I was recently reminded when with one of my patients—let’s call her Emily—that one of the greatest losses in anxiety isn’t simply peace.

It’s freedom.

One of the hardest things about anxiety is that when treatment works, it works so well that you begin to forget what life was like before. That, in turn, can make taking medication long-term more difficult.

Early in our visit, Emily said, “It feels good when you’re on it, that you forget what you’re like when you’re off of it. I feel like, ‘I don’t need this,’ but I know from experience, I feel great. I don’t need this, and then I go off, and then I have, like, a panic attack.”

Panic is part of it. But there is something else that anxiety anxiously steals. It changes your perspective on the world around you.

It is a subtle change in your freedom to think.

Your thoughts stop being free before you even realize they’ve been taken over.

They start being controlled by the anxiety rather than by the free part of your identity.

When I asked her what that felt like, she said:

“Basically, when I’m anxious, everything’s skewed, and I’ll have a thought, and I try to tell myself, ‘This isn’t a real thought. This isn’t real. This is my anxiety,’ but my brain keeps swimming around it.”

This is so so common in people struggling with taking meds. Who actually wants to?!  And it’s not only self-stigma impacting how people feel. Because look who’s telling you that? It’s your own brain. But patients are also struggling with what anxiety has convinced them is true about themselves and about the world.

The thoughts are not invited. They come without invitation. And because they come without invitation, they are not under voluntary control.

That means anxiety begins choosing for you before you have the freedom to choose.

The consequence is much larger than feeling nervous. It impacts joy. It changes the way you spend time with other people. It impacts everything.

It affects your capacity to connect with the world. It isolates you. It shapes your choices about how you intersect with the people around you. Invitations get rejected. Opportunities start narrowing. Loved ones become more of an attachment blanket than a relationship.

In a way, it changes your personality.

More accurately, it changes the story you tell about yourself.  That’s the story we are really talking about.

I said, “If you were to write, ‘Emily is a woman in her early thirties who is expecting her first child, and she…’ that story would become different. The identity you would describe yourself as would become someone shaped by anxiety rather than someone who is free to choose.”

That distinction matters.

It also matters when we begin talking about treatment during pregnancy.

The conversation cannot simply be, “Is the medication safe?”

Medication decisions during pregnancy need to be discussed together with your obstetrician because there are really two questions. One is the safety profile of the medication on the fetus. The other is the cost of untreated illness on you and your fetus.

I hesitate to call any medication “safe” because people define that word differently. What I can say is that some medications are among the most commonly used during pregnancy.

I can also tell you what is not safe for your baby: you not being well.

Even during pregnancy, studies have shown that untreated anxiety and depression affect the developing fetus. When these risks are weighed together, the benefits of treatment are often greater than the risks of leaving psychiatric illness untreated.

Near the end of our visit, our conversation shifted and Emily smiled.

“Have I ever told you that I have two older sisters? They’re both on Zoloft, 50 milligrams, and my dad is too. So, like, I don’t know if it’s, like, my destiny.”

“From a biological standpoint, we call that genetic loading. You are a creature created by your genetic design. You did not come from nowhere.”

“And maybe my baby will be on Zoloft too.”

I smiled.

“Maybe.”

I asked her one final question, “How would you feel if your child was on Zoloft? Would you feel like they shouldn’t be?”

“No, not at all.”

“Would you give them grace and not yourself? Would you be like, ‘Get on that yesterday,’ if they needed it?”

“One hundred percent.”

I smiled again.

“Maybe the question isn’t whether you deserve treatment. Maybe the question is whether you deserve the freedom to be yourself.”

Maybe that’s what self-care really is.

Not becoming someone different.

But caring for your biology enough that you’re free to become yourself again.

Questions: In what ways has anxiety, or other difficult emotions and behaviors, changed the story you tell yourself about who you are? How have they reduced your freedom?

Self-care tip: Caring for your biology is one way of caring for your freedom.

Hello Blog-verse!

I’ve been wanting to recenter myself on what this blog is about. In brief, it is supposed to be about self-care from a biological standpoint and, from there, a branching out into the psychosocial paradigms. This means that it is a stance on what our agency is when thinking about it medically, from a physician’s point of view. That means someone who goes through full medical training, including a college degree, four years of medical school, a period of primary care training in general medicine, and then completing four years of psychiatric specialty training.

For me, this included a fellowship in “Prime Psychiatry,” which is medical psychiatry—as in psychiatry for those who are suffering primarily, at the time of the encounter with me, from a primary medical illness, such as being inpatient in the ICU for pneumonia. In this psychiatry consult scenario, the patient may be seeing me for crying jags and a work up for depression while going through the life threatening medical illness. That is a different perspective on psychiatric illness than someone whose training is different, such as from a psychology or social work background.

We look at emotions and behaviors somewhat differently because our training in understanding mental illness begins from a different starting point. Medicine first asks, “What is happening biologically?” I.e., the brain as an organ, disease processes, medications, hormones, sleep, inflammation, pain, and the countless ways the body influences the mind. That is where this blog tries to begin. But it doesn’t end there.

Psychology and social work often begin by asking, “What experiences, relationships, thoughts, and environments are shaping this person’s life?” Both perspectives are valuable, but they naturally emphasize different aspects of the same human experience. I am in danger of oversimplifying this and misrepresenting, which I apologize for.

Human beings are never just biology. We are also shaped by our relationships, beliefs, losses, trauma, purpose, and the stories we tell ourselves. Understanding ourselves well requires attention to both.

In training for psychiatry, we also cover many of the therapies taught in the various schools of counseling, and likewise, they cover neuroscience. But our pivot point in medicine is always going to be from a biological level. Nor do we spend anywhere near as much time on the many schools of thought devoted to talk therapy.

That doesn’t mean the biological explanation is always the answer. Far from it. But in psychiatry it is our nidus. From there, we broaden our view to include a person’s relationships, developmental history, coping patterns, personality, beliefs, culture, trauma, purpose, environment, and so forth. The goal is never to reduce someone to a diagnosis or a collection of neurotransmitters. Rather, it is to understand how biology and life experiences continually shape one another.

What is funny about me, and I don’t know if this is true about other psychiatrists, is that I often find myself on this blog talking most about coping issues and psychological perspectives, and I’m not sure I need to improve that. So, it makes me think I need to come clean about what I really love doing here at Friend to Yourself.

One of my agendas seems to be washing up in the tide of time and experience: trying to help others understand the role of psychiatry and detangle the social perspectives of where emotions and behaviors come from and the way those perspectives help or harm access to benefits and medical care.

So much of my practice is spent helping people understand why medication is appropriate when there is a medical illness, and why emotional and behavioral pathology may reflect illness rather than a “poor choice,” “weakness of character,” or “lack of surrender to God.”

That is an extraordinarily difficult idea.

The idea is that pathological emotions and behaviors are symptoms of an underlying disease process at the cellular level from which they arise. I.e., emotions and behaviors come from a body organ, the brain. If the place where emotions and behaviors are generated from is well, there are emotions and behaviors that are well. And vice versa.

Much like when my eyesight is bad, it means that the cells, somewhere from wherever that vision comes from in the human head, aren’t working right. They should be treated medically, such as with prescription eyeglasses—a medical prescription for a medical condition. Eyeglasses don’t heal the underlying biology, of course. They compensate for it. But we don’t moralize needing glasses; we recognize that when vision is impaired, we seek a medical solution for a medical problem.

This just isn’t easy for almost anybody to understand.

The drive to think we have control over our emotions and behaviors, i.e., our identity, is so very, very high. But emotions and behaviors start somewhere. They are birthed and formulated amongst a slurry of neurotransmitters, ions, gated channels, DNA, and so much more. From there, they take shape and grow into what we finally see in a smile, feel as an impulse, experience in tears and laughter, and even recognize as affection.

Why do we so easily believe that more hard work on “my part”—through hours of talk therapy, an exercise of prayer beads, or giving ourselves a tune-up with a wrench and hand tools—should be able to fix it? We don’t do this to someone with nearsightedness but we do it with psychiatric illness.

Many medical practitioners struggle with this. Psychiatry occupies a peculiar place in medicine because our symptoms (pathological emotions and behaviors) are experienced as our identity, much more so than in other specialties. That makes it much easier to mistake disease for personality. Other medical practitioners may inadvertently counsel patients to “work on it” in one way or another through a behavior or thought change rather than directing them to a medical treatment for a medical disease. This turns the treatment of psychiatric illness mistakenly away from medical treatment and toward volitional control, as though emotions and behaviors were under the same conscious control we have when operating a joystick or shifting the gears of a manual transmission.

It’s super unfortunate because it’s hard enough for people to understand this, let alone when their clinical providers give them inaccurate medical information.

So, this blog has become, in part, a place where I try to do just that, moving from one dial setting to another, one color on the spectrum to another, and so forth. There just are not enough voices-and-volume out there explaining this.

It is still about how to be a friend to yourself from a biological standpoint, but less directly than I thought it would be when setting out. We are doing it, but a little more circuitously, in that we have to get into and through all the reasons—the many, many reasons—we don’t understand that emotions and behaviors come from the brain, which is just as much a part of the human body as a kidney or a liver or an eyeball. To care for ourselves when we are medically ill in these ways, we need medical treatment.

To be a friend to yourself from a biological perspective, we first stop blaming ourselves for what we don’t fully control consciously: our emotions and behaviors. We grow our understanding of, and modify our actions accordingly, to the fact that the brain is an organ and is the only place from which we experience ourselves.

It is the only place from which come our perceptions of what is true, of reality, of the way we identify ourselves, and of those around us.

Even though I’ve often said emotions and behaviors come from the brain, it could be said, rather, that they come from neurotransmitters, cells, DNA, hormones, immune signaling, relationships, trauma, nutrition, and sleep, if that makes it clearer. Because they do. They all converge in brain function.

The brain is an organ, but it is also the place where we experience being human.

That acknowledges the profound influence of relationships, beliefs, faith, purpose, and culture, all of which continually affect and shape the brain, from which emotions and behaviors arise in this lovely biopsychosocial person we call “Me.”

Let us, therefore, end by saying, “this blog is about”… learning to undersand ourselves compassionately by recognizing that biolgy and lived experience continually shape one another. It doesn’t abandon biology—it explains why biology matters without reducing people to biology.

What else is this blog about? Hm. I’ll work on that. There is more that constitutes our voice here for sure. Smile.

Self-Care Tip: Treat your brain like any other organ.

Question: Have you mistaken a symptom for a personal failure? Please tell us your story! We need to hear you.

The mirror is so honest. I see that as we age, things don’t stay within the lines like they should.

Lipstick, red, is creeping toward my chin. Eyebrow hair is waving, like tentacles searching for krill, over the rim of my eyeglasses. And my skin—well, in all the visible and hidden parts of my body, no one can put that back where it came from.

The frame for my canvas is less effective, and the picture shows paints are drifting.

I’m just sitting in “it” and thought—why should my thoughts not wander too, toward you?

But this untidy body is like a name tag, or like a forward to a book, or a flag that waves before we race. This is an introduction, or it can be a goodbye, this body casement. But it is not the story.

The story that breathlessly tells about me—my DNA, is a fingerprint of my ancestors and Creator. And if you look, you may not know my choices, or my sins, forgiven, or senses exchanging information between me and all that other, like the orange oriole last night who flew fast, singing over the deck I vespered at, “It is spring.” And I saw him. And because of that color, the sound, the proximity, so close to me!, The story is wide, not curated. And because my great great grandfather was someone who got energy from being with people, and because I was born fourth to my three older brothers, because I was in clinic with amazing patients all week, and ten bombs dropped on Lebanon a few weeks ago, and because, because, well because of you too, there’s a lot of story here.

When I was nineteen, or twenty-eight, or even many more years later, and before “The Great Drift” (said in a mic’d James Earl Jones deep bass voice with acoustics), I think the carapace might have been my focus much of the time. But focus or no, our humanity is rich, a tasty filo layered baklava, and more than “Me.” Our humanity is increased always because there is a “You.”

Today, three of our youth gave their testimonies in church. The title was “If these pews could talk, they would say…”

I am lonely,

I am struggling and nobody knows,

and I don’t know.

And by the end of their testimony, they each ended with, “If these pews could talk, they’d say…”

God is with me,

there are people struggling and nobody knows it … but God,

and God gave me purpose.

These three youth, normal eyebrows, lip lines intact, dewy skin, went in deep. The mirror can name the drift. But it cannot name the meaning. It cannot tell me that I belong to you, or that you, somehow, are part of me. It cannot hold the sound of an oriole, or the weight of a testimony, or the quiet way a room full of people says, without saying it—

You are not alone.

And maybe that is it, as the lines blur outside the edges—the body may wander, but the story keeps gathering. And it gathers, toward each other and God.

Question:
What part of “Me” are you mistaking for the whole story right now?

Self-care tip:
Remember your story isn’t only in the mirror. Keep on.

Hello wonderful readers. I’ve been getting some heat re: straying from my original premise of in fact being a “Friend to Yourself” from a biopsychosocial standpoint, and what does “Me” mean? I’ll just review a bit. Let me know what you think, and where I need to flush things out more.

Being a friend to yourself is more than getting a manicure every now and then, or taking the time to go shopping or watch movies, or doing what seems “fun.” In fact, being a friend to yourself often means not doing what you want to do.

That is because being a friend to yourself means taking accountability for yourself—your own happiness, your own health, your own spirituality, and your own connections to the outside world. It means acknowledging that “everything starts and ends with Me.” It means acknowledging that you are not a victim, even though you may have been victimized, hurt, misused, or forgotten.

However, responsibility doesn’t equal blame! Being victimized and being responsible can coexist. “Me” is where care happens.

We know that cash doesn’t just magically appear in our wallets unless we do something to put it there. So why do we keep waiting for our personal assets to replenish themselves? Imagine this person’s personal wallet is empty, and everyone around them is suffering the consequences. This person is so burnt out at their job that they are getting written up and in danger of getting fired. They go home and isolate in their room and never exercise. Fast food wrappers litter the floors. They never really talk to their friends or kids.

For most of us, learning to be friends to ourselves is the hardest work we ever do—and also the most important.

It’s up to us to each fill our own wallets by taking care of ourselves and taking responsibility for our own assets. That’s tangible bank. That’s what being a friend to yourself is all about.

You cannot give what you do not have.

Being a friend to yourself means caring for your body as well as your soul, and understanding that meeting—or ignoring—basic physical needs can lead to complex outcomes.

When we make ourselves a priority, we may appear to give less, but we actually have more for those we love. Just like any bank, we must deposit more than we withdraw if we’re going to protect our basic assets. And our bodies are the most important, irreplaceable assets that we’ve been given.

The choice of how to spend our assets is our own. We are free to choose self-care, or not. But when we choose to be friends to ourselves, we don’t need a mother, a police officer, or the government to strong-arm us to do what’s best, because we want, at least at an intellectual level, to take care of ourselves.

You are a complex person with many intersecting paradigms, including your general physical health and biology, genetic predispositions, coping skills, what you do to your body, what is done to your body (such as physical trauma), emotional triggers, and spirituality.

And that is the ‘Me’ I am talking about.

Self-care is not about doing what you want otherwise. It is about giving yourself what you need.

Self-care tip:
Start with one non-negotiable need your body or mind has today, and meet it before giving your energy away.

Question to reader:
What is one need your “Me” has been asking for that you’ve been ignoring?

Please Speak! Everyone needs to hear you. Keep on!

Talk therapy was upside down.

Rachel was there for the 1st time in pants. Nice pants, but still pants. She had always come, to date, dressed to the nines. Christian Louboutin red bottom pumps, Chanel suit—she was the classic OC therapist. Going into her office was a place that was so put together that one so unput-together, such as Missy, could paradoxically find space. A tidy mess, walking through like Charlie Brown’s “Pig-Pen,” with a cloud of dust floating around her, Missy would descend with her problems and float out with them one hour later.

Today though, Rachel was wearing a distress call—pants! All was not right. They spoke for her.

“What’s wrong?” Missy immediately asked.

It was like opening the hoarder’s closet door. An avalanche of woes fell out. And all of a sudden, Missy didn’t remember why she came to therapy that day. She was taken in by Rachel’s suffering. This many years later, when Missy told me the story, she didn’t remember the list of sorrows except one. Rachel’s 14 y/o cat was dying. She was, in fact, what palliative care practitioners refer to as “actively dying,” the last bit of life before the end, that can be, if not handled well, quite miserable to all, including the caregivers.

Rachel was miserable. She knew her beloved cat was miserable. Missy, a veteran ICU nurse, knew immediately what needed to be done and, by the end of the hour, had arranged for Rachel’s cat to have an at-home hospice provider come that same day and give what was needed. End-of-life is end-of-life. Rachel just could not make the call. She was so broken up with grief. And so, the therapist became the patient.

By the end of that hour, Missy relayed that she remembers feeling so well inside, so blessed, and that she was able to be outside of her “mess.” Helping someone relieved some of Missy’s own life pain.

What happened here illustrates something we see clinically. Here, in our blog narrative, I am going to make a writer’s prerogative and jump way over to the neurobiological framework of things. You’ve heard me talk about it enough to know where I’m going. I am reminded that when we have negative thoughts, one of the best ways of dealing with them is to FIRST (because I’m a psychiatrist and know that all emotions and behaviors come from the brain, and to be responsible with that means to be responsible with brain health) make sure you address the biology. Where do these negative thoughts come from? The brain.

But ALSO, because we are layered creatures, consisting of the biopsychosocial complexity of our human condition, good coping skills never go awry. In this case between Rachel and Missy, the adage that bringing more than you take is its own kind of self-care is true.

That by serving others, we in fact serve ourselves, by improving the myelin pathways on our reward circuitry. That as we love, love, love, here at “FriendToYourself.com,” everything starts and ends with Me! Yes!

In fact, by giving to others, we have less negative thoughts. By serving others, we are somehow able to, as all good CBT demonstrates, lay down some neuronal myelin in a better pathway—a more friendly brain pathway to Me. The idea that everything starts and ends with Me, scrambled together with the idea of serving others brings self-benefit, can feel contradictory, but it is not. Serving others is actually a pathway back to self-regulation.

Taking this one step further, for extra credit, would be to acknowledge that one’s agenda for helping others, in that it is also helping “Me,” is not a flaw of design. Agendas, being what they are in our human condition, and altruism a God-feature, not our own, taking care of Me is not a moral issue. It is just good self-care.

Self-care tip: When you feel those negative thoughts encroaching, help someone else.

Question for the reader: When was the last time helping someone else actually helped you? And how did it help you?

Hello Community! Every year on or around Good Friday, I try to post something about my Dad, who died in 2020 on Good Friday.

Today, I’m remembering working in the garden with him. When Dad came home from work, smelling of sandwich meats stuffed in his sport coat pockets and operating room sweat, I’d feel like my inside pieces realigned. He’d drive up, speeding to a sudden stop in the long driveway. His seat was fully back, and his knees were still just shy of knocking the dashboard—news or sports blaring on the AM radio. He’d come through the door whistling, always whistling. I’d sense him if I didn’t hear him and spring out to his location like our dog Cleo. We’d go straight to the garden most days—him whistling, and me jabbering. Somehow, I felt heard even though he whistled most of the time or hummed. He would move water lines, squish snails (“I have a personal fight with snails. It’s just between me and them.” i.e., no poisons, just shoes and thumb-to-forefinger), and pick fruit, marveling at the sweetness of the bird-pecked figs and sapote. He was patient with life, including me, even though he was always active—a character, a treasure.

Now, in my 50s, I look back on my own children and wonder what they’d say about their own memories growing up. And I have to stop myself from one thought trail or another, because it’s comparisons again, and those aren’t good for anyone. I objectively was never this gentle giant who my dad was to me. But, One, this is not the same as remembering. And Two, acknowledging with transparency, my own shortcomings that inevitably burble to the surface is not the same harmful exercise that comparisons is. Last night, reading the “blessings” that Jacob gave to his 12 sons when Jacob was dying was kind of like that—with transparency, but also with presence, he blessed. He named their mistakes and flaws within the safety of what only a parent’s large grasp can hold, and that in itself was its own kind of blessing. “I see you.” It was not a gloss-over blessing, superficial and averting the gaze. It was eyes open, seeing, and still holding. The shortcomings we live into the lives of our loved ones, inevitably human—we either remain, or we escape into a type of transactional exchange: “This is what I give you, and as long as you give me this back, I’ll remain. If you misbehave, I’ll not.”

So, as I remember my sweet Dad, I remember also my own flawed parenting, and I remember that I am, One, forgiven. Two, so grateful for Dad and my children, and I’m leaning in, in my 50s. Still here. Valued not by performance, but by more than metrics.

I remember once, when my dad was not well, he took the keys when I asked him not to. Dad drove away to go wrap his car around a pole, break his neck, and drag all of us through the sequelae. In that moment there was no calculation, just a pull toward him. What I remember then, like Jacob blessing his 12 horribly behaved sons, was that while seeing the blood all over his beat-up body and his car split in two, I loved Dad so much and wanted him, any way he came. The good and the bad together, inevitably human. Extraordinarily forgiven. Like me. Like you.

Self-care tip: Stay present with what is in front of you today, without measuring it against anything else.

Question: How are you being seen and held in safe transparency?

I just wrote a letter on stationery that my girlfriend from college/med school gave me. The stationery and I feel outdated by name, address, age, and in part because she no longer considers me her friend. The stationery reads: Sana Johnson MD and the envelope is embossed with my address from 1994. And if that’s not a knock in the old lady knees, what is?!

Today, life had several disappointments. My emotional response has been salient and I’m still letting it dissipate.

I missed my talk therapy. I then rescheduled two other much-anticipated medical appointments due to my chaos. Inattention and brain noise took a hold and I forgot a very expensive box of Costco purchases in the shopping cart where I parked. And …and I am ever aware of the heart pain that various communities are experiencing.

Lately I’ve been enjoying the concept of God’s omnibenevolence and omnipresence, His unique godly capacity to adore and remain with each person, and that none suffer alone. I’ve been waxing on and on about it in Bible studies, car rides with entrapped passengers, in treatment with the super kind-hearted physical therapist, even with my own patients! I’ve related it to genocided populations, war, victims of predators, and even surviving parents of lost children. I’m an external processor, so this is how I make things adjust, shimmy, and hopefully finally make some sense to me.

Trying it on for size, I, while praying myself back to Costco in herky-jerky hopes, think God reminded me that even in this-and-that small griefs and tensions, do not go at it alone. He stayed and suffered as I was going nuts-o. It was a slug in my spiritual gut.

I am so inconsistent. But today to a degree I snuggled a little more into His grace and mercy.

Sure enough, someone inspired by Spirit returned my costly merch! I suffered, God was with me in my suffering, I did not suffer alone. And on another topic, I materially received what I didn’t deserve, recovered merch, and did not receive what I did deserve, unrecovered merch. I know, however, that if I didn’t materially get my purchases back, the prior points would not be less true. They are not the same topic nor do they relate to each other except in the subject matter of Me.

The unseen and unknown space was an environment I didn’t feel belted or safe in, but God stayed. I praise Him.

I used this stationery to also remind me that God suffers when I do and love remains, whether I remain with Him or not.

My friend was my heart friend for years, but we lost touch and for reasons of which I can only speculate, has since chosen not to respond. I’ve tried reconnecting. It’s a deep grief for me.

I am today reminded more personally that God suffers with me and I am not alone. I will always miss her, but surrender our friendship into God’s care, like a wisp of God’s breath that gives life, and release what I don’t control.

Today it hit me that if I don’t remember these goodnesses of God even in these things, how will I if/when catastrophe truly grounds my trajectory?

Self-care tip:
When you suffer, remember that you do not alone.

Question:
Does this make any sense to any of you? Speak—we need to hear you!

Here’s the truth. The Order Matters: Sometimes you feel better before life gets better.

Something subtle but profound came up in a recent conversation.

“It’s all the same,” Caramela said. “But my perspective has changed.”

Nothing in Caramela’s external world had improved. The stressors were still there. The relationships were still complicated. The home life was still, in her words, “junky.” And yet something had shifted.

It didn’t come because life got better.
It came first — and then life began to feel better.

That order matters.

We often assume the sequence works like this:

Circumstances improve → Mood improves.

But sometimes it’s the opposite:

Biology (mental health) stabilizes → Perspective shifts → Life feels different.

Not perfect. Not magically resolved. But different.

This is where the concept of agency becomes important. We talk about not being a victim of our circumstances. But here’s the part we don’t say often enough: you cannot fully claim agency if you refuse biological care.

Medical care is part of agency.

If depression is flattening your brain, distorting your thinking, stealing your motivation — then choosing treatment is not weakness. It’s participation. It’s saying: I am allowed to support my brain.

One of the most honest moments in our conversation was this:
“The nausea makes me uncomfortable sometimes,” she admitted. “But it’s not worse than the depression was. And I still get up and do things.”

That sentence holds everything.

She didn’t deny the side effects. She didn’t pretend it was effortless. She simply chose to live anyway. She chose forward movement over paralysis.

That’s agency.

Interestingly, she connected this insight to other Al-Anon insights — where the teaching is clear: you can live a good life whether circumstances change or not. You learn to take care of yourself.

Notice what that implies.

It’s not about waiting for chaos to calm down. It’s about strengthening your internal stability so you can function even while chaos exists.

Her children had said something similar weeks earlier: even though things were still hard, they could function and have a good day. The circumstances hadn’t changed. Their experience of them had.

This is not denial.
It’s not pretending pain isn’t real.
It’s not minimizing suffering.

It’s understanding that sometimes healing begins at the biological level.

And here’s the vulnerable part: Caramela hesitated about the medication. “I wouldn’t want to tell anyone I took medication.”

That stigma still lives quietly in many of us. But what I want you to hear, especially here at Friend to Yourself:

Supporting your brain is not a moral failure.
It is not spiritual weakness.
It is not a lack of resilience.

It is stewardship.

Sometimes you don’t feel better because life got better.
Sometimes life begins to feel better because your brain finally got support. …Like wearing eyeglasses for nearsightedness.

The order matters.

And when your perspective shifts — even slightly — your entire lived experience begins to shift with it.

That is not victimhood.

That is agency.

Being a friend to yourself includes caring for your biology, not just your thoughts.

Self-Care Tip: Heal the medical and biological self to heal your perspective of everything else.

Question: How has your perspective of what is real and true changed depending on your mental health? Please tell us your story!

Keep on!

Standing in the Costco merchandise return line, I saw this lady walking out toward the exit with a cart piled high with boxes of Depends. She wasn’t that old.

I felt embarrassed.

I remembered the awkward evidence of wet pants after laughing too hard when I was pregnant. Or coughing when I was pregnant. Or basically doing anything that required any degree of bearing down when I was pregnant. She wasn’t pregnant.

The uneven balance of power between her and the rest of “the world” was announced by many boxes of Depends — the cumulative, “We don’t need Depends and she does.” In that moment, bodily control became an unspoken currency.

What does that say about me? About us?

The feeling was quieter than judgment. It was more uncomfortable than wet pants. A sudden awareness of bodies, of exposure, of who is still “contained” and who is not. Not a moral judgment, but an emotion in response to perceived loss of autonomy.

Way way way back, when I used to menstruate, I’d feel the need then too. I would hide my sanitary items going up to the teller. I’d hope hard at the people around. “Please please don’t see my period stuff!”  

Knowing people know you bleed or leak urine is embarrassing. Shame was up, eyes open, on point.

Isn’t it strange what we’re taught to hide.

We are schooled by everything. Community, commercials, the Lebanese heritage that is spliced into my DNA. Anything that signals dependency, permeability, or loss of control, is shameful. Bleeding is normal. Leaking is common. Needing products is part of being human. And yet the visibility of those needs is losing. A loss is there, of privacy, of boundaries, of dignity.

Standing there, I realized that what I felt wasn’t just that. It was vulnerability. Seeing her cart jettisoned the power-meter. It showed just how much power we quietly assign to bodily control, and how quickly that power can climb. Control, not character, had become the axis of comparison. Embarrassment wasn’t about her at all.

It was about fear.

Fear of being seen as dependent. Fear of the body betraying us in public. Fear that dignity is something you can lose simply by needing help. Unfortunately, these are not irrational fears; they are culturally reinforced and clinically familiar.

We learn early that our bodies should be discreet, quiet, sealed. That need should be invisible. That containment improves value. This belief system shows up repeatedly in clinical work — in stigma, nonadherence, and resistance to care.

What does that say about me? About us?

Maybe we are still learning how to untangle dignity from control. Or shame often masquerades as embarrassment when it’s really grief for the illusion of independence.

Question: When did needing help start to feel like losing for you?

Self-Care Tip: Notice one place this week where you hide a normal need. Then practice letting it be visible without fixing it, just to allow yourself to need something without apology.

I don’t know if you are familiar with David Asscherick, teacher, speaker, and author, but this guy’s a deep sink of knowledge and is a voracious reader.

We were talking about identity, one of yours and my favorite topics here at Friend to Yourself, where we wrestle with what makes me, “Me”.

Considering that all emotions and behaviors come from my brain, and that this can change so easily depending on the health of my brain, and if we define our identity this way… well, we’ve talked about this.

Asscherick shared this amazing poem that I thought you’d love.

Who Am I? (By, Dietrich Bonhoeffer)

Who am I? They often tell me
I would step from my cell’s confinement
calmly, cheerfully, firmly,
like a country squire from his country house.

Who am I? They often tell me
I would talk to my warders
freely and friendly and clearly,
as though it were mine to command.

Who am I? They also tell me
I would bear the days of misfortune
equably, smilingly, proudly,
like one accustomed to win.

Am I then really all that which other men tell of?
Or am I only what I know of myself,
restless and longing and sick, like a bird in a cage,
struggling for breath,
as though hands were compressing my throat,
yearning for colours, for flowers,
for the voices of birds,
thirsting for words of kindness, for neighbourliness,
trembling with anger at despotisms and petty humiliation,
tossing in expectation of great events,
powerlessly trembling for friends at an infinite distance,
weary and empty at praying, at thinking, at making;
faint, and ready to say farewell to it all?

Who am I? This or the other?
Am I one person today, and tomorrow another?
Am I both at once? A hypocrite before others,
and before myself a contemptibly woebegone weakling?
Or is something within me still like a beaten army,
fleeing in disorder from victory already achieved?

Who am I?
They mock me, these lonely questions of mine.
Whoever I am, thou knowest, O God, I am thine.

…thanks for sharing this with me. Keep on!

—

Ed Darling had the hardest time tracking. One thing led to another, and then another. The problem was that it wasn’t always a straight line, and there were a lot of open cliffs that flanked whichever idea or activity he diverted from before launching onto the next. For the others in proximity to him, tracking him was tiring and even perilous. Tiring in the sense that it took a lot of energy to follow and fill in gaps when Ed Darling moved between this and that. Perilous in that to be in relationship with Ed Darling would often leave you feeling alone and unheard, because Ed Darling had moved on to the next thing so fast. He couldn’t “stand” with you, interpersonally. He couldn’t be there long enough for you to communicate or complete your meaning and then actually receive what you were trying to give him in it.

In clinical settings, this kind of pattern is often not described relationally at all, but translated quickly into symptoms.

Many patients come to me like Ed Darling, and because I don’t prescribe amphetamines, I often don’t get to work with them for very long. Amphetamines are the accepted first-line therapy for what Ed Darling suffers with, Attention Deficit and Hyperactivity Disorder, or ADHD.

I felt rather thrilled to read about a study I came across published in Cell. It was like bulbs flashing in my face. I felt seen. Smile. I may not be eager to prescribe for ADHD, but I do enjoy the medical workup of why we feel the way we feel and why we behave the way we do.

Ed Darling deserved a good medical workup rather than jumping to a psychiatric diagnosis, or any diagnosis for that matter. We all do. There’s a reason that psychiatrists still have to complete college, then four years of medical school, then four years of specialty training. They need to be able to see the whole body and mind, and what medically can look like ADHD but isn’t ADHD.

Sure enough, Ed Darling had a thick neck, high palate, and a recessed chin. And sure enough, he’d been snoring loudly since he was a teen. On top of that, Ed Darling had been a football player in high school, and although he didn’t report concussions, he was a linebacker and inevitably, I’m sure he had chronic head trauma. Both untreated obstructive sleep apnea and chronic head trauma lead to changes in the frontal lobe that look symptomatically a lot like ADHD. Ed Darling was long overdue for some laboratory studies, including a sleep study.

The study published in Cell shows that the amphetamines commonly used don’t act on the brain’s attention circuitry as had been assumed, but instead target the brain’s reward and wakefulness centers. The study supports an increasing body of research looking at sleep, or the lack thereof, as a contributor to ADHD. Reading this, I found myself thinking less about attention as a moral or cognitive failure and more about what might be interfering with sustained wakefulness and frontal-lobe function in the first place.

What would have happened if I had just referred him to a provider for amphetamines? Well, he may have felt better, because amphetamines target the reward pathways of the brain, and people generally feel good on them. Ed Darling would have felt more awake, because yes, amphetamines target the wake centers of the brain. But that would throw a veil over what really may be going on. And then if those underlying disease processes weren’t diagnosed and treated, they would continue to do damage, even if Ed Darling was feeling better in the meantime. It would be like locking down your house when there was a slow water heater leak you didn’t know about.

Self-care in this scenario is more than Ed Darling doing what makes him feel better, more awake, more focused, taking stimulants. Self-care is Ed Darling working hard to get the studies done he doesn’t really want to do, and then the treatments that target the underlying illnesses. Ed Darling has to do this for himself. No one else can do this for Ed. I can partner with him. But ultimately, Ed has to fight for this. This is self-care from a biological perspective.

What Ed Darling’s story reminds us is that feeling better is not the same as being well. Medicine that sharpens focus or boosts wakefulness can be helpful, but it should never replace curiosity about the body that is asking for attention in the first place. True care, especially self-care, often looks less like a quick fix and more like patience, testing, and humility: slowing down enough to ask what else might be going on. When we honor that process, we move closer to treating people as whole human beings rather than as collections of symptoms.

Self-care tip:
If you are struggling with an emotion or behavior, consider asking not only “What helps me function better right now?” but also “What medical or biological processes might be shaping how I feel?”

Keep on!

Question to the reader:
Where in your own life might feeling better be masking something that still needs to be understood or treated?

Asking for presence today. For rest as well. Putting down the weights. Stepping out with the lightness that comes from this.

I ask for you the same. This is an amazing place to be. You are not alone!

Keep on!

My parents met in a small Seventh-day Adventist hospital in Benghazi around 1960. They got married about a year later. Dad had promised Mom that they’d go back to Lebanon to visit annually. But this didn’t happen due to the increasing fighting, which eventually led to the civil war around 1975. What my parents were able to do was bring together the American culture of independence with the Lebanese culture of community. That lived tension later helped me notice something larger about the culture I grew up in.

In my home country of the USA, I notice that independence is a hypertrophied muscle. It pulls hard toward self-sufficiency, spontaneous free will action, and one’s personal choices; it has crippled us.  Like a spinal torsion that develops after nerve injury, we are lopsided and hurting. When a muscle overdevelops without balance, it no longer strengthens—it distorts. Independence grew, and its growth spanned roughly 200 years of our American history, with major acceleration after WWII and cultural saturation by the late 20th century. It began as survival independence, but became ideological independence, then moralized independence, and finally identity-level autonomy. In this progression, something essential quietly slipped away. And now, with our great gain, we have great loss.

Our human condition is one that inherently wants to believe that we are powerful in our own selves. This is a spiritual condition as well, where we believe, even though often unsaid to our own inner selves, that we are our own gods. Not explicitly, but functionally, this is what we come to believe. That we have power apart from. We begin to trust our own capacity more than our need. We confuse autonomy with safety. We believe that power lives primarily within us.

This is where independence feeds into human weakness. Not because independence itself is wrong, but because the human heart is quick to translate capability into self-sufficiency. And self-sufficiency easily becomes self-dependence. We begin to live as though we are the source rather than the recipient.

Over time, this posture shapes our inner narrative:

And eventually, without realizing it, we crown ourselves as our own small gods. And we lose. We lose in this false belief. We lose the immense benefits that come from considering the collective, from nurturing it, and from feeding into it intentionally.

This isn’t arrogance in the obvious sense. It often looks responsible. Functional. Even admirable. But it is costly. Because when power is located primarily in the self, we turn into a façade. Trust becomes conditional. Surrender feels inefficient. When this posture becomes widespread, it no longer remains personal—it becomes cultural. And we practice life as a transactional culture.

The great loss of independence is not community or guidance—it is dependence itself.

Because this distortion is learned internally, it must also be undone internally. Self-care includes an intentional redirection, a turning toward the opposite direction of our cultural instincts. Strength is found in weakness. Life is found in surrender. Freedom is found not in autonomy, but in relationship. And real maturity is not the absence of need. It is the willingness to acknowledge it.

I’ve watched my parents do this when they brought fourteen of my Lebanese cousins out of the war to live with us. They didn’t think, “My private space is being infringed on! We can’t cohabitate in such a small space. My freedom is seriously being suffocated.” I’ve seen my patients do this too in the way they are willing to attend groups for mental health, such as NAMI. Some even run peer-to-peer groups. I’ve seen this when my patients come to clinic, belly side up, willing to learn, in a condition of vulnerability.

The invitation is not to reject independence, but to hold it humbly. To recognize that competence does not negate dependence, and agency does not replace grace. We were never meant to be self-sustaining systems. We were meant to be upheld.

Perhaps the truest form of freedom is not becoming our own gods, but remembering that we never were.

Self-Care Tip: Practice dependence this week—join a group, share a meal, ask for help. Get you community!

Dear Readers,

Going into the holidays, I encourage you. It is a time of so many blessings, but also pain. Wherever you are at, I encourage you to:

1.) Avoid comparisons. Per Grok: The famous saying, “Comparison is the thief of joy,” is widely attributed to former U.S. President Theodore Roosevelt, though some sources suggest variations were used by others like C.S. Lewis or Mark Twain—and it is one of my favorite sayings too. Probably because I have always struggled with it and have felt the loss of joy.

2.) Be more dependent than powerful; dependent on your higher power that is. We were not actually created to be powerful on our own, but rather to be given what we need emotionally from our higher power. During the holidays, let yourself rest rather than try to carry “it.” Then what you have in your stronghold, your bank, let it flow out and serve with it.

3.) Stick to your self-care habits. Stick to your self-care habits. Stick to your self-care habits.

This brings joy. Smile.

How are you getting through the holidays?

What self-care tips work for you?

My name is Sana Johnson-Quijada and I’ve been a physician licensed for practice, psychiatry and board certified since 2002. I have the privilege of working with NAMI Temecula Valley as a board member and in the community of the Riverside County. I write a column called, “Ask The Psychiatrist, just for the fun of it and to connect. Please send in questions of any idea, tree branch, or thread. I can’t wait to hear from you.

This is the latest: “How do I quiet my thoughts?”

Many, like Joanna, come to see me hoping I can answer this. Joanna was a young mother—five children, all between 9 months and 9 years—and I supposed she had heard of the others’ answers to her question:

“Well, what did you expect?”

And there is some truth in that. Five kids between 9 months and 9 years makes for a lot of sound, outside and inside of a young mother’s mind!

She was 19 and a half when she started having kids, and I wondered if 9 was her lucky number. But this was her time for healing and for an answer.

Joanna had asked herself,

“Joanna, look who is telling you—and look who is answering?”

Your own mind. And the telling and the answering come from the condition of your mind. There is very little you can do above the health your mind starts from.

When you hear the story of the talents…

If we consider Joanna’s brain as a bank, and all the good in her as something she is commissioned to do well by – her children, her community, her own self, and the one who invested in her—what shall she do?

How shall she deal? Right now she is spinning, almost like being buried in fear.

Her thoughts turn to how. The thoughts come fast. The story invites her to consider what she can do with what she has been given in her biology, in her health, or in her illness.

Joanna, you have bank, and the question of what can you do both with your bank and to get more bank is important. But try don’t value yourself based on a greedily given value system. Value comes from your character, but most importantly, from the One who made you—who gave you your bank. Your value doesn’t depend on the quantity of your “talents”, or money, or even what you can do for others. No. You are valued because you are you in any condition you come it. But! But… it is true that you have more to give if you are well. That is a different value system. And to get that kind of bank, it takes hard work. It takes courage. And it may take medical care as an investment in you that will then in turn bless others with your health.

"So how can I quiet these thoughts?”

My area is brain health; psychiatry. If emotions and behaviors come from the brain, then one could say:

Healthy brain, healthy emotions behaviors and thoughts.

Not many like this take. It is impersonal.

I partly agree. In a way, it is… the beginning. Not magic. Not a single answer. But it is a place to start—where grace and biology meet. Where Joanna’s noise can be understood not as failure, but as a signal:

It is time to tend to the bank. To take inventory. To be honest about what is there—and what is not. And from there, to invest again. Gently.

Starting with brain healing—such as through medication, for a medical condition like generalized anxiety—is a great place to begin quieting the noise. It means being accountable to yourself and to what you have gotten. There is no judgment in your condition. It is simply where you are starting from at this point in time. There is hope for where you go from here.

Self-Care Tip: Invest in your mental health to invest in others. Keep on!

Question: What is the beach at low tide?

Answer: It’s a crowded beach.

Low tide at the beach was so pretty until I noticed all those people with their auto repair accoutrements like wrenches and screwdrivers, kitchen tools, gardening shovels—shovels I say! People?! Shovels! —all picking, poking, and killing off the last tide pool life here on this little planet Earth. There is a frailty in our ecosystems, both in our physical and psychological.

That day, I felt a sense of mourning. And I might have been catastrophizing a little when I said, “the last of life,” but it feels like Mother Earth, Gaia, is groaning – a cornered, beautiful creature, unable to escape what we are doing in this human impact.

All these choices we make brought my mind and thoughts into the office, where I met with Frederick. He – who had once been on the verge of hospitalization due to affective instability, then stabilized with medication. However, now he came to me partially treatment adherent. What is partial treatment adherence? Partial treatment adherence looks like missing one day here and there—maybe more—of treatment. For whatever reasons, we all have good ones, not to take our meds. Frederick told me, he was irritable. I could feel the irritability, in fact, coming off him in waves; something physical but not seen. His irritability spoke at me, hit me, and brought memories of what he was like when we first found his treatment and stabilized on it.

Frederick’s struggle with partial treatment adherence mirrors the environmental metaphor with the tide pools – harmed by small, cumulative actions, lapses in mental health treatment. This creates vulnerabilities, leading to relapses – progressive deterioration in the conditions, fewer star fish to see. There is a complexity in treatment adherence as well as in consistently helping our earth.

Fred told me that he had been doing so well, he just forgot to take it every day. His pill dispenser became a confusion of days—some filled with pills, some empty. He didn’t know when he had last dosed. But he was trying. It just was. No good reasons. It just was. And as his irritability found him, I remembered those poor tide pools being slashed and hacked, Mother Earth groaning trapped beneath a shovel, like Frederick unable to escape one’s mental illness. Fredrick was in a sense cornered too.

Mental health can be like that: where we find our beauty again with treatment, become a horizon with clear skies, clapping waves, the tide pulling back. We are thrilled to see the rocks and sea life surface. Then treatment nonadherence hits us, and it feels like—no matter what—it’s just the way the Earth turns, the population interacts with us, and we are vulnerable to our own selves not taking medication.

There are no quick solutions. For example, Frederick was doing good things for long term health, like using his pill dispenser. He was educated, and he wanted care. It wasn’t like he was trying to lead his own treatment plan. His lapse in adherence just seemed to happen, like population growth, pollution, and the inevitable damage of our tide pools. There is room for compassion.

As I walked on the beach, passing these layers of families and individuals and the crazy toys they were using in the crevices of the tide pools, I wanted to stop and explain, “Please don’t touch.” Please don’t harm. Please stand and enjoy the ambiance that nature provides—the sensory privilege of seeing color and life that you had nothing to do with except not to harm. But much to my children’s relief, I did not. I walked on the grounds of Gaia filling my ears with her groaning, a cornered creation with nowhere to escape. Remember Romans 8, “All of creation groaning in earnest expectation…”.

I was there, at least, seeing our humanity in action.

And I thought of Frederick. What can I do for him except restart him on his meds and routine dosing? I felt that internal conflict of knowing when to act versus when to observe and reflect. Frederick’s partial adherence to treatment was floating in the gap between knowledge and action.  But then I also thought that suffering beside Frederick, letting him know that someone understands—that his mental illness comes back without treatment, and I’m not blaming him for it—is enough. That’s something I can do. I’m just standing with him as his body suffers, as his identity suffers, as his relationships suffer, and I sorrow with him. I bear witness.

Treatment adherence is not easy for anyone. Knowledge doesn’t always create change considering all the forces.

The other day, when walking on a much emptier beach with my daughter—newly minted in her own oceanography experience from a summer on the Puget Sound—she happily relayed to me, “Mom, we are making a difference. The ocean is slowly recovering. The measurements people are taking show that the reefs and tide pools are healing.” Both the tide pools and Frederick’s mental health journey are dynamic systems subject to cycles of harm and healing. Progress is possible, even if setbacks occur.

So I juxtapose this to what I saw: this crowded low tide, surplus of people and their tools. I think of Fred, his own relapsing condition. And I think treatment does make a difference. He has had a period of stability worth celebrating. And when, inevitably, he—like so many of the rest of us—becomes partially treatment-adherent and when he starts having symptoms again, we can remember that treatment is making a difference.

The ocean is healing in contrast with despair.  Consistent, mindful efforts—whether in environmental conservation or mental health—we can stand and bear witness to the pain, suffering in the journey and we can still hope.