 is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. To create a better world, he is an advocate for treating mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism. He serves on the Editorial Board of

H. Steven Moffic, MD, shares his thoughts on Pride, particularly during this difficult time. You can see more of his thoughts on the topic in this article: 

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

Videos

Pride: an alternative to stigma and shame. Why don't we ever hear the word in psychiatry?  

Gay Pride and Psychiatric Pride

is a licensed clinical social worker with 

Season 14 of “RuPaul’s Drag Race” included many firsts this year, least of which was that a heterosexual man was competing for the first time as Maddy Morphosis. This year’s biggest moment came when contestant Willow Pill won the title of America’s Next Drag Superstar. She transitioned to female prior to the finale of the show and became the first transgender contestant to win.

Up until now, most of the contestants on the popular drag competition had been gay men who are cisgender, meaning their gender identity aligns with their sex at birth. But the show also underscores one of drag’s higher purposes: to challenge how we think about gender identity and expression. Shows like “Drag Race” are widely credited with bringing drag into mainstream culture. They are also examples of how the larger lesbian, gay, bisexual, transgender, and queer community (

Drag has many interpretations but is loosely defined as performing in an exaggerated way that caricatures or challenges male or female stereotypes. With bold costumes, makeup, and characters, drag taps into our human desire for fun, play, and creativity. At its core, drag is a creative act—a powerful and personal form of self-expression. Many performers also credit it with giving them a voice. Others use it to explore sexual and gender identity and expression. Still others say drag helps them accept themselves.

Anyone can do drag. In fact, drag kings (women who personify men) have been around just as long as drag queens (men who perform as women). Drag is different from cross-dressing, which can be a personal and private act. Performers like David Bowie and Billy Porter have been seen by many as pioneers of the gender-fluid style movement. This has paved the way for others like singer Harry Styles, who became the first heterosexual male featured on the cover of Vogue magazine wearing a dress. Drag is sweeping into the mainstream, with more individuals using it to explore sexual ambiguity.

Embodying a character can give us confidence. Performer Beyonce, for example, has often talked about her alter ego, Sasha Fierce. The ritual act of putting on the stilettos and makeup helped her tap into Sasha’s courage and overcome nerves before performing. Known as the “Batman effect,” this self-distancing allows us to think about a situation more rationally. It can also help control feelings like anxiety, boost our perseverance during challenging situations, and increase our self-control.

Drag is not all that different from the characters we all play throughout the day: spouse, employee, parent. We often create an image to present to the world, whether it is who we are, what we feel, or what we aspire to be. As RuPaul Charles, creator of “Drag Race” and the world’s most notable drag queen, is famous for saying, “We’re all born naked. The rest is drag.”

Drag dates back at least to Shakespearean theater, when only men were allowed to act and therefore had to play the roles of women. The term “drag” is likely an acronym for “dressed resembling a girl.”

Modern-day drag grew in the 1970s and ‘80s. “Balls” in New York City provided an arena for drag queens to compete for money, awards, and bragging rights. The 1990 film “Paris Is Burning” documented the ball scene and portrayed many of those who walked in balls as poor, gay, or transgender minorities struggling to survive in a “rich, white world.”

“It was the space to be who you needed to be,” says Junior LaBeija, one of the contestants portrayed in the film. “That’s what ballroom is. You come to get your shit off, get undressed, and go back to normal.”

Each ball is comprised of categories that gives everyone a chance to compete. These could include schoolgirl or boy, town and country, or “banjee” realness, the ability to convincingly portray a straight male archetype, such as a sailor or executive. Participants stomp down runways, preen in costumes they spent hours making, and flaunt larger-than-life personalities.

In the heat of competition, ball contestants would often bicker over how each category should be interpreted. This led to the tradition of “reading,” or crafting the perfect insult designed to cut to the core of an individual’s insecurities. Meant more as a good-natured roast, reading has its roots as a defense mechanism. Subject to intense rejection and discrimination, many gay and 

 individuals have had to rely on their wit and bravado to diffuse dangerous situations.

Reading remains a tradition on “RuPaul’s Drag Race.” The show’s mini contest, Reading Is Fundamental, is a favorite among viewers. Just like any game show, “Drag Race” contestants participate in robust challenges. These queens display a wide range of talents, which include singing, dancing, acting, modeling, lip-synching, comedy, makeup artistry, costume design, sewing—the list goes on.

This season’s winner received a cash prize of $150,000—the highest ever on the show. Willow Pill (real name Willow Patterson) will also travel the world representing the show for a year. Also a first, this year’s runner-up received a $50,000 cash prize. Many contestants go on to launch careers in acting, modeling, and business. Seeing this sets a powerful example for others in the broader LGBTQ+ community. More than 80% of 

 have said seeing LGBTQ+ celebrities positively impacted how they felt about themselves.

The show also gives heterosexual audiences a glimpse into the lives of individuals from the LGBTQ+ community, including those who identify as transgender or nonbinary. Seeing them stress about the competition, make friends, and support one another—all while crafting mind-blowing creations—shows that they are human beings like everyone else.

One of the protective factors associated with drag culture is the sense of community it can provide. As drag balls evolved, houses formed around some of the more established contestants. Known as drag mothers or fathers, they serve as mentors to younger generations, passing down techniques and training as they walk in balls and represent their houses. These chosen families provide protection, validation, and acceptance for each other.

For many, house families replaced the biological ones that had rejected them. Drag mothers and fathers would often provide food and shelter to frightened LGBTQ+ teens who had nowhere else to go. According to a 2020 national survey, 29% of 

 have experienced homelessness, been kicked out of their homes, or have run away.

This rejection by family is associated with poorer health outcomes. Young LGBTQ+ adults who reported higher levels of family rejection in their youth were more than 8 times more likely to attempt 

, almost 6 times more likely to experience high levels of depression, and more than 3 times more likely to use illegal drugs and engage in unprotected sex.

Being able to find acceptance in any community can wield a powerful effect. Transgender and nonbinary youth who said their pronouns were respected attempted suicide at half the rate of those who said they were not.

Ultimately, there are as many reasons to do drag as there are costumes. Drag can be a way to release tension and vent emotions. It can be a way to safely express oneself. Many use it to explore sexual orientation and gender identity. Others do it because they enjoy the fame and glory of winning.

Drag is a powerful symbol in the LGBTQ+ community. During the HIV and AIDS epidemic, drag competitions and performances across the country raised awareness and money for research and treatment. They also provided needed comfort, community, and encouragement during a time when many were dying.

Not to mention, drag is just fun. Balls and shows are filled with irreverent humor, biting sarcasm, and scandalous double entendre. Drag has always been art. It can take contestants upwards of 5 hours to prepare for a competition, and fans delight in their jaw-dropping transformations. Meant to catch viewers off-guard, drag bends gender interpretations and is constantly stepping outside the box.

It can be hard to keep up with its evolution. RuPaul learned this the hard way in 2018 when he suggested drag was best performed by men and when he hesitated on whether fully transitioned transgendered contestants should be allowed on the show. Facing backlash, he quickly apologized, tweeting, “Each morning I pray to set aside everything I THINK I know, so I may have an open mind and a new experience.” This season, 5 of the 13 the show’s contestants were transgender.

Drag queens, and especially drag kings, are an understudied population. Research on the emotional and psychological experience of drag indicates mostly positive benefits for performers. These included a sense of status, self-affirmation, resilience, and empowerment.

 But drag performers still face unique challenges.

Like other members of the LGBTQ+ community, drag performers can endure minority stress with their experience of sexual orientation and 

. This stress can come from external or “distal” sources, such as discrimination, victimization, stigma, and pressure to conceal one’s sexuality. It can also come from internal or “proximal” stressors, such as our perspectives, expectations, and reactions.

Individuals who are LGBTQ+ are almost 4 times as likely to experience violent victimization than non-LGBTQ+ individuals. The rate for those who are transgender is even higher. Yet only about half of these incidents are reported to police.

When compared to heterosexual or cisgender populations, minority stress in LGBTQ+ individuals can lead to elevated rates of 

depression, suicidality, and other forms of psychological distress

 Compared to heterosexual adults, LGB adults are twice as likely to experience a mental health condition. Transgender individuals are almost 4 times as likely to experience a mental health condition when compared to cisgender people.

This data also correlates in youth. Compared to heterosexual youth, LGBT youth are twice as likely to experience persistent feelings of sadness or hopelessness. Further, transgender youth are twice as likely to consider or attempt suicide when compared to their LGB peers.

These troubling statistics take on a whole new meaning when intersected with racial or socioeconomic identities and their related stressors. Intersectionality is a growing field that studies how experiences of race, class, and gender combine and compound in unique ways to affect a group or individual.

, the significant distress or impairment that comes from a strong desire to be another gender, has been studied extensively among transgender populations. Although there is not a lot of research on the condition among drag queens, a 2019 study indicated self-identified cisgender drag queens reported lower levels of gender dysphoria compared to transgender women.

Under pressure from multiple sources of stress, drag can provide a healthy way to blow off steam. But it can also expose participants to potentially dangerous activities and situations. Alcohol and drugs are part of drag’s nightclub/party atmosphere. It is not uncommon for drag performers to drink to calm nerves before a show.

 Several “Drag Race” contestants—and even Ru Paul—have discussed their struggles with alcohol and substance use and addiction. This behavior can be difficult to track among drag performers and the larger LGBTQ+ community. Yet this use, along with its abuse, is more likely among individuals who identify as LGBTQ+.

According to recent research, some drag performers experience higher rates of depression in comparison to LGBTQ+ individuals who do not perform in drag.

This could be attributed to several reasons, including financial insecurity, career competitiveness, self-consciousness, and creative criticism.

 For most, drag does not pay, yet it is an art that demands many hours, material investment, and creative risks.

Drag performers may also experience discrimination from other members of the LGBTQ+ community. Some say they have difficulty making friends with people outside the drag world, while stereotypes can drive away romantic interest. On the flip-side, some performers say they are expected to perform on-demand or talk about it almost exclusively. 

As with all actors, creating, developing, and embodying a fictional first-person character has the potential to lead to a certain “loss of self” in the process. One 2019 Canadian study conducted fMRIs on actors after performing scenes from Shakespeare’s “Romeo and Juliet.” It found that acting was a deactivation-driven process that reduced activity in the cerebral cortex, which holds our self-knowledge. At the same time, it increased activity in the precuneus, which is associated with memory retrieval and perception.

Many drag performers compete out of a desire for fame. Developing a fan base and enjoying celebrity status can be a powerful motivator for any performer. Similar to any actor, drag performers may enjoy adulations onstage, only to go home to a far different reality.

“I always had hopes of being a big star. But as you get older, you aim a little lower,” drag queen Dorian Corey says in “Paris Is Burning.” “I think it’s better to just enjoy it. If you shoot an arrow and it goes real high, hooray for you.”

Drag holds the power to push boundaries, provide healing and support, and remind us to have fun along the way. While it is more commonly performed by members of the LGBTQ+ community, drag is gradually blending into mainstream society. How it continues to evolve will be a story only time can tell.

Clinicians can help this population by remembering that the motivations and challenges associated with drag performers are not so different from those of anyone else. Showcasing drag and acknowledging prominent figures within the culture helps normalize these experiences and promotes understanding. As allies, we can support everyone’s right to find their voice, share their creativity, and follow their dreams. Let’s continue to hold conversations that support inclusivity and wellness.

“Fulfillment isn’t found over the rainbow—it’s found in the here and now,” RuPaul has said. “Today, I define success by the fluidity with which I transcend emotional land mines and choose joy and gratitude instead.”

1. Robson D. The ‘Batman Effect’: how having an alter ego empowers you. BBC. August 17, 2020. Accessed June 23, 2022. 

https://www.bbc.com/worklife/article/20200817-the-batman-effect-how-having-an-alter-ego-empowers-you

2. Abramovitch S. ‘Paris Is Burning’ Emcee Junior LaBeija on ‘Pose,’ RuPaul and why he never let Hollywood tell his story. The Hollywood Reporter. June 11, 2021. Accessed June 23, 2022. 

https://www.hollywoodreporter.com/movies/movie-news/paris-is-burning-emcee-junior-labeija-pose-rupaul-1234964404/

3. Finding support. National Survey on LGBTQ Youth Mental Health 2020. The Trevor Project. Accessed June 23, 2022. 

https://www.thetrevorproject.org/survey-2020/?section=Finding-Support

4. Ryan C, Huebner D, Diaz RM, Sanchez J. 

Family rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults.

The emotional and psychological experiences of drag performers: a qualitative study.

6. LGBT people nearly four times more likely than non-LGBT people to be victims of violent crime. UCLA Williams Institute. October 2, 2020. Accessed June 23, 2022. 

https://williamsinstitute.law.ucla.edu/press/ncvs-lgbt-violence-press-release/

7. LGBTQI. National Alliance on Mental Illness. Accessed June 23, 2022. 

https://www.nami.org/Your-Journey/Identity-and-Cultural-Dimensions/LGBTQI

Performance involvement, identity, and emotion among cisgender male drag queens.

A Provider’s Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals. 

Substance Abuse and Mental Health Services Administration; 2012.

10. Knutson D, Ramakrishnan N, McDurmon G, et al. Drag performance and health: predicting depression and resilience. 

Psychology of Sexual Orientation and Gender Diversity.

Articles

How does this performance art give voice to the gender movement?

The Joy of Drag 

is Instructor of Psychiatry at the University of Central Florida College of Medicine in Orlando, FL, and Adjunct Instructor of Psychiatry at Tufts University School of Medicine in Boston, MA. He is a psychoanalytic psychotherapist in private practice.

The psychotherapy frame refers to the basic ground rules for psychotherapy: the attitude of the therapist toward the patient, boundaries, meeting arrangements, and other contractual elements of the psychotherapy relationship. It can be conceived of as the environment and relationship in which psychotherapy takes place. The late psychiatrist Robert Langs, MD, devoted much of his career to the study of the frame, the maintenance of which he described as the therapist’s “most fundamental arena of intervention.”

In the past few decades, as psychotherapy has broadened beyond its psychoanalytic and psychodynamic origins, the concept of the frame has become less known in psychotherapy training and practice. Indeed, many modern therapists have never heard the term or, alternatively, view discussions of it as archaic and reflecting a bygone era of psychotherapy. This unfortunate misunderstanding has led to a shift in the view of the psychotherapy relationship wherein, to borrow from Kernberg, many modern therapists “let it all hang out”

 and adopt a theoretically loose or unprincipled stance. Such therapists may talk about themselves, give advice, or impose their personal beliefs and worldviews onto patients.

Given these recent trends, it may be helpful to revisit the concept of the frame and, in particular, the therapist’s attitude toward the patient in the psychotherapy relationship. Such a discussion may be useful not only to psychotherapists, but also to psychiatrists who may find value in these ideas as they pertain to the psychiatric treatment setting.

The basic attitude of the psychotherapist toward the patient represents the most important element of the psychotherapy frame since it informs the therapist’s role in the treatment situation. An understanding of the therapeutic attitude yields information about other components of the frame, such as the establishment of boundaries and meeting arrangements.

The therapist is a professional and expert on the workings of the human mind who is consulted by the patient because the patient is having some difficulty in their experience of life. At times, this is due to psychiatric disorder. The therapist must remember that their role is that of expert or doctor—not friend or acquaintance. Although a liking for patients often evolves during the course of psychotherapy, the psychotherapy relationship is not a friendship. The therapist who seeks friends in psychotherapy may do so for a variety of reasons: loneliness, a dissatisfying personal life, or their own pathological narcissism. The boundaries between therapist and patient must be respected and the power differential not ignored.

Most individuals who become therapists are motivated by a desire to help others deal with the burdens of emotional despair. Although a desire to help is undoubtedly a necessary trait in a psychotherapist, it has long been recognized

a desire to help. The goal of psychotherapy is to 

from the constraints imposed on them by their conflicts, problems, and symptoms; it is not to help by doing anything 

the patient. To put it another way, in ethical psychotherapy, the therapist must 

Langs, commenting on these ideas, writes that the therapist

“avoids being too supportive, because he hopes not only to offer sustaining help but also, through his therapeutic attitude of being nonjudgmental, noncondemning, nonsubmissive, nonanxious, noncontrolling, firm, consistent, and realistic, to have a modifying effect on the patient’s personality. He knows that the constant playing of the note of supportiveness is not enough. He knows, further, that a too empathic or too profound sounding of this note may infantilize the patient.”

Perhaps the most dangerous risk of psychotherapy is that the therapist will use the patient as a tool or instrument to gratify their own narcissistic impulses. This can take many forms, from gross boundary violations to more subtle attempts to persuade, manipulate, and control, or to model the patient after oneself. The patient’s autonomy—their right to make their own decisions—must be accepted and protected by the therapist. The patient must be seen as an autonomous individual—not an object to be fixed or controlled. It has become fashionable for some therapists to proffer in advice-giving. This practice is countertherapeutic and antithetical to psychotherapy; it infantilizes the patient and promotes helplessness and passivity. It deprives the patient of the very thing psychotherapy aims to provide: freedom.

Freud, writing beautifully on this subject, reflects, “We refused most emphatically to turn a patient who puts himself into our hands in search of help into our private property, to decide his fate for him, to force our own ideals upon him, and with the pride of a Creator to form him in our own image and see that it is good.”

A vital feature of psychotherapy is therapeutic neutrality. What this means is that the therapist maintains an observing stance in relation to the patient and avoids taking sides with any the forces in conflict in the patient’s life. The reason for this is that such a stance helps the patient observe and reflect themselves and eventually to solve their own problems. This does not mean that the therapist is indifferent or blank; the notion of the “blank slate” therapist itself has always been somewhat of a myth. It should also be understood that absolute neutrality is impossible, but the concept should guide therapists in their interactions with patients.

Psychotherapy is a contractual relationship. It is essentially the keeping of promises. The therapist promises the patient to do certain things (to analyze, to aid in understanding, to provide a safe environment), and those things the therapist must do. The therapist also promises not to do certain things (to speak to third parties, to moralize, to control), and those things the therapist must not do. It is the contractual nature of the psychotherapy relationship that permits the other therapeutic work to occur, but the contract itself—and the therapist’s maintenance of it—is a significant therapeutic intervention.

The psychotherapist’s attitude vis-à-vis the patient represents a fundamental, and currently underappreciated, element of the psychotherapy frame. It is the attitude of the therapist that opens the door to good psychotherapeutic work; the therapist’s stance, too, is a key intervention, since it places the patient in an autonomous position and fosters introspection and self-initiated growth. The therapist must be neutral but not indifferent; firm but not judgmental; warm and empathic but not overly involved. They must recognize that the way to help the patient is through exploration—not imposition. They must be and do all of these things, but above all, they must respect the uniqueness and creativity of the patient as an individual human being.

2. Rankin C. Otto Kernberg on Psychoanalysis and Psychoanalytic Psychotherapy. 2000. Accessed June 27, 2022. 

https://www.psychotherapy.net/interview/otto-kernberg

An Elementary Textbook of Psychoanalysis. 

The Technique of Psychoanalytic Psychotherapy. 

6. Freud S. Lines of Advance in Psycho-Analytic Therapy. In: Strachey J, ed & trans. 

The Standard Edition of the Complete Psychological Works of Sigmund Freud. 

7. Yeomans F, Caligor E. What is neutrality in psychotherapy anyway? 

https://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2016.6a20

Let’s revisit the therapist’s attitude toward the patient in the psychotherapy relationship. 

The Therapeutic Attitude in Psychotherapy

A study found that psilocybin-assisted meditation interventions alter the neural processes that underlie symptoms of social anxiety disorder (SAD) and may have complementary effects.

In the study, a qualitative systematic literature review, researchers aimed to address the limited efficacy of current first-line treatment for SAD by identifying the potential mechanisms used in a combination of psilocybin and mindfulness treatment to adjust the anomalous neural activity underlying SAD. Researchers followed Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines in a literature search on PubMed using separate search strings for psilocybin treatment and mindfulness meditation.

In the search string for psilocybin, researchers used the keywords “Psilocybin, LSD, Neural activation, brain imaging, nuclear, tomography, fMRI”; for the search string on mindfulness, they used “Mindfulness meditation, Neuronal Activity, Networks, Brain imaging, Tomography.” They selected 30 experimental studies that all had been published in a peer-reviewed journal, assessed the effects of psilocybin/lysergic acid diethylamide (LSD) or mindfulness meditation, and involved the performance of neuroimaging with fMRI.

The researchers analyzed these studies for the effects of combined psilocybin treatment and mindfulness meditation on brain activation and connectivity, biased attention toward social threats, heightened self-focused attention, negative self-perception, brain regions involved in low perceived emotional control, and brain regions involved in post-event rumination.

Their findings suggested a complementary effect of the combined treatments on the neurological mechanisms involved in SAD symptomatology: Psilocybin appears to cause acute disintegration of core neural networks, which are reintegrated in the post-acute phase, during which, the integration of mindfulness meditation exerts modulatory effects. The researchers suggested that this breaks the “vicious maintenance” of SAD by decreasing self-focused attention, while additional complementary effects of the treatments on frontoparietal control over the limbic cortex alter negative self-perception and emotional regulation.

The researchers concluded that the complementary effects of psilocybin and mindfulness meditation interventions may help patients with SAD experience unbiased perception of social situations by improving their control over attention allocation and facilitating regulation of negative self-referential processing and emotional control. They concluded that “future studies should investigate whether psilocybin-assisted mindfulness-based intervention can provide therapeutic benefits to SAD patients who do not remit following conventional therapy.”

Don’t be afraid, ty to meditate—potential effects on neural activity and connectivity of psilocybin-assisted mindfulness-based intervention for social anxiety disorder: a systematic review

Treatments alter the neural processes underlying SAD symptoms.

Complementary Effects of Combined Alternative Treatments on Social Anxiety Disorder

In recent years, researchers have conducted an increasing number of clinical trials for psychedelic therapies for the treatment of several psychiatric conditions. However, few of those trials included individuals with physical and sensory disabilities. In response, Mintz et al

 provided 4 suggestions to help stimulate diversity inclusion in future research.

“We emphasize the need for extensive disability awareness training for those facilitating psychedelic therapies and encourage psychedelic researchers and therapists to exercise cultural humility toward individuals with physical and sensory disabilities,” wrote the authors.

Here are their recommendations for psychedelic research organizations.

1. Meet and exceed the basic requirements of relevant disability rights legislation.

Psychedelic research groups should strive to meet and exceed the basic requirements of the Americans with Disabilities Act Amendments of 2008, Section 504 of the Rehabilitation Act of 1973, and other legislation. By including experts in disability law on the team, current and future psychedelic therapy trials can strive to implement measures beyond what the law requires.

2. Engage in direct dialogue with individuals within disability communities about their thoughts and concerns related to psychedelic therapies

By speaking to members of the disability community, researchers can best assess what accommodations are needed. Those accommodations should then be considered across all phases of research.

For example, a recent psychedelic trial for depression, anxiety, and demoralization among men who were older and long-term AIDS survivors utilized the expertise of consultants, which benefited the overall study design, execution, and analysis.

3. Incorporate disability awareness into training programs for guides who facilitate psychedelic therapies.

“Disability inclusion requires ongoing work,” wrote the authors.

 To ensure the best possible outcomes, training programs should include: discussion of disability rights history, the medical and social models of disability, the disability paradox, and the ethical issues arising from disability inclusion in psychedelic therapies, such as how to obtain informed consent, how to work with the caregivers of participants with disabilities in psychedelic therapies, and how to protect those with disabilities from harm and exploitation.

4. Demonstrate cultural humility toward people with disabilities.

Disability communities have experienced injustice from health care providers and researchers. It is paramount that individuals with disabilities are not seen as “guinea pigs” for experimentation. Additionally, the idea that these individuals need to be “cured” is ableist and wrong. To build trust with disability communities, researchers must be conscientious and transparent in their interactions.

Mintz et al asserted that “participants with physical and sensory disabilities should not merely be considered eligible but, also, actively recruited into psychedelic studies as both an intrinsic matter of justice and to expand the evidence base for treatments that will soon be broadly available.”

Do you have any recommendations for how mental health clinicians can incorporate disability inclusion into practice? Tell us about it: 

Physical disability and psychedelic therapies: an agenda for inclusive research and practice.

2. Anderson BT, Danforth A, Daroff PR, et al. 

Psilocybin-assisted group therapy for demoralized older long-term AIDS survivor men: an open-label safety and feasibility pilot study.

How can psychedelic research incorporate disability inclusion into future work? 

4 Recommendations for Disability Inclusion in Psychedelic Therapy Research 

Healing is an elusive concept. According to Firth et al, “healing is a commonly used term, and despite research… understanding of the concept remains confusing and inexact.”

I cannot really define it, but I know it when I see it

My first lesson in real healing was from a nurse in medical school. I had contact with many instructing physicians in my first 3 years of medical school, but a nurse taught me about healing. She told me to hold one of our patient’s hands while he waited for surgery. I remember at the time thinking that was not my job. I was already indoctrinated in the 

There is an imaginary emotional wall between me and my patients, and what I do for people is limited to what I was taught to do as a doctor

. On this rotation, that was diagnose them and cut them open.

But I complied with the nurse’s request. I held the patient’s hand and talked to him while he waited. And I realized as I sat there that he became more human to me. I had already inadvertently thought of my patients as a little less than human. But this time, my humanity connected with his. To this day, he is one of the patients I remember the most. He was so frightened, and he held on so tight. When the surgery began, I knew him more as a person and his outcome meant so much more to me. And when he was riddled with too much cancer to fix and later died, it was harder. But, looking back it was worth it. I was the only person he asked for every day during his hospital stay, and I went often to visit with him after my rounds were done. So, I know our connection touched him in some way, too.

To me, healing is when a patient feels seen and heard and a connection is made—and because of this connection, they feel a little less alone and their suffering is reduced. I would agree with an article in the 

that said, “Healing may be operationally defined as the personal experience of the transcendence of suffering.”

This lesson finally hit home with me much later in my own journey of suffering. Despite my early lesson in healing others, I settled into being a physician in the modern sense. My primary roles were labeling individuals with a diagnosis and writing prescriptions. Being required in an outpatient setting to see patients every 15 minutes leaves little to no time for anything else.

If they needed anything other than medications, I sent them to therapy. When they said therapy was not working, I recommended that they eat healthier and try some exercise, and I raised their medication. When they did not have the motivation and energy to do this, I raised the medication some more. They still did not get better. So, I put up that wall between myself and my patients even further. I also held tight to an emotional wall inside. I told myself that this was all so I could survive. I mean, the suffering we deal with as physicians is unbearable if you feel it all, right? There was not anything else I could do to help them, right?

Frustrated with 15-minute appointments and the advent of electronic medical records causing only about 7 minutes of that time really being spent focused on the patient, I turned to doing inpatient psychiatry full-time. I enjoyed being able to spend more time with my patients based on how much I felt they needed. I practiced inpatient psychiatry for many years—years of regularly being on-call and working holidays. I first became ill when I sustained a very large DVT during my pregnancy with my son. This led to a series of DVTs and a diagnosis of complex regional pain syndrome. I suffered from chronic pain in my leg and at one point was told I would never walk again and would be on disability the rest of my life. Despite this, I took the bare minimum time off and I continued to work at times in a wheelchair or ambulating with a cane.

And I built the wall bigger. The pressures of admitting and discharging so many very ill patients in a short time in addition to my personal struggles took its toll. But I told myself I could do it. I continued to push through—until around year 18 of being a physician when I realized that the ball in my chest, the agony in my foot, and the exhaustion were finally unbearable. I looked around and had nothing more to give—nothing more for my kids, for my husband, or for my patients.

 I was last on that list. When I had nothing to give anyone anymore, I had less than nothing to give myself. I slogged through the days believing I would get cancer or just drop dead, not knowing what to do. One day, a patient punched me in the face to the point that I sustained a concussion. I thought, 

. I finally woke up and knew I had to make some drastic changes in my life.

So, I dug into what my grandmothers taught me and went back to church. I would cry through the whole service, but I kept going because I believed in the strong women who raised me and the example they set with their faith. Going to church led to daily prayer. My doctor recommended an 11th surgery. I prayed about this and felt that God told me this was not for me. So, I set out on a journey of seeking alternative health care.

I sought out traditional Chinese medicine, did cupping, and had acupuncture. I went to an Ayurvedic physician and drastically changed my diet. I saw an osteopath and had regular manipulation. I saw an integrative medicine physician and worked on my microbiome. I decided that I would try anything anyone suggested to me. There were no bad ideas. I was now trying methods that were made fun of in my medical school classes and still by colleagues. But I did not care—I was so broken, and the Western medicine system had failed to heal me, so it was this or I was going to fall completely apart and die of the pain.

Next, I went to a reiki practitioner. We met weekly, then she encouraged me to learn how to do it on myself. I performed reiki on myself once or twice a day for months. Through all of this, I started to see my health slowly improve. I now understood that my health journey was 

 responsibility, not my doctor’s. I made the decisions, and I had found countless options at my fingertips. My progress was slow, but for the first time in many years, I was making progress.

The solution for me was multilayered. I ended up divorcing. I realized I had suppressed trauma and dealt with it. To this day, I continue Ayurvedic herbs and follow some of the diet recommendations. I pray many times a day. I have regular massages. I practice yoga, and now that I am improved enough, I am learning Capoeira. I also found a world of self-healing techniques on my own that I still use daily: things like affirmations, journaling, sound therapy, eliciting the vagal response with cold and massage, earthing, moving intuitively to release stored trauma, tapping, ASMR, and many others. All of them were online for free. Along the way as I started to heal, my suffering reduced. I realized my healing was in my hands and there was a world of options out there for me to self-discover.

This drastically changed how I practiced medicine. I found myself in a new job at a brand-new state-of-the-art state hospital. With less pressure to admit and discharge so many individuals so quickly, I was in a better position to further heal myself and to heal my patients. Along my journey, my energy improved, the pain reduced, and I reconnected with myself—and the emotional wall came down within me and between myself and others. I could connect again with myself and my patients. I found I do not feel overwhelmed by the suffering as I told myself I would. I thrive on the joy of connection, and when I feel stressed, I have so many stress-relieving options to do for myself any time I need them. Now I know about a world of options I can offer to my patients, too.

Healing myself led to a realization about how I could better heal others. I found a lot of early-stage, but promising research on the holistic health treatments I used for myself being used for individuals with mental illness.

 We can now blend them with modern psychiatry in the field of integrative psychiatry. I took the job as the medical director at the state hospital where I work, the Neurodiagnostic Institute (NDI), and I created the opportunity to develop an integrative psychiatry program for the patients most in need: adolescents and adults with severe mental illness. We are now providing evidence-based, whole-person healing with several healing modalities to indigent and incarcerated adults and youth who have exhausted all their available resources.

I now regret all the times I told patients and families that I had nothing else to offer for their or their loved one’s mental illness. Clinicians are often so focused on the medications and psychotherapy as though that is all we can offer patients. We are not taught about many of the things I self-discovered on my own journey. And it is everyone’s responsibility. If you truly want to heal and connect with your patients, talk to them about anything and everything that might help.

Not all the healing techniques I tried were right for me. Not all of them made a huge difference, but even the ones that did not make a difference gave me hope. They helped relieve my suffering, and they gave me something to do every day to get through the day. And eventually the ones that were for me became habits in my daily life and led to my own healing. Now when a patient or family member asks what else they can do, I have a world of options to talk to them about—and I know they work because they helped me.

In our Advanced Treatment Center for Integrative Psychiatry at the NDI, we can offer a mixture of healing techniques like yoga, sound therapy, neurofeedback, grounding, integrative psychological therapy, etc. Patients do not just have to wait for the next medicine change or the next appointment to begin healing—they can actively work to heal themselves or help a family member move toward healing.

Healing myself led me toward the ability to better connect with and offer healing to my patients. I can also speak directly about how I have struggled in my life and the solutions I discovered for myself. In this vulnerability of sharing and connecting, walking alongside patients on the path, and offering hope for chronic illness, healing is possible for us all.

is medical director of the Neurodiagnostic Institute in Indianapolis, Indiana.

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The meaning of healing: transcending suffering

3. Govindaraj R, Varambally S, Sharma M, Gangadhar BN. 

Designing and validation of a yoga-based intervention for schizophrenia.

The microbiome: a new target for research and treatment of schizophrenia and its resistant presentations? a systematic literature search and review

Wendan decoction (Traditional Chinese medicine) for schizophrenia

How can offering hope for chronic illness make healing possible for us all?

Healing Our Patients—and Ourselves

 is assistant professor at Baylor College of Medicine, Menninger Department of psychiatry. She specializes in cooccurring psychiatric and neurological disorders.

Tales From the Clinic: The Art of Psychiatry

, we delve into a very common neuropsychiatry comorbidity: headaches. Headaches are a common comorbidity among a variety of psychiatric diagnoses. This neuropsychiatric condition can be challenging to manage due to a strong overlap with somatization.

“Mr Wright” is a 37-year-old man with no medical comorbidities who has been in the United States for more than 10 years. Mr Wright presented to primary care with a 4-month history of headaches that were unresponsive to over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs). He is started on amitriptyline 25 mg at bedtime daily and is referred to psychiatry for “anxiety” without any further notes on symptoms of 

. The patient is worried he will be labeled “crazy” and is upset that his suffering is not being taken seriously.

He appears to be in good physical health with good grooming, although he is somewhat reluctant during the 

. He reports that he has been living with his wife and child, and he works at a restaurant. He has teenage kids who do not live with him, but reportedly has a good relationship with them.

, Mr Wright relays that they persist all day long and encompass areas around his bilateral temples and occipital area, although the pain may migrate between these areas. He has tried to lay down to rest, but the relief in pain is temporary. He is unable to focus on driving and has missed several workdays because he did not feel like he could pay attention while driving. He stretches his neck in a variety of different angles during our interaction to help relieve the pain, along with some excess eye blinking that he seems unaware of. He denies a premonitory sensation occurring prior to his movements.

After repeated queries into his stressors around the time his headaches started, Mr Wright is able to verbalize an incident that occurred a week before their onset: He was accommodating his sister at his home after an interpersonal conflict with her husband. The brother-in-law had held him at gunpoint outside his home. He had run inside to safety, and the brother-in-law had eventually left. His sister has since left, and the patient feels that the turmoil of an abusive relationship in his sister’s life is persistent and acceptable to his sister and the rest of the family. He recalls a similar event over 20 years ago when he was chased by a different family member in his home country. At that time, Mr Wright also felt his life was in danger and had to run to safety, and since then, he has been an anxious person in general. He has never received any mental health treatment (including psychotherapy) before.

 (PTSD) including nightmares, flashbacks, and avoidance of increased arousal.

A chart review shows that Mr Wright was seen in the ER twice since he met with his primary care provider. On 1 occasion, he had acute chest pain; negative EKG and cardiac enzymes led to a discharge. On the second occasion, he was evaluated for unprotected sexual contact with an unknown individual. Mr Wright had chosen not to mention any of these instances of his interaction with the medical system, and the psychiatrist chose not to discuss them either.

He was started on amitriptyline 25 mg by his primary care physician 2 weeks ago, and he has been using it as needed on nights he is unable to sleep. He finds it useful, but he is unable to get relief from headaches. He is unable to verbalize any correlation between a life-threatening event and the onset of his headaches.

At the conclusion of the visit, patient and physician agree to continue amitriptyline, but agree that the patient should take it more regularly for best therapeutic results.

As per a systematic review of a global burden of disease across the United States, in 2017, the 5 highest incidence rates of neurological diseases included 

 Migraines have consistently been among the top 3 neurological diseases in terms of disability adjusted life years.

 As a testament to how frequently psychiatrists and neurologists see patients with headaches and psychiatric diagnosis, in 2019, the most frequent psychiatric comorbidities in individuals with primary headaches in the United States were anxiety and depression, followed by posttraumatic/stressor and trauma-related stress disorder. These comorbidities are found in 25%, 23%, and 15% of the general population, respectively.

It is inevitable then that one is likely to come across patients with both primary and secondary headaches in psychiatric practice. Recognizing headaches can be a powerful tool in evaluating the quality of life of our patients. Headaches can be triggering and perpetuating factors for psychiatric conditions in addition to being an important consideration in identifying the best pharmacological options for treatment.

In primary headaches such as migraine and tension headaches, there is no source for nociceptive activity such as a hemorrhage or 

. Many theories have tried to explain connections between distress and primary headaches. Existing studies on connections among distress and primary headaches clearly show that the most important triggering events for primary headaches are distress and sleep issues.

 Stress has also been linked with the transformation of episodic migraines to chronic migraines that carry a greater burden of disease.

 Interestingly, repeated exposure to trauma, even without a formal PTSD diagnosis, is prominent in chronic migraine headaches as compared to healthy adults without migraines.

Biopsychosocial factors are believed to be involved in headache perception. Transactional models propose that the mismatch between threat perception and capability to deal with the threat can be applied to the subjective sense of pain in migraines, as well as to any other pain syndrome.

 Among personality traits, locus of control being perceived as internal versus external predicts better headache outcomes.

During the current COVID-19 pandemic, the role of sudden change in psychosocial environment due to shutdowns among those with preexisting migraines has been investigated. Contrary to the impression that headaches would worsen, at least 1 study has recorded improvement. The study documents reduction in migraine intensity and frequency in adolescents during COVID-19 shut down in Italy in 2020.

 It is reasonable to speculate the reduction in academic and social pressures as being helpful in this improvement and underscore the role of psychosocial intervention on patients with migraines. Moreover, it would be interesting to see if there is an uptick in migraine presentation to neurologists and psychiatrists due to the chronic stress induced by the pandemic, over and above migraine in individuals caused by 

Migraine headaches have a bidirectional relationship with a spectrum of psychiatric illnesses, the strongest correlation being with depression, anxiety, and bipolar disorder. There is evidence of shared genetic predisposition, as well as functional and structural alterations in pain-modulating brain areas, including the amygdala, anterior cingulate cortex, and periaqueductal gray in both migraine and affective disorders. Moreover, they share similar abnormalities in the HPA axis as well as common mechanisms of action of treatment modalities.

The concept of central sensitization is often used to explain pain-related conditions, including migraine. Patients with chronic migraines (as compared to episodic migraines) have more somatic complaints. The role of pain sensitization in episodic migraines has also been investigated in episodic migraines. A recent study suggested that slowly repeated evoked pain sensitization could in fact be useful as a clinical predictor for episodic migraines.

Serotonin, norepinephrine, and the GABAergic system have all been implicated in the etiology of psychiatric as well as primary headaches at the level of neurotransmitters. As such, the evidence for using serotonin and norepinephrine reuptake inhibitors (SNRIs) and tricyclic antidepressants (TCAs) that target these receptors for preventative treatment for migraines remains strong.

Managing psychiatric symptoms in patients presenting for treatment with headaches may present a unique advantage in overcoming barriers to talking about optimizing mental health. When establishing goals for treatment, it may be useful to educate the patient about the benefit of SNRIs and TCAs in managing headaches as well as mood and anxiety disorders. This may help patients verbalize their mental health needs in the face of 

. At times, presenting an SNRI or TCA as a headache medicine only may help with adherence to treatment in patients who have difficulty expressing their distress.

One of the many challenging difficulties in managing headaches is that initiating SNRIs or TCAs for headache management can itself carry a risk for inducing headaches. A careful consideration of the timeline for medication-induced headache may aid in separating the superimposed symptoms. Clinicians may benefit from considering medication withdrawal as a reason for headache exacerbation when treating psychiatric patients with comorbid headaches and a history of noncompliance. Venlafaxine is notable in this regard for its withdrawal syndrome.

Headaches are a common comorbidity among a variety of psychiatric diagnoses. 

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