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