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Generalized Anxiety Disorder – HOW DO I QUIET MY THOUGHTS?

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…

…A man had three servants.

To one he gave five talents.

To another, two.

And to the third, one.

The one with five talents invested wisely and returned with ten.

The one with two also doubled his and returned with four.

To both, the master said,

“Well done, thou good and faithful servant.”

But the one with one talent came back and said:

“I did not want to lose it in an investment, and I did not want you to be angry with me if I did. So I buried it.

Here you go. Here is your one piece of silver—safe and sound.”

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!

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Standing Witness to Suffering with Treatment Nonadherence

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.

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Stigma! Stigma! Everywhere Stigma!

Our work is not done. I am heartbroken this morning after speaking with… let’s call her Carol.

Carol and I have been working together for about two years and have achieved moderate treatment response for her mood and anxiety issues through both talk therapy and pharmacotherapy efforts. She is a high-functioning mother and wife, working full-time, and truly just an amazing person all around. However, Carol has had a long history of attention deficit and hyperactivity disorder (ADHD), which was successfully treated during her teenage years but has gone untreated for years. It is now seriously deteriorating her quality of life in multiple ways: you guessed it—at home interpersonally, at work with her productivity, and even affecting her self-image.

The limitations of my clinic in treating ADHD are significant. I have been fully telehealth since COVID and never had a nurses’ station to monitor the necessary vital signs or perform an EKG (heart rhythm monitoring), which is required during treatment with ADHD-indicated amphetamines. My standard practice has been to collaborate with the patient’s community primary care physician (PCP). I send my clinic note along with my contact information for any questions, provide treatment recommendations and parameters, and then follow along as the consulting clinician while the PCP prescribes accordingly. This process works out about 80% of the time, I would estimate. I am very grateful for the collaborative relationships I have built with our attentive and generous community physicians, whom I’ve had the pleasure of working with over the past 23 years in our area.

On the rare occasion over these past 23 years, however, things haven’t gone as well as one would hope. Carol had such an experience. And, of course, I thought of you, dear NAMI people—you who are so vocal and active in fighting community stigma related to mental health.

Carol started a norepinephrine agent approved for ADHD and followed up with her PCP… let’s call him Dr. Dan, to consider an amphetamine. Unfortunately, she experienced a relapse in her anxiety due to the norepinephrine agent. By the time she was able to see her PCP, Dr. Dan, she was having full-blown panic attacks. These were occurring out of the blue, even awakening her from sleep, leaving her absolutely terrified.

Dr. Dan, in brief, gave her the riot act: “You need to stop eating carbs and lose weight. You are on a lot of really heavy meds. If you did, you’d be able to get off of those meds. Think of your kids…” And I thought, “Noooooo!” My skin even hurt as I listened to Carol recount this. It was so painful.

Dear Peeps, we are not done. Data shows that the best way to combat stigma is through peers—not through doctors or clinicians. Wow! So, please, please keep talking and living out your beliefs in mental health. You make an enormous difference for an enormous need.

Self-Care Tip: Everything starts and ends with “Me”. To decrease stigma, start right here, with Me and let it spread. Even to your PCP!

Question: How has stigma affected your mental health journey? Please speak! Keep on!

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Understanding Medication Nonadherence

“I’m doing really well!” Gene said, and he proceeded to tell me just how well things were going for him.

Gene, a father of three, a husband, and employed full-time, had a life marked by chronic worry and intermittent bouts of depression, occasionally punctuated by panic attacks. We had been working together for several years. During that time, he had experienced some periods of stability.

I was glad to hear how well Gene was doing: exercising regularly, sleeping through the night, performing well both at home and at work, and feeling more agency in his life.

Wonderful, right? Stability is a good thing. But what wasn’t so wonderful was the cycle Gene often found himself in—swinging from severe anxiety to depression, to anxious depression, to what he believed were symptoms of ADHD, and back to anxiety again, a bird in flight without a compass. This pattern played out between his visits. He would come to the clinic one day looking like a shiny penny, only to return in crisis during the next follow-up. Why was he stuck in this cycle? Maybe it was biological—or maybe not. One thing, however, was certain: Gene had a recurring habit of self-sabotage. He loved to self-adjust his medications.

During this particular clinic visit, Gene rushed through his medication list, likely sensing that I wouldn’t be as pleased with him as I was when he had shared his successes at the beginning of our appointment. I noticed him fidgeting as we talked, his eyes darting right, then left. That’s when I knew—without him even saying it—that he had altered his medications again. On his own.

Have you ever been in a relationship with someone you cared about, where their behavior forced you into a confrontation you never wanted to have? Like a friend who drank too much at every dinner party, leaving you no choice but to say, “You have a drinking problem.” Or a child who spent more of your money than agreed upon, and even though you could afford it, you knew it wasn’t good for them, so you had to say, “I can’t give you money anymore.” And it leaves you feeling gutted. You’d much rather be the “Yes-man,” the generous one, rather than the uptight enforcer. You feel misunderstood, even a little resentful, that you were in essence pressed up against the wall without anywhere else to go but into the confrontation. No one thinks about how hard it is for you to have to say “No,” in whatever fashion the situation called for. No one considered that is not something you ever wanted to do. “I don’t want to be this person!”

When someone in your personal life behaves in a way that forces you into uncomfortable confrontations or makes you feel cornered into addressing issues you’d rather avoid, it’s often described as emotional manipulation or manipulative behavior.

This can also be seen as a form of boundary pushing or boundary testing, where the person knowingly or unknowingly disregards your limits, forcing you into a position where you must enforce your boundaries, even if it’s uncomfortable for you. Sometimes, this is referred to as being emotionally strong-armed or coerced into conflict. These situations can make you feel trapped into playing the “bad guy” role, despite your best intentions.

Gene was doing a form of this in our clinical relationship. He’d be in a crisis, call me and I’d see him, reactively rather than proactively. Then Gene would go and play around with his medication dosages and/or stop or start other medications he had at home at will.

This behavior, where a patient adjusts or changes their medication regimen without consulting their healthcare provider, is called medication nonadherence. More specifically, when patients alter their dosage, skip medications, or stop taking them entirely based on their own judgment, it’s often referred to as self-medication or self-adjustment of treatment.

This behavior can undermine the effectiveness of the treatment and lead to unstable health outcomes, as seen with Gene, where it contributed to his ongoing cycle of anxiety and depression.

“Gene”, I said. “As we’ve discussed many times before, I can’t continue in a patient-doctor relationship with you like this because it’s not good for you. In essence, you are treating me like a dealer. We are not a team.” I did not want to say it but had to. “Gene, if you do this again, we’ll have to terminate our work together.”

Gah! I hate doing that!@#@#^&*%^&*(!!!

There are so many reasons patients do this and it’s not something to be ashamed about. See this post, A Tiffany Diamond Isn’t This Good, to go over reasons for treatment nonadherence. It’s so common that it’s almost normal, but it doesn’t carry a moral value. That’s not to say that it’s not hard on the medical providers, nor harmful to the patient and that’s why it is better to deal with it upfront rather than let it go on and on and on.

Confronting a patient about treatment nonadherence can lead to several positive outcomes, both for the patient and the therapeutic relationship. Here are some key benefits:

  1. Improved Understanding: By addressing the issue, you can help the patient understand why sticking to the prescribed treatment plan is critical for their health. It opens the door for education about the risks of self-adjustment and the benefits of adherence.
  2. Strengthened Trust and Communication: Having an open and honest conversation builds trust. It shows the patient that you’re not just a prescriber but a partner in their care. When patients feel heard and understood, they are more likely to be honest about their struggles, leading to better outcomes.
  3. Identifying Barriers: Confronting nonadherence can reveal why the patient is making these changes—whether it’s due to side effects, misunderstanding, financial issues, or other personal reasons. This insight allows you to address those barriers and adjust the treatment plan if needed.
  4. Tailored Treatment: If the patient feels the medication isn’t working or is causing problems, discussing it allows you to collaboratively adjust the treatment plan in a safe and effective way. This can make the patient feel more in control while ensuring their health is prioritized.
  5. Prevention of Future Health Complications: Addressing nonadherence early can prevent the patient’s condition from worsening. This proactive approach can reduce the likelihood of unnecessary health crises or hospitalizations.
  6. Patient Empowerment: Confronting the issue respectfully and collaboratively can empower the patient to take an active role in their treatment. This can lead to greater self-awareness and better long-term adherence to medical advice.

By having this conversation, the clinician and patient create space for a more individualized approach that acknowledges the patient’s concerns while ensuring their safety and well-being.

Self-Care Tip: Work together with your treatment providers! Be a team :). Keep on!

Questions: What are good reasons you’ve found for treatment nonadherence? We need to hear!

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I bless you

Thinking about you, Friends. And they are good things.

I bless you today. I bless you with all the kindness found in knowing one’s flaws, grace in knowing your own, mercy when you are right, and forgiveness when you are not. I bless you with peace.

May your journey be one in company of love.

Have a lovely day Friends.

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Check out these ladies working their self-care over!

youtube.com/@tamree3970

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Cell Phones and Addiction

By Ella Quijada

It is widely recognized that smartphone use can be compulsive and problematic. Humans are consumed by the allusion of connection. The reward pathway in our brain chases notifications, the bright blue lights, and endless scrolling. Our biology trades reason for mere seconds of dopamine. Many refer to this smartphone dependence an addiction. Excessive use of smartphones shares similarities with other recognized impulse disorders and behavioral addictions as recognised by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (Chen & Ting, 2020). Defined symptomatology of smartphone addiction includes forms of physical, psychological, and social harm. Problematic characteristics of excessive smartphone use compare to the criteria for gambling disorder and substance abuse in the DSM-5 such as: “Tolerance/increased in frequency, duration, and quality in order to attain the same level of satisfaction; Preoccupied/obsessive thoughts; Dangerous use/continue behavior despite the negative impact; Difficulty in controlling; Impact negatively on functioning in occupational, social, and daily life; Withdrawal” (APA, 2013). Using a questionnaire consisting of psychological-social and technological dimensions relating to these criteria, 48% of 416 sampled university students were identified to be smartphone addicts (Aljomaa, Al.Qudah, Albursan, Bakhiet, & Abduljabbar, 2016). 

People around the globe, specifically young adults, are not ignorant of these statistics. A growing number of Gen Z-ers are taking this concern into their own hands in what The New Yorker identifies as a “dumbphone boom” (Chayka, 2024). Whether or not abandoning a smartphone is a genuine trend, there is no question that a less advanced phone would decrease time spent online. The author of the New York Times best-selling books Chasing The Scream, Lost Connections, and Stolen Focus, explained that “The opposite of addiction isn’t sobriety – it’s connection” (Hari, 2018). Therefore, in pursuit of real connection, smartphone users should consider transitioning to a flip phone to nurture their social, psychological, and physical safety. 

While most people who use technology agree that cell phone dependence has negative consequences, many would not consider the flip phone as a practical solution. Critics have argued that smartphones are essential for staying connected and accessing information. A survey from 500 respondents from two different universities reveals that students perceive smartphones to have a “positive influence on their communication pattern” (Adelabu, Esiri & Sanusi, 2015). This is largely valid in terms of long distance communication and convenience. However, smartphones do not offer any essential communication that flip phones cannot accomplish. On the contrary, research has shown many downsides to the compulsive connectivity of smartphones.  

The addictive nature of smartphones often leads to safety hazards, unproductive tendencies, and decreased intrapersonal and interpersonal skills. Intrapersonal skills involve the management of one’s own thoughts, emotions, and behaviors. Interpersonal skills enable collaborative and empathetic interactions with others. Competencies from both intrapersonal and interpersonal realms are critical to authentic connection and overall-well being. However, technology has the potential to hinder this emotional intelligence and communication. A quantitative correlational survey revealed that “the significant value of interpersonal skill (p= .73) and cell phone addiction is (p = .19)” (Niaz & Qasim, 2022). This demonstrates an inverse relationship between cell phone addiction and interpersonal skills. Nonverbal decoding skills were further measured using self reported data measured from the Emotional Sensitivity subscale along with objective measures from standardized tests such as the Diagnostic Analysis of Nonverbal Accuracy-Adult Faces and the Workplace Interpersonal Perception Skill (Blanch-Hartigan, Correale, Ruben, & Stosic, 2020). The findings categorized two types of participants, active and passive technology users. Active users who posted content and frequented digital applications performed significantly worse on objective measures of nonverbal decoding skill (Blanch-Hartigan, Correale, Ruben, & Stosic, 2020). In contrast, flip phones embody passive technology that protects both digital and physical interpersonal communication.

The lack of both intrapersonal and interpersonal skills are also correlated to mood, anxiety and attention disorders. Experimental studies have revealed that “emotions happen within a social context and are partly regulated through other people” (Hofmann, 2015). Excessive screen time averts this interaction and in term coincides with psychological disorders like “social anxiety, depression, impulsivity, and loneliness, as well as attention deficit problems” (Ting & Chen, 223). Problematic smartphone use also fosters body image dissatisfaction and negative influence on productivity and quality of life (Lee, Lee & Suh, 2016; Wright, 2021). There are biological explanations for why screen time diminishes productivity. Smartphone use results in neurological changes by increasing levels of gamma-aminobutyric acid (GABA) in the brain, which decreases an individual’s attention and control (Sigman, 2017).

This attention and control deficit, as well as impulsive smartphone activity, poses safety threats, specifically on the road. Using a flip phone minimizes distractions, such as impulsive texting and browsing, and therefore reduces the risk of driving accidents. Multiple studies have found that the traditional tactical button interface of a flip phone encourages intentionality. This interface has advantages “in a driving context in terms of lower visual demand due to the existence of enhanced tactile discrimination of key location and textual cues that are present on and between keys” (Donmez, Mehler, & Reimer, 2014). Texting and driving and mindless scrolling is of course less convenient on a flip phone. 

There are many solutions to subsidizing digital addictions and protecting one’s psychological and physical safety. Digital critics suggest blocking certain apps, restricting screen time, or even discarding the mobile phone all together. After failing at the above attempts, transitioning to a flip phone is what worked for me. It is minimalistic, cost effective, and still supports the basic pillars of digital communication. As the New York Times author professed when ditching his $1,300 iPhone 15 for a $108 Orbic Journey, “the more boring, the better”, (Hill, 2024).

Adelabu, O., Esiri, M. & Sanusi, O. (2015). Smartphones and communication patterns among students in higher institutions. Singaporean Journal of Business Economics and Management Studies, 4(1), 56–63. https://platform.almanhal.com/Files/Articles/70117

Aljomaa, S. S., Al.Qudah, M. F., Albursan, I. S., Bakhiet, S. F., & Abduljabbar, A. S. (2016). Smartphone addiction among university students in the light of some variables. Computers in Human Behavior, 61, 155–164. https://doi.org/10.1016/j.chb.2016.03.041 

American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (DSM-5) (5th ed.). American Psychiatric Pub.

Blanch-Hartigan, D., Correale, J., Ruben, M. A., Stosic, M. D. (2021). Is technology enhancing or hindering interpersonal communication? A framework and preliminary results to examine the relationship between technology use and nonverbal decoding skill. Frontiers in Psychology, 11. https://doi.org/10.3389/fpsyg.2020.611670 

Chayka, K. (2024). The dumbphone boom is real. The New Yorker. https://www.newyorker.com/culture/infinite-scroll/the-dumbphone-boom-is-real 

Chen, Y. Y., Ting C. H., 2020. Practical resources for the mental health professional. Adolescent Addiction, 2(8), 215-240. https://doi.org/10.1016/B978-0-12-818626-8.00008-6.

Donmez, B., Mehler, B. & Reimer, B., 2014. A study of young adults examining phone dialing while driving using a touchscreen vs. a button style flip-phone. Transportation Research Part F: Traffic Psychology and Behaviour, 23, 57-68. https://doi.org/10.1016/j.trf.2013.12.017.

Hari, J. (2016). The opposite of addiction isn’t sobriety – it’s connection. The Guardian. https://www.theguardian.com/books/2016/apr/12/johann-hari-chasing-the-scream-war-on-drugs

Hill, K. (2024). I was addicted to my smartphone, so I switched to a flip phone for a month. International New York Times. link.gale.com/apps/doc/A778627865/AONE?u=anon~412c637b&sid=googleScholar&xid=5927539c. 

Hofmann, S. G. (2014). Interpersonal emotion regulation model of mood and anxiety disorders. Cognitive Therapy and Research, 38(5), 483–92. https://doi.org/10.1007%2Fs10608-014-9620-1

Lee, S. B., Lee, S. C., & Suh, Y. H. (2016). Technostress from mobile communication and its impact on quality of life and productivity. Total Quality Management & Business Excellence, 27(7–8), 775–790. https://doi.org/10.1080/14783363.2016.1187998

Niaz, A. & Qasim, A. (2022). Cell Phone addiction and interpersonal skills among youth. International Journal of Innovative Science, 7(12). https://doi.org/10.5281/zenodo.7525338 

Sigman, A. (2017). Screen dependency disorders: A new challenge for child neurology. Journal of the International Child Neurology Association. https://doi.org/10.17724/jicna.2017.119 

Wright, M. F. (2021). The negative online experiences of maltreated children and adolescents. Child and Adolescent Online Risk Exposure, 283–301. https://doi.org/10.1016/b978-0-12-817499-9.00014-4 

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Teacher teacher

Today a patient, speaking with a sense of peace and hope, reminded me of the saying, “When the student is ready, the teacher will appear”.

Mm mm.

Self care indeed.

Keep on!

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God-Love and Palentines Day

While Audrey and Marlo peruse their Cheesecake Factory menus I people-watch. (I already know I’m going to have the vegan cob salad.) The place is filled. Some are sitting alone, while others are working hard on feeling connected. And once more, a weightlessness hits me.

It amazes. God loves each person in this topped off restaurant.

Even as self-absorbed as I am, a rhythm of thinking that God is all about “the fantastic me,” a Quincy Jones funk beat breaks in. Bounce. Boom. I realize that He is just as intensely absorbed with each individual.

When the weightlessness intrudes, I try to understand it, grasping. Where is the root or rock to grasp while I fall? The only way to date that I can is through our children. We love each of them, not in a quantifiable or qualifiable way—it just is. Weightless. And that’s how God loves us. It simply exists. It’s not about an amount.

I also hesitate to say that it’s qualitative, even though God’s love is relational. Qualitative implies measurability, and God’s love is immeasurable. It just is.

I hope you had a wonderful Palentines. (The term Palentine originates from the combination of the words “pal”, which is another word for friend, and “valentine”.) And if you didn’t, for whatever reason, know that you are loved.

Self-Care Tip: Know the love and value you are held in.

Keep on!

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How to Avoid Puddles and Suffering

Like walking around parking lot puddles, we spend our lives trying to avoid losses and suffering. That makes intuitive sense and I’d recommend continuing to do that. Smile. However, consider the reversal processing of that.

https://images.app.goo.gl/oFKuUV1hJw93VMiw9

In film development, there is this option, after the negative image has been developed. The film it is totally bleached away using an acid bleach that starts the development of the negative image. This leaves the unused silver halide untouched, but it is not fixed out, as it will later be used to form the positive image.

In mental health, I might consider this the self care we do for our biology. The stuff no one can do for us. Like the basic 6: food choices, clean air/sunlight, exercise 3-5 days a week, sleep greater than 6.5 hours a night, spiritual, and taking your medication. No one can do these for you. That is what I call being a friend to yourself. They are the most important part of avoiding those puddles in life.

Self-care tip: Doesn’t need saying again after this blurb. :) But let me know how it is going for you! Please reply. People need to hear your voice.

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Sad day grieving – by community person

A woman in our community shared this with me about her grief and I thought you’d appreciate it, and even relate.

This woman lost her mom when she was 19 years old to breast cancer. Then, her only sibling had a sudden heart attack in his late 40’s. Then, shortly after, her father died in a matter of days from COVID. Her dad was alone in the hospital. This woman was minutes away and not allowed to be with him, to hold his hand while he passed. There’s other miseries that punctuate the in-between spots but we really don’t need to list them all.

As tragic as her story is, and it really really is, she’s not the only one with grief. She, unfortunately, is not specially targeted by the universe to suffer. But suffering is a lier like that. (…The meaning of LIER is one that lies, as in ambush.) It makes each of us feel like we are “special” in our suffering. And then that “being alone experience” leads us to more isolation, toward progressing danger of becoming a victim to it. We are in danger of practicing “Terminal Uniqueness.”

“Terminal uniqueness” refers to the belief that one’s experiences, feelings, or struggles are so unique and individual that no one else can truly understand or relate to them. It’s a mindset that can hinder connection and empathy with others who may be going through similar challenges. In reality, while each person is indeed unique, many share common human experiences. Recognizing this can foster a sense of connection and support. And that’s not friendly.

I’m blown away that this woman reached out when she did. That she fought the current pushing her into isolation.

Yesterday marked a sad day for me, and after attending my brother’s service last night, I penned down these reflections:

What signifies healing? Is it the capacity to discuss painful matters without tears streaming down your face or suppressing the choking sensation that seizes your breath as you attempt to stifle the cry of agony?

Today, I found myself ugly crying—recalling this day four years ago when I lost my brother as I woke up. I sobbed while being embraced by my family this morning, as we tried to share the weight of this memory. During our ritualistic journey, we laid flowers on their headstones to mark our presence, and I cried again at my family’s gravesites. Despite my efforts to smile through the tears, I continued crying while driving home, in the shower, and even now in my bed. It’s the kind of crying that causes your eyes to swell shut and your sinuses to congest, forcing you to breathe through your mouth. Physiologically, it happens as you squeeze your eyes tightly to stop the flow of tears, pushing the fluid into any available space. It’s the kind of crying where sobs cannot be silenced, your heart literally squeezes in your chest, and you become light-headed from the effort. It’s unsustainable, but grief takes you there time and time again.

So, I attempt to reframe my brain, tricking my body into thinking it’s a good idea to endure this again another day. To face and even embrace what lies ahead, because those of us still here are the fortunate ones, right?

But for now, in this moment, I miss my nuclear family—the core of my memories, my childhood, the ones I call mine. I miss them from the top of my head to the tips of my toes, with every breath and heartbeat, every fiber of my being. I miss them in an abyss, a void that never diminishes. In these moments, I realize I am forever changed by their loss and acknowledge I may never find my way back because, in the center of it all, there is nothing and no one that can fill that piece of my puzzle.

Self-Care Tip: If you have your own story you’d be willing to share, please do. Be in community with your suffering.

Keep on!

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Subclinical Depression

  • Are you irritable?
  • Do you have a chronic illness?
  • Does your family complain that you don’t seem like yourself?
  • Is it hard to feel pleasure?

These, and more, Signal a high likelihood of a chronic untreated, low-grade depression. Your quality of life could be much higher.

Today I’m speaking for a group of all unmarried females ages 25-55. Varied educational backgrounds. The members are all Christian so I am told that they usually appreciate scriptural references, and also real life examples and practical applications.

Subclinical depression reminds me of those verses in Revelation about how/(whom) we don’t see ourselves.

14 And unto the angel of the church of the Laodiceans write; These things saith the Amen, the faithful and true witness, the beginning of the creation of God; 15 I know thy works, that thou art neither cold nor hot: I would thou wert cold or hot. 16 So then because thou art lukewarm, and neither cold nor hot, I will spue thee out of my mouth. 17 Because thou sayest, I am rich, and increased with goods, and have need of nothing; and knowest not that thou art wretched, and miserable, and poor, and blind, and naked…

Revelation 3:14-17 (KJV)

A people who are doing relatively well by the looks of it, but who are not really able to see that although this is how it seems, they actually are in a condition of suffering.

I don’t really use a lot of Bible verses in my general speach or writing because I just don’t know how to do it w/o become icky and preachy but i’m going to try. Please give me as much of a break as you can and know that yup. I hear it too. Ick. It’s not God’s fault. So there you have it.

But why would depression bring this seemingly unrelated reference to Laodicea? Because of the next verse.

18 I counsel thee to buy of me gold tried in the fire, that thou mayest be rich; and white raiment, that thou mayest be clothed, and [that] the shame of thy nakedness do not appear; and anoint thine eyes with eyesalve, that thou mayest see.

Rev 3:18 (KJV)

I don’t know if the word “insight” was even around when John the Revelator wrote this but that’s what he was talking about.

You can’t listen to your insight and intuition all the time. You have to have a healthy dollop of distrust for your own inner voice. The siren’s song of our inner self to isolate and “do it on your own”, however dulcet and powerful, are dooming.

When Marsha suffered a dramatic loss in the stock market, she became crippled by anxiety and irritability. It had the further outcome of estranging her from her spouse and friends. She spent all her clean, controlled, but lonely time, alone, like a many thorned beautiful rose in a glass vase.

Marsha and I tugged with this concept, like holding onto different ends of a rope. She did not want to start pharmacotherapy. She did not want to disrupt her flow.

Sometimes our lives are “in flow,” but it’s not a healthy flow. We are doing some healthy behaviors, such as exercising, getting our sleep, eating well. However despite this, our emotional disease progresses, unchecked by uncomfortable deliberate efforts. Sometimes we are medication adherent even, and yet our behaviors and emotions are not kind to ourselves. We remain in a condition of suffering, isolated; unable to connect to self and others. We are undertreated but we can’t see it. We think because we are going to work, taking care of things, we are “making it.”

As my beloved residency attending used to tell me,

Look who’s telling you that.

By which of course he meant, your own brain can not be the best mirror of your soul.

Compare Marsha to Madge.

“I like the way he sees me.  I have a lot of trouble seeing myself.”

Madge really had it going, as far as I was concerned.  In this one statement, she is insightful.

Juxtaposing being able to see into oneself with the self-declaration of not being able to see, is ironic.  It is lovely, like going toward anxiety to diminish its power over us.  It is complex, as are the many hues of gray.  A beautiful weed.  Great weakness.  Useful trash.  It is a pretty great irony to come to that place of wisely recognizing how little wisdom we have.

We have trouble seeing ourselves. Part of what makes it so hard to be friends is that doing that is like shaking our own hand.  When we try, we are a purse flipped inside out.  The crude insult, “Her head is stuck up her own a–!” comes to mind.

Back to our handy John the Revelator, …

18 I counsel thee to buy of me gold tried in the fire, that thou mayest be rich; and white raiment, that thou mayest be clothed, and [that] the shame of thy nakedness do not appear; and anoint thine eyes with eyesalve, that thou mayest see.

Rev 3:18 (KJV)

Everything he counsels us to buy is from outside of “Me” and in this case, the “eyesalve” is the brain-changer.

Looks who’s telling you that…

Now if you want to know more about undiagnosed untreated chronic depression, lets talk today at the meeting.

Keep on!

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Sleep Well, (or else, get to getting you some.)

The Biopsychosocial Model of Evaluation and Treatment in Psychiatry | SpringerLink

The intricate tapestry of sleep intertwines with various aspects of life, reflecting its impact on physical health, emotional well-being, and interpersonal relationships. Let’s weave these threads together.

Here is the outline for tonight’s NAMI meeting:

  • **Understanding the Biopsychosocial Model:**
    • The importance of the biopsychosocial model in addressing sleep difficulties. By considering internal and external factors, embrace a holistic perspective.
  • **Importance of Biological Perspective:**
    • The recognition of sleep as a fundamental component of our biological identity – Sleep is not merely a restful activity but a vital process that shapes our emotional and behavioral well-being.
  • **Tools for Better Sleep Hygiene:**
    • Practical tips for better sleep hygiene serve as actionable tools to enhance the biological foundation of our mental health. From bedroom habits to daytime activities, these tools offer a roadmap for fostering healthy sleep.
  • **Daytime Alertness and Stimulating Medications:**
    • Underline the importance of daytime alertness, emphasizing the connection between wakefulness-promoting activities and overall mental well-being. The introduction of stimulating medications provides an additional layer for those facing challenges in staying alert.
  • **Personal Stories:**
    • The challenges of adopting better sleep hygiene are a human issue we all have, and our home system/culture paved the way we got here.
  • **Psychiatric Vital Sign: SLEEP:**
    • Underscore its diagnostic significance. This reframing encourages a proactive approach in assessing and addressing sleep-related concerns.
  • **Cultural and Emotional Complexities:**
    • There are cultural and emotional complexities tied to sleep, acknowledging that changes in sleep habits involve more than just physical adjustments. It’s a journey of self-discovery and adaptation.
  • **Advocacy for Sleep:**
    • The call to fight for one’s sleep urges individuals to prioritize their well-being. This advocacy is a powerful reminder that prioritizing sleep is an act of self-love and perseverance.
  • **Sacrifice for Well-Being:**
    • The essence of sacrifice for a healthier, more capable self. Prioritizing sleep is not a selfish act but an investment in personal and relational well-being.

In weaving these narratives together, the common thread is the recognition of sleep as a foundational pillar for overall health. Whether approached from a medical, psychological, or personal standpoint, the message remains clear: prioritize sleep for a richer, more vibrant life.

One of the many reasons I speak at these meetings is that it gets me thinking and writing more.  In brief, we’ll talk about, well, sleep!  (Smile.)

Keep on!

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Psychiatric Hospitals and Homelessness

Hello “FriendtoYourself Community”!

Have you ever heard of a day hospital? In the psychiatric treatment options, the day hospital is a gem. Sometimes it is known as a “Partial Hospital Program”, or PHP. This hospitalization is called a “step down unit” as well and is classically where people go when they need more than typical outpatient care with either or both of a psychiatrist and a talk therapist, but they are not needing full inpatient care in a hospital where they stay overnight. In my community, one of our hospitals is working to develop a day hospital program.

I’ve been asked about my experience with patient’s of whom I’ve referred to psychiatric day hospitals. “They” want to know about the demographics of whom I send, why the patient’s go, and their outcomes. They have a concern that by providing day hospital care, it puts the community at risk for increasing homelessness. You can see the pavers span a distance before arriving at that conclusion but it is understandable if we walk. Fears are important. None of us are above them.

Oftentimes, patients on initial evaluation come to me in crisis because they wait. They prefer to try anything else before seeking help, even resorting to unconventional methods. There has to be something in their life that pushes them to the point of willingness to see a psychiatrist. They come to me when it’s either see me or go to a psychiatric inpatient hospital bed. They may not qualify for a 5150, (a legal hold when someone is danger to self, danger to others, or gravely disabled – unable to provide food, shelter, or clothing for themselves). Yet although they are not disabled, at that time in their illness, I may still not be the best match for their medical care.

Outpatient clinical psychiatry is for people not in crisis. If you’re having an emergency, you should not be in my office. My outpatient clinic is not equipped to deal with emergencies, aside from being able to call law enforcement. For those in a psychiatrically fragile condition, they need more. In outpatient clinics, there are fewer allowances for this.

So, it was with Anna. Seeing a psychiatrist was the very last thing she was willing to do to get better.

People like Anna come to me at a critical juncture in their life. It’s a choice between visiting me or heading to the emergency room.

Let me introduce you to her. Anna is a 38 year-old mother of three. She’s been married for 15 years and comes from a family who survived their own depressive mother and a father who excessively drank alcohol. Her mother parented in the ’70s and ’80s when there were not many options for her. Her mother had tricyclics and MAOI‘s until Prozac came out in 1987. It was a different world of understanding mental illness and being able to treat it. Anna and her three siblings grew up with a depressed mother and an alcoholic father. Depression is contagious. So, Anna grew up with a household of depressives. Not only is it impossible to live with depressives without getting depressed, but she also had the added burden of her genetic loading written into her DNA. She was at high risk of developing depression herself.

In high school, Anna met her first and last boyfriend, Dave, and she thought he was everything; religion, hope, and fresh backed cake. They went to college together, moving in their freshman year and dropping out when she got pregnant. They had an active life before pregnancy, going out all the time and having common interests. They were best friends. It was the happiest time of her life. Then, when the babies came, life became more difficult. Dave started using drugs and alcohol, and they hadn’t had sex in eight months. They were not connected, and Anna found herself really loving her kids but not liking them. She could hardly stand listening to them cry. Their needs, as expressed through their angry voices, pulled on her viscerally. She felt like she was losing her mind.

Now, her children were irritable, and in this next generation, the contagion of Anna’s depression spread through the family. You can trace, now, three generations have suffered because the biological was never treated. The psychological and the sociological followed and also became misaligned.

When Anna first came to me, I was actually happy because she was entirely treatable and had huge resources that she hadn’t yet accessed. I knew Anna had this coming, and I was happy because she was totally treatable. My heart also broke to see something that was so treatable savage three generations.

Even so, I knew that the outpatient clinic was not the best treatment for Anna because, in outpatient clinics, the services we offer people in crisis are not the best for them. Anna was in crisis. She was having morbid thoughts that life wasn’t worth living. Her whole family had become emotionally ill in the context of the contagion of her depression. And she felt like she was losing hope. This was a higher level of care than what I could offer in the clinic.

In an outpatient clinic, I don’t generally see people more frequently than every three to six weeks. Anna needed to be seen much more frequently, especially in the short term while her medications were established and had time to take effect. She needed intensive therapy, more than what outpatient therapy could offer and intensive enough so that it could actually reroute the way her automatic thoughts traveled in her brain. She needed intensive dialectical behavioral therapy that helped when something triggered her mind, and the electrical conduction traveled across her neurons; then it actually chose a better pathway.

When a patient like Anna comes to see me, I refer them to the outpatient program, a higher level of care than what I can generally offer as an outpatient clinician. You can see the reverse of this as well. When a patient stabilizes from an inpatient psychiatric hospitalization, then they should be referred to an outpatient hospital program rather than to my clinic. This outpatient hospital program in this scenario is called a “step-down program”, one that allows them to continue the healing with intensive and close follow-up; (generally 5 days a week for 4-12 weeks). We call this a step-down program or a step-up program, depending on which direction the patient is coming from.

I’m happy to report that Anna went into the outpatient hospital. After nine weeks of intensive psychotherapy with weekly physician monitoring of her medication, medication adjustments, having a nurse available to her five days a week, having an individual psychotherapist assigned to her, as well as attending groups every day, I am so happy to say that Anna is back in our community. She’s back at home with her kids, and stable on medication. Her illness, her biology is healed, and now her family is starting to heal.

In fact, Anna is able to work again. She is a certified ultrasound technician, and she’s now helping to support her family. She and her husband are healing together; he is now in treatment as well for his alcoholism and no longer uses drugs to escape. And you can see how close it was for Anna to lose everything. She almost lost her family; she almost lost her capacity to be gainfully employed and contribute to her community. She almost lost her marriage; she almost lost everything that she considered worth living for. Now she has it back. It’s humbling, and now I see her in the clinic every 4 to 8 weeks depending on her needs. Sometimes we go 12 weeks because she’s stable. I always know when somebody’s stable because they really don’t want to see me that often.

And every time I see her, I really wish I could see her more often. It’s the bummer of being an outpatient psychiatrist.

Self-Care Tip: Go get medical care for emotions and behaviors that aren’t working out before they escalate. Sooner is better! And if you don’t, just go as soon as you are ready. Just get in. Keep on!

Question: Have you every gone to a day hospital? What is your opinion of having these in your community? Speak! We need to hear you.

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Seasonal Recommendations

Different ways that holidays affect Mental Health

Fall is here!

In Southern California we have a glossed version of this and not the classic effect. But what we do have, includes this. Every morning when I wake up and open our bedroom door to the great outside, the fall “air” bursts in, hits my amygdala and a slurry of happy neurotransmitters perfuses throughout in a language I don’t have the best words for. I “smell”? or sense? or something, the air, and it says, “Fall is here.” So lovely and wonderful.

The problem in psychiatry, of what these changes do to our biology, come from the body rhythms. Some of us lose the sun to Jack Frost’s government. Some struggle with the time change. And the holidays have their own weighted steel tipped boots that kick up at any of us within kicking distance. Relationships struggle.

Here is a quick list of Fall simple treatment options I just thought you might like:

1.) How to Have A Stress-Reducing Conversation, from the research of Drs. John and Julie Gottman.
2.) UV lamp to help with the seasonal influence on mood and circadian rhythm, with a 10,000-lux intensity with full-spectrum light bulbs.
Also get 10-20 minutes in the morning and in evening before sunset of what sunlight you can.
3.) 10-20minutes of exercise every morning routinely, getting your heart rate up, thereby helping especially with mood, anxiety, and circadian rhythm. Of course you can do more but for many, this is a reasonable bite off of life’s apple. Consider just starting with a video from online that will even do 5min of core, and so forth.

Happy Holidays!

Keep on!

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PGY-3 Medical Student Lecture

Hello Friends!

I thought you might enjoy the outline of a lecture I’m giving Tomorrow to CUSM (California University School of Medicine) 3rd year medical students. It’s one lecture intended to cover mood spectrum and anxiety spectrum disorders.

Ha!

Here’s the outline:

  • **Psychiatry as a Type 2 Error Problem:**

Type II Error Explained, Plus Example & vs. Type I Error – Investopedia

In psychiatry, assume people are much worse than they look until proven otherwise. Unlike other medical fields where you prove the existence of an illness, in psychiatry, you want to rule out disorders, not rule them in.

  • **Monitoring and Recognizing Depression in Yourself:** Monitor our own selves for subtle signs of depression. Depression often manifests in small changes like sleep disturbances or increased irritability. It’s essential to catch it early, as depression can have profound physiological effects, akin to a bear chasing the body constantly.
  • **Depression as a Physiological Issue:** Depression is not merely a result of stress or external factors—it’s primarily a physiological issue. Treating mild depression proactively is crucial, as it not only impacts the individual but can also affect the entire family due to its viral nature.
  • **Seeing People as Brains, Not Just Individuals:** Shift the perspective from viewing patients as individuals with stories to understanding them as brains in need of healing. By focusing on the brain’s physiological state, it becomes possible to reduce suffering more effectively.
  • **Combining Physiology and Coping Skills:** Physiological aspects, address them first and then integrating coping skills. Changing habits takes time, but when combined with improved physiology, it becomes a potent approach for reducing the impact of depression.
  • **Environmental Influence:** The temporal impact of environment but stress that the viral influence of depression can be severe. Living with someone experiencing depression can affect the entire family, emphasizing the need for proactive and aggressive treatment.
  • **Genetics and Heritability:** Genetic loading and heritability, understanding family history and genetics is crucial in psychiatric assessment.

I want to give each of these students four years of psychiatry residency, just so they can grasp some of this. I don’t know how to get it to the community. Depression is biological. Physiological. It is dramatically under diagnosed. It is largely responsible for treatment nonadherence in any area of medicine. And it destroys our own lives.

I remember when I was a Psychiatry graduate of 6 years, when the word sounded through our community. Dr. Schultz’s, our beloved residency director, the one who had joked around with me, who had worked so hard to eliminate my imposter syndrome and who gave me a sense of being among my people, he shot himself. In our clinic’s corner bathroom, between seeing patients, he used his own gun.

I am still grieving him. He was a mentor. He was a friend.

But more than his impact on my life, he was a father of a preteen son, and was survived by many beloved family.

I’m sure you, readers, have your own stories. Maybe even against your own person. Please share them here. We need your story. Somehow, our community, our practitioners, our own medical graduates, don’t understand. Depression ruins us. And treatment can heal.

Keep on!

NAMI – Come Join Us! (Insomnia)

Roads-To-Recovery-Series-Flyer-NAMI-Ask-The-Psychiatrist-8.5×11-00374700-1Download
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Where to trust

Sometimes, ok quite often, we feel misunderstood by others and unclear of our paths going forward. We are not alone, dear readers, in this.

This is what Taylor swift says,

“How did I go from growin’ up to breaking down?
And I wake up (Wake up) in the middle of the night
It’s like I can feel time movin’

How can a person know everything at eighteen
But nothing at twenty-two?

And will you still want me
When I’m nothing new?”

I’m thankful for her voice in this.


I am nothing new and my personal value has to be on aught else besides novelty. Nor can it safely be placed in my behaviors and emotions.

It is our life duty to discover where to put our trust. In our own capacity? In identity? Or where? We are vulnerable to our biology one could say. But we are able to trust something someone somewhere. And whether it is fortunate or unfortunate, I can’t hand you trust like a baton.

You got this though.

Sending you readers all my affection. Thank you for joining me in this life journey of being a Friend to Yourself.

Keep on!

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Being in the trenches is not the Pathology

The trenches are not the pathology.

Image from page 553 of “The Journal of nervous and mental disease” (1874)

The stressors, the triggers, the many things that go very wrong every fraction of a second in our lives—these are not the pathology. These are normal. These are what we all have.

The pathology is being alone.

Don’t hang out in the morass of bad-alonen. Be in community. Push for that in your life. It may not come “naturally.” Community is part of self-care.

Keep on!

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$400 million and the cost of life

My reaction when I heard this was about the money. I thought, “Why not put that money toward mental health?” And I proceeded to look up related costs and details that wrapped around me like strings, making me dance. My emotions got involved. But if you know me, you’re thinking, “When aren’t they!?” Smile.

I continued to reflect and landed on, the value of our lives. How rotten does someone need to be before they should end it? How horrible should their tally of mistakes, and even volitional wrongs, quantify? And then I get caught in the eddy of political thought about law and the impact on community and so forth. And that is just not where I want to go either.

There has to be more than a bank account of talents, good deeds, beauty, popularity, and all the accoutrements that marks us. Life, your life, matters. That’s the truth of all of it. The world is better with you in it.

My patient, Ronald, came twelve years ago with a severe depression. He wasn’t interested in anything. He had 39years of successful employment in the entertainment business and used to love it. He just didn’t care. He wanted to retire and even just die. We jostled his medications and the right ones fell into place. Now he cares.

Ronald is now interested. Interest led him to purpose and that now gives him a greater sense of the value of his own life.

My patient, Evelyn, also in treatment for many years, has struggled more finding her treatment response. Sometimes she is “there” with her mental health, and sometimes she is not. Often she hates herself. She relives years of horrible sexual, physical, emotional abuse during the worst of it; thoughts intruding without invitation. She loses her freedom to choose her own thoughts. She wants to die then. Other times, she sees her value. It is a “life-er”, this battle for the mind and body and spirit. Today, Evelyn doesn’t want to die but still she isn’t doing well. Life has swung again and got a kidney punch in. She can barely breath.

The community at large must say, “Evelyn, you think you are ugly and rotten inside but it is a false perception” of an over-watered cactus, putrid smelling. Even so, that’s not the point. The point isn’t how good or bad we are. The point isn’t performance. There’s waaaayyy more than that which marks us for life.

400-million dollars. How many should suicide a year to justify the expense? If we could, we would pay for a net around each one of those who have lost their tether. But regardless, we must know, each of us, “No matter what condition you are in, the world is better with you in it than without you.”

Self care Tip: Step away from the edge and know you have value no matter what condition you are in.

Questions: Have you ever thought about not wanting to live? Why are you still alive?

Keep on!