The Unhelpful Pendulum Swing from Medical Gaslighting to Discrediting Psychological Science and Practice
Today's newsletter is all about the biopsychosocial model and how long-overdue societal pushback against medical gaslighting can inadvertently contribute to whole-person care gaps.
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A few months back, a well-known menopause voice on social media posted a video ridiculing a provider who had referred a patient with perimenopause-related symptoms to therapy. Her message was essentially — We don’t need to talk about our feelings, we need to sleep. We need to get our libido back. We need to stop having joy-stealing hot flashes. We need to be taken seriously, not told it’s in our head!
As someone who has experienced incredibly harmful medical gaslighting and dismissiveness, I get it. I have personally experienced the hurt and anger and betrayal that comes from vulnerably sharing life-shattering pain with a trusted provider only to realize they are knowingly or unknowingly more committed to protecting their comfort and illusion of control (“If I can’t figure it out it must not be real”) than our wellbeing.
AND as someone with a doctorate in clinical health psychology and specialty training in reproductive health concerns, who has spent countless hours in the therapy room with historically gaslit people managing birth injuries, endometriosis, perinatal loss, and yes, menopause symptoms, I wish more providers understood that the BRAIN AND THE REST OF THE BODY ARE CONNECTED. I wish more providers understood that therapy is not just “talking about your feelings” or only for those with severe depression or anxiety, but that health psychologists (and other mental health clinicians with health psych training) can also play a role in improving sleep, assertive communication, physical symptom experience, consistent engagement in health-promoting behaviors, etc.
Extreme pendulum swings are almost never helpful, and that’s true here as well. One concerning pattern I’ve been seeing (especially on social media) is that as people are increasingly empowered to push back against medical gaslighting and advocate for different diagnostic tests, treatment options, or second opinions, many are also falling into the trap of wholesale rejection of psychological science and an indiscriminate refusal to consider its role in treatment.
Like most of you (I’m guessing), I’m not fan of the phrase “it’s in your head…” but not for the typical reasons.
Because actually… it IS in your head. Literally everything is “in our head.” The entirety of human experience is a complex interaction between our physical world, biological state, social context, life history, psychological vulnerabilities, etc. all processed by… drumroll please… OUR BRAINS.
That doesn't mean it's not also in our bodies. That doesn't mean it isn't real. That doesn’t mean it isn’t treatable.
This is the essence of the biopsychosocial model, which argues that health (both physical and mental) is optimally understood and addressed when our case conceptualization encompasses physiological factors (genetics, illness pathology, physical injury, etc.), psychological components (thoughts, emotions, and behavior), and social considerations (including economic and demographic components, sociocultural norms and messages, and social support).
(If you follow me on instagram, this is also why I refuse to post about mental health in a vacuum. Our sociocultural reality and the policies that shape healthcare, availability of postpartum support resources, protection of the environment and access to nature, etc. are directly linked to maternal mental health and my work as a psychologist).
I don’t have a problem with the phrase itself… because it’s largely true! I have a problem with the way it’s selectively applied to psychological and chronic pain.
Mini science lesson on how we experience pain: the thalamus relays the signal to the somatosensory cortex (—> physical sensation), the frontal cortex (—> cognitive response) and the limbic system (—> emotional response). Guess where all of that happens? Ding ding ding! That brain! (e.g., Garland, 2012).
If I got my leg cut off by a lawn mower (I tried to choose a very dramatic example of a clearly physical injury that NO provider would ever utter the phase “it’s all in your head” in response to) — guess what would process my perception of that pain? My brain. Guess what this sensory experience would come with, likely after initial shock and stabilization? Thoughts and feelings.
In 2020, the International Association for the Study of Pain defined pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage,” and recognized that pain cannot be inferred simply from activity in sensory neurons (Raja et al., 2020).
Pain is a sensory, cognitive, social, and emotional experience. Just like basically everything in life.
So no… I don’t have a problem with considering our brain’s role in somatic experiences. I have a problem with how a referral to therapy or discussing psychological components of a physical health condition have historically been medical code language for and/or understandably interpreted as — “There’s nothing actually wrong with you. You’re crazy.” I have a problem with how these words are often spoken with, “this isn’t real or attention-worthy” undertones. I have a problem how “it’s in your head” has been used as a dehumanizing catch-all “diagnosis” for women’s health concerns and an excuse for providers to not troubleshoot complex symptoms.
And now — I have a problem with how many of those pushing back against medical gaslighting are paradoxically reinforcing these harmful messages, contributing to siloed care, and perpetuating stigma. I have a problem with how many people are not getting connected to appropriate support because of the way that addressing psychological contributors has been framed as standing in opposition to versus actually increasing the efficacy of efforts to physically heal.
While taking a nuanced, biopsychosocial approach can feel overwhelmingly complex and messy, I’d argue that this interconnectedness can actually be seen as a good thing (and why I spent seven years of my life earning a PhD in clinical psychology). Because this means that there is more than one way to positively impact our lived experience, beyond just the physical. This means that even for those of us with birth injuries or endometriosis or intractable perimenopause symptoms… we can still play an active role in shifting how our brains process and interact with sensory information.
I want to be clear, this is not an “either/or” debate, but an interdisciplinary AND. We can simultaneously advocate for more person-centered medical care, work with providers to troubleshoot persistent physical symptoms, and also consider building a healthcare team that includes psychological support.
If we’re going to use the term, “this is in your head,” let’s make sure we use it appropriately (i.e., about EVERYTHING ;)), not just when referring to somatic symptoms that don’t line up with what we can directly see or understand.
For those who are willing to share in the comments, I’d love to hear more about your experience with medical gaslighting and/or ways in which mental health providers have been helpful or harmful in your own experiences of managing physical health conditions or somatic experiences.
If you missed it, check out last week’s post on mindfulness-based approaches to managing pain and other somatic symptoms. And stay tuned for my next one, in which I’ll share more about how our brain’s well-intentioned attempts to notice and avoid threats can at times worsen versus improve symptoms, as well as strategies for breaking these cycles of hypervigilance.
xx,
Kimberley
Disclaimer: The content provided in this newsletter is for informational and educational purposes only and is not intended as medical advice. It is not a substitute for professional therapy, diagnosis, or treatment. If you are experiencing mental health concerns or medical issues, please consult a licensed healthcare provider or mental health professional. Kimberley Johnson is not responsible for any actions taken based on the information in this newsletter.