LGBT Mental Health

Dr. Laura Roberts (00:05):

Hi, I'm Dr. Laura Roberts, Editor-in-Chief for the Books Portfolio of the American Psychiatric Association, and welcome to the APA Books Podcast.

Dr. Laura Roberts (00:14):

Well, welcome everyone. I'm so pleased to talk with you today with Psychiatry Unbound. This is a podcast of the American Psychiatric Association's Publishing portfolio. Today we're going to be speaking with just one of the most special people I've known in my life and in my career, Petros Levounis.

Dr. Laura Roberts (00:43):

Petros is a graduate of Stanford University, and since I'm broadcasting from the Stanford University campus, I give a little emphasis and shout out there. Petros serves as Professor and the Chairman of the Department of Psychiatry at Rutgers New Jersey Medical School. He's also the Chief of the Psychiatry Service at University Hospital in Newark, New Jersey.

Dr. Laura Roberts (01:04):

Petros is a polymath. He's good at pretty much everything, I think. Board certified in general psychiatry and addiction psychiatry. He's also certified in addiction medicine. He has written many, many books. We'll talk about that in just a minute, but this morning he's generously agreed to talk with us about his upcoming book, the Pocket Guide for LGBTQ+ Mental Health. Petros, welcome to the APA Books podcast.

Dr. Petros Levounis (01:32):

Hi, Laura. Thank you so much for having me in your show and thanks for the kind words, too.

Dr. Laura Roberts (01:36):

Yeah. Yeah.

Dr. Petros Levounis (01:37):

You're one of the very most special people I know too, so thank you.

Dr. Laura Roberts (01:41):

We'll have a lovefest with our podcast.

Dr. Petros Levounis (01:42):

Yes.

Dr. Laura Roberts (01:47):

Petros, tell me about this book, this Pocket Guide, and where the idea came from, and what was the inspiration behind this work?

Dr. Petros Levounis (01:56):

It's the product of two different ideas. One is we've done some LGBTQ work before. We did the LGBTQ Casebook, which is primarily addressed to the US psychiatrist. Then we did the Pocket Guide to Addiction Assessment and Treatment, which was a much smaller volume and really addressed, not only to the US psychiatrist, but to international audience. We work hard to put our ideas so that they are applicable to a wider audience. So after the success of the Pocket Guide to Addiction Assessment and Treatment, we said to ourselves, why we do a similar thing for the LGBTQ mental health work that we've done? And that's where the pocket guide idea came about.

Dr. Laura Roberts (02:49):

Yeah. And so the pocket guide is a project that you and Eric Yarbrough have taken together.

Dr. Petros Levounis (02:55):

Yes, yes. Eric Yarbrough is a dear friend of mine, but also the immediate vice president of the Association of Gay and Lesbian Psychiatrists. He wrote the definitive book on transgender mental health, also from the American Psychiatry Association publishing, came out last year. So I was delighted to collaborate with Eric in this pocket guide. Yeah. He's a wonderful, wonderful collaborator and author.

Dr. Laura Roberts (03:25):

Yeah. He's a wonderful person. And he's working on another book for us, which we'll talk about at another time, but I think he's going to be a prolific contributor to the field. So you and Eric put this idea together of developing the pocket guide, who do you hope will read the book? You say it will also have an international audience?

Dr. Petros Levounis (03:44):

Very much so. When it comes to LGBTQ mental health, we have probably one of the widest range of expertise in this area. There are some people who know a lot about LGBTQ mental health, who see a lot of LGBTQ patients. And then there are quite a lot of psychiatrists, mental health professionals, both in the United States and abroad, who know very little about LGBTQ mental health. And they have very honest and very well-meaning questions, which to you and me may seem a little basic, but on the other hand, they have to be addressed.

Dr. Petros Levounis (04:27):

For example, you are in a gay relationship. Who's the man, who's the woman? Something that may sound not a very sophisticated question to some of us, but on the other hand, it's a very honest question. It comes from the right place, curiosity and empathy and warmth. And these kind of questions need to be addressed. So that's the idea of pocket guides, to have a very, very wide audience, the psychiatrist who practice in Athens, Greece, or Istanbul, Turkey, or Cairo, Egypt or Rome, Italy. Anywhere across the world.

Dr. Laura Roberts (05:07):

The other thing I really like about this book, which I think it's got a beautiful intent, is just this wonderful chapter structure, very simple, very straightforward, and really relates to populations and identities. I have it in front of me. Maybe I could run through it, but you have a chapter that's dedicated to lesbians, gay men, bisexuals, transgender people, queers, questioning people, intersex people, asexual people, pansexuals, and allied heterosexuals. Such a simple, straightforward, thoughtful structure. How did you and Eric arrive at that?

Dr. Petros Levounis (05:47):

I think it came out of the idea that in 2019, we need to know something about the culture surrounding these identities. So we start each chapter with a cultural context. And that cultural context is quite different in asexuals and pansexuals and lesbians and gay men. Everybody has access to the internet these days, so it is not all that difficult for, for psychiatrists and other mental health professionals to learn about these different cultures. And of course the book helps the practicing clinician orient herself for himself with this particular subculture of sexual orientation and gender minorities.

Dr. Laura Roberts (06:41):

So what advice would you offer around seeing patients who maybe move between some of these cultures and how to make sense of the fluidity across the different cultures?

Dr. Petros Levounis (06:55):

So that's an excellent question. What advice would we have for patients who may be finding themselves one day being on one side and the other day being on another side of this spectrum of sexuality? Celebrate the diversity of humanity. I would say this is the bottom line here. It may maybe stressful at times, but at the end of the day, we're all humans and finding yourself more on this side or on that side is for the most part, part of the continuum of normal sexuality. So that, I think, is the message of the book altogether.

Dr. Laura Roberts (07:39):

Okay. That's beautiful. That's great. You know, in my own work, I've been very concerned about the special health needs and issues of people with limited resources, barriers to care, individuals who identify in groups that are not in some way considered mainstream. Your book touches on these populations. Again, what advice do you have to clinicians to help our patients, the people we care for, who really have tremendous barriers to care. They might be psychological barriers. They might be very practical resource barriers. There might simply not be resources available in the geography where they are. So just what guidance do you offer?

Dr. Petros Levounis (08:20):

Yeah. Yeah. Two parts to this question. One is the medications that we use in our world. And for the most part, the pharmacotherapy of different sexual orientation and gender minority populations is essentially identical to the classic pharmacotherapy guidelines that we have for the general population. A few very specific differences for some transgender and intersex patients, but for the most part, the pharmacotherapy is the same.

Dr. Petros Levounis (08:58):

On the other hand, the psychotherapy and the psychosocial interventions do depend very much on the availability of resources in the subcultures and the communities where the patient is at. In one word, my advice here is the internet. The internet has done a lot of damage. In another book we're preparing, we're going to talk about technological addictions and people who become addicted to [inaudible 00:09:29] and all kinds of things about the internet.

Dr. Petros Levounis (09:34):

But when it comes to issues of finding a kindred spirit, finding somebody from a similar community, being able to share experiences, create a community, the internet can be absolutely wonderful. And that is true for both patients and clinicians. This is a recommendation that both sides need to take advantage of.

Dr. Laura Roberts (09:56):

Yeah. Good. So let me ask you, do you think your book will be controversial? Are there any controversies that you touch upon in the book?

Dr. Petros Levounis (10:07):

There is one controversy that the book does not really address very much, but we have discussed it. And that has to do with the issue of fluidity of sexuality and gender. There are some people, including myself, who feel that women in general may have more fluid sexualities. And there are other people who feel that this is yet another sexist structure to put women down and feel that women have less of a robust sexuality than men. And both sides have a very good argument. Very little data, but very good arguments on both sides. And that was a controversy that we felt was more like LGBTQ Mental Health 201. And the pocket guide is LGBTQ Mental Health 101. So we didn't really delve too much on that controversy.

Dr. Laura Roberts (11:07):

Let me also comment on what an amazing partner you've been to APA, just in general as an organization, but to the publishing group in particular. You've published, written or edited more than a dozen books and nearly all are with us. You've done the Handbook of Office-Based Buprenorphine Treatment of Opioid Dependence, the initial edition in 2011, and then another second edition in 2018. The award-winning LGBT Casebook that was published in 2012, and won an award from the Society of Sex Therapy and Research Health Professionals. That was in 2014 that you received that wonderful award. The Addiction Casebook came out in 2014, and that was based on DSM-5 and a very, very valuable contribution to the field. The Behavioral Addictions in 2015, which had a really neat video component to it. And you engaged your medical students at Rutgers in that project. What fun.A Pocket Guide to Addiction Assessment and Treatment in 2016. Becoming Mindful, integrating mindfulness into your psychiatric practice. And then Motivational Interviewing, again in 2017.

Dr. Laura Roberts (12:22):

First of all, you have a lot to say and say it beautifully. And thank you. I'd like to just spend a minute talking about motivational interviewing because it's a wonderful tool and skillset, and the mindset behind it is so fabulous. Could you just comment a little bit about this idea of inviting the people we care for forward as opposed to more negative, or punitive, or harsh approaches of the past?

Dr. Petros Levounis (12:51):

Yeah. The original idea of Motivational Interviewing came out as a response to the more classic addiction treatment, which had confrontation as its cornerstone. Confront the denial of the patient. Break down her or his defenses. Slap them around, sometimes even physically so that we can build them up from scratch. Motivational Interviewing came out, and I said, "No, no, no. This not only is not productive, but is actually quite hurtful and most people would do worse for this kind of highly confrontational approach."

Dr. Petros Levounis (13:29):

So it produced a different way, a different approach to the patient, a much more collaborative approach with a patient, one that celebrated self-efficacy, that the patient can do it herself or himself, and expressing empathy to the patient. Being in this journey together. One of more unique parts of motivational interviewing was the idea of developing discrepancies. Other psychotherapies, including cognitive behavioral therapy, aim to resolve ambivalence, to move people forward, to help them change, to remove obstacles from in front of them.

Dr. Petros Levounis (14:14):

And motivation interviewing takes a step back on this one. Instead, no, no, no, ambivalence may be a good thing. Especially in the beginning phases of treatment, we like discrepancies. We like when people get confused about where they're at and where they would like to be. It's an opening. And that's why motivational interviewing does particularly well for people who have no interest in changing anything in their lives, or have very, very little motivation for changing their behavior or treatment.

Dr. Petros Levounis (14:47):

Motivational interviewing identifies this tiny, tiny bit of discrepancies between where the patient is at and where the patient would like to be, drives a wedge between the two and actually helps them move forward. It's truly counterintuitive in a way, but a quite effective approach. And from the more general to the more specific, if people who listen to this podcast, they want to gauge themselves as to whether they're really doing motivational interviewing or not. Research has shown two parameters that bubble up as the ones most predictive of being faithful to motivational interviewing concepts.

Dr. Petros Levounis (15:25):

Very simple. Number one, if the patient talks more than you do, there's a good chance that you're consistent with motivational interviewing. If you find that you're talking more than your patient, there's a very good chance that you're not consistent with motivational interviewing. And the second one is to do more statements than questions. If you are on a ratio of two-to-one statements versus questions, there's also a very, very good chance that you're consistent with motivational interviewing.

Dr. Petros Levounis (15:55):

Reflections, whatever the patient says, either a simple reflection, just tell her or him what they just said, and you'll be amazed by how much this facilitates the conversation and lets the patient bring up all kinds of other things, or more complex reflections, where you put a little bit of interpretation in your reflection. Think back about your psychodynamic psychotherapy where we do a little bit of interpretation. Either, or. Just state it back to the patient, don't inflect upwards at the end of your statement, making it a question, just go all the way down, just make it into a statement and you will see how many wonderful things are going to come out of your patient's mouth.

Dr. Laura Roberts (16:37):

That's amazing. It does make me think about how I think many clinicians would love to be able to adopt some motivational interviewing techniques in their practice, but feel a little intimidated by taking out a whole new skill set. So just that one example is how people can begin to incorporate these techniques right away. Are there other very simple, straightforward approaches, maybe just to start with, to integrate into one's clinical practice?

Dr. Petros Levounis (17:09):

Yeah. Something that we wrote about and we published it with Carla Marienfeld, who's one of our co-authors of the Motivational Interviewing along with Bachaar Arnaout, is the idea that it's a very simple technique. It's Just Do It, that we titled our article. And part of it is another idea that could be very helpful to somebody starting at motivational interviewing work is not to be afraid to give advice to the patient. Sometimes motivational reviewing has been misinterpreted as being a very passive approach.

Dr. Petros Levounis (17:57):

This is not it at all. You can be very upfront with the patient. "I have an agenda. Of course, I would love it if you were to quit cocaine, who wouldn't? Of course I would. That's my goal, and I'll be very upfront with you that I would like us to get to the point where you would not be using cocaine at all. But this is your life. This is what you're doing, and I'm here to help you."

Dr. Petros Levounis (18:18):

So don't be so much caught into the idea of what you want versus what your patient wants. You may have different agendas. This is perfectly okay. You don't have to be coy about it. You don't have to dance around it. You can be very, very upfront in a motivational interviewing sense. So that would be another major advice I would give to people starting motivational interviewing.

Dr. Laura Roberts (18:38):

One of the very first techniques I learned was asking a patient, "How much do you smoke a day?" And they'll say, "A pack." And you'll say, "Why not two packs?" It's so unsettling and so disruptive and so nonjudgmental. It makes the person feel like they've actually achieved something.

Dr. Petros Levounis (19:01):

That's a wonderful, wonderful one. What it actually does, this paradoxical intervention of just saying, "Okay, I'm surprised. I thought you would've said two six packs and you just said one six pack," or whatever it is. It forces the patient to articulate the little crumbs of motivation that they may have in their own words, and then capitalize on that. Instead of you telling them about the promised land and how wonderful life will be if they stop using, or if they cut down. You just force them to say what is it in themselves that they have already achieved. What is the little motivation that I have already been able to put in place? And then capitalize on that one.

Dr. Petros Levounis (19:46):

There is one thing that I would like to bring from one of the other books that you so kindly mentioned there, and that is the buprenorphine book, the Office-Based Buprenorphine Treatment of Opioid Use Disorder. Few people know that this is the only volume, the only book that the government has sanctioned to give you the buprenorphine waiver. What I mean by that is that by studying the book and passing a rather straightforward 20-multiple-choice question exam on the internet, you can get your waiver instead of taking one of those live or internet eight-hour buprenorphine courses.

Dr. Petros Levounis (20:31):

So the second edition, not the first one, but the second edition of the buprenorphine book does give you the waiver. And I think this is an incredible resource for people who have very busy lives, and they just want to study the book on their own time, and then take the exam. It's an alternative to the course, and I just want to make sure that people know that.

Dr. Laura Roberts (20:55):

Yeah, no. So tell us a little bit more about that. So you worked it out with the FDA where they saw that this book essentially represented the core curriculum necessary for this prescribing privilege?

Dr. Petros Levounis (21:09):

Correct. SAMHSA more specifically. And yes, SAMHSA gave us the okay for that. Again, the only book out there that has this privilege of being able to grant the buprenorphine waiver. John Renner was the one who did most of this work.

Dr. Laura Roberts (21:30):

Well, Petros, I want to thank you so much for talking with us today and really the wonderful work that you do in our profession. I'm personally very grateful to you, and I think the world's better for the work that you do. Thank you so much.

Dr. Petros Levounis (21:44):

Thank you so much, Laura. Thank you very much.

Speaker 3 (21:55):

Our original music is by Willa Roberts. Our executive producer, Tim Marney. This podcast is made possible by the generous support of Stanford University. We are a production of American Psychiatric Association Publishing, John McDuffie, publisher. Be sure to visit psychiatryonline.org/podcast to join the conversation, access show notes, and discover new content. Or subscribe to us on your favorite podcast platform. Thank you.