Image of three women with their heads together. Is it really “all in my head”? by Megan Lothian, LCSW

Is it really “all in my head”?
Exploring the impact and overlap of gaslighting, unconscious bias, trauma, and healthcare disparities on women’s experiences in medical spaces

by Megan Lothian, LCSW

The overlap of chronic medical illness, access and equity within healthcare, and traumatic experience have all been top of mind as a psychotherapist. Especially as we are coming off of Mental Health Awareness month and an awareness month for a handful of chronic illnesses, facing a threat to women’s reproductive healthcare, and still navigating the Covid-19 pandemic.

I am sure I am not the only mental healthcare professional hearing stories from my patients about medical professionals dismissing their health concerns and/or linking causation of their symptoms to their mental health diagnosis, body weight and/or diet, lack of self-care practices, etc. While things like self-care, food intake, exercise, sleep, and mental health all undoubtedly impact our physical health, the amount of times that legitimate medical issues are dismissed in the name of something more “controllable” by a patient is never too surprising, but often disappointing. In an interview on medical gaslighting with Dr. Duarte, a Northwell Health Pain Management and Neurology doctor, he stated: “I do still see patients who have been shuffled around to different clinicians and ended up seeing a psychologist. Often times it’s because they don’t have pain that fits neatly into a cookie-cutter category. And some conditions, like chronic pain, respond to mindfulness—making them more likely to be dismissed as psychosomatic.” Sadly, patients’ experiences with medical professionals often add a secondary wound on top of existing wounds.

Earlier in the Spring, The New York Times posted an article about the experiences of women and people of color in medicine, highlighting the experience of medical gaslighting.  NYT also recently published a piece titled, “Why Heart Disease in Women Is So Often Missed or Dismissed”. Both articles in NYT reported diagnostic errors occurring in approximately one out of every seven encounters between a doctor and patient, and that when compared to men, women are more likely to be incorrectly diagnosed in a variety of situations. Moreover, women are twice as likely as men to be diagnosed with a mental health diagnosis when their symptoms are actually more consistent with symptoms of heart disease.

Patients who have felt that their symptoms were inappropriately labeled as minor, or deemed as primarily psychological, are using the term “medical gaslighting” to capture such experiences. These dismissals and diagnostic errors only further exacerbate the mental health stigma. As NYT points out, the term originally derives from a play called Gaslight about a husband’s attempt to drive his wife insane. Many patients, but particularly women and people of color, describe the search for an accurate diagnosis and treatment as “maddening”.

This gaslighting experience described in the NYT article is nothing new. Take hysteria, for example, which began with Hippocrates in the 5th century BC, and continued through various countries and cultures. During the Victorian era, the term hysteria was a common medical diagnosis, especially for those with a uterus. The term hysteria derives from the Greek word for uterus, reflecting the original belief that hysteria and its symptoms were caused by a “defective womb”.

More contemporary ideas about hysteria include neuropsychiatrist Pierre Janet’s assertion (the 1880s) that hysteria resulted from a person’s own warped perception of their physical illness. In the early 1900s, classical psychoanalyst Sigmund Freud’s treatment of hysteria gained notoriety. Hysteria was used to capture a range of symptoms including a swollen abdomen, chest pain, increased heart rate/pulse, excessive emotion, amnesia, and changes in both sex drive and appetite – symptoms that could be caused by any number of overlapping conditions. Freud, because of social politics in Vienna at the time, actually ended up retracting his original theory that female hysteria was a result of trauma, “which the patient fails to confront, because it will cause them too much mental anguish”, and is converted into physical symptoms in the body. Freud shifted the focus away from trauma, and focused on sexual drives and impulses, “curing” patients of their repressed impulses which were manifesting in physical and/or behavioral symptoms.

While the fields of psychoanalysis, psychology & neuropsychology continued to evolve in many ways, and in many directions, the diagnosis of hysteria was not actually removed from the DSM until 1980. While labels like hysteria miss the mark and provide little insight into the roots of health concerns, our bodies do remember trauma. Mental health symptoms can present physically in the body, and we can see an impact on both mental and physical health from chronic stress and chronic illness. This relationship between traumatic experience and the body has strongly influenced current evidence-based trauma treatments within psychotherapy (somatic experiencing, sensorimotor therapy, relational psychoanalysis/psychodynamic frameworks, etc.). This is why it is so important to hold the mind-body connection sacred and explore all interconnected factors in healthcare before arriving at a diagnosis.

The Covid-19 pandemic is highlighting, more than ever, disparities in healthcare when it comes to race, gender, and socioeconomic class, and continues to unfortunately showcase the systemic ableism that transcends. Alongside these threats are the risks to women’s reproductive rights which would disproportionately impact women of color and women with less economic and social resources. In the March 2022 article about medical gaslighting, the NYT drove home the importance of a “call for more extensive training in medical school about unconscious bias and racism within health care”, especially within the context of the pandemic and how much light it has shed on the disparity in care, both nationally and globally. Within the psychotherapy world, as well as healthcare as a whole, we need to pay close attention and consideration to the nuances and intersections of chronic illness, trauma, medical gaslighting, and bias.

In the world of psychotherapy, we acknowledge that multiple truths often co-exist. A person can have physical symptoms that arise from co-occurring traumatic experiences, mental health diagnoses, and physical symptoms from illness that has not yet been diagnosed. We need to spend the time validating the patients’ reality and becoming curious with them. We might ask: how is this person being taken in and seen within the environment of health and wellness? How does their identity, and the way they walk through the world impact treatment within our healthcare system? These questions are important to consider and use. Sometimes we cannot untangle what is what, and regardless of root causation (if we can even know it diagnostically), symptoms that require treatment and care should receive adequate consideration, treatment, and care.

Part of my job as a mental health professional is helping patients seek support and advocate for themselves. This could take several forms: talking with a trusted therapist, medical provider, and/or family member about your concerns. When seeing a new provider, patients can prepare by bringing a list of current diagnoses, medications, a detailed medical history, knowing their patient rights, and practicing responses to commonly asked questions. Having the space to share, process, and troubleshoot potential barriers can also be helpful.

Dr. Alyson McGregor, an MD at Brown University and author of “Sex Matters: How Male-Centric Medicine Endangers Women’s Health—and What We Can Do About It” says that “until more changes occur, women and patients of color might want to consider bringing a friend or relative with them to their medical appointments. It really helps if you have an advocate there that can intervene and say things like, ‘She (they) is (are) not normally in this much pain”.  McGregor goes on to say that “It’s sad. We go in on the defense and ready for it to happen, because it’s so common.”

Having a trusted companion or advocate at appointments can reduce some of the understandable anxiety patients often feel. It can also make a great impact on how the person is treated. In some cases, second and third opinions are warranted if you don’t feel heard and respected during a consult. Dr. Mieres, a Chief MD within the Northwell system, stated that “if a woman feels like she’s not taken seriously by her doctor, she needs to find another provider. A good physician takes the time to listen to a patient and steer them in the right direction.”

The historical, social, and political factors mentioned continue to have an impact on whether or not women of all identities and demographics receive appropriate diagnoses, treatments, and equitable healthcare. Ongoing stigma surrounding mental health, specifically women’s mental health, and the ways in which women are held in mind (or not) within the medical system at large, create barriers in the ability to receive care. This negatively impacts mental health as it generates feelings of mistrust (both of oneself and the medical system), isolation, and invalidation. Advocating at the micro, mezzo, and macro levels is necessary to continue working on increasing access.

It is promising that the dialogue around healthcare disparities is continuing to evolve.  It is our duty to work together to further the conversation and create more space for these experiences to be shared, as we know our bodies better than anyone else.

Sources:

https://www.nytimes.com/2022/03/28/well/live/gaslighting-doctors-patients-health.html

https://www.nytimes.com/2022/05/09/well/live/heart-disease-symptoms-women.html

https://www.medicalnewstoday.com/articles/the-controversy-of-female-hysteria

https://www.alysonmcgregormd.com/book

https://www.northwell.edu/katz-institute-for-womens-health/articles/gaslighting-in-womens-health


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