Episode 77: OCD (Part 3): Differentiating OCD, Autism, and Tourettes Behaviors and Enhancing Healthcare [featuring Dr. Stacy Greeter]
Oct 24, 2024
Show Notes
Navigating the healthcare system and advocating for needs can be a frustrating and invalidating experience, especially for neurodivergent individuals who exhibit interwoven behaviors associated with OCD, autism, or Tourettes.
In this episode, Patrick Casale and Dr. Megan Anna Neff, two AuDHD mental health professionals, and Dr. Stacy Greeter, an AuDHD and OCD child/adolescent and adult psychiatrist, discuss the multi-faceted challenges of accessing appropriate healthcare, the nuances of differentiating between behaviors related to OCD, Austim, and Tourettes, and the significance of authenticity in professional environments.
Top 3 reasons to listen to the entire episode:
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Gain valuable insights into how to navigate the healthcare system more effectively by preparing questions, bringing an ally, and scheduling frequent consultations, emphasizing the importance of patient self-advocacy in medical appointments.
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Understand the distinctions among stimming, tics, and OCD compulsions, and learn to differentiate value-driven actions from fear-based compulsions, helping to provide clarity and reduce pathologizing behaviors that bring joy.
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Discover the importance of authenticity and individuality in both medical and therapeutic fields, hearing firsthand experiences from professionals who embrace their neurodivergent identities to foster better client outcomes and work cultures.
As you reflect on this episode, consider the importance of advocating for your needs within the healthcare system. Remember, your voice and experience are crucial in navigating these complex environments.
More about Stacy:
Dr. Stacy Greeter is an AuDHD and OCD child/adolescent and adult psychiatrist in Sarasota, FL. Her autistic special interests include fantasy creatures and everything psychiatry. She uses metaphors from fantasy universes such as Star Wars, Lord of the Rings, and The Little Mermaid to make complex psychiatric concepts more relatable and advocate for autistic patients and other autistic doctors.
- Website: stacygreetermd.com
- YouTube: youtube.com/@stacygreetermd
- Psychiatry Boot Camp: stacygreetermd.com/psychiatry-boot-camp
- Free Resource on Healthcare Advocacy
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Transcript
PATRICK CASALE: Hey, everyone. You are listening to the Divergent Conversations podcast. We are two neurodivergent mental health professionals in a neurotypical world. I'm Patrick Casale.
MEGAN NEFF: And I'm Dr. Neff.
PATRICK CASALE: And during these episodes, we do talk about sensitive subjects, mental health, and there are some conversations that can certainly feel a bit overwhelming. So, we do just want to use that disclosure and disclaimer before jumping in. And thanks for listening.
MEGAN NEFF: Welcome everyone back to the series that almost wasn't because of my emotional avoidance. We're hopping back into the OCD series. And I'm so excited for our guest today. We've got Dr. Stacy Greeter.
STACY GREETER: [INDISCERNIBLE 00:02:24] before.
MEGAN NEFF: Greeter, okay, yeah.
STACY GREETER: I was actually…
MEGAN NEFF: Wow, I almost pronounced it right.
STACY GREETER: Mm-hmm (affirmative).
MEGAN NEFF: Dr. Stacy Greeter who's a autistic, OCD, ADHD psychiatrist. And Patrick has the official bio if he is done choking.
PATRICK CASALE: Wow, what a good place to start [CROSSTALK 00:02:43]-
MEGAN NEFF: Or we can let Stacy introduce herself.
PATRICK CASALE: I feel like I need to redeem myself. It's so cool.
MEGAN NEFF: Okay, you redeem yourself by reading the bio.
PATRICK CASALE: Dr. Stacy Greeter is an autistic ADHD and OCD child, adolescent, and adult psychiatrist in Sarasota, Florida. Nope, not going to happen.
STACY GREETER: I'll take over now, that's cool.
MEGAN NEFF: Okay, tell us about your [CROSSTALK 00:03:06].
STACY GREETER: Okay, okay, okay. I'm so excited to be here, loving this podcast, big fan. So, my autistic special interest is everything psychiatry.
MEGAN NEFF: Well, that's convenient for you.
STACY GREETER: And it's so nice, right? And profitable in a capitalist society, which is also a form of privilege. And my other autistic special interests are fantasy creatures, especially, the fluffy ones. So, I make these elaborate story-based fantasy themed like Star Wars themed, Little Mermaid themed is coming up this weekend presentations to explain complex psychiatric concepts like that-
MEGAN NEFF: Oh, my goodness-
STACY GREETER: …relatable.
MEGAN NEFF: That's amazing.
STACY GREETER: So, yeah. So, the one I was telling you about where I copied your idea of the Venn diagrams is a dragon differential diagnosis presentation and that one is all dragon-themed.
MEGAN NEFF: This sounds amazing for kids and adolescents, young adults.
STACY GREETER: And adults like me because we got to be playful, too. Yes, and I think, in a way, the humor and the story can make things resonate. So, you can talk about intersectional marginalization or talk about internalized ableism, but it's in a story with a character. So, you can digest the material more is my goal, anyway.
MEGAN NEFF: That is so beautiful. I am going to go, like, find your resources for this because that sounds incredible. Oh, my goodness.
And so, I'm so curious what you're doing with the Little Mermaid because I wanted to be the Little Mermaid growing up. Like, she was a special interest. And I now understand why I, like, very much wanted to just live in water where it was quiet and, like, sensory soothing.
STACY GREETER: Okay, yeah.
MEGAN NEFF: But what is your Little mermaid theme that you're [CROSSTALK 00:04:48]-
STACY GREETER: Okay. I've been trying to find a photo for you too, while I'm looking this too because I was playing around this weekend. Okay, so it's called Still Not Quite Part of Your World. And it's about [CROSSTALK 00:05:12]-
MEGAN NEFF: [CROSSTALK 00:05:12].
STACY GREETER: Right? Like, that classic sense of how Ariel thought I don't belong underwater, so it's because I need to be on land. But then, I realize I don't belong on land either, and it's because I'm autistic and ADHD. And she realizes this after the diagnosis of her daughter Melody. And Prince Eric is going through stuff trying to make peace with, like, is this a label that's going to be harmful for our child? What do we do? How do we process that?
And then, he sings a musical number about wanting to understand her autistic world better, which is sung by child psychiatrist Alicia Cho because I cannot sing so. And then, we have Ursula, who is continuously dropping the ableist comments throughout the presentation. And Flounder is adorable. We have a lot of fun. I'm very blessed.
MEGAN NEFF: Oh, my goodness. And is this something you put on YouTube? Or, like, where is this?
STACY GREETER: Yeah.
MEGAN NEFF: Okay, cool.
STACY GREETER: So, we're doing it live first at Dragon Con. And then, later we're going to do a recorded version online, yeah.
MEGAN NEFF: Okay, this sounds so incredible. And I-
STACY GREETER: I have a lot of fun. All right, here's the picture. Now you can see, okay, there you go. Can you see that?
MEGAN NEFF: Yes, that's amazing.
STACY GREETER: [INDISCERNIBLE 00:06:41 ]. That's my backyard, actually because-
MEGAN NEFF: Oh, my goodness.
STACY GREETER: So, I'm super excited. I'm hoping psycho-educational fan fiction can grow into a thing.
MEGAN NEFF: Yeah, no, actually, I have a friend who does like superhero therapy that's neurodivergent-
STACY GREETER: Yeah.
MEGAN NEFF: …friendly. I think that intersection of like fan and neurodivergence and therapy because you're right, it makes it so much more playful, so much more accessible.
STACY GREETER: Yeah, so I think it gives me opportunity for Ariel and Eric to talk about their regrets as a parent when they were trying to get Melody their daughter to suppress her stimming. But you know, it's lovable characters. You know what I'm saying? So, then we can, kind of, like, talk about grieving, regret, things like that, in a more, I think, manageable way. Yeah, I hope.
MEGAN NEFF: See this is what my brain's not good at. Like, my brain can be like, "Here's the science of it." But, like, turning it into story, turning into narrative, turning it into a world. I love brains that can do that. And I'm a little bit jealous of your brain right now.
STACY GREETER: Oh, I'm jealous of your brain. Your resources are amazing, amazing.
MEGAN NEFF: Well, and it sounds like you, like, are able to take some of them and then, like, turn to playful and fun, which I'm so excited to see.
STACY GREETER: Yes, yes, yes.
MEGAN NEFF: Well, oh…
PATRICK CASALE: I'm done dying now, which is great.
STACY GREETER: I'm glad you're alive. Patrick. Welcome back.
PATRICK CASALE: I've been thinking what a wonderful way to start. Like, what if I had just fallen off the chair, right?
MEGAN NEFF: So, were you choking? Or was this like because of your throat issues?
PATRICK CASALE: Yeah, I had some throat [INDISCERNIBLE 00:08:24].
STACY GREETER: You aspirated your spit or something?
PATRICK CASALE: Yeah, yeah, that was fun. So, I watched your video that you sent me, that was all about, like, the Lord of the Rings and OCD.
STACY GREETER: Okay, okay, [CROSSTALK 00:08:35].
PATRICK CASALE: Yeah, that was really amazing. Like, as a huge Hobbit, Lord of the Rings, Tolkien fan that is right up my alley in terms of how to learn about something because for me, I don't do well when I'm reading like scholastic text or research-based text. I kind of immediately glaze over and can't process the information. So, that was super helpful. And it was really just cool to watch that from that perspective. So, thank you for sharing that resource [CROSSTALK 00:09:05].
STACY GREETER: Yes, Patrick. I have one, it was a different one where Smog and my husband does the voices for me, thank God he does, God bless him, shout out to that, where Smog talks about the difference it made in his life when he switched from a non-affirming therapist to a neurodiversity affirming therapist.
So, at first, you know, his special interest in collecting, cataloging, and researching Elven artifacts was treated like OCD symptom that needs to be suppressed. And he felt shame and an internalized sense of brokenness. And then, Smigiel helped him get a neurodiversity-affirming therapist who recognizes that that is part of what he needs for his sensory system because it's a special interest, yeah.
MEGAN NEFF: Okay. So, that's so interesting. I feel like we're going to, like, get to all the things we want to talk about, but probably in a very divergent way. So, I kind of want to dig a wall there, yeah, of-
STACY GREETER: Classically, yes.
MEGAN NEFF: Yeah. It's very classic of, like, special interests being treated like an OCD thing. Is that something that you see happen in psychiatry and mental health?
STACY GREETER: Yes.
MEGAN NEFF: Okay.
STACY GREETER: Yes, yes.
MEGAN NEFF: Yeah. So, do you have, I'm so curious, if you think, like, are there, so special interests, yeah, how are those, like, conceptualized as obsessions. Like, what [CROSSTALK 00:10:34]-
STACY GREETER: I know. So, for example, let's say there's a kid and he's organizing his Pokemon cards.
MEGAN NEFF: Okay.
STACY GREETER: So, on the surface the same behavior can be many different things, right? So, you have to dig at what the person's experience of that behavior is. So, a kid organizing Pokemon cards could be like, you know, no matter what it just doesn't feel right. And if I don't get it just right, I'm going to feel wrong forever. So, I can't stop. I wish I could stop and just leave them alone, but I got to keep doing it. What if something bad happens if that card is next to that card, or maybe even there's some anthropomorphization of the Pokemon characters, like they're next to each other and they might not like each other, and then all kinds of bad things will happen.
So, in that example of OCD the narrative is I can't stop. There's a control that this has over me, and I don't like it. And it's fear-driven. What if blank happens if I stop?
MEGAN NEFF: It's unpleasant.
STACY GREETER: Yes.
MEGAN NEFF: I feel like it's unpleasant versus, like, organizing for a special interest, it's pleasant, it's joyful. Yeah, yeah. I feel like that piece is so huge. I love that. Okay.
STACY GREETER: Mm-hmm (affirmative), right. So, digging down into special interest, what would it be like if you were forced to stop? Well, that would be sad. That'd be terrible. I might miss it.
And then, in addition, like tics, especially, more complex tics can get confused and be hard to piece apart. And then, generally, with the tic there's like an urge, like a physical urge to do the thing that builds over time. And-
MEGAN NEFF: I know you're talking about like Tourette Syndrome [CROSSTALK 00:12:43]-
STACY GREETER: Yeah, like Tourette.
MEGAN NEFF: Okay.
STACY GREETER: Tourette.
MEGAN NEFF: Yeah.
STACY GREETER: So, with the OCD, the urge to do the behavior is based on fear and it dissipates the longer you resist it. With the tic, it's more of a sensory, physical urge that will build the longer they resist the behavior. So, I'm really into that detailed differential diagnosis-
MEGAN NEFF: [CROSSTALK 00:13:08]-
STACY GREETER: …so that we don't cause harm to people.
MEGAN NEFF: Absolutely, absolutely. Because I mean, yeah, when we pathologize the things that bring us joy and the things that soothe us, like, that is so harmful, absolutely.
And yeah, I mean, given how often OCD and autism overlap, it makes sense that this sort of confusion would happen all the time, especially, if one's diagnosed but the other isn't, yeah, absolutely.
STACY GREETER: So, like a kid can start with a special interest in Pokemon, and then, because of their OCD then they develop an OCD behavior surrounding their Pokemon cards, yeah.
MEGAN NEFF: I haven't had language for it, but like complex OCD, I'm trying to find language for it because in the classic OCD text, it's like ego-dystonic, right? So, it's typically things… Like, when I get intrusive images, they're things that are very not value-aligned.
But like I saw this in one of my kids, children, who's vegan. And, like, it comes from her hypersensitivity, her hyper empathy, but then developed OCD around it. No, there was actually an ego-dystonic nature to it, but then the contamination OCD that grew out of it.
So, her and I came up with so many metaphors of like, it was like a two-headed, what was the metaphor we used? We actually used a lot of playful imagery. It was like a two-headed beast, and one head was a snake, but they had to eat from the same buffet. And one was like, values-aligned. But that's why it was so hard to treat the OCD-
STACY GREETER: Interesting.
MEGAN NEFF: Because they had to eat from this [CROSSTALK 00:14:44]-
STACY GREETER: Yes.
MEGAN NEFF: …source, but that sort of OCD where it intersects either with a value because you're autistic and like very value-aligned, or it intersects with a special interest, that's a whole different beast because they're inter-tangled. Have you, like, seen that in autistic OCD folks you work with? That kind of more messy OCD presentation?
STACY GREETER: Yes, yes, yes. It's often messy. Like, the same behavior can have multiple layers to it.
MEGAN NEFF: Yeah, yeah. Well, and I'm maybe jumping ahead, I don't even know if you do exposure or I don't even know how much therapy you do, but like, are there things you do when it's like this is a special interest and we want to protect it, but then we also want to address the OCD?
STACY GREETER: Yeah, yeah, it's tough. So, I do some psychotherapy. I'm more into internal family systems therapy and ACT.
MEGAN NEFF: I like both of those.
STACY GREETER: Then exposure and response prevention. Usually, I'm referring out to a different therapist for that because it's not as much my thing.
MEGAN NEFF: [INDISCERNIBLE 00:15:53].
STACY GREETER: So, the question is, I'm trying to understand the question. The question is how… Can you give me-
MEGAN NEFF: So-
STACY GREETER: …another question?
MEGAN NEFF: Yeah, so when the OCD is focused around like a special interest it's also a good thing. So, like, versus an OCD where it's purely ego-dystonic, it's probably experienced as like different from self, but it's like there's part of it that is soothing, there's part of it that is consistent with self, and then there's part of it that has become either obsessive or contaminated. Are there ways you've found to work with [CROSSTALK 00:16:32]-
STACY GREETER: I think asking people to imagine, so what if OCD wasn't driving this and it was just your values? What would you be doing? Okay? So, you know, someone-
MEGAN NEFF: That's a great question, yeah.
STACY GREETER: Right, so someone who really draws a lot of fulfillment and comfort from their Catholic Christian beliefs, but now they're on the rosary, and they're doing it over and over again, and it has to be a certain way. And they're developing religious group velocity. So, now something that they really value and have a lot of fulfillment from that is part of their spiritual being, unfortunately, has been contaminated by OCD. And so, now we're piecing apart what is values-driven and what is compulsive and fear-driven.
MEGAN NEFF: I like that.
STACY GREETER: It's complex.
MEGAN NEFF: It is so complex, especially, when you throw in our kind of all-or-nothing thinking. Like, I know, for me, as a child, I've gotten a bit better with this as an adult, but I still struggle with it, once I have a bad experience with something it's like the whole thing becomes contaminated and bad. So, I think it could really easily become once, like, something that's a source of comfort because contaminated by OCD, the temptation might be just to throw the whole thing out versus to reclaim this is the part that's value-aligned. So, I love how you help folks tease that out because that's so important to be able to reclaim that and not let OCD take it away.
STACY GREETER: Yeah. And OCD preys on stuff that's really important to us.
MEGAN NEFF: Yeah.
STACY GREETER: I went through a time when… It was in residency, and I went through an OCD of, well, what if I am not asking my patient if they're suicidal in just the right way that would encourage them to tell me the truth about that? And yeah, right?
And so, I was working on that, trying to not repeatedly ask them in different ways to try to gain some surety…
MEGAN NEFF: Oh my gosh, wow. That would be an interesting. I would love to read more about that therapist with OCD because there's a lot of risky things we work with. And so, of course, that's going to be a, like, breeding ground for OCD. And so, how therapists learn to work with that. Like, that's such a poignant example of wanting to do risk assessments correctly. And, wow, okay, we're having kind of a mind moment of just like that, yeah, yeah, it can really impact how we show up.
STACY GREETER: Mm-hmm (affirmative), right? And so, yes, I have a couple good therapists, actually, I see, so this is good, right? So, now I feel like what's interesting is because you have OCD, and when you go through OCD treatment you reach this kind of above where you would be if you didn't have OCD. I'm going to try to explain that better.
Okay, so, like, because I really, like, kind of dove down into this I'm very mindful of how I ask, my emotional affect when I ask, how neutral I am about asking. It's like, I really had to work on it because of the OCD.
MEGAN NEFF: Yeah, yeah, yeah. I think, I'm tracking, but like, in a sense-
STACY GREETER: Yes.
MEGAN NEFF: …is it partly because OCD brings more emotion up for you that you had to work on how you, yeah, ask those questions?
STACY GREETER: I guess. And I think that the treatment of OCD forces one to really intentionally think about what they value and like, live in line with that in these spaces. Does that make sense in a way that I don't know if I would had, like, otherwise I wouldn't have given that much thought to how I did my safety assessment.
MEGAN NEFF: Yeah, yeah. I think that makes sense. But can you unpack it a little bit more? Yeah, like how OCD causes you to give more thought. Is that how you said it?
STACY GREETER: Yeah, I think because you have to figure out what is the OCD and what is your values-based response.
MEGAN NEFF: Yes, I feel like [CROSSTALK 00:21:15]-
STACY GREETER: And you have to separate those.
MEGAN NEFF: Yes.
STACY GREETER: And so, in order to separate those you're going to really want to figure, like, what is my most valued, most effective way of doing a safety assessment and do it that way, and not the way my OCD tells me to do, which is ask someone three or four times in different ways with like a clear affect that you don't want them to say yes, yeah, yeah.
MEGAN NEFF: So, you're not allowed to say yes to this question.
STACY GREETER: Yeah.
MEGAN NEFF: Okay. I feel like you've just described, like, the hypervigilance that is my life. I think I do that-
STACY GREETER: Really?
MEGAN NEFF: Throughout my life of, so it's one of the things that has made me, I'm realizing, like, really feel like I'm struggling with burnout, with owning my business, is I, like, catching airs or going back and redoing material. Like, so much of that I think is obsessive and OCD-driven. And it's freaking burning me out. But I'm always doing that, like, is this me being obsessive or is this values-aligned?
And then, same thing with my parenting. Like, I think when you live with OCD, well, yeah, you're constantly doubting your mind, and it's like the doubt and disease. But teasing out is this… And partly, because we only live with our minds. And I don't know about you, but I'm guessing, since you're also ADHD, you've probably had OCD since childhood.
STACY GREETER: Yeah.
MEGAN NEFF: So, it's like you've only lived with this mind. So, getting that like, what is a reference point? Since I was little I've been like, "I just wish I could experience someone else's mind." And I think it's that question of, is this a decent reference point to be using, or is this an OCD or an obsessive reference point?
STACY GREETER: And we never have a clear answer to that, no matter what, ever.
MEGAN NEFF: And that probably drives burnout. And I'm just now making that connection. That we're probably always-
STACY GREETER: That's an unanswerable question, right? That's the fantasy of the neurotypical me, and like, they just know naturally how to be the perfect psychiatrist, right?
MEGAN NEFF: Yeah, this is the neurotypical brain. Yeah, yeah, yeah.
STACY GREETER: Yes. No, I hear you. I hear you. These are unanswerable questions. We have to make lots and lots and lots of peace with ambiguity.
MEGAN NEFF: Yes, yes, yeah, yeah.
PATRICK CASALE: That's very true. And it's kind of like constantly trying to parse it apart and put it in different buckets from time to time to think like, is this what's driving the ship, or is this what's driving the ship, or are they both co-driving at the same time and collaborating? It can be very confusing and overwhelming. And trying to, like, use someone else's mind as a reference point would be a nice fantasy, for sure. I think about that a lot of like, is this what everyone else experiences, or is this how everyone else thinks about this? Which, yeah, that's, like you said, Stacy, unanswerable in so many ways. Stacy, do you have a-
STACY GREETER: I still try to get my therapist to do it for me, though, anyway.
PATRICK CASALE: [INDISCERNIBLE 00:24:27].
MEGAN NEFF: I used to do it with my therapist and at one point he was like, "I kind of feel like you're treating me like a neurotypical…" Like, how did he say it, "Like this neurotypical…" I mean, he didn't use the [CROSSTALK 00:24:39] reference point. And I was like, "Oh yeah, I guess I am."
I ask my spouse a lot because he doesn't have autism, or ADHD, or OCD, so he's my reference point. But yes, all of it's a fantasy.
STACY GREETER: I hear you. And not to minimize that I love and hate being autistic and ADHD. And I do think there are many ways in which medicine self-selects for autistic traits, and that psychiatry feels like being a fish that finally gets to swim in water with the kind of candid, authentic, direct, deeper conversations we get to have.
MEGAN NEFF: Medicine self-selects for autistic traits, meaning a lot of autistic people end up in the medical field.
STACY GREETER: Yes.
MEGAN NEFF: So, that is something I've had people ask about that. I see that, but it's also like one of the fields where it's so uncomfortable to be publicly autistic.
STACY GREETER: Yeah, yeah. So, that's something I'm working on, too. I'm doing a presentation at Stanford on supporting autistic doctors, especially, during medical training-
MEGAN NEFF: Oh, my gosh.
STACY GREETER: … and residency and fellowship, you know.
MEGAN NEFF: That's amazing.
STACY GREETER: In part. Our usual autistic thing of, like, advocating to try to heal from our own trauma. And that's the biggest reason I'm so openly autistic because it's so hard to be openly autistic in the medical world, yeah.
MEGAN NEFF: Yeah, yeah. I know quite a few who are in the medical world, but are not out because it would be too detrimental, yeah.
STACY GREETER: Yeah. So, I'm like, anytime I can make it just a tiny bit safer for someone else, just a touch. Yeah. It was kind of fascinating. My favorite part of discovering I was autistic was being able to tell my patients, and just seeing that glow of connection, and excitement, and some hope. And that's really exciting. But it has been really mixed and challenging coming out to physician colleagues.
MEGAN NEFF: Yes, yeah, I would assume so, yeah, yeah. I'm sure the patients feel so lucky to have you and the colleagues, yeah.
PATRICK CASALE: Did you, Stacy, want to go down that pathway of talking about… You had kind of floated the idea of navigating the psychiatric, and medical system, and how to be more supportive for…
STACY GREETER: I'm cool with that. I'm cool with also sticking with OCD. I thought that was our topic originally, by the way, Anna, was a different topic.
PATRICK CASALE: Yeah. I'm glad I messaged you to say like, "Hey, how do you feel about A, B, and C?" And you're like, "Oh, shit, that's not what we're talking about."
STACY GREETER: I made a Word document, but that's okay.
MEGAN NEFF: I'm so sorry.
STACY GREETER: No worries, I like talking about OCD.
MEGAN NEFF: Okay, cool, cool. Actually, now I'm having like, a memory of, like, yeah, because I think you reached out a long time ago, before we had this series set up about navigating.
STACY GREETER: Yeah.
MEGAN NEFF: I mean, I do think that'd be helpful, especially, it sounds like you've prepped for it because I do know a lot of-
STACY GREETER: It's possible.
MEGAN NEFF: …we've talked a lot about navigating medical systems and how hard that is, and we have a global audience. So, I know we're-
STACY GREETER: It is so hard. And so, here I am. I mean, I also feel like I straddle multiple worlds because I'm a doctor, I'm a patient, I'm autistic, and so I have definitely experienced a lot of invalidation and dismissal at the hands of medical professionals. And I also say that with a lot of compassion for other medical professionals who are very burnt out. And on top of that, the medical profession through training, like people are either kicked out of med school or shamed if they don't know the answer or they can't get it right. And that really sets people up where then they have a patient with chronic pain, a thing they don't understand. And instead of "Oh, yeah, I don't understand this, that's okay." It's like, "Nope, you're wrong. You can't have this thing as a defense." Does that make sense?
MEGAN NEFF: It does make sense. I mean, so, like, you're kind of trained into a binary of, like, it's your fault or the patient doesn't make sense.
STACY GREETER: Yeah, yeah. What I think is that medical training does not set us up to be able to be vulnerable, to be able to embrace being wrong. And that, unfortunately, is a detriment, especially, when you're working with an autistic patient who has all the things, and is yes, me too.
Okay, it's like, for example, I go to the neurologist and he does the nerve conduction study, and I'm having severe neuropathy pain. And after the studies, he says, "You're fine, you're great. You don't need to come back, bye." Right?
And it's like, no, the nerve conduction study might be normal, but clearly I am not fine. I'm not experiencing fine. I think that to be able to sit with and fully accept suffering that we both feel responsible for and yet are helpless to understand or treat is hard.
MEGAN NEFF: Yeah, yeah.
STACY GREETER: Which is to emphasize that it's really not your fault when you have an interaction like that with your doctor, I think as autistic people, too, we're used to blaming ourselves when social interactions don't go well.
MEGAN NEFF: Absolutely.
STACY GREETER: That, well, you know, the doctors said that to me because I must have come off weird or… And then, it's like this whole subculture in itself medicine that's very hierarchical. So, I think it's fascinating that autistic doctors get great connections with their patients, but have trouble with their colleagues.
MEGAN NEFF: Mm-hmm (affirmative). I have that experience [CROSSTALK 00:32:06]-
STACY GREETER: Because we're less, right? Because we're less hierarchical. We're like, on your level, great. That works great with the patient, not with supervisors, etc., right? So, I think that's really hard. And they call it the triple empathy problem. So, there's autistic versus holistic. And then, on top of that is patient versus doctor. And there's separate subcultures.
So, you know, with my patients I can joke around and be like, "Well, that question might offend a neurotypical. But now you've given me an opportunity to info dump about my special interest and do some extra research to learn some more stuff about psychiatry. So, thank you so much.
PATRICK CASALE: I think you're so right though. Like, you're talking about the neuropathy/neurologist experience, which [CROSSTALK 00:33:02]-
STACY GREETER: Yes.
PATRICK CASALE: …true because I just had this experience a couple days ago where, like, I waited so long to get into a neurologist office. Took almost 10 months of advocating, advocating, advocating like, "I need to get in. I need to get in." Rejection of referral, rejection of referral, finally get in. Doctor spends possibly 12 minutes tops, stumped the entire time confused by what I'm presenting. And the recommendation is like, "Oh, like, well, why don't you go back to the sleep specialist who referred you here? Because it sounds like the issue you're experiencing is impacting your sleep."
And I'm like, at that point as the patient and someone who obviously has a little bit more access to some resource in terms of being able to advocate, you're just kind of like, "I give up." Almost. Like, the I think the reality for so many of us is like, I just give up. Like, I just wave the white flag. I'm just going to be destined to live in this kind of, like, hell that exists for me physiologically a lot of the time.
So, like, navigating the psychiatric system as well can be so challenging for our clients, right? If they don't have access to resources, information, maybe they see someone who only gets to spend 10 to 15 minutes per visit, or the patient ends up feeling like I'm made to feel like I'm med seeking. I'm made to feel like I'm over-exaggerating. I'm like minimizing. I am, like, creating this narrative that isn't real. And then, you end up questioning your own mind. Like, is this really happening to me?
STACY GREETER: Totally, totally. Lots of invalidation, unfortunately, is happening in the medical profession. And it's also part of neurotypical culture that we just expect people to know what to do, or what to say, or what it means to be a patient, right? So, that's why I made this long document, How to Be a Patient and Interact with Neurotypicals. Right, it's like there's really a huge part the patient plays in successful treatment.
MEGAN NEFF: Yeah, absolutely, yeah. What kinds of things are on that document?
STACY GREETER: Okay, so I have my table of, like, the doctor's expert in diagnosis, but you are expert in your subjective experience. The doctor is expert in the dosage of the medication and how to communicate with them outside of appointments, but the patient is expert in your symptoms, and your response to the medicine, and whether or not you take the medicine because I think that role clarification is really helpful. And then, I have a whole section on, honestly, how to mask and deal with people who have big egos to get your needs met, you know, about, like, when you're walking into the medical appointment. And I hate that, and I've got a lot of flack for that, but I'm like, this could be life or death for people who are seeing a specialist and they have no access to another specialist who takes their insurance, you know? But-
MEGAN NEFF: Sometimes, like, masking is a survival response, and sometimes [CROSSTALK 00:36:17]-
STACY GREETER: Yeah, and this is about survival, unfortunately. And I say, so, walk into the appointment not wanting to be right, but just getting your needs met.
MEGAN NEFF: That's such good advice because doctors-
STACY GREETER: And then, to a safe person right afterwards.
MEGAN NEFF: Yeah because that invokes-
STACY GREETER: Yes.
MEGAN NEFF: That can invoke a defense. And then, like, in the doctor. And it can also cause a person be misperceived when they're coming in. And I think for a lot of us autistic people, it is like, "I want you to see the facts because then I know we'll have the same idea." But it comes across as like, "I need to be right." Because it's like, "I need you to see these facts that I see." And so, that's such a helpful reframe. I really, yeah.
STACY GREETER: Yeah. And like, some doctors are going to love that.
MEGAN NEFF: Yeah.
STACY GREETER: Some, some are.
MEGAN NEFF: Many won't, though.
STACY GREETER: Many won't, unfortunately, you know? But to be prepared to let go that it's not your job to correct or convince your doctor or something. It is your job to get your health care needs met, whatever that looks like.
MEGAN NEFF: Yeah, yeah, yeah.
PATRICK CASALE: Yeah. That's good advice because I think it's so easy to, like, especially, as autistic people, we've probably done a decent amount of research, right? On like our symptoms or our experiences, and come in with ready to present it all, and the doctor can kind of take offense to that, as if, like, "Well, you didn't go to medical school, so I'm not going to listen to this." Or, "We don't have time to talk about this." Or, "This is being blown out of proportion." And [CROSSTALK 00:37:56]-
STACY GREETER: Right.
PATRICK CASALE:…a lot of invalidation, unfortunately, which is just such a common experience.
STACY GREETER: Yeah, I also think, and if the doctor's willing to do this, so I'll write up questions for my patients to answer ahead of time because with people being on the spot, trying to process everything, it's just terrible, it's terrible, right?
MEGAN NEFF: Right.
STACY GREETER: So, I'll be like, you know, you kind of know what questions you want to ask your patient, or at least the gist of them, to be able to have them do that while they're calm, collected, and regulated, yes.
Plus, I think taking notes is super helpful. And asking if you can bring an ally with you to the appointment to help you process everything. And then, scheduling more frequent appointments, since you can't cover everything at each appointment.
MEGAN NEFF: Right, right, yeah.
PATRICK CASALE: Yeah, that's really good advice. I like that a lot.
I want to touch on something, and I'm going to diverge back to OCD because [CROSSTALK 00:39:03]-
STACY GREETER: All right, we're diverging again.
PATRICK CASALE: Yeah, let's take this car down a different exit. You had mentioned when you messaged me, like, the differentiation between stimming and OCD repetitive behavior.
STACY GREETER: I have a chart. I'm going to pull up my chart. So, Patrick was asking me about stimming tics and OCD compulsions. And I like things in nice visuals, in different colors. So…
MEGAN NEFF: I do too. [INDISCERNIBLE 00:39:32].
STACY GREETER: Nice. So, stimming is self soothing whereas tics are annoying. And the compulsions, and all of these could look the same on the surface, compulsions associated with OCD, fear-driven.
Also, stimming is present from like tiny, tiny toddlerhood, generally. And like, tics are coming out around age seven, usually, OCD compulsions average age 10. And then, we're we're going to ask the person what would it be like if they were first for a course to stop stimming? That would be more distress inside. Whereas tics, they're like, "Yeah, I wish I could stop that. It kind of annoys me." And the urge builds the longer they resist it.
Compulsions, the fear like, oh my gosh, I need to wash my hands because they're dirty. I'm going to get sick. The longer they go and resist acting on the OCD fear and doing the compulsion, it dissipates over time.
So, those are some main differences. I have a chart on treatment differences too, which is why it's so important to distinguish them, right? Because stimming collaborate with the individual to help them do what regulates their body, but find alternatives to stims that cause harm, and they can decide when they want or need to mask and suppress. And when they can be authentically unmasked and safe to do so. And we don't treat them with medicine, right? Whereas the tics and OCD compulsions, of course, we're treating them in their various ways. And then, medications are different, yeah. I might show you one of my Dragonite Venn diagrams.
MEGAN NEFF: Ooh, I'd love to see that.
PATRICK CASALE: Yeah, please do.
STACY GREETER: Right? Oh, this might be an old one presentation I pulled up by accident, but…
PATRICK CASALE: And for those of you listening, if you want to watch and see these graphics, these are in our YouTube channel, so make sure you tune into that as well.
STACY GREETER: I have them on my website where you can download every single slide too, under the Psychiatry Boot Camp section, you know?
MEGAN NEFF: That's so cool. Yeah, I was going to ask, like the document you talked about for, like, the guide [CROSSTALK 00:41:51]-
STACY GREETER: Yeah, it's called How to Win it Being a Psychiatric Patient.
MEGAN NEFF: And is that available? Like, people could go download it, or is that…
STACY GREETER: I can make it available?
MEGAN NEFF: Oh, you don't have to. I'm just curious.
STACY GREETER: I mean, I can send it to you. I don't know. I guess I could put it on my website maybe.
PATRICK CASALE: Yeah.
MEGAN NEFF: I mean, if you're comfortable, that's your decision, if you're comfortable with it. I think that'd be a resource a lot of people would benefit from, but…
PATRICK CASALE: Yeah, if you send it to us and you feel comfortable with it being out in the world we can link it to the show notes, too.
MEGAN NEFF: Or we can link to your website.
PATRICK CASALE: Yeah.
STACY GREETER: That would be cool. Yes, yeah.
MEGAN NEFF: I like how you're adding in Tourette's so much because you're right, like Tourette's can look both like OCD, and autism, and ADHD. So, I like how you're also adding in Tourette's and tics into the conversation.
STACY GREETER: Yeah, I'll show you my Tourette's versus OCD Dragonite now that I have them up, okay? Sorry.
MEGAN NEFF: Okay.
STACY GREETER: There's so many versions of stuff on my computer. It's kind of scary.
MEGAN NEFF: My computer's very ADHD. And I realize that's a big part of my stress, yeah. So, I [CROSSTALK 00:43:03]-
PATRICK CASALE: Mine is very autism driven, and it's so clean, and I have one icon, and nothing else, and nothing else will ever live on there.
MEGAN NEFF: I am so jealous.
PATRICK CASALE: I'm jealous I can never find anything because I delete it all.
MEGAN NEFF: Oh, gosh, sorry, that's…
STACY GREETER: So, these are the things I made that I got based on [CROSSTALK 00:43:21]-
MEGAN NEFF: I love the egg. It's amazing.
STACY GREETER: I have fun. I have fun, definitely. Cool.
PATRICK CASALE: I like that visual. I think that helps for people who need to see it visually, to process it, and also, just to have fun with it. We've talked about fun on previous episodes, and like, how playfulness is so important with a lot of the stuff that we talk about. And it sounds like you really do try to incorporate playfulness, and fun, and joy into your practice, and into your business, and into your life. And I'm sure that has a trickle-down effect to the patients that you support and serve as well.
STACY GREETER: I hope so. It's interesting that you mentioned playfulness because it brings up what we were talking about earlier. Because I feel like in medical training, maybe professionalism was like the antithesis of that, almost sadly. I don't know how you Megan and Patrick experience professionalism, right? And then, so I think, I've definitely found that the more I can move into a freer, vulnerable, more playful, authentically autistic self the better psychiatrist I am?
MEGAN NEFF: Yeah, absolutely. I think that makes so much sense. Yeah, professionalism, I really tried to be. That as a big part of my mask, but it never came naturally to me. And when I shifted to just seeing neurodivergent clients, a much more playful therapist emerged, and it felt so much more congruent with me.
And one thing I talk about a lot it, I use this concept, I call it play shame. But I think a lot of neurodivergent children [CROSSTALK 00:45:18]-
STACY GREETER: I haven't heard that.
MEGAN NEFF: …a lot of…
MEGAN NEFF: Yeah, I mean, it's just a Megan Anna brain combo. Like, I think a lot of us as children experience a lot of shame around how we played because either it wasn't right or it was too much. And so, I think for a lot of us, we've perhaps sorted it.
And so, I think, for me, getting reconnected with playful parts of me has been such a big part of unmasking because those were the parts that were so repressed. A lot of them are very ADHD parts, and so, they were the parts that I had a lot of shame around. I thought these were immature parts. So, for me, reclaiming play has been such a big part of my neurodivergent, like, identity.
STACY GREETER: Yeah. And then that gives-
MEGAN NEFF: [CROSSTALK 00:46:01].
STACY GREETER: …your patients permission to play, and be authentic, and vulnerable, and connect with those parts too.
MEGAN NEFF: Yeah, yeah, yeah. And I noticed that. I noticed a lot of neurodivergent therapists and medical providers, there's a playfulness to a lot of how they show up in the world, whether it's how they dress, whether it's making dinosaur egg Venn diagrams. Like, there's a playfulness.
STACY GREETER: I have serotonin molecules on my dress.
MEGAN NEFF: Yeah [INDISCERNIBLE 00:46:32].
PATRICK CASALE: I think so much of that unmasking experience when we are "trying to figure out what's professional for our field" is embracing that authenticity, and that personality, and really showcasing it because it also mirrors for your clients, for your patients, for the people you support to give them some permission to do the same. And that's why I like what you said before about, like, being more open in the medical field because so many people aren't able to be. So, it really does help model that for people that this can be a possibility, you know, in some contexts and situations. So, I think the more we align with who we are, the more it shows up in the work that we do regardless of the work that we do.
STACY GREETER: Yeah. And I think it's a process for me because when I… the voice will come in from residency. Like, no, you shouldn't do it that way. That's not the right way, the professional way. And I just get better and better at putting it to the side.
PATRICK CASALE: Yeah, good. I mean [CROSSTALK 00:47:39]. I've always kind of had to, like, buck the system mentality, or even in grad school, whenever we were being told, "This is how you show up as a therapist." Or, "This is how a therapist presents or dresses." I was always just kind of like, "That's not going to work for me, so I'm not going to do that."
I also have be privilege to say that more often than a lot of people. So, you know, those go hand in hand, but it just never was going to be a fit. Like, that's the group practice culture I've cultivated is like, I don't care what you dress like. I don't care what you look like like. Like, I don't care that you just dyed your hair hot pink. None of that stuff bothers me. Some of the stuff I see in these therapeutic Facebook groups I'm always just kind of confused about, like, why are you so bent out of shape over some of this stuff? So, I think the more we can do this, the more you can model and just represent as well.
STACY GREETER: Yeah. And then, the more energy and presence you have with the patient because you're not trying to devote so much of your work to be the professional version, right? Like, you could do it, but at a cost.
MEGAN NEFF: Yeah.
STACY GREETER: At a cost, and it would cost your energy and presence with your patient.
PATRICK CASALE: Yeah.
STACY GREETER: Slash client.
PATRICK CASALE: Yeah, exactly. And then, it comes down to, for me, like, which energy cost is more important. Like, my over expenditure into presenting, and looking, and appearing professional, or my over-expenditure in terms of, like, being able to unmask more safely, be more authentic with the people I support, give them better client outcomes. Like, the juice is worth the squeeze for me in terms of, like, saying that's where my values align, and that feels way more important to me at this stage of my life.
STACY GREETER: Definitely. But I'm in private practice, a place of privilege. I actually wanted to go into academic medicine because I love teaching so much and be at an academic medical center, but it is emotionally safer for me to be in private practice, and then, have the privilege to be unmasked, and authentic, and have a culture of my office where there's open, direct, vulnerable, egalitarian, non-hierarchical communication. That was a mouthful, sorry.
MEGAN NEFF: Well, I see that all the time. And I think a lot of, especially, when folks have the privilege and ability to pivot to private practice because I see that a lot where medical providers or therapists will say, like, everything's great with my patients, but it's all the system stuff I can't do. Yeah, so it makes sense that you are in private practice. I see that pivot a lot. It makes sense.
STACY GREETER: Yes, yeah, I'm grateful. I'm really grateful.
PATRICK CASALE: Same, same.
STACY GREETER: And I feel like there's some depth and authenticity in the discussions we get to have with our patients that I can't imagine another place. I just love the psychiatry so much and that way of relating is a very autistically-oriented way of relating. And then, I get to incorporate my special interest into teaching about psychiatry. So, yeah, I'm really, really fortunate.
MEGAN NEFF: I love that. And do most of folks you work with, are most of them autistic ADHD.
STACY GREETER: A lot of them are. Not everybody, not everybody, you know? So, I'm in a smaller town community psychiatrist, so I'll take all kinds. That being said, you know, as autistic people find each other-
MEGAN NEFF: We do.
STACY GREETER: And since I'm openly autistic, there are a lot of patients looking for an autistic doctor. I started a spreadsheet of people who… for doctors to put their info down if they were okay with publicly sharing their neurotypes.
MEGAN NEFF: That's amazing.
STACY GREETER: I can send it to you. And there's also a tab for therapists and a tab for assessment. I think I have maybe four people on there so far on the doctor's side. So, it's not easy to have doctors coming out as autistic. Yes, but, you know, definitely, just for anyone out there listening that people will really, really, want to connect with you and your autistic self.
MEGAN NEFF: Yeah, absolutely. This comes up a lot of like, we just need autistic directories for everything. Like, we need to be able to find the autistic hairstylist, the autistic doctors, the autistic-like, just everything so that we can… Because it does, it cuts down the labor so much, like, when we're working with… I mean, I just did a social media post that reviewed the cross-neurotype studies, right? Like, when we're communicating within our same neurotype, it just cuts through so much of the labor. I'm excited for, like, 10 years from now, where just all these amazing directories exist and are synthesized. I mean, autistic brains, like, we should be able to create this, right? Collective effort.
STACY GREETER: We're working on it. I'll work on it. We all will, right? Yeah. I think so much has really grown, especially, in the therapy world to make it safer for therapists to come out as autistic. So, I'm really hoping we can do more in the medical professional world.
MEGAN NEFF: I hope so too. I hope so too. I think so many, both for the medical providers who are autistic and like, burning out, and for the patients looking for those people, yeah, yeah.
STACY GREETER: Yeah. Studies show that if you are an autistic doctor and you have worked with another doctor you believe is autistic your rate of suicide is lower.
MEGAN NEFF: Really. I mean, that makes sense. But wow, yeah.
STACY GREETER: Yeah.
MEGAN NEFF: Yeah, yeah, yeah. I mean, that could be a whole other conversation is mental health with medical providers, which speaks to the culture that you were describing.
STACY GREETER: Mm-hmm (affirmative).
MEGAN NEFF: Yeah, yeah. We have diverged.
PATRICK CASALE: Yes, and I think it feels like we're at that place. So, we've talked for a little about an hour. It always feels like, oh, wow, that was an hour. Geez, at least. Thank you, Stacy, for coming on, and sharing, and being vulnerable, and just being who you are. And I think what an asset to not only the Florida community that you serve, but anywhere that you can be in contact with patients, and be supporting them in their journeys.
So, can you tell the audience where they can find you. And we'll link that in the show notes as well.
STACY GREETER: Thanks so much, Patrick. My website is stacygreetermd.com. So, it's S-T-A-C-Y-G-R-E-E-T-E-R-M-D.com. And my YouTube channel, where you can enjoy those videos is @stacygreetermd. S-T-A-C-Y-G-R-E-E-T-E-R-M-D. Thank you so much for having me, Patrick, and Megan.
MEGAN NEFF: Thanks so much for coming on. I've really enjoyed this conversation. It's felt very alive. It's felt playful at times. I've learned some new things. So, thank you so much.
PATRICK CASALE: Yeah.
STACY GREETER: Thanks.
PATRICK CASALE: Yeah, really appreciate it. And sorry to drop that we're talking about OCD-
STACY GREETER: It's cool.
PATRICK CASALE: [CROSSTALK 00:55:55] one or two days beforehand.
STACY GREETER: That was cool. I like talking about OCD.
PATRICK CASALE: [CROSSTALK 00:56:1] and like we've both [INDISCERNIBLE 00:56:05] conversation, so thank you for pivoting and diverging.
STACY GREETER: Sure.
