Incompetence in Mental Healthcare

[Outline of black tree branches in shape of a side profile of a head]

6/22/18

The recent high profile suicides of Kate Spade and Anthony Bourdain have led the media to highlight the nation’s climbing suicide rate. Tweets and posts by the famous and non-famous alike shout out that help is available; you have options; it gets better. Those who are posting mean well, but they need a reality check. Finding support within our current system is no small feat; we’re going to need more than encouragement on social media to impact mental health in our country.

Folks may look for support from both personal relationships and paid professionals, and the posts I’ve seen advocate a mix of both. Although I also value both sources of support, this piece is about the latter. For those with access (which should be EVERYONE), professional care can provide intensive and transformative support, in the forms of medication and therapy, that we can’t find in personal relationships.

Yet there are so many things that can go wrong when it comes to finding a mental healthcare provider. Even after locating a professional in your area who has room in their schedule for you and fits your insurance and/or budget, one must filter through a mass of incompatibility and, dare I say, incompetency.

One may move on from a therapist because they find their methods ineffective and their opinions unhelpful. Other times, a provider’s ignorance about the patient’s lived experiences may present an insurmountable barrier to adequate care. This second piece is especially relevant in the case of people from marginalized communities who do not share the normalized cisgender heterosexual white able-bodied (etc.) experience. To use an example from my community, The National Transgender Discrimination Survey found that 50% of transgender people reported having to educate their medical providers about trans-specific healthcare.

In this piece, I’m going to dive into my own story to show how my path to receiving adequate (I know, the bar is low!) mental healthcare has been difficult and winding. Because I have the privilege to be insured through my dad, my frustrations have not been financial , and have largely stemmed from interacting with incompetent providers.

At times in this journey I felt helpless and alone. My goal here is to help readers who find themselves on a similar path feel less isolated. I also hope that those who do not share my experience gain awareness of how challenging it can be to reach out for, and find, mental health care. And, for everyone’s sake, I have interspersed some comic relief gifs to ward off despair.

I’m Fine… ?¿ ¿??

[Ross from Friends saying “I’m Fine” when he is clearly not]

It feels reasonable to start this retelling when I went off to college. Not only was I saddled with a challenging courseload, I also had to learn how to manage my own health, including healthcare.

For a long time, I was my own biggest barrier to receiving adequate care. Despite the loneliness and homesickness that bubbled within me, I consistently earned good grades. I blocked out my emotions by keeping busy and viewed my academic accomplishments as proof that I was doing just fine… in all aspects of my life. If I ended each quarter with a good GPA, how bad could things really be?

I had a sense I was dealing with mental illness, but I was also convinced that the symptoms associated with anxiety and depression (to be diagnosed later) were crucial to my success. Like most college students, I put my self-worth on my grades. I was hypervigilant about meeting my own high standards. I felt no sense of inherent worth, but rather believed academic success determined my value. I couldn’t help but think that I’d lose my drive without these thought patterns.

Even in the rare moments when I connected to how I really was doing (not well), and contemplated getting help, I was sure it would be far to embarrassing to discuss my thoughts and emotions with a paid stranger.

Help

[Captain Jack Sparrow saying “That’s just maddeningly unhelpful.”]

For three and a half years I lived in the delusion that having good grades and not being okay were mutually exclusive. This started to change halfway through my senior year. On top of my ongoing anxiety and depression, I had started having regular panic attacks. I felt like the symptoms were on track to take over my life, so I finally reached out to the campus mental health clinic for help.

I showed up to my first appointment a month later as this was their soonest availability for a new patient. I felt so vulnerable that I was already on the verge of tears as my Bad Therapist led me into her dim, windowless office. At the end of the hour, I stared at the soggy ball of tissues in my hands as I listened to her recommend that I see a psychiatrist to start medication.

Another week passed and I entered the office of a resident psychiatrist. Once she heard what was going on, the Psychiatrist I offered to write me a prescription for an SSRI. Because I had internalized the stigma that taking drugs to treat mental illness means you’re not trying hard enough to get better without “cheating,” I was hesitant to follow her recommendation. As I wrote above, I also worried that if my anxiety and depression went away so would my academic success. Psychiatrist I was understanding and let me know I could contact her if my thoughts changed.

Back in Bad Therapist’s office, things started to fall apart. When I told her I had decided not to start medication, she was visibly disappointed and said that medication was the only thing that could help me right now.

Long term talk therapy, which she saw as the only other effective treatment, was not an option because I was graduating and moving away in three months. Bad Therapist also delved into why she didn’t think other popular treatments, namely behavior or exposure therapy, would not be a good idea for me. She explained that she didn’t “believe in” these therapies because, despite being “supported by scientific evidence,” they “seemed mean.” Since the therapist saw a dead end looming, she suggested we make this our last session. It was only my third out of ten available appointments at the campus clinic.

As I walked out of her office, part of me felt relieved not to have to see her again. Even before she cast me off, I had little faith in Bad Therapist. When I told her the cherished story of how I told my then-boyfriend I was interested in him and she pathologized how I acted, apparently having no qualms about spoiling the memory for me. In another instance, she asked out of the blue, “When was the worst time for you?” as if poking blindly at my brain with a blunt instrument to find what was wrong, not caring how much needless pain she caused.

At the same time, I felt totally hopeless; the person I had come to for help had given up on me. The good news was that I still had Psychiatrist I’s email. A week or so later, I was struggling more than ever and reached out to ask for a prescription for an SSRI. If medication was the only thing that could help me, I’d have to go for it. It felt like things couldn’t get much worse.

Psychiatrist I fit me into a gap in her schedule and I was sitting in her office within a couple of days. When I told her why I wasn’t in therapy anymore she was troubled. She firmly explained that medication wasn’t the only option for me, but that she recommended it as part of my treatment. In addition to writing the prescription, she offered to refer me for cognitive behavioral therapy at a nearby clinic. As she explained how this therapy could be highly effective for treating my symptoms, I felt grateful to have someone on my side.

Cognitive Behavioral Therapy and Medication

[Oprah nodding as she blinks through the tears.]

When I started medication, two months had passed since the initial request for help. Within a few weeks my panic attacks became less frequent. My mood and anxiety improved at times, but were still unstable. Luckily more help was on the way.

A couple weeks later, I started cognitive behavioral therapy with Psychiatrist II. I was soon soaked in tears in this appointment as well. I felt exposed spilling my personal thoughts to a stranger and was skeptical that anything could be worth this level of embarrassment.

To my surprise, Psychiatrist II affirmed me in ways I had never heard from my first therapist: “Wow, that sounds really difficult.” “I can imagine why you’d be overwhelmed.” “You’re being really strong.” Although I didn’t quite believe these comments, they introduced the strange new idea that I was dealing with a lot and doing my best.

As with the therapist, I left the initial appointment with puffy eyes. The difference was I felt understood and respected instead of confused and disconnected. This foundation of trust would allow us to delve into difficult and meaningful work in the weeks to follow.

In the coming nine hour-long sessions psychiatrist II led me through activities and conversations that challenged the firmly set thought patterns that were connected to my panic attacks. We talked about the accuracy of my ideas. I got to estimate the likelihood of my worst fears becoming reality and was forced to face that, by my own admission, these scenarios were extremely unlikely. We contemplated whose rules I was following and why. Psychiatrist II took notes on a white board, giving me new perspective of the ideas that constantly whizzed around my mind.

With the skills I learned in cognitive behavioral therapy, I started to take note of which patterns of behavior were useful and which were detrimental to my well-being. Although I still dealt with intense anxiety during and after therapy, I slowly began to move beyond some of the thoughts that weren’t serving me.

My time with Psychiatrist II was all too brief, but those weeks imbued me with the belief that it was possible to have a positive experience with a mental healthcare provider.

Here We Go Again

[Jessica Williams shaking her head in disbelief]

After I graduated and moved to Seattle, I hung tightly to my positive memories as dealing with mental healthcare providers again became difficult. My search for providers was complicated by being newly out as queer and transgender. As a reminder from the introduction, it’s important to note that finances did not add to my difficulties because I remained (and remain) on my dad’s insurance plan.

The psychiatrist I first tried out ended up being a white man in his late seventies, at the very youngest. Although older providers absolutely can be trans-competent, I received no indication that this man safe to be out to, and I was not about to find out. I answered his questions with the bare minimum of detail so I could get my prescription and bolt.

The search for a therapist was similarly discouraging. Despite specifically requesting someone LGBT-competent, I think the secretary just assigned me to the clinic’s token gay provider. Like the psychiatrist, this therapist was a fifty-plus year old white man who gave no indication he had ever thought about gender. When I began to talk about the struggle to embrace my trans identity, he responded by describing how good Eddie Redmayne was in The Danish Girl. He was also unfamiliar with writing letters of support for top surgery or hormone replacement therapy.

It was clear that this therapist was not an LGBT-competent provider. NEWSFLASH: being gay does not automatically educate you on how to care for the entire LGBT community! I gave up on him after our second appointment.

I was back at square one. I heard about plenty of mental health professionals who serve the transgender community, but couldn’t find any who took my insurance. I gave up on finding providers for months.

Currently:

[Data from Star Trek showing a mixed range of emotions]

I got by alright without a therapist, for a while. I wouldn’t recommend this strategy, however, because it meant that I had to do the extra work of finding someone precisely when I didn’t have much capacity to spare. Luckily, it only took a few phone calls to stumble upon Current Therapist.

I was able to relax a bit after seeing that her online intake forms had more than two options for gender, including a blank for write-in answers. There were also places to list one’s preferred name and pronouns. This was a system in which trust could be built.

Current Therapist and I have been seeing each other three to four times a month for about six months now. I’m relieved to have a regular space to make my mental health and well-being the focus without fear of judgment.

Then there is the matter of Current Psychiatrist. After months of depending on my primary care doctor to maintain my SSRI prescription, I recently sought a psychiatrist to shift the dosage and/or medications. Because it was extremely difficult to find a provider that had availability to see new patients, I was grateful to find a provider in a well-known LGBT-competent office.

Current Psychiatrist and I have now met once a month for three months. The increased dosage of medication he prescribed at the end of our first session has helped me enormously. However, despite his knowledge of trans-specific care, he is generally condescending and fails to give off any sense of empathy. I’m not satisfied with this care and know I deserve better. I’m in the process of looking for a new provider soon.

Through it all, I have built up the skills and confidence to advocate for my best interests, something I will continue to practice and refine for my entire life. Receiving the care I deserve is empowering, and everyone deserves to feel similarly in control of their well-being.

No Easy Way

[Animation of two cats cuddling]

As we are all aware, this country’s healthcare system does not serve the needs of the general population. Currently, affordable care is a privilege, and many folks cannot access medical and/or mental health support. On top of that, many people face discrimination and ignorance based on their identities. For example, the aforementioned National Transgender Discrimination Study found that 19% of transgender people reported being refused care as a result of their trans identity. Finally, as I discussed throughout this piece, we have the task of sorting out well-meaning, but incompetent providers.

All this is to say that when we tell people to reach out for professional help, we need to realize that finding a provider that will actually HELP isn’t simple. Asking for support is sometimes said to be the hardest part, but what about asking for the second, third or fourth time? What about when you put yourself out there only to be met with confusion, misunderstanding, and/or judgment? Or when appointments make you feel worse and deter you from reaching out in the future?

My answer is not a solution, but a suggestion that we resist jumping to conclusions about people with mental illness(es) who aren’t in therapy or taking medication. No one else has the right to tell us we are failing if we haven’t found care that is respectful and supportive; we are all the experts on our unique circumstances and are doing our best to navigate them.

If you’re looking for a place to place the blame, please direct it towards is the financially inaccessible and impossible-to-navigate healthcare system. Instead of targeting the individual, work to change the structure. Concern about our collective mental health is most effectively mobilized to advocate for better-educated providers for marginalized communities and affordable care for all.

You can follow Alix on Instagram and Twitter @_transing_.
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Trans Lifeline and/or Ingersoll Gender Center.

white, trans/agender, femme often disguised as masc, NW-based. exploring gender beyond traditional narratives. patreon.com/alixperrywriting