February 13, 2023

Psychology, Sex, and Intimacy

Whether it’s framed as a “Hallmark” holiday, or a tradition that couples around the world take seriously as a date to engage or reengage with romance, Valentine’s Day raises feelings, questions, and desires to the surface for almost everyone. When those feelings, questions, and desires feel uncomfortable, painful, or completely new, it can be the very best opportunity to talk to a therapist about sexuality, and intimacy.

 

In this edition of Care Insights Jestina Franks shared her perspective as a counselor and sex therapist on why talking about sex in therapy is an important conversation for deepening personal understanding, and life satisfaction – whether you’re coupled up or not. 

 

So, we talked about sex.

Jestina works with Heading Health, and is a LPC-S and AASECT Certified Sex Therapy who offers virtual therapy to patients in Texas. To kick off the conversation about sex and therapy, Jestina thought it was important to set a baseline understanding of why sexual intimacy is such an important topic even though it’s often ignored or skimmed over in therapeutic settings.

 

 “Sex is an important part of who we are.  We see many images in social media and think this is what my sex life should look like and this is how I should feel when I have sex.  Those images can be further from the truth and can create anxiety.  It’s important to talk with your therapist about these concerns,” Jestina offered.

 

Sex and Satisfaction Beyond Biology

Discussing sex in the world of psychiatry often stops with conversations of physical performance, as mental illness itself and some medications prescribed to treat mental health disorders can negatively impact a patient’s sex life. Be it medication side effects or the impact of long standing stress, mental health takes a toll on intimacy and sex.  Finding a balance between effective management of concerning symptoms of anxiety and depression can come with a trade off. 

 

“There can be some psychological barriers that can impact our sexual functioning. Also some psychiatric medications can have side effects that can affect your sexuality.  It is important to educate yourself how medications can affect your sex life, and ask questions,” suggested Jestina.

 

“While some issues with sex and intimacy may have physical causes, very often psychological causes are at the core. Sexual dysfunction can be caused by anxiety, self-confidence issues, and trauma. These are things that are not just affecting life inside the bedroom, but also everyday. So proper screening can shed light on deeper issues that could easily be overlooked if the right questions aren’t asked.” Jestina shared.

 

The door also swings both ways as well, and collaboration between mental health care and physical health care providers is crucial for optimal care. “Mental health professionals need to collaborate with physical health providers too to ensure that sexual health issues are not medical, “ she noted. “Sexuality is a part of who we are as humans, and it’s not a one size fits all. It’s a unique part of who we are and it’s different from everyone else.  Our sexual health contributes to our overall wellbeing.”

Seeing a Therapist who Specializes in Sexual Health

However, it’s not always that simple as stigma around sex is still a large barrier. Jestina sees a parallel between sex and mental health in the way that culture, and the medical system, has been slow to invite an open dialogue. 

 

“Sex is so taboo. It’s a part of ourselves that we keep hidden and don’t talk about. Mental health was just like that at one point, and still is in a lot of ways. But, what a lot of patients, and even many providers, don’t consider is that sex therapy is a specialization within behavioral health that is focused on sexuality and sexual functioning. While you can talk to your therapist or psychiatrist about sex, getting referred to a provider with specialized training in sex therapy offers tremendous benefit – especially for those who have experienced sexual trauma, or are seeking support surrounding their sexual orientation, sexual identity, or have had a major life experience that has impacted their experience of sex and intimacy” 

 

The conversation can also be much more fluid when speaking with someone trained in sex therapy because the elephant in the room isn’t being ignored; it’s front and center. “Sex therapists are there to educate on communicating openly and honestly with your partner, find the root of sexual issues or challenges and move towards a fullfling, and pleasurable sex life.”

 

Something that many people are surprised to find out is that this work is not just for couples. 

 

 

Sex therapists very often work with individuals, especially when someone is working through a history of abuse or trauma, or when someone is  seeking support for issues of sexual preference, orientation, or identity, or experiencing a big life change like dating after divorce, medical illness, or another large life transition.  “Having a therapist who is sex positive, knowledgeable, compassionate, and empathetic empowers people to take control of their sexual health and wellness, and you don’t have to wait until you’re having sex with someone else or partnered up,” encouraged Jestina.

How to Pick a Sex Therapist

Not every therapist is going to be able to offer the same level of skill as a therapist who has specialized training. For those who feel that their therapist may not able to provide support Jestina suggested asking for a referral. Jestina also empowered people looking for a sex therapist to consider the qualities that would support them best, “Sex therapists are trained to help process concerns such as low libido, mismatched libidos, lack of desire, pain during sex, erectile dysfunction, sexuality and identitiy, and alternative relationships such as polyamay or open relationships and a host of other sexual health or wellness concerns,” Jestina explained.

  

“I would encourage people to ask questions and advocate for yourself. You can ask about a therapist’s education and qualifications. For example some sex therapists are AASECT certified which means they have gone through extensive training. You also will want to know if the therapist has had experience working with a population similar to yours.” 


Cultural sensitivity and community experience can have a positive impact in building rapport, and people may with to seek out sex therapists within or allies of the LGBTQIA+ community, have experience working with people who have a history of sexual abuse, or  people experiencing issues with sex and intimacy post divorce or loss, and  aging populations may want a therapist who has insight in maintaining a positive sex life in their golden years. According to Jestina sex therapy needs to be culturally sensitive, and inclusive, otherwise it will completely miss the mark.


“There’s a need for therapists who want to get more training in sex and intimacy. For those interested in the field I would encourage them to check their bias at the door. What appeals to a client may not appeal to you, but it’s not your job to judge. Those unique desires and preferences may be key pieces to that individual’s overall identity and experience of the world. It’s a sex therapist’s job to guide and support the healthiest and most authentic experience of sex and intimacy for the person they are helping,” concluded Jestina.


And, for those still nervous to talk about sex during therapy, or unsure of the benefits, Jestina had this to say, “Seeking professional help can give you the tools and resources to process what you have experienced. [Sex therapy in particular] will give you a safe space to process your trauma, learn coping skills, explore ways to feel safe in your body, learn how to create and set boundaries, and use positive communication skills.”

Important skills for everyone – no matter their relationship status. 


For those interested in learning more about sexual health, sex education, and sex therapy, the American Association of Sexuality Educators, couselors, and Therapists has resources for patients and providers at AASECT.org

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Care Insights: Community Health & Black Mental Health with Shaunae Tolson, LPC

Therapy Insights: Community Health & Black Mental Health with Shaunae Tolson, LPC

February 6, 2023

Black Mental Health & Black History Month

In this Care Insights we spoke with Shaunae Tolson, LPC.  Shaunae is a counselor who offers virtual therapy services to Texas, and is part of the care team at Heading Health.


Shaunae shared with us her inspiration for entering the field of mental health, her perspective on providing mental health care and receiving mental health care as a Black woman, and what she feels is the duty of the medical system and those in health care when it comes to not only serving individuals but also being the change she hopes to see for all patients.

February is Black History Month, a month that serves to recognize the contributions and achievements of Black individuals, with special focus on sharing important stories of the people and moments in Black history that have and continue to play a central role in U.S. history, and offers a powerful reminder that Black culture is American culture.  In our conversation with Shaunae, she shared what this month means to her and how Black Mental Health should be part of the conversation, this month and every month.

 

 

“Well, obviously, being a Black woman I grew up black with all the challenges that come with growing up Black. And for me, and many people in my community,  mental health was not mentioned or talked about or acknowledged. The closest thing you get to counsel is ‘go to church’, ‘give it to God’, or you’re told to pray or talk to the pastor,” Shaunae reflects.

 

 

“I think that’s why it’s important to talk about Mental Health when we talk about Black History.”

 

 

Mental Illness, PTSD and Survival

Shaunae grew up in what she called a ‘rough, inner city neighborhood’, and recognized that most people in her community were experiencing significant challenges. Now, as a therapist she is able to empathize with her clients who have been raised in similar circumstances. Shaunae shared that she feels that what may be labeled as ‘mental illness’ is often survival mechanisms and habits for coping.  The impact of living under extreme stress for a prolonged period of time often creates mental and physical health symptoms that aren’t always obvious, because surviving becomes another part of daily living.

 

 

“I was an inner city kid. And I feel like a lot of inner city kids suffer from PTSD. For me, having family members that have gone through the legal system, we suffered, but we had to suck it up. No one really talks to inner city kids about the exposure they have had to really difficult circumstances, and what impact witnessing these things is having on them”

 

 

“What I know now about PTSD, as a counseling professional, is that it’s just survival tactics really.  You’re often forced to learn them and sometimes just don’t have a choice in the matter. It can come with aloofness, a numbing, pretending like you’re unbreakable, or coming across as standoffish or disrespectful. But what people need to realize is that at the end of the day – basic needs always win. You do what you think keeps you safe.” Shaunae shares.

 

 

Shaunae’s personal experience concerning the difficult nature of mental health diagnoses, and even misdiagnoses, when dealing with trauma echoes broader issues of racial disparity in mental health care. A 2018 study from Rutgers University compared the diagnoses given to over 1600 people and concluded that very often Black men with a diagnosis of schizophrenia were much more likely than non-Black individuals with a schizophrenia diagnosis to also qualify for a diagnosis of major depression and PTSD. Yet, the screening for mood disorders and diagnosis of major depression was often not given.  Discussion of this study also noted the finding suggests a bias towards screening Black individuals for psychotic symptoms over mood disorders.

 

 

Undertreated major depression is significant, as it is a misdiagnosis of schizophrenia, in both instances the potential for inappropriate treatment or undertreatment comes with significant health risks.

 

“You know with police brutality, lack of opportunity, crime, and a lot of what happens in rougher neighborhoods relates to people doing what they know to do based on the demands of their environment. And it takes time and perspective, and really the ability to step away, to realize that sometimes coping techniques are dysfunctional, and understand that your feelings do matter.  But it’s hard to form that sort of perspective if you’re stuck or you’re unsafe. You have to survive first. Mental health or emotions are not going to be seen as a priority, because they’re emotions. They don’t feed you, put clothes on your back or keep the electricity on.”

 

The challenge of offering support to an individual when societal factors play a large role in a patient’s suffering is an aspect of her job that Shaunae embraced, ”I think that’s why it’s such a  passion of mine. The work is complicated because I’d often have to say to someone, ‘You’re right, you still have to survive, unfortunately, because of the cards that you were dealt and the situation that you’re dealing with’.” 

Doing Healing Work In a Broken System

The resilience of the people Shaunae supported in her time in community mental health stoked a passion for her career in counseling. When Shaunae reflected on her time in community mental health she shared that one of the most difficult aspects of that work was not being able to change the environment she was sending people back into after their session, but that community centers were the heart of change for neighborhoods like the one where she raised.

 

 

“I’m a huge advocate of community centers,” Shaunae shared excitedly.

 

“I worked in community mental health. So, I dealt with, you know, America’s true people. And I’ve heard a lot of things, and witnessed a lot of emotion that stem from really horrible experiences. Even though I couldn’t necessarily change their experiences or what they were going through, I  saw the impact of just being heard, and having a safe space for letting it all out,” Shaunae remarked.

 

 “We can’t fix the situation. Most times we have to send them back to where they came from and they have to continue to survive. But I don’t think people understand the impact of just having a brief moment of not having to worry.”

 

Community centers are often frontline areas of support for low-income people who live in inner city environments. While the American Affordable Care Act did begin to close the insurance gap, Black individuals still trail behind in coverage, and are much less likely to have private insurance making access to quality mental health care difficult and cost prohibitive. Safe spaces where counseling, support groups, social services, and recreation, become centrally important in providing low cost and zero cost access to meaningful access.

 

 

“When you’re worried about basic needs emotions are not going to be a priority. But there can also be some acknowledgement and support. And that goes a long way. Just a space for releasing is impactful.”

Need for Black Mental Health Professionals

When asked about her perspective on receiving mental health counseling for someone of the same race, Shaunae’s response was nuanced and thoughtful. It was clear this is a topic she’s considered often in her own life and in her career. 

 

“I have a mixed perspective. It’s not always necessary for your therapist to look like you, but sometimes it can help. Some of the greatest therapists I saw were white women. I never felt like they couldn’t help me because they didn’t understand my struggle or that I couldn’t meet with them, but I also will add that at the time I was already studying this work. So I had some awareness. But, in reflecting back, the biggest reason I was able to navigate [having a white therapist] was because growing up my mom always made a way to ensure we were able to go charter schools. I was not a stranger to being in predominantly white environments.”

 

One important aspect of reducing stigma and improving care and access for the Black community relates back to a greater need for diversity in the mental health field in general. The APA reported that as of 2015 the field of psychology was less diverse than the nation as a whole, and that only 4% of professionals in the psychology field identified as Black. While beneficial care is not reliant upon racial, gender, or sexual orientation matching between patient and provider, there are real benefits to care when a patient feels more comfortable building a rapport with someone of their own background. 

 

In Shaunae’s own therapy journey, connecting with a therapist who was a Black woman made a difference for her. She shared, “When I got my first Black therapist, that shifted things for me. I can’t even pinpoint the exact shift, but it took my treatment to a deeper level. Having that connection of culture was significant. A lot of the things that I explore with my current therapist, who is a Black woman, are also things that I explored with white therapists. However, now with that shared connection I’ve been able to revisit those topics and process the experiences more deeply. Her understanding of the Black experience, and being able to ask certain questions about the Black experience and being a Black woman especially, helped.”

 

Rapport is a significant indicator of therapeutic success, even more so than a specific theory or modality used in session. Research on cultural competency and its relationships to therapeutic outcomes is gaining more traction though a precise definition of what it means to offer culturally competent care is still difficult to pinpoint. But, research shows that providers can unintentionally contribute to increased racial and ethnic disparities in care, and on the whole the system needs improvement. Though the fact remains that racial and ethnic minorities are less likely to receive psychological care than the white majority, and in order to meet the need more BIPOC are needed and white providers need to become more immersed in providing care to a culturally diverse patient population.

 

“For Black people who may be resistant to therapy, or nervous to talk, having someone that they immediately feel like they can trust and relate to might make a big difference. Someone of a different race, who’s just very textbook, just not aware and simply feeding what CBT told you to say if a client says a certain thing – that’s a turn off.”

 

 

Given that the overwhelming majority of psychology professions are white there is a tremendous need for learning and education around what it means to offer culturally competent, sensitive, and relevant care. Shaunae shared, “Clients who have come to me after experiencing a white therapist or someone who just wasn’t culturally aware said it was off putting and it made them quit there because to them it’s like, ‘I don’t need you to tell me what the textbook said or to watch calming soothing videos, I don’t need that, I need you to hear me and know what I’m talking about.’”

How Mental Health Practices and Providers Can Support Change

“When it comes to changing Black Mental Health I think first of access. Access provides the opportunity for a powerful trifecta: Awareness, Perspective, and Trajectory. Awareness comes through psychoeducation and therapy to unlock the path to psychological freedom. This leads to a shift in perspective, and that unlocks hope. Hope is needed in order to change the trajectory of one’s life; a life that may have seemed unattainable.”


Facilitating space for hope can be a change with insurance gaps, and difficulties in access – even with the advent of virtual therapy.  When asked what she thinks mental health practices and providers could do to influence systemic change and promote greater access, Shaunae had very concrete ideas of what she’d like to see.


“Educational assistance, and medicaid. I don’t know the logistics behind convincing more companies to accept medicaid, or how to improve the care that comes with it, but when I was working in community mental health accepting Medicaid was huge. Unfortunately when it comes to medicaid, people don’t always get the best care, and we need to change that too. I believe mental health practices and providers have a responsibility to figure it out.”


In the short term, Shaunae challenged practices and providers to align and support organizations already offering care to those who need it. 

“I remember when I was growing up in the projects there was a community center. It was just a place for us to escape. It had recreational activities, and people we could talk to if we needed. Simple things like that. Mental health care practices should support the places in the community that are already doing the work. Centers are monumental because there’s no transportation barrier, and financial barriers aren’t there. Growing up, I didn’t know what yoga or Pilates or meditation was. Community centers are starting to bring some of these things that we, even I, preach to our clients.”


From Shaunae’s perspective an action everyone who cares about improving mental health care equity can do is to find ways to support safe spaces, “We need places where at least you get a break, because we all need a break.”

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