Find Empathy, owned and operated by Empathie, LLC, is approved by the American Psychological Association to sponsor continuing education for psychologists. Find Empathy maintains responsibility for all program content.
Adherence to disease-modifying treatments (DMT), as well as health-promoting behaviors, can have a major impact on prognosis and clinical outcomes in persons with multiple sclerosis (MS). However, some studies demonstrate poor adherence, especially for injectable DMTs (only 41-88%).
It is important for the psychologist treating an individual with multiple sclerosis to understand the different types of DMTs (e.g., injectable vs. oral vs. infusions). They should also understand barriers that may impact uptake or adherence, such as needle phobia, or worry about severe side effects such as progressive multifocal leukoencephalopathy (PML) infection. Helping patients understand “shared decision making” in regard to medication, could lead to increased adherence due to an increased sense of agency with the chosen medication.
This podcast will help psychologists and mental health providers learn about the different types of DMTs used by individuals with MS, common barriers to adherence, and the concept of patient-provider shared decision making.
[00:00:00] Meghan Beier, PhD: Welcome to the Find Empathy Podcast, where we discuss the interaction between health and emotions.
My name is Dr. Meghan Beier, and I’m a clinical psychologist with training in Health Psychology, Rehabilitation Psychology, and Neuropsychology. In this first series, we’re going to focus on a population that I work with very closely, individuals and families living with multiple sclerosis.
If you would like continuing education credits for listening to this episode, please head over to findempathy.com/learn.
If you’re a mental health provider that specializes in health populations, like multiple sclerosis, please, also head over to findempathy.com and click on, “Get Listed.”
We would love to list your practice in our directory and being listed is free. We’re trying to help families and people living with chronic or acute medical conditions find the providers that can help them most.
Introduction
[00:00:00] Meghan Beier, PhD: Welcome to the Find Empathy Podcast, where we discuss the interaction between health and emotions.
My name is Dr. Meghan Beier, and I’m a clinical psychologist with training in Health Psychology, Rehabilitation Psychology, and Neuropsychology. In this first series, we’re going to focus on a population that I work with very closely, individuals and families living with multiple sclerosis.
If you would like continuing education credits for listening to this episode, please head over to findempathy.com/learn.
If you’re a mental health provider that specializes in health populations, like multiple sclerosis, please, also head over to findempathy.com and click on, “Get Listed.”
We would love to list your practice in our directory and being listed is free. We’re trying to help families and people living with chronic or acute medical conditions find the providers that can help them most.
[00:01:02] Meghan Beier, PhD: Bron Webster is our guest who lives with multiple sclerosis. You’ll hear from Bron several times throughout this series on multiple sclerosis, she will talk about fatigue, mood, and her vocational journey. In this first episode, we hear her describe her diagnosis and deciding on disease modifying medications.
[00:01:24] Bron Webster: And this is often something that people with MS face. I had to know what I wanted. And I actually wrote to my member of parliament and say, I have MS, this drugs come in, but it seems that because of the way it works in my area. I don’t get this drug.
[00:01:45] Meghan Beier, PhD: Dr. Thrower is a neurologist who will discuss what we know about MS disease modifying medications, as well as treatments for managing persistent symptoms.
[00:01:55] Ben Thrower, MD: So I am a neurologist, I’m the medical director of the Andrew C Carlos MS institute at Shepherd Center in Atlanta, Georgia. I’ve been here for about 20 years. Coming out of neurology training, I, my wife and I were in Spokane Washington. And so I was actually in general neurology to start off with and Spokane is a, a hotspot for multiple sclerosis.
Uh, the prevalence is probably around 220 per 100,000 people. So over time, about 50% of the patients that I was working with were people with MS. And really started realizing that I was fascinated by the MS community. And I also felt like I wasn’t doing a great job of offering comprehensive care to the MS community. That what I was doing was not enough. That I need a team of other health professionals, physical therapists, occupational therapists, mental health professionals, case managers.
[00:02:51] Meghan Beier, PhD: Finally, we will hear from Dr. Aviva Gaskill a psychologist that will discuss techniques for helping our patients with adherence.
[00:03:00] Aviva Gaskill, PhD: My name is Aviva Gaskill. I’m a clinical psychologist. I have a PhD in, in psychology with health emphasis. And I graduated from the Ferkauf Graduate School of Psychology at Yeshiva University. I have a small group practice just outside of Philadelphia. I work mainly with people who are chronically, um, sometimes people who are terminally ill.
Bron Webster
[00:03:25] Meghan Beier, PhD: We start this episode with Bron Webster.
Bron Webster is many things. A blogger. A podcast creator and host an entrepreneur. But above all she has committed. Bron is an expert in MS patient advocacy who works with a leading university in the UK and their neurology medical students. So she’s used to representing the MS community with a no agenda approach. Bron was diagnosed with multiple sclerosis in 1996 and is still mobile, though much slower these days.
She has three members of her family living with MS. One blood relative and two in law relatives. She also had a brush with cancer, salivary gland, very rare in 2014. So it’s fair for her to say that she’s a survivor. Bron is the creator host and producer of a new podcast about MS called the MS Show.
[00:04:15] Meghan Beier, PhD: I’d love to hear you just share a little bit about who you are and what your journey with MS has been.
[00:04:24] Bron Webster: Well, Hi Meghan. I’m really, really grateful. I’m actually really excited about being involved with this piece of work that you’re doing.
So here I am, I’m a person with MS. And I was diagnosed a long time ago. So my diagnosis came when I was in my mid twenties back in 1996. So what that means is it’s before any disease modifying drugs were available on the market. It’s also around about the same time when the [00:05:00] different groups of multiple sclerosis were being labeled. So before that multiple sclerosis was just called multiple sclerosis. But roundabout 1996, people was categorized with remitting and relapsing or secondary progressive or primary progressive. I was diagnosed with remitting and relapsing or relapsing and remitting.
And at the time I was having a few symptoms that had caused that to be diagnosed. So they were little tiny invisible symptoms. So I’d lost some vision and I’d got some numbness down, one side of my rib cage at the back. And what I, then three months later had a conversation where my dad admitted something to me.
And he just said, I’ve actually got MS, Bron, but I’ve never told you. Wow. So he’d spotted the sort of signs and symptoms. And he was the one that was there for prompting me to go and have tests and get the diagnosis. But I’ve got to say that actually for the first eight years or so, it wasn’t having much impact at all.
The relapses that I had were, they, they were very much invisible. They weren’t affecting my life or my work or my burning the candle at both ends. I was still living it large as somebody in their mid twenties who were single. And it took around about eight years before, before shit really got real. So this different symptoms that I was experiencing impacted on my ability to drive, my ability to walk, but they got better.
So up until that point, I was living pretty much in denial. I’ve got a badge that said this person has been diagnosed with multiple sclerosis, but actually there was not a lot more than that. And there wasn’t really any information or support, and there were no medical professionals qualified to sort of step in and support me at that point in time.
So it was when I was in my sort of early thirties that I started to reevaluate things. I started to reevaluate what was happening and what was going on. Because actually this is really, really hard for me to deal with on a day-to-day basis. So living as a single person, commuting to work, holding down quite an important job, when I was living with different symptoms. And when I was really battling this relentless fatigue. Just made me think, what am I doing? Why do I live this many miles from work? Why have I chosen to do this and drive to work? And so I just started having a really big life evaluation, I think, at that point in time.
[00:08:40] Meghan Beier, PhD: When you were talking about, so that period of time where, you were almost in denial. Were you having any symptoms at that time? Or it was invisible, not only for the people around you, but it was also invisible for you? You weren’t really experiencing a lot?
[00:08:57] Bron Webster: Right. Good question. So, I didn’t have symptoms that were there all the time during that sort of eight year period. What I had was flare ups and relapses, that came and that might disappear after three, four weeks. Those types of symptoms might have been difficulty in balancing, or a feeling of vertigo.
You know, I felt like everything was spinning. And then the sensory issues as well. So those are the types of things that I was experiencing during that time. But they weren’t really impacting me an awful lot.
[00:09:44] Meghan Beier, PhD: Right. And I think it’s so important that you pointed out that at that time, there were not disease modifying medications on the market, and it’s really only early 2000s, and even up until now where there has been such an advance in [00:10:00] treatments. When was it that you were finally, or were you ever put on a disease modifying medication? And if so, what was that decision-making like for you and who did you go to for that? Cause you said you didn’t really have an MS specialist in the beginning there.
[00:10:16] Bron Webster: So around about 2001, my dad told me about this new drug that has, that’s come out, that’s supposed to help reduce the number of relapses. I couldn’t actually, I approached my, so in England, it’s called a general practitioner. I don’t know if it’s like the medical doctor, the MD, um, that everybody goes to see in the states.
So I went to see my GP and they are, they one, they weren’t aware of it, and two they weren’t keen on it. And I had to go through a process of fighting my corner. And this is often something that people with MS face. I had to know what I wanted. And I actually wrote to my member of parliament and say, I have MS, this drugs come in, but it seems that because of the way it works in my area. I don’t get this drug. And we obviously get free health care in the UK, so we don’t have to take out insurance policies to cover the treatment or anything. So I understand that there’s a certain budget, there’s a finite budget. But I fought for it. And so I did for around about 2001, I took the early injectables, which I took Rebif, which is an interferon beta. Which looking back is awful, but that’s all there was. And I took that up until the point at which I was getting pregnant and trying to get pregnant. So I took that for about six years.
[00:12:05] Meghan Beier, PhD: It’s not the same medical system, but many of the people that I’ve worked with have also had to go through experiences of fighting their insurance company to get onto certain MS medications or, if the generic wasn’t working for them now that there is a generic for things like Tecfidera, they had to fight to actually stay on the original medication that they were on originally and not being forced over to the generic.
So I think that message, even though it’s not exactly the same, you, you know, fighting your corner, that as you said, is something that people have to experience in many different aspects of life. Or many different areas of their MS.
[00:12:45] Bron Webster: Yeah, I think, and it’s not just MS, but definitely in terms of with MS, I think there’s, there’s two sides of it.
There’s one. You have to know what you, what path are you on? Because likewise, after I’d had my daughter, I didn’t really want to go back onto the disease modifying drugs. I then had a cancer. Which was in my saliva gland. And it was very, very rare and it made me very, very reluctant to just jump on to taking disease modifying drugs.
So I then had to have a discussion with my neurologist around, well, actually I want to be drugs free, and he really wanted me to be on the drug. So I think, yeah. With multiple sclerosis. A lot of it is about having conviction in your own wants. You’ve also got, you’ve got to listen to the experts and with hindsight, which is a wonderful thing, as I see my disease starting to progress, I think would I have been in a better place had I actually taken some disease modifying drugs for these sorts of latter years? I don’t know. Right?
[00:14:09] Meghan Beier, PhD: Yeah. Nobody can know. I know one of the neurologists that I work with talks about this idea of shared decision shared decision-making, which is, I think is what you’re talking about, which is knowing what you want and having a provider who you can partner with to help you on the pathway of whatever it is, that’s important to you.
So there are many people that I work with who are not on disease modifying medications, but they feel very strongly about other ways that they’re managing their disease. And so if you have neurologists or providers in your corner who are willing to work with you, no matter what pathway you take, that’s really important.
And finding a provider maybe that is, as risk averse as you are, or not as risk averse as you are, because there’s as as [00:15:00] many different options as there are for people with MS. I find that there are many different neurologists who have differing opinions about what they feel comfortable with.
[00:15:08] Bron Webster: Yeah, absolutely. And I think it’s about that doctor, patient relationship and make it just balancing it out and just making sure that it’s. You are both working in your best interests and is it shared decision-making all the way. But likewise, I also think there’s an element of responsibility on me for me to educate myself and not just take everybody’s recommendations at face value, but to know what I want and where I’m basing that decision.
Ben Thrower, MD
[00:15:50] Meghan Beier, PhD: In the beginning of this episode, you heard Dr. Thrower introduce himself, how he got started in MS, and the drive to provide better care for people with multiple sclerosis. In addition to his work at the Andrew C. Carlos MS Institute at the Shepherd Center in Atlanta. Dr. Thrower is a clinical instructor of neurology at Emory University and participates actively in clinical research.
He serves on the board of directors of the Georgia Chapter of the National MS Society and he has served on the board for the Consortium of Multiple Sclerosis Institutes. Combining his professional interests with his love of motorcycles. He founded the nonprofit organization, HAMS Hogs against MS. Here, he continues by sharing more about comprehensive multidisciplinary MS care. And how he started a comprehensive MS program in Spokane, Washington before moving to Atlanta.
[00:16:50] Ben Thrower, MD: In the Spokane Washington area, if you wanted that sort of comprehensive care, you went all the way to Seattle or all the way to Dallas. There was a big chunk of the country that really didn’t have that level of care. So I started farming myself out actually to other MS centers. Worked, I worked some with the Can Do MS folks. I spent time with Randy Schapiro and formed a vision of what I thought good MS care looked like. We were very fortunate that a Catholic non-profit hospital system in Spokane stepped up to the plate as it had the same vision that we did. And so, formed the Holy Family MS Center.
Came to Atlanta because all of our family is here. Our children were growing up without extended family. And have been here ever since.
[00:17:34] Meghan Beier, PhD: I wanted to talk to you about MS treatments. I know when I started, which wasn’t that long ago, there were only a few disease modifying medications on the market and now there are quite a bit more. And as I hear many more coming down the pike. So can you speak just a little bit about what are the types of disease modifying medications that are out there? The different categories and what’s coming into the future.
[00:18:04] Ben Thrower, MD: Sure thing. So when I finished residency training in 1992, we had zero FDA approved treatments. 93, we had the first FDA approved therapy in BETASERON. Now we have over 20 FDA approved therapies. There is some overlap, as you mentioned, there are classes, classes of drugs. So we have our, our original platform therapies.
So we have glatiramer acetate and which was one of our original injectable drug. We have interferon therapy, several different options there. And these are all injectable medications. Probably not used as much. But there is still a place for those medications, that there are individuals who are doing fine on those drugs and they have been on those medications for many, many years and are doing okay.
We have a class of drugs called B-Cell therapies. So this would be Ocrevus and KESIMPTA, RITUXIMAB, which is off-label, TRUXIMA, which is off label. These are Anti-CD20 monoclonal antibodies (mAbs)that work on B cells in the immune system.
The most of these drugs are given by infusion twice yearly. KESIMPTA is a subcutaneous injection given monthly. Very effective class of drugs.
We have a class of drugs called Sphingosine 1-phosphate (S1P) receptor modulators. These are oral medications. This would be GILENYA, MAYZENT, PONVORY, and ZEPOSIA. When these are medicines that work by basically locking up some of the lymphocytes in the lymph nodes. They’re not going to kill a cell. They’re just not going to let those inflammatory cells get out and cause active inflammation.
We have natalizumab or TYSABRI, which is a, it was a once a month, sometimes a little less frequent IV therapy. Very effective drug. Works by keeping inflammatory cells out of the brain and spinal cord. If you think about inflammatory cells trafficking in well, there’s a receptor on the white blood cell. There’s a receptor on the blood-brain barrier. And that’s sort of a lock and a key mechanism, if you will, to [00:20:00] open that door and let that inflammatory cell in. That, uh, natalizumab is going to block the ability of the white blood cell to use its key to open the door.
We have MAVENCLAD or cladribine. Oral medication, which you could argue sort of reset the immune system, if you will. It’s a drug given in courses by mouth. Of one year apart and is going to sort of lower the numbers of T cells and B cells. And hopefully let them repopulate in a less angry state in a, in a state that would hopefully not just sort of drive the auto-immune disease that is MS.
I would argue Lemtrada, alemtuzumab, very similar, roughly a similar mechanism of action going to reset your immune system. All also given in courses of, of the drug, spaced out about a year, apart from each other. We have a lot of different options out of AUBAGIO. You shouldn’t have, AUBAGIO or teriflunomide. Oral medication. Again, great to have all of these different options out there. You can’t say that one option is right for everybody. And that’s where the, sort of the, that dance between the healthcare team and the, the patient and their support partners is going to come into play.
[00:21:17] Meghan Beier, PhD: And with so many different medications, I imagine that sometimes it’s challenging to figure out which is the right one to start with. Scott Newsome, who’s a neurologist at our team. One of the things he talks about is sort of this patient provider connection where they, you have to weigh out everybody’s sense of comfort with the side effects. Can you tell me a little bit about how do you work with your patients to decide on what medication they should try?
[00:21:46] Ben Thrower, MD: Sure. I totally agree with Dr. Newsome. So there, you know, all of these medications have a risk benefit profile. So each of these medications, you could give a score or a grade based upon how convenient are they, how safe are they and how effective are they? And so all of us make our healthcare decisions with some sort of internal thermostat as to what are we comfortable with.
Risk are we willing to tolerate how aggressive do we want to be in managing a certain health condition? And there’s no right or wrong answer to that. I can give two very reasonable people the same information about, of the safety and efficacy profile of medicine and one person may say that sounds absolutely wonderful, and the other person said absolutely not that’s unacceptable.
I know, as a, as a neurologist where my bias is at. I am biased toward wanting to be, uh, to start people on a more effective therapy early on. So they’re kind of two camps of thought and how we use these therapies. Escalation therapy, which says I’m going to pick a, maybe a modestly effective drug, but it has a great safety profile.
And if the patient does well, with that. If they have great control their MS, that’s wonderful. If they don’t, then I’ll move up to something more effective. The other camp would be more, it we’ll call it induction therapy. This camp would argue, I want to be as aggressive as I possibly can within the bounds of safety to put this MS fire out as quickly as possible. And I think a lot of MS centers have over the past few years, migrated a little bit more towards that induction therapy camp, realizing that there, the fire does need to be put out. And sometimes by the time we know that the person’s not doing well on a given medication. And that it’s time to move on. There may be irreversible damage done to the central nervous system.
And so, so, so my bias is sort of that more effective therapy that may not fit with what the patient’s desire is. And at the end of the day, My job is to be the guidance counselor and to put everything on the table at a level that the, the patient and their, their support team can digest it, that they can make a fully informed decision. And if their decision ultimately is not an agreement with mine, they went and that’s the way it should be. They are, they’re the driver of this healthcare team.
We always want to continue to educate. We realized that how a person looks at a treatment decision, isn’t static, it’s dynamic. When we diagnose multiple sclerosis, I feel like if the poor person with MS is trying to drink from a fire hose. There’s all this information just bombarding them. and maybe they’re not prepared to make that decision at that point. So I think we want to, gently circle back sometimes to those decisions and say, are we still at the same place now? Or are we still good with that?
[00:24:37] Meghan Beier, PhD: I hear a lot of people when they’re trying to decide on their medication, especially when they’re newly diagnosed, they tend to have some fears about side effects. So I know, when I started grad school, it was all about TYSABRI and PML. Can you talk about some of the side effects that many of your patients have concerns about?
[00:24:56] Ben Thrower, MD: Yeah, I think that the fear of, of [00:25:00] infection. So PML is obviously a big one. In the MS world 25% of people that have contracted PML as a side effect of any of our therapies have died, ultimately. So it’s obviously very serious. I think we’ve learned a lot was as it relates specifically to TYSABRI and PML. As you know, as you know, when, when the first cases of PML popped up, we didn’t have JC virus, antibody testing. And when we had that, when we did get it, it was just a simple yes or no it’s positive or negative. And now we have the index values where we can sort of be a little bit more sophisticated in our risk stratification and how we talk to individuals and help them make a decision. So they can, the fear of infections is certainly one of the bigger concerns.
Cancer fears. Am I suppressing my immune system in a way that’s going to put me at risk for secondary cancers? I think that’s a discussion we have, you know, with, with people, very commonly.
In the COVID era. I mean, people are concerned, am I putting my self at higher risk for COVID. Or am I going to affect, how a vaccine might work?
[00:26:05] Meghan Beier, PhD: Some of the things as a mental health provider that I work with people around are adherence, or even sometimes, needle phobia. Can you tell me a little bit about what are some of the barriers that you see in people maintaining the medication that they’ve chosen to start with?
[00:26:22] Ben Thrower, MD: I think, I always think of certain roadblocks to care that, that there are sort of common themes that people with MS struggle with. And maybe even bigger than just the medications. I think that needle phobia, when we only had injectable medications, you know, telling someone, listen, we have therapies now for MS where we had nothing. That’s the greatest. The not great news is going to be a, it’s going to be an injectable medication. And, you know, there was a certain, I don’t want to do that. A certain reaction from a lot of people. I think having other individuals with MS, share their experiences with the MS community was much more meaningful than you or I as healthcare professionals saying, “it’s not that big a deal!” Well, we did test doses of the injectables on ourselves and healthcare teams. So I can say what it felt like one time, but I couldn’t tell someone what it felt like to do it week after week after week.
I think some of the other non-medication barriers that we see are hurdles that people face are using assistive devices. There’s that I don’t want to use an ankle foot orthotic or a cane or a walker or a scooter or power chair. Uh, I’m giving into my MS. And this I there’s a feeling like I’ve crossed this bridge that I can’t go back on now. And so we’ve always tried to encourage people, don’t think of these things as steps in the wrong direction. Just think of them as tools. There, it’s a tool that you do what you need to do. If I handed you a nail and say, go put that in that board and I don’t give you a hammer, you would think I was crazy. You need the right tool to get the job done. And I try to encourage people think of these things as just tools to help you get the job done.
Bladder function is a big one. You know, if we have someone who has a neurogenic poorly emptying bladder, when we start having discussions about doing intermittent self catheterization, that is a big barrier for a lot of people. It’s just a no-go for a lot of individuals for them to think about. And we really have to educate that, you know, having a bladder that’s that is partly full most of the time has really big health implications. That you’re at risk for UTI. Is you’re at risk for a secondary hydronephrosis from that back pressure being reflected upstream.
[00:28:33] Meghan Beier, PhD: I’m glad that you brought up some of these other symptoms, because you know, and tell me if you think this is right or wrong, but I kind of think of medications as disease modifying medications, those things that control the actual disease, and medications that may be help to treat the symptoms, those symptoms that stick around. Is that an accurate statement?
[00:28:53] Ben Thrower, MD: Absolutely. I use the three buckets analogy. I say we relapsed management bucket. So they’re the steroids and things like that. You’ve got your symptom management bucket. And you’ve got your disease modifying therapy bucket. And then hopefully in the future, we’ll have a fourth bucket. And that’s actually having discussions about neural repair and, you know, everything that we do in treatment ultimately fits into one of those buckets.
I think it’s really important though, that we, as healthcare providers, let people know, what am I trying to accomplish with this? You know, if I put you on a disease modifying therapy, that’s really not symptom management and we shouldn’t expect symptoms to get better. And that’s your insurance policy for the future. And hopefully you’re not going to get any worse, but that’s not going to manage your spasticity. That’s the second bucket. And I think one of the, the prices that we’ve paid for advances in neuroimmunology and all of these, these 20 plus, uh, therapies available available. Now, as we do spend a lot of time talking to the MS community about that bucket. And sometimes I feel it is at the expense [00:30:00] of the second bucket.
In terms of improving someone’s quality of life right here and right now, we’re probably more likely to do it with the second bucket than we are the third bucket. They’re both important. Yeah, I think we really need to make sure we’re, we’re spending a lot of time with that symptom management bucket.
[00:30:16] Meghan Beier, PhD: Absolutely. And this is a huge topic, but broad strokes overview, what are some of the most common medications or treatments that you are seeing every day for symptom management?
[00:30:29] Ben Thrower, MD: I think fatigue would be certainly up there very high on the symptom list of patients. You would list that as one of their most bothersome symptoms. And, and it’s, it’s an odd area because it’s the number one symptom complaint for many people with MS, and yet, we have zero FDA approved treatment options. We use things and we use them commonly. So stimulant drugs and amantadine and, you know, Modafinil or armodafinil. But technically there is no FDA approved treatment option. We certainly look at it, managing comorbidities that might impact fatigue. Things like mood issues, sleep disturbances, um, and try to sort of do a multidisciplinary approach to manage fatigue.
Spasticity, uh, is, is a big one. Uh, we were just part of a very large survey that looked at at how spasticity and spasms really impact people with MS and are probably under-recognized and potentially undertreated by the medical community.
Bowel and bladder symptoms, uh, are something I think that, that people with MS may be somewhat reluctant to bring up. And because it’s our duty to put that out there because it’s certainly something that affects quality of life. I’ve seen individuals who are very resistant to leaving their home or taking vacations or attending family functions because of bowel or bladder symptoms.
Right? Yeah. It’s just, it’s sad because we, we, we have, we can treat that.
[00:31:54] Meghan Beier, PhD: Yeah.
[00:31:54] Ben Thrower, MD: Yeah. I think those are some of the big ones. I love talking about gait dysfunction with people with MS. The, you know, I think sometimes we underappreciate how significant ankle dorsiflexor weakness, or foot drop can be, because it’s just a domino effect. If you start dragging your foot, then you’re going to, circumduct your leg. And then you’re using muscles to walk that you weren’t designed to use, and you’re going to fatigue so quickly. And getting people in with a good physical therapist to address that, you know, ankle dorsiflexion weakness. I think it pays big dividends for people with MS.
[00:32:28] Meghan Beier, PhD: I wanted to also ask about side effects. I’m thinking, when I see somebody, if they’re on a bladder medication like oxybutynin that often can lead to cognitive changes. What are some of the other medications or treatments that might lead to mood or cognitive changes?
[00:32:44] Ben Thrower, MD: So I think fatigue is certainly something we deal with with a lot of our medications. You think of most of our antispasmodics, you know, Baclofen and tizanidine. Fatigue can be a big side effect with, with those drugs. Um, some of the things that we do for off-label for pain management, Gabapentin and pregabalin, you know, same thing, we see fatigue as a, as a side of. Uh, of those medications.
And when we go back to some of our older disease modifying therapies, you know, some of those, the, the, definitely with the interferons, we saw mood changes as a, as a potential, uh, a side effect with, with those drugs. And I think we’re, we’re trying to do a much better job of screening for depression, because again, it has such a big ripple effects on so many other symptoms.
People’s cognition looked worse, their, you know, their energy level looks worse. Uh, we spent a lot of times trying to sort out sometimes when people complain of fatigue, you know, how much of this is primary MS fatigue, lassitude, how much of it is secondary side effects from medications and how much maybe anhedonia from their mood changes? You know, just the lack of desire to do things. And sometimes they’re layered on the one on top of the other.
[00:33:54] Meghan Beier, PhD: Yeah, I, and I know that you have such a great multidisciplinary team at your center. When you’re thinking about treatments, either for symptom management or for disease modification, what, what can mental health providers do to support those recommendations that you make?
[00:34:11] Ben Thrower, MD: I think, you know, we, we really all need to be part of that, that comprehensive and integrated team. We use the term comprehensive a lot and because we want all the pieces of the puzzle, but one of the things I’ve really seen over the years is the pieces of the puzzle need to talk with each other and communicate well. So they need to be integrated. We have team meetings once a week. Mental health is certainly a big part of that. I mean, we having a DEC dedicated counselor, you know, as part of our team to who really understands some of the challenges that people with MS and their support partners and go through is, has been just vital. Our neuropsychologists, you know, wearing, doing the cognitive screening to help sort out some of those issues. I think sometimes even the vocational rehab folks, I think they were a, you know, um, mental health health
[00:34:58] Meghan Beier, PhD: an important hat.
[00:34:59] Ben Thrower, MD: [00:35:00] Yeah. They really do. And it’s funny. I feel like in some ways, we all, I’m sure it’s the same at your center. We all overlap some with each other.
So sometimes, you know, the patient comes in and they’re there talking to you as a mental health person. But they’re also gonna say by the way that, that, you know, that Baclofen that the doctor put me on is horrible, it’s relevant. So that’s part of that feedback loop. Sometimes you may have more time to spend with the patient then another member of your team and you may get a piece of information or a view of the patient that someone else didn’t get. And it’s up to all of us to share a kind of those pieces that we get the, the entire mosaic of what’s going on with the patient.
[00:35:38] Meghan Beier, PhD: So feedback loop and staying in touch with the whole team. So I think those are all the questions that I had written down. Is there anything else that you think would be really important for mental health providers to know about MS treatments?
[00:35:53] Ben Thrower, MD: Yeah. I just think you being aware of the changes that are, you know, All of the therapies that are coming down the line and think having just at least a, you know, a 30,000 foot view of, of an awareness from the patient brings it up is, is crucial. You know, maybe not knowing all the intricacies of the mechanism of action, at least having some basic familiarity with those I think is crucial because the patients, I think don’t always separate out, will you wear this hat? And that part that they think, well, muscle is just one, one team. So they’re going to have discussions and maybe outside of our specific areas of focus.
We have a lot of cool stuff coming down the line. And I think it’s good for all of us to be aware of because patients will ask. They’ll say, well, you know what, what’s the next thing. And we’re seeing a lot of me-too drugs out there. Drugs that maybe don’t have a different mechanism, but maybe they offer convenience or an improvement in safety that something else didn’t.
I think we’re going to see a new class of drugs on the horizon, the BTK inhibitors. Which is another class of B-Cell therapies that are, you know, just attack it from a little bit different angle. And then hopefully we, you know, we will see the holy grail of MS care, that’s neural repair. Do we reach a point when we can reverse disability?
Uh, and it just, it feels like a lot of the time, talent, treasure that was spent on the lab research. The basic research is starting to pay off now in the clinical realm that we’re seeing more trials and, know mesenchymal stem cell therapies, and other, other things that might hopefully give us that, that, you know, true, true cure for multiple sclerosis.
[00:37:33] Meghan Beier, PhD: Absolutely. That’s such a good news and I, and I a hundred percent agree. I think when I recognize the names of the medications that people are saying to me, I think it goes a long way to creating some rapport and understanding.
One final question and that’s are there any particular resources that you really like that you direct patients and support partners to?
[00:37:55] Ben Thrower, MD: Yeah. There’s so many great organizations and they each do something really well. And it’s almost like you need to look at each one for its strengths. The National MS Society is that, you know, the big dog. They are going be the major education source and the major funder of, of research dollars. MSAA and Multiple Sclerosis Foundation, wonderful organization, not funding research, but doing a lot of grassroots, supplying resources to individuals with Ms that maybe the National MS Society is not going to do. Can Do MS you know, all the wonderful work that on, you know, getting that message of wellness and exercise out and now really jumping in both feet into the educational arena. There is a wealth of information out there for people with MS and I think that the only caution I would give is for people to sometimes have a little filter up as well.
Especially the newly diagnosed because everyone’s going to be throwing information at them and they just want to make sure that that information is coming from a good, reliable source. People are never going to go wrong with one of those groups that I just mentioned. If it’s, if it’s not from one of those sources, maybe still valid, but I would certainly do a little research and vetting of that information to make sure it’s a good stuff.
[00:39:10] Meghan Beier, PhD: That’s great. And finally, if people want to follow the Shepherd Center or learn more about your group where can they get that information?
[00:39:18] Ben Thrower, MD: Absolutely. So shepherd.org, S H E P H E R D.org is our website. There’s information about research that we’re doing. There is a shepherd of Facebook page as well. There’s one specifically for MS. If you look up MS Institute S hepherd on Facebook, you’ll, you’ll find us. And so, yeah, lots of different ways to check out what we’re doing.
Aviva Gaskill, PhD
[00:39:38] Meghan Beier, PhD: In this final interview we hear from Dr. Aviva Gaskill. Dr. Gaskill has a PhD in clinical psychology with health emphasis. She has extensive experience helping individuals cope with acute, terminal, and chronic medical problems, including cancer, pain, insomnia, Parkinson’s and multiple [00:40:00] sclerosis. She is a designated Partner in MS Care from the National MS Society. And in this interview, she focuses on the challenges with medication and MS managing adherence and partnering with our patients to help them manage their medications and symptoms.
[00:40:20] Meghan Beier, PhD: As you know of Aviva, there’s a lots of medications for multiple sclerosis. They come in pill form, they come in self-injections, they come in infusions. It’s a really challenging thing for a lot of people to decide what type of medication they should be on. And there’s lots of thoughts and feelings that go into making a decision with your medical provider about the best medication.
So in your work with health populations, like MS, what are some of the biggest worries that you hear from people in terms of choosing a medication or thinking about their medications?
[00:40:56] Aviva Gaskill, PhD: I think, I would say injectables people are generally always more adversive You to. I’ve worked with people who themselves are medical providers and give injectables, but when it’s yourself, it’s really much harder to self-inject. And so that’s obviously an issue that comes up a lot.
The side effects of different medications and also, I just have particular patients who seem more prone to side effects or more, likely to have side effects from medications and as you’re sort of more sensitive to medications. And so I think knowing that about yourself feels really important. And being able to have an honest and open conversation with your physician about that feels incredibly important.
I think something that comes up for a lot of people is also trying holistic options first, right? That works sometimes. It does not work for other things, right. There’s no there’s not necessarily substitutes for certain medications. With that being said, there’s also no substitute for changing your diet and exercise, that’s as good as changing your diet and exercise. And so, you know, trying to make sure that you’re doing, you know, the best you can with managing the holistic options versus, if there is something that you can make a dietary or otherwise lifestyle change in before you go to the medication and you’re that kind of person who wants to try that first go for it, but, you know, make sure you’re doing that right. And make sure you’re doing it with support to make those changes.
I will say, and I want to point this out because it feels really important. There are particularly for women and people of color, I think they often get flagged as being drug seeking. And that comes up in the ER, let’s say for African-American folks who are going who live with sickle cell disease and are going to get treatment or other people living with other conditions.
And so I think it’s really those can be significant barriers for some people and things like. Are important to sort of talk to your doctor about that you, if you have a doctor that you trust and to be able to consider when you’re addressing some of these issues because it is is a big, big barrier for people.
I think it’s important to identify all of the barriers for some people that’s financial, you know, obviously some meds cost a tremendous amount of money. And so figuring out, financially what’s feasible for you, medication wise can be important in terms of what your insurance will cover and what they won’t.
[00:43:22] Meghan Beier, PhD: So one, one thing that came up with one of the medical providers who I interviewed, she talked a little bit about this worry that she has when she talks with people who want to go the holistic route. So we know in MS that the early, the earlier you get on a disease modifying medication the more stable you are for longer, the less disability you might accrue over time. And so her goal is to get people on a disease modifying medication and a high efficacy, one as early as possible. Some of our patients really want to try a holistic approach to managing their disease, and that mismatch can feel very uncomfortable for both the provider and the patient.
So if you have somebody who comes to you with that type of mismatch or concern, how do you approach it?
[00:44:16] Aviva Gaskill, PhD: So that’s someone where I would, look at motivational interviewing. What are the pros and cons for you of taking this med or not taking this med? Also what are the pros and cons of you staying with this provider versus going to someone else? I agree, and I think knowing the literature that we know in MS and being able to talk to patients, non-judgmentally about the fact that this is the case with MS in particular feels really important.
Because there’s so many stories on the internet of people, quote unquote, curing their multiple sclerosis, right. Or whatever, whatever the, you know, the diseases with, you know, diet and exercise and. Both (a) that that has not actually been proven to be true at all. And yet I think it’s [00:45:00] important to meet people where they’re at in terms of what they’re willing and ready and able to do. And so for providers being able to continue asking permission to talk about that medication or those medications that they would want to encourage their patient to consider, and also for patients to try and keep keep your mind open to the fact that your provider is an expert. I think what can deter people so often when we’re talking about meds is providers becoming judgmental, we’re seeking judgmentally to their patients and throwing someone off and sort of saying, well, you know, that’s just not going to work, so you need to take that. Well, that’s, that’s not going to work to help get someone to take a medication either.
[00:45:38] Meghan Beier, PhD: Right.
[00:45:38] Aviva Gaskill, PhD: And so, you know, really, again, asking permission, talking to the person like another human being. And if you don’t have a provider that speaks to you, like you are a human being, you need to find one.
Um, and I know that can be, I know it’s easy for me to say that, but I, and I know it can, the reality can be that it can be very difficult if you live with, let’s say a rare condition to find someone who can help in that way.
It actually does get me a little bit into what I wanted to mention, which is also that you need to take your medications. We’re not just talking about when we talk about medication adherence, taking them at all, or or not taking them at all. But we need to make sure people are taking their medication correctly. I once had a patient who was talking about double dosing as vitamins after, a day of missing one.
Well, that may be okay for some medications and it’s very much not, and sometimes unsafe with other medications. And so you have to be really, really careful about that. And talk to your doctor about what happens if I miss a dose. Is it okay for me to, take my medication every other day or every other week? And, you know, depending on that doctor, depending on that particular medication that may be okay. And again, because of, as you know, the half-life of medication, sometimes that can work better for certain medications and not so for others. And so we have to be really mindful. And patients and providers also talk to your patients about, how are you taking your drugs? How are you taking your medications? Are you taking them correctly? And if you’re not, not speaking to them with judgment, but just sort of saying, okay, it seems like you’ve maybe gotten some mixed messages about this, or maybe took it upon yourself to change things here. I really want you to go talk to your provider about this, or I’m concerned that you’re doing this because it can have these implications if you’re not taking your medication, let’s say consistently. And um, what might help to get you to take it more consistently? And again, those could be financial barriers that come up that could be things as simple as setting an alarm on your cell phone to make sure you take your medication at the same time every day.
If you live a lifestyle where you’re let’s say, you know, on the road for work half the time you know, making sure that you have access to your medication or you know how to get access to it, or maybe you have a backup in your your travel bag or something like that. You know, these are all important things to consider when we talk about medication adherence.
[00:48:01] Meghan Beier, PhD: I think an important point that you bring up is that sometimes people don’t know what they don’t know. And so I’m not assuming that everybody has the same educational starting point in terms of medications or even their diagnosis is really great. As a mental health provider, many times what I do is I start with trying to find out what people know and what their assumptions are, and just asking about those things, helping guide them, to finding where they can get more information so that they can start to educate themselves.
And also really talking about when we talk about D resistance towards medications, or maybe not taking them accurately, what are some lines in the sand essentially that tell you this isn’t working for me, or if I’ve not taking a medication if I have this particular symptom, maybe it’s time for me to start that medication.
Cause I think a lot of times people talk in generalities and until you start to really problem solve and identify concrete, Markers of I’m going to change this behavior when, or if this happens. That can be a good thing for people to try something that feels right for them. But then also change later on.
So I don’t know if you had any other follow-up thoughts to that.
[00:49:21] Aviva Gaskill, PhD: No, I think it’s a great point, right? If you have a medication that works for you, great stick with it. Sometimes you can even be on something for a long time and then all of a sudden, a side effect pops up or it’s been a side effect that you’ve lived with for awhile and it felt okay for awhile, but now it starts to feel intolerable.
You know, I think then talking to your provider about, about what is coming up for you. Or saying I think it might be a time for me to change my medication. And I also want to go back to something which is that we’re all very fallible when it comes to medications. I know I, myself, and I’m a, a doctoral level mental health provider [00:50:00] who specializes in working with people with chronic and terminal medical conditions.
And I still have messed up taking my meds sometimes in life. And so again, recognizing that that’s a very human error and like you said, sometimes we don’t know what we don’t know about about medications. And so, maybe we take something for too long. Or we take ourselves off of our antibiotic dose before it’s time, right? That’s like a really common one. Uh, and really asking your provider. And making sure you ask, whether that’s in the room when they provide you that medication or on your patient portal or calling your provider and saying, I just want to make sure I’m doing this correctly. Or I feel like I might’ve messed up. Or I did mess up. Not avoiding having that conversation because I think it’s really important to be able to talk to your provider about about those errors or, questions that you have.
And again, those just could be about changing your medication, but all meds don’t work for everyone for all time. And again, medications do have some have very significant side effect profiles. And so it’s important to be able to, to talk to your provider about that when it comes up and, and that’s totally okay. And if you’re what makes you feel like it’s not okay again, maybe it’s time to consider either getting a new provider. Or, you know, addressing that with them and saying like, you’re making me feel terrible about, simple question that I have here and that’s not okay this is a question that I need to have answered for my own safety.
[00:51:34] Meghan Beier, PhD: You had brought up the idea of helping people have conversations with their providers. Can you talk a little bit more about that? You know, how do you help patients have productive conversations with their medical providers?
[00:51:47] Aviva Gaskill, PhD: Yeah. I think we’re all humans. I think right now, especially during COVID medical providers and this is not an excuse for them, but they are tapped out. They are so done. They are so overwhelmed. I mean, you’re talking about wait lists for six months to get an appointment with a primary care doctor in my area. And if it’s a, it’s a first, you know, patient new appointment.
And so that is both horrible as a patient to have to deal with, but also horrible as a provider to have to deal with. And so, again, as a patient, you know, being a human to another human being and saying again, I know you have another patient, but I really need this question answered. This is about my safety and my, my life. And don’t think you’re being dramatic for saying that. It’s a very important to be able to be your own advocate and yet so hard. And I know there are so many providers that can make you feel like you’re not worthy of, you know, advocacy, but you are as a patient and you deserve and you need someone advocating for you. Quite frankly, if you don’t do it, no one else is going to or they’re not, not a ton of people who will do that for you.
[00:52:56] Meghan Beier, PhD: Yeah, absolutely.
[00:52:58] Aviva Gaskill, PhD: Just being a human as a patient also in saying like, I need this, I need you to answer this question before you leave.
[00:53:04] Meghan Beier, PhD: I’ve had people talk to me about, is it okay if I ask my provider question A, B, and C? My answer is always yes. A hundred percent you, of course, it’s okay for you to ask that. And you know, if you feel like you have to word it in exactly the right way, just to not get yelled at or judged for asking the question that would be a red flag for me.
[00:53:25] Aviva Gaskill, PhD: Definitely. And, you know, to put it in into a little bit of a different perspective, we can do certain things maybe for a loved one or like a child that we wouldn’t be able to do for ourselves. And I know, you know, for me, I’m a mom. And I remember I was talking to my sister-in-law, you know, when I had my first kid a few years ago and she said to me, don’t ever hesitate.
She’s not a medical provider herself, but she said don’t ever hesitate to call the pediatrician. I never do. I don’t care if it feels like the stupidest question in the world. If I need that question answered, this is my child. And I need that question answered for them. Can you do the same for yourself? Can you not feel like this is a stupid question or because again, what is very obvious to the provider may not be so obvious to you, or it may not be obvious to them either. There, again, fallible human beings. We all are.
[00:54:16] Meghan Beier, PhD: So I want to switch gears a little bit to when somebody is taking a medication and they’re running into barriers either maybe they’re forgetting their medications or maybe they’re having insurance issues, or maybe it’s just, they’re getting adverse effects from doing a self-injectable medication. What do you do to address those barriers? I know it’s different for each kind of medication in each person, but do you have any sort of general recommendations for helping mental health providers address adherence issues for people with MS.
[00:54:48] Aviva Gaskill, PhD: So again, I think number one is always identifying what is the barrier here? That could sometimes be, and I know this may sound vague, but like a general just feeling of, Ugh, I don’t want to have to take another medication or I don’t [00:55:00] want to have to deal with this anymore. That can be finances, memory cognitive fatigue, side effects, like no, which is a really often overlooked one and often one that is really shameful to people and they don’t like to talk about, but it’s very important and makes a lot of people not take their meds or erectile dysfunction.
Right. Which would fall in a similar but slightly different category. So those are some things obviously also things like what you said, right? Having anxiety, or almost like mini panic attacks before you’re about to do your self-injectable, which is not uncommon at all. You know, these things are very treatable.
And so I just want to point that out. So again, barriers I would say are like, understanding exactly how to take your medication and how to take it properly. I think I always do. I always go back to motivational interviewing, talking to people about their ambivalence about taking that medication.
What is it? That is the the barrier for you. What are the pros of taking the medication and what are the cons? Talking about the cons you’re more likely to continue to cause people to be inadherent or, you know, with their medication rather than becoming adherent, actually, when people talk about why they don’t want to take them then sometimes we can talk about solutions to those obstacles, or maybe there’s not an easy solution.
But you know, it can feel like our relief to just talk about it. And to just start to get it off your chest or to, again, start to think about potential work arounds. Or, well, maybe this thing is stopping you, but actually this other issue of why you should take this medication is so much more. But until you talk about this, this thing stopping you, then, then you can get to the reason that you really do need that medication and why it is healthier and more helpful to you.
And we’re colluding with patients when we don’t talk about their ambivalence to take medication. We’re colluding with them in, and, you know, and continuing to be a barrier to treatment, basically.
I think helping patients gain expectations about how medications can and will help. Because sometimes patients think I’m going to start this medication and I’m going to feel all better, or I may have a procedure and I’m going to feel all better.
And that’s not necessarily the case for a lot of medications and procedures. They’re not like a 1, 2, 3, one and done. Right? And so that’s important to recognize as well. These are not gonna just get rid of all your symptoms. And again some medications just slow down the disease process like many MS medications, or Aricept for for Alzheimer’s.
But other medications really can. Um, prevent symptoms or things like that. And again, so understanding what the medication can and will do for you. One thing that I like to do, particularly with injectable, there’s a couple of things that I like to do at, particularly with injectable.
So one is and a lot, again, a lot of providers don’t talk about this, but when I worked at Montefiore hospital with Dr. Josephine Menardo, when I was in graduate school, we had an amazing, amazing nurse who specialized in diabetes and she had a diabetes clinic there once a week. And she would have people pinch their skin really hard before giving their injection of insulin.
And it really does help a lot. I know it seems like a silly thing or a minor thing. It actually can help medication adherence incredibly. You don’t feel the needle going into your skin. If you pinch the skin really hard or if someone’s injecting you having them pinch the skin really, really hard can help. And one thing that I have done with some patients when it’s possible, I had a patient many years ago, at one of the VA’s that I worked at, who lived with multiple sclerosis and he was on what was only available then was, was self-injectable medications. Now, fortunately we have orals which are wonderful options. He would again have this kind of mini panic attack when he would go to self-inject. And so, because he happened to be someone at the VA, we would have him come in, so that he didn’t have to inject himself, but someone in the staff at the clinic staff could do that for him.
I know that’s not a possibility for everyone, for every medication, but if you take your med less frequently, like once a month, that may be an option. Asking your provider about that, because it’s often the self-injection, that’s really hard for people, but when someone else does it, it doesn’t feel great, it’s not something people want, but they don’t feel nearly as averse to it. And for him, it was a way for him to become immediately, adherent to his meds.
There’s also, some exposure treatment. Even if you’re not, quote unquote needle-phobic right. Some people are okay with needles, but again, that feeling, that feeling of dread kind of comes over them when they do take a medication or, and often again, that’s more injectables, but doing exposure therapy around that, like David Mohr’s, self-injection exposure treatment.
Finding out what the ugh is, right. Finding out what feeling of dread is for you. Feeling out what does this medication mean to me? And how is it affecting [01:00:00] me? And again, it could be something, another side effect. It doesn’t have to be a self-injectable issue, but finding out what that is for you, why are you averse to taking this medication? There’s nothing wrong with you for being averse to taking this medication, that’s very normal. Then we have to help you try and overcome that if this is a medication that you need to take.
I will also, I just want to mention too, that there are certain meds, like self injectables and anti-psychotics that have a high non-adherence rate. And so, you know, making sure that when you’re working as a provider with people who are on certain medications that have high non-adherence rates, you know, to really try and help patients manage that and focus them with that. Why are you on this treatment? What is it doing for you? What feels terrible about it? And again, a lot of the stuff can be, solved or addressed with a few conversations with both yourself and caring providers. And sometimes even maybe a change of medication.
[01:01:06] Meghan Beier, PhD: A lot of times when people are having some of those reactions just talking through the different options of medications can be really helpful, especially in MS. If people are forgetting their medications that are oral sometimes switching to an infusion can be a great option because they don’t have to worry about remembering it. It’s a, it’s an appointment that they have to go to.
[01:01:27] Aviva Gaskill, PhD: No dissimilar from, you know, a woman who is, you know, on the pill and then switches to an IUD or something like that. Yeah, Exactly.
[01:01:37] Meghan Beier, PhD: Exactly. Yeah. And so there’s lots of options to sort of problem solve it. You know, sometimes we talk about pharmaceutical companies in a negative light, but in, at least in the MS world, many of them have medication programs. That if people are unable to afford their medication or they’re struggling with taking it, for some reason, they have nurses on staff that can help you problem solve through that or provide extra support.
So if this is a medication that you and your provider want you to stay on and that you don’t want to switch to a new medication, sometimes tapping into those resources that the pharmaceutical company provides can help you financially or have community supports around taking it. I always encourage people to reach out to them as well. If they’re providing it, use that resource.
[01:02:26] Aviva Gaskill, PhD: 100%. I think I read a story a while back about a woman who wasn’t taking her medications because she, her meds needed to be refrigerated and she didn’t have a refrigerator cause she couldn’t afford one. Whoever her providers were helped her to obtain her refrigerator, you know, something small, but that is a barrier.
If you let’s say need to take your medication at lunchtime, it needs to be refrigerated and you don’t have a refrigerator at work. What do you do? Well, you know, maybe you can bring a cooler bag with you or something, but again, that’s not necessarily something that’s affordable or easy to come by for everyone. It may feel like a silly thing, but it, it is a barrier to treatment. And is it a barrier barrier to adherence.
[01:03:05] Meghan Beier, PhD: Well, thank you so much. I think you brought up a real, a lot of really great points for medical providers, mental health providers to talk about with their patients around MS treatments. Any other thoughts that we didn’t cover?
[01:03:19] Aviva Gaskill, PhD: No. I mean, first of all, I just want to thank you again so much for having me. I guess I would say providers need to be very mindful of our own biases when we’re addressing these issues and making sure that we’re not making assumptions about our patients you know, and how we treat them. I think that can come up in medication adherence. I think as providers, not assuming why a patient isn’t taking their meds or that they just don’t want to, and it’s that simple, right?
There’s usually a reason why someone doesn’t want to. And if you can get to the heart of that and you can change a lot for them
Conclusion
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