A note before today's guest post: Today's article was submitted and written before the Covid 19 crisis reached the US. At this moment, all medical health professionals are maxed out on what they are giving to the public to keep us safe, and we are deeply grateful to them for the risks they are taking and sacrifices they are making daily. This advice, as most things on this blog are, focuses on looking at longterm overarching problems that take time to solve. I fully support everything Amy is advocating for in this article, and I recognize that with the current state of the world, it's not yet the time to move on these changes in a systematic way.
CN: general discussion of treatment for mental health, shortcomings of the medical system, and intersections between mental illness and other forms of oppression.
Have you ever seen the cost difference between a therapy visit copay versus a primary care copay under standard insurance in the U.S.? For my insurance, visiting a clinic or my primary care is three times cheaper and does not require me to wait 3-5 months for an initial appointment. For some, primary care and clinic physicians are our first, and possibly only, source of mental health care.
Physicians can have a major impact on how we treat, understand, and confront our mental health. But, I’d like to offer that we, the patients, have much to teach physicians about approaching mental health care. Getting a prescription or checking-in during routine physicals are not forms of mental health care, but they can be the first steps to getting the care you need and deserve. Physicians may be the more accessible option for mental health consults but they are often not trained as mental health experts and I learned first hand that doctors don’t always know best.
It only took ten minutes for me to be diagnosed with clinical depression, by a clinic physician, not a therapist. Twenty minutes after that appointment, I was picking up my new antidepressants at the pharmacy. Strangely enough, I made this appointment for an allergy flare-up at my local clinic, but things took many quick turns. After describing a nasty sinus infection, the physician asked about my sleeping patterns, which prompted me to explain my poor sleeping habits as a result of my anxiety. Soon, he was asking if I had ever been diagnosed with depression. This appointment then turned into an interrogation ala the DMS-5 depression criteria.
Due to health insurance limitations, I had always just dealt with my mental health problems before this appointment. So, at the time of diagnosis, I was excited. I had never discussed my mental health with a medical professional even though I was fully aware of my history of depression, attention deficiency, and anxiety.
The clinic physician sent me off with a prescription for SSRIs and told me to ask the desk for a list of local therapists. But, the doctor did not know that I couldn’t afford therapy, and I had no information about what therapy would do for me anyway. I was desperate enough at the time to believe that the anti-depressants would fix all my problems.
In retrospect, the diagnosis process was sloppy and confusing and I was given a bad fit of medication for my mental illness, which left me feeling confused for months. The clinic physician did not know me or take the time to know my needs; he saw my depression as a problem that needed a quick fix, thereby overlooking my symptoms of anxiety and ADHD, as well as the social factors impacting all these conditions. I was not ashamed of my depression, I JUST needed someone to listen. However, without this first visit and prescription, I am not sure I would have had the will to start the process of finding the right medication, eventually finding one that stabilized my mood, making life more manageable.
My story is one of many. When I first really got to know the disability community, I soon realized how I could relate to them through my mental health history. While I have a chronic pain condition that I always considered a disability, never did I treat my anxiety and depression as disabilities. Often, discussions of mental health lack a disability perspective, which limits understanding of how social structures and attributes contribute to experiences of mental illness, which is called the social model of disability.
In the social model of disabilities, yes our mental and physical experiences are very real, but it is the social and physical world that disables us more than our bodies and minds. In this way, I began to view the difficulties I experienced as not just a result of my depression and anxiety but of how the world is largely not built for mental illness. Social and workspaces do not account for how anxiety prevents me from sitting still or how depression inhibits my focus. Sometimes, my depression causes me to take months to write articles or I cannot write at all.
My different needs resulted in my exclusion. Although the Americans with Disabilities Act (ADA) does cover mental health, there remains a conceptual distance between disability and mental illness. Even if people with mental illness don’t identify as disabled, they may take comfort from engaging with the disability community and history.
Finding my place in the disability community also raised my awareness of the insufficiency of the medical system, including the ableism and classism that prevents many people from accessing quality care or any care at all. I learned from them that my mistreatment from healthcare workers and inability to access regular mental health care was not unique.
Upon further research, in the U.S., reports from 2018 show that:
“Access to [mental health] care is improving, but most Americans still have no access to care. The report states that 12.2% (5.3 million) adults with a mental illness remain uninsured, and 56.4% of adults with a mental illness received no treatment. Over 24 million individuals experiencing a mental health illness are going untreated.”
This problem goes beyond the U.S. Even in wealthier countries with universal healthcare like Spain, Italy, and the UK, there is a lack of access due to overcrowding and understaffed mental health care units. In the coming years, physicians, in general, may be faced with more patients seeking mental health care as a result.
Even as there’s been a major push to de-stigmatize mental illness and mental health discussions, all this hard work to provide mental health support won’t reach everyone who needs it. It is crucial that we encourage people to seek the help they need and assure them that needing this help does not make you any less of a person. While promoting destigmatization, we must also be fighting the financial and logistical obstacles to care, such as minimum insurance coverage or a lack of providers in a region. To begin this process, we need healthcare professionals on our side.
Medical professional training is the place to implement both a shift toward destigmatization of mental illness and increase access to care. Physicians have a powerful social authority, and so their perspectives on mental health and mental illness need to be one of the forefronts of de-stigmatization. At the same time, they have a greater capacity to encourage changes at the system level. The first step in tackling this challenge is helping physicians change their approach to the mental health of patients on a daily basis.
Based on my experience and disability advocacy work, there are 6 major things I wish physicians knew when working with patients with mental health concerns:
1. Let us feel.
Mental health care is not about forcing positive thinking, it’s about letting ourselves feel without judgment and asking why we have those feelings. In my case, repressing and ignoring my symptoms of depression and anxiety only hurt me more as I tried to “act normal” without ever asking why I was having these feelings. By silencing us with the rhetoric of “positive thinking” or “just take these pills,” there’s never any chance to explore our emotions and what might cause them. Moreover, without allowing patients to fully express their feelings, the diagnosis process will be lacking critical information about their experience.
2. Consider how disability pride is a possibility.
There is nothing shameful about having a mental illness or needing mental health care. When medical professionals think mental illness is something to be ashamed of, it demonstrates an immense misunderstanding that our mental health determines our social worth. While not everyone with a mental illness may identify as disabled, the concept of disability pride or the related mad pride can potentially make providers realize their own internalized ableism.
3. Respect that Identities and bodies are complex in different ways.
There are social and cultural histories that help explain why people of different backgrounds and cultures hold different attitudes and beliefs about mental health. As such, physicians must consider these differences accordingly. Here, we must encourage physicians as well as ourselves, to think and act intersectionally. Adopting an intersectional framework into routine care is a massively complex, yet vital project. My thoughts here are but a mere start of things that need to be better understood about mental health. I am reminded of Patty Bern’s notes on disability justice for the activist collective Sins Invalid:
“We know that we are powerful not despite the complexities of our bodies, but because of them. We understand that all bodies are caught in these bindings of ability, race, gender, sexuality, class, nation-state and imperialism, and that we cannot separate them.”
We are powerful because of our differences, and this power is undermined when our differences go unnoticed. If a physician cannot consider how factors such as gender and class contribute to our identities, then how can they properly care for our mental health?
4. Account for our lifestyles and access barriers in treatment plans.
Accessing mental health resources can be difficult and expensive and even if patients can access care, the process of accessing that care can create a new set of stressors. As such, giving patients referrals to therapists is only one step. Sending patients on their way with just a list of local care resources with no further instructions can make patients feel devalued as if their individual lifestyle and needs have not been taken into consideration.
Listening to patients’ concerns and discussing care access barriers with them can be life-changing, allowing the patient to be recognized as a person, not just a numbered time slot on the doctor’s schedule. Many communities do have free/low-cost mental health care options, which physicians and their office staff could familiarize themselves with. In the long term, clinics, practices, and hospitals could also hire more care managers whose job is to create personalized care plans.
5. Think at the level of systems and environments, not just individuals.
Similar to not assuming a patient can easily access mental health care, we must take the burden of responsibility off of the individual. Mental health problems arise from a web of personal, social, and environmental factors. So, blaming a patient’s lifestyle choices as the cause of mental health problems is reductionist and misguided. It is common for physicians to focus on our lifestyle factors, such as “drinking too much coffee” or “you need more exercise.” When it comes to mental health especially, some conditions are beyond our control. I cannot control how someone treats me due to my gender, sexuality, job, or disabilities but this treatment can still seriously impact the state of my mental health.
6. Give us space to make choices.
The best approach a physician can take is to explain our options while accounting for what we want and need. Reflecting on my experience, the physician never explained my options. It was as if an SSRI was not only the only choice but mandatory. His action seemed to say, “You’re sick, take this.” When you’ve lost a degree of control over your thoughts and feelings, the last thing you need is more of your agency being taken away.
The reality of mental health care is this: There’s not enough care to give, and even when you can access care, the quality of such care can be just as risky as going without if physicians do not account for the complex histories, identities, and factors that contribute to mental health and patient identity. This issue is compounded by another reality: there is also a massive shortage of physicians, especially primary care physicians in the U.S. As a result, patient visits are shorter and less thorough, with more work falling on nursing staff.
Given that, I want to be reasonable about what we expect physicians to do. I do not expect them to replace therapy but they have a responsibility to reassess their practices, giving mental health care the attention that we all deserve.
Physicians should expand their coverage of mental health during regular check-ups, without thinking that this replaces the personalization and long-term regular practices of therapy. Rather, if it is a physician’s job to attend to our physical well-being, then they cannot sufficiently do so unless they include the impact of our mental health on our bodies and vice versa. Physicians can serve as the starting point for mental health care by listening to patients, advising them of their options, and working with us and their offices to establish a mutually agreed upon patient-centered care plan.
About the guest blogger: Amy Gaeta is an activist, poet, and Ph.D. candidate in the Literary Studies and Visual Cultures (doctoral minor) programs at the University of Wisconsin-Madison. Her work focuses on the collision of militarism, technology, and the category of the human in the 21st century. Amy arranges aspects of disability studies and feminist technoscience studies in her efforts to promote social justice and mend the gap between activism and academia. You can find her discussing all this on Twitter, Instagram, and on her website.