Portrait of an Old Woman

Portrait of an Old Woman

It is New Year. Another year.

Another year older. I hate getting older.

I joke about it – about forgetting a name here and searching for a word there, about new wrinkles, about an age spot, about the difficulty of getting rid of a flab around the stomach. But it bothers me. It feels as if somehow every day I am getting closer to being a smaller, weaker me with less ‘me’ in it.

Couple of days ago, I stumbled onto a new app on the phone that ages your picture for you. Supposedly, this will make you friendlier towards your future self, so you will take care of it better. Well, ‘it’ being me, really. Obviously. I knew that.

I found a picture of me on the phone I thought looked like ‘me’. The ‘me’ I know. The ‘me’ I like. I hit the “aging” button on the app…


I had come to visit Mrs Beren.

Her face looked small and fragile against the white hospital sheets. Old. Quite a bit older than her fifty-nine years, in fact. With so many chronic diseases, it was no wonder.

She had put on lipstick, I saw. Not a bright garish red I would have expected from someone who was vain enough to bother with makeup while being in the intensive care unit. No, it was a tasteful light pink that did not clash too strongly with her tired and pale face, wrung out from endless nights on a hospital mattress.

She was a strong woman, I knew. Not her body – that was weak – but her mind. I had always been fascinated by it for the years I had known her.

Strictly speaking, I didn’t have a reason to be here, monitoring her progress with the disease that had landed her in the hospital, for the umpteenth time. She had everything wrong with her. She could no longer walk due to neurological damage and depended on her husband to lift her from the chair to bed at night, and back to the chair in the morning. Her kidneys had failed her and her husband brought her to dialysis three times a week. Just this year, she had been in the hospital with pneumonia, urinary tract infection and now again with fever and sepsis that the doctors had not found a reason for yet.

Mrs Beren was not my patient.

Her husband was.

I had no reason to be here.

But her husband had asked me. I had run into him unexpectedly in the hospital hallway, looking out of place and out of sorts. I had been surprised to see him – he was one of my healthier patients, with a minor heart problem, who I saw for routine visits only once a year. He always came with his wife who drove herself into the room in a motorized red wheelchair. I had been confused by it at first – why bother coming to her husband’s appointments when clearly she was so much sicker than he? But after a few visits, I realized that this was their life. The edges of individual lives had blurred. It was a unit, with her being the guiding force. It had always been the two of them, all their lives since they were teenagers. When I asked questions from Mr Beren, the wife answered half of the time. They joked about how the new reliance on a wheelchair for transport no longer allowed them to enjoy traveling that they had been fond of in the earlier days of marriage. When I asked for a report on his exercising, it was the wife who proudly told me how she pushes him to go for a walk each evening – with her driving her motorized wheelchair, right next to him. They told me about the adjustments of their house they had to make, about the new car they had to buy. The life in their little unit had changed to accommodate her increasing disability but at the core they were still the same people.

I had not asked for their life story. It had just naturally flown out of them, piece by piece, over the years’ worth of visits.

So here I was, staring at Mrs Beren’s pink lipstick.

“I ran into Roy in the hallway”, I started. “He told me you could use a visit.”

“Good old Roy”. She looked up, pensive. “How did he seem?”

Confused by the question, I hesitated slightly. “He seemed … well. Worried, of course. About you. I know you have not had it easy lately.”

“No.” I could see she was testing the words before speaking. “I don’t think it will get any better, frankly. And I am pretty tired of being sick. I just don’t know what will happen to Roy when I’m gone. He is not strong.”

Implications were heavy between us. Not strong like her, getting herself to all her husband’s appointments in a wheelchair. Not strong like her, worried about her husband while lying deathly ill in the intensive care. Not strong like her, making herself pretty with lipstick on what she thought may be the last days of her life.


After I first hit the “aging” button, I slammed the phone down. The woman who had looked back at me from the picture was old. Heavily wrinkled, with saggy skin and grey hair.

Also, unmistakably me. It was chilling. Unnerving. A little nauseating.

I picked up the phone again and tried to look past the wrinkles. The confident pose I had liked on the initial picture was still there. The sparkle of enjoyment in the eyes was still there. The smile of general happiness with life was still there. It was me. Old – yes, but still ‘me’.

It made me feel better. The woman on the picture wasn’t smaller or lesser. Just different.

I don’t have a choice in getting older. But as a colleague and friend likes to point out frequently, the alternative is far worse. So, I can choose how I get older. I can choose to be the “me” I like even when old. I can choose to be strong even when sick.

I can choose to put on the lipstick.


Screen Shot 2018-01-01 at 2.22.09 PM

Portrait of an Old Woman, by Guido Reno

Stigma and Me: Me-on-Me Crime

who me?

Me-on-Me Crime!

I was doing my speed walking thing on the Balboa Beach cottage lined shore. Gorgeous, it was. Fluffy thoughts were everywhere. I was purposely passing under the low hanging docks to upscale some lower body muscles. Some string bean teens with their fishing poles moved into the water’s leisurely lipping edge ahead of me. Who wouldn’t be distracted by such poetry?

Can you guess what I did? I looked up. I lost my squatting waddle.

When someone driving on the freeway slows down to look at an accident on the shoulder, we call them “rubber-necks.” What do we call someone who walks taller, someone who loses her shorter self under a low dock when “speed walking” at approximately four-miles-an-hour?


This was more painful than my three cesarean-sections. Of course, there was no anesthesia when I sped into the solid, immovable wood. I loosely figured, with physics being what it is, that I received in return the equivalent to someone slamming me with a baseball bat. I was never great at physics but I remember that Force = mass * acceleration. I am not telling you how much “maaaass” was involved, so, for the disgruntled forensic’s enthusiasts out there, we just won’t know how hard I was hit back.

As the blood was pouring down my throat, out of my mouth, down my face, and as I gargled the words, summarily “help,” to 911, I thought, “That wood was not there before, because, why would I do this to myself?!”

How are we our own enemy? I’m learning a lot about stigma these days, in preparation for a couple CME talks coming up. Stigma is a molded and remolded term, but for our purposes, we’ll say that it can be broken down into, prejudice and discrimination.

Prejudice refers to our attitudes, beliefs, and emotions.

Discrimination refers to action, what we do about it, and behaviors.

I really like this. It helps to see where “Me” plays into our own stigma behaviors toward our own selves. For example, skipping our medications on and off.  That would be, discrimination, when it is done in response to a conscious or unconscious prejudice about taking medication. Maybe taking medication induces feelings of shame or blame. Then we behave with missing pills.

Another example of stigma, is seen in our aging “baby boomer” population. Turns out, psychiatric patients are living longer too. Social workers and other professionals are admitting more and more psychiatric patients into senior facilities, e.g., assisted living, nursing homes, home health services at home, hospice, etc., and the staff at these agencies do not know how to work with psychiatric patients.  So, the senior facilities try to send these patients to psychiatric hospitals or hospital emergency rooms, and the nursing home or senior facility won’t accept them back into their program afterwards, stating “We don’t have the staff or programming to work with psych patients.”

Senior nursing home/assisted living facilities are realizing that they need to hire/train their staff to work with psychiatric patients in their senior years and that this is part of their growth as an organization and their commitment to providing quality care to seniors.

The prejudice comes from feelings, such as inadequacy, on the part of those serving psychiatric patients. The discrimination is when the patients are turned away. Everyone loses.

It’s an exciting time for senior facilities. It’s an opportunity for their staff to learn new skills and understand that with even some basic training on communication skills, therapeutic interactions, some do’s and don’ts, they CAN admit and care for psychiatric patients in these senior facilities. Everyone wins.

The most important message in learning about stigma, is we hurt ourselves any way it turns. And why would we do that to Me?

I still have a headache, three days later. My teeth hurt. And I’m not as pretty.

Self-Care Tip: Break it down – What are you feeling? How are you behaving to yourself?

Question: How have you been prejudiced and acting out toward yourself? How have you eliminated stigma toward yourself? Please tell us your story!

Keep on!

How Do We Age Well?


Ella Rose

In preparing for retirement, for aging, we put money away like Smaug The Dragon who knows his coin.  We imagine we will gain freedom, retain vitality, interest, and motivation, perhaps enjoy the affection of those we served through life.  But do we prepare for what is really coming?

I’ve been asked, how do we age well?  And guess who asked.  An aged man.  I tugged on my chin a little to hide my discomfiture.  After all, I would like to sit at his table and listen in on his story of doing what he had inevitably done, grown old.  I’d like to hear what he is pleased with.  And what he regrets.  I’d like to hold up the memories, like picture slides to the light, and see if I recognize anything.  Maybe something I might relate to.  Something I might more deliberately emulate.  I might feel more secure, knowing what he has done before me.  Maybe I’d think I am safe.

Remember that song,

A foolish man built his house upon the sand, A foolish man built his house upon the sand, A foolish man built his house upon the sand and the rains came a tumbling down.  The rains came down and the floods came up, The rains came down and the floods came up, The rains came down and the floods came up and the house upon the sand went splat!

(The hand motions make the song.)

But why ask me about aging?  Do I look so old already?  What the!?  Fine then.  I’d like to say, grow old continent and stock full of Botox.  Nah.  That wasn’t it.  (Mind wandering already you see.)

Or maybe, we who are aging wonder quietly if this person, or that might have a trick of doing it better.  This person wants to hold up my picture slides to the light and gather security to them.  That person wants to do more than hoard coin, and another doubts the vitality and wonders if she’d know what to do with it if it were waiting there for her after all in the end any way.  “How do we age well?”

Start with Me.

Me, where there is freedom to choose, the chance of change, the place where cause begins.  (The 3 C’s done our way at Friend to Yourself :).)

As a psychiatrist, it’s easy for me to think first of the biology of aging of course – brain health over time and to recall that the brain is connected to rest of the body.  I could tell this aged man that he’ll be wanting to get oxygen to his brain at night and use his cpap regularly.  I could speak of motility and exercise, of caloric intake and sleep hygiene.  We might spend some time on medical care for psychiatric illnesses common in again, depression, dementia, anxiety, and so forth.  We might speak of the inevitable process of losing friends and family, aging past a child or losing pets.  But as many so often remind me, psychiatrist’s only have the truth that their perceptions allow.  😉

A dear Obstetrics and Gynecology specialist told me the other day that she has become more convinced than ever that the processes of coming into the world and that of leaving the world are the same.  Having delivered countless souls into life, she has been marked, as if the luminescence of so many branded her.  She carries the knowledge of their entry and of those who have already died.

I remember my niece who died at 9 years and 28 days.  Not so old.  Not so aged.  Some how we think of death when we think of aging, not when we think of nine-year-olds.  However my niece did age well.

I suppose aging is like any system, as strong as its weakest member.  The wonder is that if we believe in aging, we believe our lives run on a line, on Time, which is after all, a human construct, a philosophy and based on Magic. Aging well as implied by my OB-gyn colleague, is looking at it from both ends, looking at what is in between, and looking at what is outside of birth and death.  Aging well includes exploring the essence of Me, what bit of Magic came before Time and before zero and numbers and philosophy turned into math.

How do we age well? Does aging imply disease? Aging is linear. They’re different but definitely paired… Help me on this?

keep on.

Getting Older and Getting Born


Sana_Set09_LeoChaves_032 (Photo credit: LeoChaves)

Turned another year over. Forty one now. Sometimes I already feel like there is a toe tag on me. Other times I ride the consciousness of now and innocence, as if I have forever to do whatever it is I am living for. As if fear did not pulse around me, as if life held no shame, then I carry my 41 years as lightly as a daughter spatters kissies over her mother’s arms.

Getting older is all the hype now. I was not alive 100 years ago but I wonder if 40 was the “new sexy” then. Gwyneth Paltrow is lovely. Me and Gwyneth. We have so much in common.

Huffington Post featured 30 Celebs Who Are Aging Gracefully. Tina Turner, Sting, Sigourney Weaver, the list is full of real people sharing our life-space. Remember Working Girl? Boom.

I look at my parents, friends, patients, myself, strangers on the street and stories that symbolize a person’s life lived. I look and I think of someone who climbs Everest. I think of frostbite. I think of a long long journey. I think of death.

The day before my birthday, the excitement made waiting too much to endure. A small chocolate bar, a handmade card with misspelled words and two tightly folded dollar bills disregarded the calendar date. Neatly arranged on my night table, I was told by their giggling toe-toe hopping agents, “Happy Birthday tomorrow, Mommy! I’m so glad you were born!”

And I was born again. Just like that. Love labor.

Some women have birth the way it is supposed to happen and others suffer. After my third child, my OB-Gyn, I love that woman, told me with nothing more than fatigue and honesty, “Sana, you should probably stop at three. Pregnancy and delivery is just not easy for you.” My pregnancies and deliveries were not that easy for her either.

Our rebirths also come easy and come hard. We almost die. We cruise through as if we were made for it. “She was made to have babies!” (Dodge the loogie I cannot help but hurl. Damn those women with baby-making bodies!)

I know we think things like this about people without brain illness, (if they even exists.) Maybe we think they do not have the suffering we do. Maybe we think we have it worse. We think at least we are misunderstood, when we hear,

“Get over it!”

“Just calm down!”

“Would you relax?!”

Breath. Yummy. How we love that. The list of these is longer than the path up Everest. And so helpful. Who has actually calmed down when told? Notice the exclamation points. Exclamation points symbolize emotion, in case the mountaineering porters saying the helpful emotion-directives did not know.

During our long long or short journeys we get to be born once, twice, forty-one, or the last time, because of Love. We do not get a Love that is measurable liquid or linear, like Time. Love is not healthy or unhealthy. It does not curl into our DNA, and is not dispensed by privilege. Nor a jury of Sherpas. Calm down.

Love is. Love is, and Love offers us a newness over and over and over and over because.

We have different birthing experiences, but I am glad you were born. You are loved.

Self-Care Tip:  Allow Love to bring you new beginnings.

Questions:  How has birthing gone for you?  What have been some of the new beginnings you knew Love brought you.  Please tell us your story.

What We Will Do For Brain Health – Looking For Heroes

Death and the Maiden #2

Image by CapCat Ragu via Flickr

My dad is turning seventy-seven tomorrow folks.  He could have died a gazillion times before now, but it is the tumbling of those near-deaths into big life that teaches and recruits me.  He makes life feel like open space, warm skin, color and lyrics.  Now his spine is crumbling, his legs are weak, his lips are always moving in and out like a rabbit and he’s almost too hard of hearing to comfortably socialize with.  Still, it is the life, the interest he has, the way he doesn’t stop growing that somehow dims the many times he might have died.  Why does the one time he will die seem impossible to juxtapose against any future then?  Where will life go, if he is not there to infuse us with his humble will?  I think it may fall asleep with him but I know it will not and I cannot imagine it otherwise.

These past few posts we have talked about “special efforts” for brain illness.  We asked, “Is there any treatment you think is too extreme to consider to get brain health?”  We have not said the reason we cannot fairly answer.

I don’t know how life will be without Dad; we never know how life will be when our brain is bad and then more bad.  It’s hard to tell.  We can only imagine and usually our imagination will be wrong anyhow.

Any answer to this question, “Is there treatment you think is too extreme to consider to get brain health?” is shaped by our understanding of what “extreme” means.  It changes shape and margins with the degree of brain illness.  With each turn, as our disease process exacerbates, so progresses our willingness to believe what is reasonable versus what is “extreme.”

Many of you have told us of your own specifics in your fight for brain health.  People do heroic things and I’m thinking you and I might have a bit of a living hero in us.  In part, it is the inherent unknown in growth that testifies to life itself.

“Is there treatment that you think is too extreme to consider to get brain health?”  I imagine my answer would be, no.  Please tell us more about yours.  Your view from your degree of extreme helps.  Keep talking.

Self-Care Tip – Let the hero in you speak, grow you and testify to life.

The Testimony of The White-Headed People – Connection and Aging

Once again, I find myself in a café.  This doesn’t happen often enough for me.  But here,Almond paste tart with chocolate mouse and blueberries

I am

at the wonderful le Croissant Bakery, indulging not only in the quiet of my private thoughts, not only in my delectable chocolate croissant with coffee, but also in the ambiance.

Here, there is this completely lovely group of white-headeds, maybe ten of them at a table, sharing the treasured community of each other.  None of them walk completely upright.  One is wearing his oxygen tubing with tank in tow.  The ladies are coiffed irregardless of their folding skin and thin hair.  Fruit tart

I am

so blessed to be in their community, testifying to me that aging doesn’t have to be done alone.  Flourless Chocolate cake with Ganache inside

I am

sure, 100% sure, that none of them are aging as they dreamed.  Each of them have outlived many loved ones and the ground they walk on has changed many many times.  They have, each of them, learned to walk again after suffering the type of loss that put’s any of us in bed.

I am

blessed.  This collection of café moments they have together does not account for these losses.  This does not resolve their ongoing conflicts or pain.

But none of them,

Almond paste tart with chocolate mouse and blueberries

I am

100% sure, did not let those things keep them from having this moment together today.

All this sureness without having checked my notes with them?  Yes.

I am.

Crumbs on a Plate

Image by rockbadger via Flickr

Your Pain is Not Special. It Is Normal.

Self-Care Tip #243 – See yourself as special rather than your pain and know that you will find your normal again.

What is your normal?

When we were kids, we all had a perspective of what normal was.  Let’s say it was “here.”  Let’s imagine we were lovely then, nurtured and emotionally bonded.  We struggled through peer conflicts, social anxiety and rivalry.  We wanted a bike.

Two Sisters

Image via Wikipedia

Then we got a little older.  Maybe our parents divorced.  Maybe, a sibling died.  Maybe we were abused or in an accident and damaged.  Damage changes normal.  What we never would have thought would be acceptable in our lives became acceptable.  We suffered.  We lived.  Life was indiscriminate and ignored our status.  We think there must be a mistake.

What is our normal at one point, filtered through remaining hopes, grew into regenerating fantasies, through real potential and it moved again.  We are older now and more suffering comes.

Where is our normal?  We survive our child, our own dear perfect boy, hanging from a tree.  Normal?  No dear God!  No!  And we continue to live.

Two years.  Two years are what it takes for our biology to catch up to the shock.  Two years are what it takes for us to begin to accept and realize that in this new normal we care again.  We choose it in fact.

People don’t remember his name or talk about him and we can’t remember his eyes.  We are ashamed and lose our breath from panic just trying to see them.  We want to bang our head because we know there is something wrong about feeling normal! Ever! Again! after that.  But we do.

Our normal mutates over financial ruin, abandonment and a growing healthy list of disfiguring illnesses.  We accept them and say yes please.  Live.  We want to live.  This is acceptable.  This is normal.  Our friends die.  Our memory.  We can’t find our teeth.  Our heart stops.  We die and the world finds normal.  The world chooses just like we did.

What we don’t think will ever be allowed to happen while we brush hair, clip our nails and microwave food, happens. We endure these changes.  We find normal again.

What is your normal?

My brother, Vance Johnson MD, is a physical medicine and rehabilitation specialist.  He said that during his residency, close to 100% of spinal cord injury paralysis survivors he worked with wanted to die after their injury.  Many of them would beg him to let them die.  They would cuss at him for keeping them alive.

I leaned very heavily on the studies and data during those times.  It was very hard.

Vance said that what kept him faithful to his task was knowing that close to 100% of them after two years would be glad they were kept alive.

Even the ones who were basically breathing through a straw and that’s all that moved on them; even they wanted to live.  These people found a new normal.

Where is our normal?  We will want it.  We will adapt.  Biology will catch up to our reality.

Remember that your pain is not special.  You are special.  Not your pain.  Pain is normal.

Question:  When this happened to you, how did normal find you despite the rubble?  How does this concept feel to you, that your pain is not special?  Does it make you angry or what?  Please tell me your story.