psychiatry

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Why It’s Just So Hard To Take Meds

Adherence is subtle. Adherence is not the same as “compliance.” People are generally good people trying their best with what they understand and what feels right for them.

This matters, because nonadherence might not be defiance—but rather distress.

When someone doesn’t follow a treatment recommendation, it’s not generally because they don’t know they’re supposed to. Nonadherence comes from subtle reasons. “I can’t look at my bottles every day. I feel like trash for taking so many pills.” Needing medication often feels like evidence of personal failure rather than a neutral medical tool. Every time someone looks at the bottles, opens the lids, and swallows the pills, they’re fighting self-stigma. It’s hard to see yourself surrounded by pills and medication bottles.

This is where the daily work of adherence becomes invisible labor rather than willpower. It’s not one decision—it’s an argument you have with yourself over and over.

Consider using a pill box. Put the bottles away. Don’t even look at them until you have to refill the box. At least then you aren’t fighting that inner voice every day that says you are a bad person. That voice affects adherence far more than knowledge. This small tweak quiets self-judgment.

If a patient is not adherent, the patient, me, and anyone else who is part of the treatment team need to figure out why. Reframe nonadherence as a shared problem to solve, not a personal failure. People are not actually trying to sabotage themselves.

Even when teaching resident clinicians, I ask, “Whose responsibility is it if a patient is not adherent?” The confident answer is, “The patient!” Well, no—not entirely. It’s our responsibility. Ours. Us. If the patient isn’t adherent, there is a good reason why. We just haven’t figured it out yet. That’s our job: to teach, to explore, and to sell hope.

Being right doesn’t change lives. You can have all the facts in the world and still not take the medication. What changes behavior is feeling understood and having agency. Correctness without connection is for the birds.

For example, a lot of nonadherence comes from what patients are hearing outside the office. Family members. Therapists. Friends. “You’re on too many meds.” “Meds are bad.” “Good job! You got away with taking less.” People go home, hear this, and feel like trash for needing treatment. Stigma can live in relationships, not just inside the person.

It helps to name the voice patients carry with them after they leave the office. Naming it helps it lose power.

When that happens, one option is calling the people who are talking in the patient’s ear when they’re not with the provider: a husband, a brother, a parent, a friend. If I call them on my phone, the caller ID, they’re not going to pick up. But if the patient calls them, then they pick up. Here, the voice belongs to someone specific and takes on more shape. Often these are influencers in stigma or bias around treatment. I introduce myself and ask if they have concerns. They might say they think the patient is on too many medications or that medications don’t work. That’s important to know. It may be what the patient has been absorbing and what’s been influencing their ability to adhere to treatment.

Then I say something like, “That’s important. What if we reduce dosages?” Sometimes that’s something we want to do anyway, to keep side effects low and to layer with another class of medication. Lower doses, fewer side effects, and better receptor targeting allow for more comprehensive coverage. Now we’re aligned.

Now the voice in the patient’s ear is part of the plan and has become an advocate.

Adherence isn’t about forcing people. It’s about removing the quiet barriers that make it hard to stay in care. Shame. Stigma. The feeling that something is being done to you instead of with you.

When you and yours join into the discussion early, then you get to declare for yourselves, over and over again, whether the treatment is worth it. Because it is a decision that has to be made again and again. Everyone involved feels agency. No one is victimized by treatments. In order to be my own friend, I have to be that friend even at a biological level.

That’s the work. Not just prescribing, or just taking a pill, but figuring out why someone can’t adhere.

Self-care tip: If something meant to help you feels shaming, change the ritual around it before blaming yourself for not sticking with it.

Question: What part of your self care is hardest to follow because of how it makes you feel about yourself, not because you don’t believe it helps?

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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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Do I have to stay on medication?

Medication treatment duration is a multi-threaded rug.

Some ask about the effect “wisdom and growth” has on their need for ongoing medication versus growing out of the need for medication therapy. It is normal logic to think that we should behave better and feel better when we know better. This leads many to wonder if it’s time to come off of medication therapy.

Let’s work on this by considering these variables.

  1. Coping skills. 

Coping skills are how we deal with stressors. When something happens to us, like getting yelled at, honked at when driving, or suffering a loss like a break up – our automatic thoughts and actions may be kind or unkind to ourselves. They may serve us well or may not. Coping skills can be intentionally grown, such as through dialectical behavioral therapy, and/or may require medical treatment. Coping skills regress with mental illness. But there are therapies that will improve them, helping our resilience, and helping us choose to continue vs. taper down medications.

  1. Recurrence.

Has the patient had multiple episodes. Multiple episodes of mental illness will signal differently, as compared to a single episode, in regards to risk of relapse.

  1. Genetic loading. 

What’s the family history of mental illness? Genetic loading. Genetic loading. Genetic loading. It tells the story of our biological risks. 

  1. Risks and Benefits.

Weighing the disabling impact the disease processes have on a patient’s life against the risks of medications. Consider the psychic suffering. We suffer and the suffering is real. Compare this to what we don’t like about taking medication. Weigh it and find your balance. Medication may be too “costly” to continue.

  1. Impact of disease process on future brain health. 

Mental illnesses in general are progressive, and the medication therapies not only treat the current symptoms but also are prophylactic (preventative and protective) against further brain insult. The brain now, if mental illness goes on, will be a different brain in ten years. We are fighting for that person too when we fight mental illness. Our future selves.

  1. Full treatment response.

Even though the patient has been on medication for a long time, what is the current condition of the diseases and the treatment response? Is the patient fully treated? Symptom free? Or does the patient have ongoing symptomatology even if improved from prior to treatment? For example, if the patient’s depression has resolved but they still have symptoms of anxiety then they are at a higher overall risk if medications are stopped. Being better may not be good enough. Or it might.

Self-Care Tip: Staying on medication can be discomfiting but take a turn with your treatment provider to consider.

Question: What is being on medication like for you? Tell us your story if you stopped it or if you chose to stay on it.

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Involuntary Movement and Medications

“Tardive Dyskinesia Awareness Week was May 1-7, 2022.”

This comes at a good time for me as well. Last week I was just working with a patient, “Joe”, who was suffering with an “involuntary movement.” Joe had taken an antipsychotic as an augmenting agent for his treatment resistant depression and had a brilliant response… as far as his depression-disease went. Within one week of treatment, his jaw-breaker-depression started to dissolve small pieces away. He was astounded. 

Truth be told, I get astounded too, when my patients show these kinds of “Whaaat?!” responses. Although it is less than before, still too often (20-60%), patients work hard on getting treatment responses that remain elusive. Too often, I watch someone’s life step down from one loss to another due to their disease process, like a slinky. They start taking days off from work, then weeks off. Their most beloved relationships plunk, plunk, less and less connected. They stop getting out of bed much. And so forth. These are not just words. Brain disease is real. Whether it is depression or psychosis, anxiety or dementia, and more, it’s not any less medical than a deadly cancer. 

But when patients like this, with whom we have determinedly worked toward healing, all the while, together, watching their life losses… well it is grievous.  And miracles, such as Joe experienced, astounds us. 

About a month later, I started to notice that his mouth was moving without his conscious intention. His lips jerked together, like a “purse string” pulled on them. This is one of many early symptoms of dopamine blockade that might happen with antipsychotics. For Joe, it resolved easily by decreasing the dosage of his medication. He was reluctant to do this, considering the benefits he enjoyed with the medication. Thankfully, however, his benefits remained even with the lower dose.

Joe had been experiencing “acute dyskinesia.” If Joe had stayed on his antipsychotic agent over time, or one could say “tardive,” and at the higher dosage, the involuntary movement might have worsened and become more difficult to get rid of. Involuntary movements are also more often experienced in the elderly population and from older classes of antipsychotics, but they still can happen in the newer ones. 

These secondary movement disorders are grouped under the name “extrapyramidal side effects,” (or EPS,) of which tardive dyskinesia is one. And in case you were wondering more about its cause, it is described in PubMed: “The mechanism of EPS is thought to be due to the antagonistic binding of dopaminergic D2 receptors within the mesolimbic and mesocortical pathways of the brain. However, the antidopaminergic action in the caudate nucleus and other basal ganglia may also contribute significantly to the occurrence of EPS.”

For reference, NAMI also has a clean, well described, web-page on tardive dyskinesia worth reading for more details. It doesn’t include all the names of the newer agents which can be hard to keep up with. These “second generation antipsychotics” are frequently increasing in number as our medication options through research increase.

Understand that TD is a movement disorder. Not all movement disorders are caused by medication and deserve a medical work-up. It may or may not be reversible and the risks and benefits of treatment need to be evaluated progressively, over time.

Keep noisy. Keep talking. Keep asking. Keep on!

Questions: Would you please tell us about your involuntary movements if you’ve experienced them? Or seen someone with them?

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In the mean-time, Waiting for Treatment Response

A crowd of Neuro-receptors fill our brain like a high school mosh pit. It’s noisy and possibly dangerous up there. It’s hard to focus. The negative thoughts are drumming. Medical treatment for depression is the Arthur Murray instructor to our brain-dance. And it takes time.  

When we take medication, the neurotransmitters targeted in our brain have to respond to the neuro-messengers that are the medication. Some receptors downregulate, i.e., decrease in number or activity. Other receptors likewise, upregulate. Again, this takes time. For example, fluoxetine, or Prozac, which came on the market in the late 80’s, is one of our most familiar antidepressants. When we start the medication, (and please don’t call them drugs because no one is panhandling for fluoxetine… Nor are we taking fluoxetine to get a high, but rather to treat a medical illness)… 

When we start fluoxetine, it can take 3-6weeks to start experiencing the benefits. Furthermore, during the first few weeks it is common to feel worse before we feel better. Worse anxiety, worse depression, this is because the receptors are learning a better dance. And it takes time to learn. And learning in this case feels worse before it feels better. 

You ask, what do we do until the medication takes effect? Marvelous consideration. Because here we are, asking for help, and our psychiatrist gives us something that makes it worse. Ummm. 

In the first couple weeks, which can feel like forever, perspective being what it is, a cloudy lens, feeling worse is described by the health of our brain. The brain, from which all emotions, behaviors, and sense of reality come from, takes time to heal.

We come to the psychiatrist by the hair of our chinny chin chin, almost dead inside. We waited, of course, to make the appointment. Waited for our courage to catch up with our disease. And then we waited for an appointment to open up three months later, seemingly forgotten at the train station scanning the crowd for kindness and help to come. And then? Then we receive treatment that takes another month to start, to start I say, not finish, the healing it promised, (a promise that values at about 50-60% of the time to come through. That’s the statistic for fluoxetine to be effective for each of us with our first trial of depression treatment. Thereafter, the likelihood of responding to fluoxetine diminishes after each trial.) 

This is the lighting on the stage for your question, “What do we do in the meantime?” We survive?

It’s too easy to come up with behavioral solutions that if they were to work, they would have already done so during that waiting – ex: 2 months of worsening mood, 2 months to call the psychiatrist, 3 months to get in for your appointment, 1 month for the medication to start working = 8 months. 

You’re not a dummy. But we’ve been advised as if we were by our community. “Feel better.” “Snap out of it.” “Pull yourself together.” “Be strong.” It’s not like you didn’t think of these on your own and were waiting for someone wiser to tell you to get on with life. But, If you are able to, please do get on with it. Go exercise. Sleep better. Eat better. Look at the world with hope.

For the rest of us with melancholia, ie. major depression, the choice left us when we lost brain health. Similar to the alcoholic choosing not to drink, choosing to feel well isn’t a choice. When the medical illness recovers, we gain our freedom to choose those things back. 

During these “8 months” there are some things that can be done however. 

Go to a psychiatric partial hospital program, (“PHP”).  This is a day hospital where you attend for about 6 hours, 5 days a week, for about 4-9 weeks. It’s incredibly supportive. But more than that, PHP teaches dialectical behavioral therapy, (“DBT”), a type of therapy that has been shown to make changes at a cellular level. There are changes to our automatic thoughts, so that when something triggers us, our pre conscious response is more friendly to “Me.”  It’s not a “stick-shift”, but rather increasingly automatic. The key is to work toward brain health. 

Others will collaborate with their psychiatrist to augment fluoxetine, or whichever antidepressant of choice, with another medication that can help pop you out of depression sooner. These treatments are not generally long lasting and don’t treat the underlying illness. Rather they treat the symptoms here and now. Some examples used include stimulants or thyroid replacement therapy. 

In the end, be in a community of support – be it PHP,  outpatient therapy, or NAMI. 

Support is the shell to our drippy egg, while we wait for our medical treatments to take effect. 

Question: Have your efforts in treatment worked out? What’s your story?

Self Care Tip: Don’t give up! Pursue treatment. Your illness is treatable. But in the meantime… be in a community of support. Keep on!

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More on Dying

Tonight my husband cast this up on our monitor/TV. “This was my colleague.”

A couple who worked in palliative care used social media to share their experiences after one of them received a terminal diagnosis. It was later featured on The NewYorker.

https://www.newyorker.com/culture/the-new-yorker-documentary/what-is-it-like-to-be-dying

Watching with him the face of dying threw me back to watching my Dad. The way they both, Kathy Brandt and my dad, smiled up with tight faces, skin pulled over bones. So much love there. Dad would smile and I heard him say in it, “I love you Sana. Will you still love me while I die?” There is an insecurity I imagine in that process of saying goodbye.

Then when Kathy Brandt apologized to her audience for her condition. Her “weakness” was something to say sorry about. We also apologize for our weaknesses; for things we had nothing to do with other than that we are the carrier of some biology gone bad – major depressive disorder, cancer, alopecia… Name it. It will take you a while to cover all the things that we apologize for that describe our humanity more than they describe our fault.

Maybe we apologize rather, not in shame, but in empathy toward our listeners. There is a consideration of what our defect imposes on them. That could be. But I wonder what would happen if we didn’t apologize. Instead, allow the others to let our flawed selves just hang out there in the space between us, bringing them into a greater awareness of what we are going through. “Hello. There is no brush off here. Rather come be in my suffering and we will commune. You and me.”

There was no mention of God, what happens after death, or the meaning of life. I don’t know what they believed. They seemed like they just wanted to share the basic experience, the breathing, (…my dad rattled again in my mind when I heard that,) the changing face and body, the personality coming through, the relationships affected and so forth. This gives us space to be there with them, without doctrines setting up lines and corners we have to navigate. Not so bad. I appreciate them.

Speak: Let us know what you think of this documentary. Give us your adjectives. What notes does it hit for you; the resonance you hear and where you find your community. Speak!

Selfcare tip: Allow yourself not to apologize.

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Wanting, with a capital “W” …and God

A perfect world for me would include Wanting, with a capital “W”. We would want and have the energy and motivation all included, like a first class Qatar Airline’s ticket with real linen napkins for your glass of water with gas. We’d feel the desire to do things, and good things too. We wouldn’t crave that trash like cookies, ice cream, or chips until we couldn’t taste it any more. Nor would it drape us over couches all day watching tv or fill our heads with cotton-candy audiobooks.

A place of safety would have us full of urge and interest for growing our inside parts, the creative parts, the parts that parallel play with what is Love. We would Want, like a coil that unravels, like my puppy seeks my hand, like the people on Easy Street in a better place.

Wanting is a gift. It isn’t a right. People who have never lost it, they just have no idea about existing in the absence of it. But those poor souls who have lost it, who don’t Want, who have felt it leave them like a mist into the ether, that is hard.

I’d like to tell you a story to help you understand. And there are so many patients clamoring to speak, but my own voice for them is clipped by limited skill and talent. Their voices are most eloquent. For this, I refer you to the National Alliance on Mental Illness, (NAMI), who are people for people. An awesome resource.

However, in my own effort, know this: Wanting is a gift. I’ve seen what it looks like when it is gone, and it is vacuous, a void, a space where if not filled, devils come to occupy. The devils of our broken minds. Depression, that is dark. Down down, feeling like it will suck you into the earth and plants will grow out of your carbon compost.

Priscilla asked me why she felt this way. Why was the gift taken, without clear reason? That familiar phrase, “I don’t have a reason to feel this way. Everyone says I should feel good about my life. But I don’t. I don’t even care if I die. I don’t care about anything.” It’s a familiar phrase because many in Priscilla’s patient cohort say almost the same thing word for word.

I don’t proselytize in clinic but I am open to whatever religion people come in with and how they practice it in the world of mental health. For Priscilla, this was her conflicted outcry.

“I need help. I can’t go on like this. I’ve prayed for help. I’ve asked God to heal me. But I’m still so depressed. Please pray for me. Please help me.”

All the like minded believers are feeling super fine with her right now. “Yes. Pray about it. God can heal you.” And maybe some are thinking she must even be a little culpable. Even if at a dusty genetic level. Yet for whatever reason, God has gifted them with lovely Wanting. Not her though. Many here would think emotions and behaviors are spiritual issues, moral, and connected to salvation. I do. …As a psychiatrist, may I? But looking too close at that, at moralizing emotions and behaviors, is like poking the IRS, so all is quiet.

Her outcry, “Please help me!,” was a spiritual request synchronous with a physical and temporal one. “Please help me…” feel and behave well. It’s sounds of Naaman asking Elisha to remove his spots of leprosy. Or the crippled beggar, stretching his hand out to Peter. Or Esther fasting to beg for the lives of her people. “Please help me.” The spiritual is there with the body.

In my life, having practiced in medical research as well as clinical care for 18 years, and after a super super long many years of schooling, after having walked through church and daily Bible study, (and this is a run on sentence as that’s what this unfolding in my professional experience feels like sometimes), I am comfortable with asking God to help Priscilla, whilst helping her see and achieve how God, S/He, is going to do that for her through a medical approach.

But the absence of Wanting in her life, wanting to get up in the morning, wanting to read her Bible, wanting to take care of her kids, to shower, to have sex, when she doesn’t want this, it isn’t fair. It isn’t because she was bad, or is less than any of us, or doesn’t have the ear of God. I’m very comfortable saying that she has a treatable objectively identifiable medical illness. Thank God. God is all that is good, and kind, and God has mercy for us bleeders, the jacked up, the mean spirited and the ruined. God sees what is wrong with our bodies and minds, and God doesn’t resent us getting medical help. How absurd otherwise.

Self-Care Tip: Give yourself a break and ask for help. There is a better place. Keep on!

Questions: Have you ever experienced the absence of Wanting? Or seen it in someone else?

What did it look like? Please tell us your story. We need to hear.

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Your False Intuition

The curse of “intuition” in Data Science - Towards Data Science

You can’t listen to your 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 go to therapy. 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.

During these times, we need to disrupt the flow. It is laminar, even lovely in its quiet arc, that dishonestly soothes. We need in this case, turbulence and a different direction.

If what you are doing isn’t working, add turbulence and do what is uncomfortable. In Marsha’s case, we both laid the rope down, (smile,) and she pursued a day hospital where she worked on changing her automatic thoughts toward those that were kind to herself. When something triggered her, how she responded, and before she even knew she was thinking about it, was healthier.

Question: Have you ever been misguided by your own thoughts? How do you safeguard against an intuition that may not be kind? Please speak and tell us your story?

Self Care Tip: Don’t let your own intuition be your only voice of reason. Be a friend to yourself.

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Science and God Awkwardly Related

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God and science are as awkward together, culturally, as someone walking in on you in the bathroom, mid stream.

People think science and God can’t be related. Like there’s a gap.

My son and I watched, “The Exodus Decoded,” a 2005 documentary, directed and starring Simcha Jacobovici, and James Cameron. In this, the history of the Biblical Exodus is presented through a scientific paradigm.

My son was discombobulated. “Mommy do you believe that!? What do you think? Do you think science explains the miracles God did? I don’t.”
True. He hasn’t had the benefit of decades of higher education to influence his thoughts but irregardless, he is not alone in this.

A pharmaceutical representative I was speaking with explained, “People feel like religion or spirituality are emotion-based whereas science is coming from a field where you have to be objective and unbiased. I think also like you get too much feelings involved, you know? No go.”

Is it like, “God and state,” so is God and science? Like it’s wrong to relate it. Is it not ethical?

Many of us think, mixing these ideas leads to less validity. If that were true, what does it say about who God is? That would be a pretty limp God, who is separated from “one” of His creations with another. Nor is it that kind to “Me”. Me Me Me. Remember? Everything starts and ends with Me here at Friend to Yourself. If keeping science and God separate were true, it increases disconnection in my life. And we are created for connection.

Question: In the words of my son, “What do you think? Do you think science explains God’s miracles?” Or what?

Self-care tip: Allow the gap to fill in between your Higher Power and the explained in your life, however you will. It will improve your self-care.

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PsychU video – Sleep, in the world of Behavioral Health

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God in the Space of Synthetics

Hello Friends!

I’m going to try something a little different today. I’m posting a dictation between a patient of mine and me because I think it has flow and a nucleus. (There are a few small changes made in liberty, and no identifying data.) Let me know what you think of the content.

Psychiatrist:  …And so we were talking about perfectionism, right? 

Patient:  Yes. 

Psychiatrist:  And about how you are not being kind to yourself when you expect yourself to be all healthy.

Patient:  I’m not being kind to myself when I don’t want to take this or that because I don’t do synthetics. (This is what my patient was using to describe medications.)

Psychiatrist:  I like that you used the word synthetics, because I’ve never put it in that perspective with patients, and you did that for me. 

Patient:  Well, there are non-synthetic and there are synthetic. 

There’s body recognizing things, plants, and then there are the synthetics, what the pharmaceutical companies produce. And I’m a very negative pharmaceutical company person. 

Psychiatrist:  Compare that to other inconsistencies in our life. Such as, I’m going to be all-natural, I’m only going to wear hemp.

Or take it to the point where I’m going to weave my own clothes because it’s really natural and I know exactly what’s in it. Versus saying that I’m moving forward and I’m going to take what science has offered to us. I’m wearing polyester right now. 

Or, I’m willing to take over the counter “herbs” because they don’t have the pharmaceutical stamp on it, or maybe I like that it grows out of the ground. But none of that has been governed. Aside from the “he-said-she-said evidence,” there’s often little science behind some popular over the counter remedies either. 

Let’s consider that perhaps the study data, comparing in a regulated way, one patient with another, defined synthetic agents, and then allowed my body to be its healthier self. It gave us objective data. Numbers. Sure they have their flaws and weaknesses as we learn in statistics that all does. Poke holes in it as you wish, but at least there is a degree of transparency.

Patient:  Maybe for me it’s more trust, because I feel like people are so over-medicated today. And it’s easy to write out a prescription than to really deal with the issue. 

(Me, on the sly: This view, that practitioners prescribe for reasons other than for the medical benefit of the patient, is one that I honor with humility, and stand up and listen when others voice it. Annals fill the internet search engines on it, I’m sure. I will still pick at it a little, I’m a stubborn nubby person like that.

Let us note together that the word, “easy,” in this context isn’t so kind to our person. Taking medication to treat a medical illness is often not easy. It is one of the most courageous acts in someone’s life. And this wonderful lady, who came into my scary office, was a great example of this kind of courage. She wasn’t here doing what was easy. She was giving her emotional entrails a work-over with her psychiatry venture.

This patient, whom I will name hereafter, Lady Courage, was “really dealing” with the issue, in contrast to her self-described mores. Might we suspect the insidious tendrils of “Mister Stigma” shaming her? Yet here she was… Just fabulous!)

Lady Courage: I’m more one that, “Let’s really deal with your issues, and then your mind should come around, everything should come around.” That’s how I view it, because if you don’t fix the underlying problem you’re never going to fix the problem with meds.

Psychiatrist:  Okay. But you’re willing to say there might be some inconsistencies in that right now.

Lady Courage:  Right, no, I’m not … 

Psychiatrist:  It might not be entirely false, but it might not be entirely true. 

Lady Courage:  Exactly. 

Psychiatrist:  We were saying, “I can be healthy but still have disease in my life.” 

Lady Courage:  Yes, that’s true. 

Psychiatrist:  Because I don’t have to be perfect. 

Lady Courage:  Right. And I do find that a little bit hard. But since you put it in that aspect of being, “healthy with disease,” I can see that. I probably never saw that before, because I did always separate the two, either you’re one or the other. 

Psychiatrist:  Wow. 

Lady Courage:  Yeah. 

Psychiatrist:  That’s poignant. Is that how you see God as well? 

Lady Courage:  In what aspect? Like, yeah … Well, you know what? I try to strive to walk in His ways. I haven’t always walked in His way, so I do have guilt about that, but I shouldn’t have that and I know He’s already said He’s forgotten it, He’s washed me clean. So it’s just receiving it for myself. And that just is faith. And I know then it makes me feel like I’m lacking a little faith, but I know I should be stronger. But, yeah, The Word is something that I strive to follow, and it’s hard. 

Psychiatrist:  So do you feel like God is, “either/or,” in the way He looks at you? What about the parts of you that are diseased? 

Lady Courage:  Well, no, yeah, He’s going to heal that. 

Psychiatrist:  But what if He doesn’t right now? What does that mean about who God is?

Lady Courage:  Well, He sent me here probably in hopes that you can help me to heal. He provides these avenues for us, so that we can get healed. 

(Folks! So good! Smile.)

Psychiatrist:  So you somehow think that God enters into the space of the synthetic. 

Lady Courage:  Well, yeah, I guess so, yeah. I do, okay. It’s so contradictory, but in one aspect I do take a thyroid medication that is a synthetic, but I know I have to take that and I understand it and I don’t feel it’s abusive. And I look at my blood work and I know where I’m supposed to be and how much I should be, so I feel confident. But when it comes to things like this that I’m not used to taking, and that don’t show up on labs, and it involves transforming my brain, I’m not really on board with that. 

Psychiatrist:  So when you use the word transforming my brain, I understand you’re saying that it’s making you into something different? 

Lady Courage:  It can alter your brain, yes. 

Psychiatrist:  Okay, so that’s the part I think that’s very scary for people, because they think it’s making them into somebody they’re not. But in reality the medications are there for healing who you already are. So for example, today you feel more like yourself than you did last week. 

Lady Courage:  Well, yeah, last week I was desperate and hurting and losing weight and scared. 

Psychiatrist:  And today you’re closer to who you think your healthy self is. 

Lady Courage:  I think today I’m … Yes, I’m much closer to my healthy self. 

(Q: Closer to who God is creating you to be? Closer to God’s will even?)

Psychiatrist:  In all of these scenarios, at each point we want to think, “What does this say about who God is?” If He or She, (but we will say He to simplify because it’s culturally appropriate,) is kind and loving like you mentioned, then would this belief, X, Y or Z, be true?

Self-Care Tip: Lay out our beliefs next to that standard, that premise in our life. And because we’re a lot crueler to ourselves, then we would allow other people to be, it can rescue us on occasion.

Questions: “What does this say about who God is?” Please speak out!!! …and, Keep on!

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Medication vs Drugs

I imagine some day I’ll understand why users think drugs are healthier options for them then medications.

“Doctor, I don’t think my wife will be comfortable with me adding another medication. It seems like I’m already taking so many!”

Context: Brennon is using THC “for sleep” he explains. Not recreation. It’s “medicinal.”

Boy. We are going to have to redefine what “medicinal” means in the urban dictionary vs. in the medical. 

It’s as if the masses out there are acting like it is stigma behind any opposition of THC vs. science. Folks, there may be stigma involved but it’s mostly science. THC is, 99%, not medicinal. 

My cousin is a hospice nurse and she and I were discussing this. Along the meandering conversation way, we came across, that in her field, many are taking CBD. (I know most of us think CBD is THC-free but it’s not unless it’s thoroughly governed by the FDA.) When we were in our wandering conversation about this, I imagined out loud to her, “If I were dying, I’d want to take a good trip on LSD, do a line of cocaine, and have free access to heroine. Why not?! “

My cousin politely explained that in end-of-life, most people, not apparently ignoramus blind bigots such as myself, prefer to stay alert in their last moments with their loved ones. 

That makes a lot of sense. My “free ticket” to white clouded oblivion suddenly didn’t look as appealing. I’d like that too. I’d really like to have connection with my loved ones. At any time. 

This is the effort in psychiatry as well, believe it or not. When we medicate, we are seeking to align ourselves with the patient’s agenda, toward connection and not away. Toward quality of life and not to harm. Toward hope. When we encourage to take medication, it is not to seek oblivion and isolation. Rather medication is for connection.

Brennon is not alone. Many think that medication takes us away from connection. Away from connection to ourselves by turning us into something we are not. “Doctor, I don’t want to take anything that will turn me into someone I’m not.”

Away from connection to God by taking our willingness to submit to His/Her will, away from His/Her power and toward depending on science instead, as if there is an either/or. No, there is no either-or unless we put it there. There are no dividers between science and God. He/She made them both. They are fluid to Him/Her.

Nor is taking medication taking us out of connection to our partners, nor our family who thinks medication is a cop out and whom are loaded with their own journey of self-discovery over their own self-stigma toward medication. As if taking medication makes our patients less loyal to their loved ones, thereby less connected.

It’s so layered why we think medication is worse. Even worse than mind-altering THC. Even worse, than the disabling illness, or whichever idea it may be.

Question: What is medication worse than for you?

Self-care tip: Seek connection, “even” through medical ways. Be a friend to yourself. Keep on!

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Love without connection

Delicious rocky road Baskin and Robins chocolate cake was staining Fred’s teeth bright vampire red from the frosting. It mesmerized me as we bantered. Though, not enough to completely distract from the trigger setting off my sympathetic tone. 

“So, you are writing about God and psychiatry?” (Ba-boom!)

Fred is an enormous genius, well published and internationally acclaimed. (I’ll call him, “Dr. Fred” to give some cred, because he really is all that.) He’s super kind with real attachment to his friends and the random stranger, but still intimidating as heck when he wants to grapple ideas.  I sent up a prayer that God be in this talk and not my pride in the talk. I botched up good once or twice but in the end, if nothing else, I was blessed.

In his own life journey, Dr. Fred had done his own Jacob-like wrestle with God. He was still recovering from it, I think. I respected him so much. Some of us are given the chance to wrestle and we choose not to. Fred had courage and character. He brought his all to this interest of who is God.

To clarify my starting line in this discussion, I offered up my little premises; 

  • God is, 
  • God is Love, 
  • and We Are Designed for Connection. 

He nodded. “Ok then.” I felt a little deflation in his interest because much of his personal wrestle was prior to that line/premise I drew – “God is.” Even so he rallied and engaged.

“Ok then. What if you were to say that we should bring and deliver love ourselves? In all interchanges. In all encounters. We bring love. What’s wrong with that? Do I need to have this God in that case?”

Honestly. My little corner of the world, my home, my church, my grocery store, all would be better if I/we lived this way. I am proud and blinded by it. I interpret the world and call what is real and truth as defined by my own sight and how good could that be by definition? I am not loving enough.  

The idea of bringing love is wonderful. That’s not a difficulty for me in concept. My difficulty is where it starts from and ends from. It’s a place of disconnect. A place that starts autonomous from a Creator. A Maker isn’t there at the end either tying me to Him/Her. Connection. With what I understand of Dr. Fred’s perspective is that even if we were to bring love, give love, generate love, in the end, we are alone. Disconnected. It is because we are created and connect at all points that we are never alone.

I guess, inherent to the word “Love,” well it means connection to most of us. So this is a hard bridge to shimmy. It’s like water water everywhere and nothing to drink. We have this sense of goodness, kindness, call it love, in our lives, but we are still alone. I’m cringing because I don’t have it. This sounds pompous and I’m sorry. Forgive me. I’m offensive. But I don’t think God is offensive. So I’m getting it wrong. Help me?

When we run into something that doesn’t fully make sense, the problem’s not with God. It’s with us.

I am a Christian whose church doesn’t like a lot about her.

So, I was standing on stage singing songs, my service/therapy dog, Timothy, chose to lie down, belly side up one step down with his goods in full view of the saints. I think that’s when I officially lost their favor. Timothy comfortable on the raised dais, …just no. Next thing I knew, Pastor and I had a most awkward phone. Basically I learned that emotional support animals and therapy animals, no matter their licensure in these, are not legally defended to attend church.

But church is different than God. To me, it is full of people like me. Proud. Blinded by pride. Defining the world around them, what is truth, what is real, all through their senses, no matter the biopsychosocial condition of their organ; their brain. They need me as much as I need them partly because none of us can be a mirror unto ourselves. Sometimes we both get that, and it’s lovely. Other times, not so much and we fall apart. In the end, though, I remain connected. Connected because I am created. I am carefully made. I am wonderfully made. Marvelous are God’s hands that made me. My soul knows it well. Ps 139:14.

Self-care tip: Find your connection. There is Love.

Question: Tell us about connection in your life. Where is it? What is it? We need your voice.

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“Off To Sleep!” with you!

Ladies and Gentlemen! It’s time to go to sleep! Wait. Not till you read this.

PsychU, a patient education website, has invited me to present on sleep. These are their questions and how I hope to respond. Do you have any recommendations, other interests, directives? Please help me! Smile.

1.       Dr. Johnson-Quijada, in what ways is sleep important for our behavioral health?

Sleep rudders our biology ship, (if “rudders” may be used as a verb.) Our biology is the reason we have emotions and behaviors. Take out the brain and we don’t have any problems with emotions and  behaviors. So the biological health of the brain and body is where our focus should begin with when thinking about emotional and behavioral well-being.  This is not in exclusion of other import paradigms, such as the psychological or sociological influences on what make us who we are.

But let me ask you, 

Where do emotions and behaviors come from?

Now think about it and answer your true beliefs.

I was speaking with a wonderful physician the other day to whom I asked this question, (let’s call her Doctora.)

I respect Doctora for her character, personality, standard of medical practice and interpersonal beauty. She is a bulldog in the operating room. When patients need studies done that insurances won’t pay for, she tears barriers to treatment apart with vicious tools of rightness. And she cares.  She sits.  She asks.  And she cares.  She sees the person in the paper gown, each one for the person she knows them to be and the person yet unknown.

I admire Doctora greatly not only for these qualities but also because it gets personal.  I, who have my own special practice of medicine, cannot do her’s.

When just a green bumbler in medical school, there was a fateful day when I shadowed another great artist of medical care into a locker room.  I suited up in that blue sack they call scrubs.  I put little blue sacks over my tennis shoes too.

Do you know why there are blue sacks on the surgeon’s shoes?  So what is on our shoes won’t contaminate the operating room. But also so that when wet things come out of the human body and fall onto their feet, their toes won’t feel squishy. Yep. That’s what was going through my mind as I scrubbed my hands, each finger and each finger nail the ten minutes it takesto reach what is considered clean.

Surgery in progress, the color red mixed with a smell and monstrous sensual force that clobbered me to the ground.  I swooned, gagged and promptly ended my surgical career.

There is nothing more irritating to a surgeon than someone who doesn’t appreciate the “fun” of “cutting.” Yes. I irritated this mentor and others too I’m afraid.

This doesn’t keep me, unfortunately, from pleasuring in telling people, “I am licensed to do surgery.”  I am you know.  Any Jane with a medical license can pick a scalpel up and bring back the dark ages, or contemporary, depending on who holds the license.  I’m irritating to my mentors, remember.  It reminds me how anyone can go online and pay to become a marriage registrar, i.e. perform a marriage ceremony for couples.  My brother did that twenty years ago and has yet to perform the marriage ceremony for a willing couple.  For real judges and clergy, this might be irritating too and that makes me a little happy as well.

Anywho, Doctora and I were rolling with the injustices haranguing us in the practice of medicine, both from the angle of the physician and the patient. I was pumping her up for being the cutting-wonder who she was and she was dutifully marveling at my jabber-mouth work that she would, “never be able to do in a million years.”  Somehow this brought us round to how our culture avoids embracing the biological paradigm of anything inside our skull but is so willing to celebrate it for any other part of our human bodies.

Where do emotions and behaviors come from? 

Doctora answered me with a frozen breath. Then after I warmed and soiled the air with a lot of jabbering and she was finally able to speak, she said,

I would just be horrified if my brain got sick!

I wondered if it was scary enough to clobber her to the ground, but I do agree.  Terrifying.  Don’t you think?

So sleep is important from a basic rudder-rudimentary perspective of healing, restoring, and preserving our biological identity.  

If we don’t sleep well, a disease process may develop. 

During sleep, we heal from injuries, both physical and mental. Our brain actually shrinks for a small period, squeezing out, like a sponge, the toxins that accumulate during the day. It becomes smaller in mass without the fluid that filled it. The toxins drain into our cerebral spinal fluid (CSF) and after a period, the brain absorbs new clean CSF and expands in size again. Without deep sleep, the brain retains the toxins it accumulated during the day and those toxins go on to damage the brain cells, summarily over time, potentially harming the brain health and leading to disease. 

These treatments relating to sleeping well are often better than pharmaceuticals when it comes to processing and treating stress. When we sleep, we allow our broken neuronal connections to regenerate. We re-stock our shed with ingredients like cortisol, hormones, and neurotransmitters that are fertilizer for well-nourished thinking, kind behaviors, and stable emotions. During sleep, our memories consolidate; they find their place in the folds between our cells and root down into our rich minds.

I have seen regular, restorative sleep bring someone from a place of mental decline to no longer needing psychotropic medication. Everything works better with sleep.

2.       What are some of the tools that you like to use to help people develop better sleep hygiene?

Sleep Hygiene, according to Dr. Q! 

1. Bed is for  

The bedroom is only for sleep and for sex. This means no food, no phone, no TV. If you are not having sex, then all you get to do here is sleep. This might be an adjustment for the entire family, if your spouse is used to clicking on the late news or your kids want you to read them stories in your bed. But your subconscious has to recognize this place as a sanctuary, and not the place to read one last chapter or check Twitter. 

(I have yet to have someone tell me that this improved their sex-life, but one would think!…”)

2. Naps

No naps longer than 20 minutes during the daytime. If you are tired and have the luxury of lying down during the daytime, do it! But set your alarm to wake you up in 20 minutes, and then make sure you wake up fully. You can take these “power naps” 20 times a day if you want to, as long as they are no more than 20 minutes at a time. Anything longer will break into your deeper stages of sleep and throw off your sleep cycle (also known as sleep architecture or circadian rhythm) at night.

3. Exercise

Exercise, but not before bed. Exercise during the day can help to regulate your sleep cycle by making your body tired at night, but make sure you do not crowd it against sleep initiation. Try to get 40-60 minutes of aerobic exercise, 5-7 days a week. Look at it like a pill, prescribed by a doctor. This is something you need to do not for your waistline, but for your medical and emotional health. Every day, tell yourself, “I’m exercising so that I will feel good, so that I will sleep good, and so that I can do what I want in life.”  Some say, “I’m exercising for my brain!” 

4. Lights

Keep the lights dim before bed, and turn off the screens early. Darkness releases melatonin from the pineal gland in our brains, which helps to regulate our sleep cycle. Light suppresses it. Melatonin is a cornerstone in sleep architecture. Having your face six inches from the computer or TV before you lie down doesn’t give your body much time to turn itself off. (Some people who feel they must be on the computer or TV before bed have found that wearing sunglasses for at least the last 30 minutes helps.)

5. Routine

Go to bed and get out of bed at the same time every day. Enough said there.

6. 30 Minute Get Up

If you go to bed but cannot fall asleep in 30 minutes, get up and do something else until you feel sleepy. Then go to bed and try again. Refer back to the other rules when choosing your activities (no screens, no reading in bed, etc.).

7. Caffeine

No caffeine in the second half of your day. Period. No matter how good that iced latte looks. Decaffeinated is the way to go!

8. Alcohol

Do not use alcohol to sleep. Alcohol is a depressant (will make you depressed) and also blocks deep sleep. Alcohol hits the same receptors in the brain as the benzodiazepines mentioned above. 

9. Nicotine

Do not smoke before bed or if you awaken from sleep. Nicotine is stimulating. (It also decreases blood flow to the penis, so that’s one less of only two allowable bed activities we are allowed… Bummer.)

10. Sleeping Aids

If you cannot fall asleep in 30 minutes, consider taking a sleep aid. Do not take any over-the-counter sleep aids except natural melatonin, valerian root, or chamomile. Others almost all contain diphenhydramine, which blocks your deep sleep. You may end up sleeping a longer amount of time, but you will not be getting restorative sleep. 

If you talk to a doctor about a prescription sleep aid, do not take benzodiazepines, such as diazepam (Valium,) temazepam (Restoril,) clonazepam (Klonopin,) alprazolam (Xanax,) or lorazepam (Ativan.) These also block deep sleep. Sleep aids that don’t block deep sleep and sleep architecture include atypical benzodiazepine receptor ligands – such as zolpidem (Ambien), eszopiclone (Lunesta), or zaleplon (Sonata). Trazodone (Desyrel) is also safe for sleep structure and maintenance. The newest FTY (Friend to Yourself) sleep aids are Belsomra and Silenor. Sometimes people will find that combining sleep aids, such as zolpidem with trazodone, is more effective rather than using only one agent. Some of these wash quickly out of the body, and some take a full eight hours.

11. Sleep With Me

Do not sleep with your pets or children. Pets and children are disruptive, and no one gets the rest they need. Get the sweet buddy-dog out of bed.

It is not personal. It is sleep hygiene.

I’ll insert here, that one thing that gets left out of most sleep talks, is how to be awake. 

Because, the opposite of sleep is not just slogging around in a haze. It is alertness, attention, and memory.

Sort of abandon sleep hygiene for a while. Give yourself a break from the disappointment. And then be firm on the effort of daytime alertness.

Practically, all of this means reading, writing, talking, and moving. No nap unless before noon. The body requires all these to be alert. And vice-versa for alertness.

This is where I additionally bring in the concept of a stimulating medication such as provigil. Don’t confuse this with taking caffeine. Caffeine is metabolized way too fast to be helpful in this regard. There are others one may discuss with their treatment provider.

3.       What parting words do you have for other practicing psychiatric healthcare professionals regarding this topic? How about for the consumers?

For providers and consumers alike, remember our identity is as humble as the cells from which is is generated from. Our identity is as vulnerable as those cells are. The basic needs of the body, such as sleep, lead to the most beautiful and marvelous developments that this life can bring. Without our biological health, without healthy sleep, everything in our body and what our Me connects to, is affected.

Questions for you, readers: Again, do you have any recommendations, other interests, directives?

Please help me!

(Smile.)

Keep on!

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Besmirching God with My Crazy

I’m sitting here in a volunteer medical clinic for a 60K attendee camporee. It’s humid and hot and we are seeing a lot of dehydration, amongst other things. 

As a psychiatrist, I’m humming the Hallelujah chorus as I discover how much general medicine I still remember, from gout, viral rashes, respiratory and ear infections, cuts and bruises, and so forth. The group I came with teases me that if someone comes in for a cough, two hours later they will have disclosed that they were abused as a child and be swallowing prozac.  I am ignoring this implication that I am missing “the point” by treating for psychiatric needs. Ignoring and missing, at least it’s consistent.

Our theme from this camporee week is appropriate.  We have been looking at the life of David. In these, we see a whole lot of psychiatry going on, both medical/biological, and that which has to do with volition. King Saul demonstrated a sure biological mental illness. And David pretended to be crazy – call it, “acting out.”  

God put this in the Bible for some reason(s). Question: What does this say about God’s character? I mean, we certainly don’t look up to people with acting out behavior, like David. Nor do we necessarily look up to people with mental illness like Saul, either. What does this say about who God is? Why does God put this in the Bible?

The Bible didn’t describe this as psychiatric, behavioral, acting out, or general medical.  It just told the story. These ages later, we can do more with the story. Here in time, with the knowledge that the generations have given us, we could say something psychiatric was going on. But generally, despite this knowledge, we ignore the medical condition. We still talk about them with a weighted moral perspective, as if they departed from their spiritual walk in these behaviors, rather than consider the medical condition of their brains.

David is getting a javelin thrown at him while playing the harp. Patton State Hospital for the criminally insane might have housed king Saul if he were alive today. Then, David is in front of the Philistines with King Akesh, where he “pretended to be insane; and while he was in their hands he acted like a madman, making marks on the doors of the gate and letting saliva run down his beard.” (1Sam 21.) 

Dr. Martorell, a neonatologist, told me,

“I see so many people afraid to discuss problems such as depression, anxiety, other psychiatric illnesses and even family problems or abuse.  Yes, partly due to the fact that they may be judged as not having enough faith or not taking care of their health or not following certain principles.  

Primary Care Nurse Practitioner Carrie stated, 

“God and psychiatry go hand in hand I believe, but many Christians don’t think psychiatry has anywhere to go in the church. This is sad because my mom had bipolar, but nobody could help her.  She needed the ‘extra help’. The church thinks we should be able to handle it ourselves.”

You may have seen the lock-down type who says, “Keep it in the family. Don’t tell others what goes on here. It’s none of their business.”  

Dr. Martorell said, 

Our cultural or family upbringing has a lot to do with how free we feel to discuss these issues.  In certain cultures mental health problems are simply not discussed.  If it gets brought up, the family directly or indirectly tells the affected person suffering not to discuss these outside the home, as though it were some dark secret that cannot be disclosed.

Nurse Carrie said, 

“Everyone thinks we should deal with things on our own, and we shouldn’t have to talk to people about our problems and what’s going on in our lives.”

Ironically she is describing a condition of the church of independence. Yet inherent to being a believer is the learning to depend on someone else, God. 

Nurse Carrie said, 

“Why is it with depression and such, we can’t work as a church and have medical get it done.”

Many say, ‘If you go see a psychiatrist, it’s a sign of weakness. You’re not a good Christian.’ These are the comments I’ve heard of through the years.  You should just pray, and God can take everything away.”  

When my aunt suffered colon cancer, she didn’t get medical treatment in the beginning, preferring to have herself anointed, and follow a “homeopathic” approach. Later as it progressed, she changed her mind and found it was too late. So although largely, it isn’t only in psychiatry that we misrepresent who God is, we need ask ourselves, Who is God if what we believe about this is true?

Dr. Martorell shared,

As a neonatologist, I see infants born prematurely. Their brain develops outside the womb and are simply not the same as those that develop in a dark, quiet environment listening to mother’s heart rate, free of noxious/painful stimuli inside the womb.  As much as we try to imitate a womb with our incubators we can’t provide the same care.  When these infants are followed up for years, some develop physical deficits such as cerebral palsy, blindness, the need for oxygen, and the inability to eat on their own. These physical problems are easily seen and various treatments can be provided.  They are also at greater risk for developing learning deficits, hyperactivity/inattention problems, depression, anxiety and some academic papers even suggest increased risk of schizophrenia.  The thought behind these is that billions of synapses are occurring during pregnancy and the way these synapses connect is different in premature infants.  It is also interesting to note that the brain volume preset at birth occurs during the last 4 week of pregnancy. As these children grow up they need treatment for physical problems as well as psychiatric problems they may develop.  

I realize that it is not just in our churches that we are afraid to address this issue but I see it in the families of my newborns.  So many of these moms self medicate with illicit substances in order to treat their anxiety or depression.  Our culture as a whole has neglected to look at these issues as a medical problem that needs treatment.  So many children and teens are committing suicide.  Our own “well educated” health professionals have some of the highest suicide rates and yes it is occurring in our christian institutions as well as outside.  

Nurse Carrie said, 

“In this kind of approach, people are saying S/He’s not a loving and forgiving God and S/He doesn’t understand us.  If you deal with psychiatry, you’re a sinner. Why can’t you get it done with God on your own. He’s not a loving God, saying this person is not allowed to take medication. The pastor’s describing a cruel God because he’s not allowing the person to get the help he needs.  Like if someone’s leg is bleeding and you refuse to give that person a band-aid. 

But, God is always loving. This can’t be true.

I don’t think the pastor has a right to tell the parishioner that.”

Maybe we just succumb to the awkwardness of it all.  Too awkward to talk about God in our community.  Too awkward to talk about psychiatry in our church. There are so many reasons we approach emotions and behaviors this way but in the church or outside of it, let’s consider the question, What does this ay about God’s character?

I was cleaning up a leg laceration about 1 1/2 inches long and 2cm deep. I placed the triple antibiotic ointment and approximated the edges with steri-strips, yet still encouraging the patient and her guardians to take her to the urgent care to get stitches. This wasn’t a sterile environment and our supplies were limited. While working on the wound of the young teen, I asked a few brief psychiatric intake questions. It turns out, no. She didn’t have anxiety, or depression, or psychosis. What do you know!? Not everyone does. But she and her guardians were super pleased to pray together before they left and I was blessed by them.  

God is a God of love and the kind of God that cares about all of it in all of us. S/He is kind and not miserly, discriminatory, or punitive in interest and connection to us.  

It sounds like from what i’m writing that psychiatry isn’t seen as a legitimate form of medicine in the church. Or maybe the church doesn’t refer to it, or support it.  

A friend from my group read this post and responded. 

“We hear a lot about emotions and behaviors in the church, and related directives. We don’t hear however about where emotions and behaviors come from. 

I hear, ‘just pray more,’ or that I am lacking in faith. The people in the church get defensive, as if they have to defend God. And that’s not it. Honestly, it’s not complimentary to me that they think I’m insulting God. They are in a way attacking my spirituality. But I know God is helping me and He’s here with me. But I’m still this way. I still feel this way.

There’s a taboo that mental health and disorders all get grouped into this one cringeworthy word, “Crazy.” We’re almost protecting God from crazy by staying away from it in the church. We forget about the sin factor. The separation between us and God. The loss of connection. The word crazy isn’t very nice. So if we say crazy and we say psychiatry and God, it’s almost like we are besmirching God.  

Self-Care tip:  Ask, and ask again, What does “this” say about the character of God? It comes back to “Me.”

Question:  Do see the Bible and your church talking about psychiatry? Where and how? What does it say about who God is? 

Keep on!

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Emotions come from the brain.

Margarit was a lovely twenty-something, with blue-black bouncing hair above a slim pixy framed physique. She smiled easily and chattered like she was on telephone call that was about to lose reception. Her hands moved, conducting her thoughts between us. She was dressed like one of the cool girls on campus, out of my echelon, and who just might stab me in the back if I didn’t know better. But I did. She wasn’t mean. She was super sweet, like honey, and cane sugar, and mangos. Margarit was nice. But she had always wondered if she was being so nice all the time, because she was too nervous to be otherwise.

She came because she was constantly preoccupied by worries over things, “no one should be worried about”.

There had been the counsellors, therapists, and pastors consulted. Margarit and her parents had done their due diligence. With initiating each effort toward getting help for Margarit’s anxiety, they anticipated some degree of success. They thought things would get better. And sometimes they did, in degrees, and for a period of time. but the anxiety always came back. It got to the point that Margarit was put in home school, referenced her looping thoughts for everything, and was socially immobilized.

Maybe you’ve read, Gulliver’s Travels, 1726 by the Irish writer and clergyman Jonathan Swift. When Gulliver shipwrecked and washed ashore unconscious, the numerous tiny Lilliputians effectively tied him down. The rope anchors were so small, like acupuncture needles, yet Gulliver could not move. That’s what anxiety does to us. We become internally preoccupied by it and can’t think much outside of our thoughts. We are immobilized.

The anxiety Margarit had been harassed with since a child took her freedoms away. It chose for her before she even knew what she would decide. Example; friends want me to go to the mall with them. “No,” Before her thoughts could even play with the option. Maybe she wouldn’t have gone anyways. Or maybe she would have. The anxiety chose first though and she wasn’t given the chance.

By Margarit’s third visit, she had improved significantly. She was getting to know herself, she thought, for the first time. I met the parents this visit and they looked at me as a front. I supposed it had been them up against so much for so long now, that they had learned to go at the world this way, like a man plow they both held on to. They asked me why no one had ever recommended for Margarit to seek medical treatment for anxiety.

"We would have done anything asked by one of these professionals we took her to. We thought they should know what to do, but they didn't tell us to get her medical help."

In my mind, I flashed to Naaman being told by Elishah to dunk in the dirty Jordan river seven times to cure his leprosy (2Kings 5). Psychiatry is the filthy river and dunking in it is the nonsensical act of taking psychotropics based on magic and miracles. They were here reluctantly having preferred to start with clergy and therapists, beat up by inappropriate guilt, but ready now to consider that anxiety, in Margarit’s case, is a medical symptom of a biological illness.

The question of why no one had referred them toward a medical approach for their daughter’s illness is a good one, though. I asked a pastor what he thought, and he spoke of the difficulty of not being a medical specialist; not knowing when to refer people. And what of the therapists? Likewise, I guess, that they generally have been trained to approach emotions and behaviors through a psychological and sociological paradigm. And what of the parents themselves? Did they, when their daughter broke her collar bone in the 3rd grade after Christy pushed her off the swings, take her to the emergency room or to the movies for a night out? The ER. But when her daughter showed preoccupied thoughts that permeated her days, affecting her choices, small or large, affecting her sleep, and so forth, they did not think that the thoughts were related to anything medical, coming from her brain. They did not think that the thoughts were more than coping skills, or habits, or choice.

It is a condition of our humanity to want to look at thoughts and behaviors as many bits of our life control to be manipulated intentionally. As if we could. Like “The Matrix.” Or cooking a soufflé. Or driving a 1969 Chevrolet Camero. Shift already! There’s the good intentioned phrase, “Calm down.” “Take a chill pill.”

Oh good. Someone finally said it. If they didn’t I never would have thought of that. Now I am calm because I was told to be calm.

Emotions and behaviors come from the brain. Take the brain out and no matter what chaos hits, we would feel fine. Take the chaos away, and leave the brain in, we are still left with the brain, and what ever condition of health the brain is in.  So if the brain is ill, it expresses itself in a way that is ill. If the brain is healthy, the emotions and behaviors are healthy. They are symptoms of a medical condition.

Question: Where do you find your sense of control comes from, considering the biological paradigm? Let’s talk folks!

Self-Care Tip: Consider the biology behind whatever it is that feel and do.

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Four Horsemen – Lovin’ Better




So good. I want to practice this in my home.
More and more I see that I love because God loves me first.
This is a good place to start in living in a love relationship.
Keep on!
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Where Your Shame Is

One of my strong memories of Marcy will stay, of this Halloween. 

She was tired after her day at school. She had gone back to college to get her nursing degree. She was tired, like a shirt that had been over washed in hot water. She was the kind of tired that looked like the good emotions in her water bottle had been slurped down, and the refill was still in the fridge in her kitchen corner. At home. And she was still in the car.

These feelings started to increase and crescendo, and pretty soon she was tieing into memories of failure in her past. A young child who heard her parents yelling at each other in foul language. Marcy heard, “My family doesn’t love each other or me.” A kid who dressed poorly and Mom said, “Go change. You look terrible.” Marcy heard, “I’m an ugly kid.” A teen who didn’t get invited to the parties that she knew were going on. She heard in this, “I’m not likeable.” A young adult who watched her mother walk out on her father. Marcy heard, “I’ll never be someone worth committing to.” And now on halloween, with her daughter coming home from school, Marcy felt like a failure as a student and as a mother.

She told me about this, last week. We were in the quiet space of my office. Lamp light shone over the beta-fish hiding behind his splashing filter. 

Marcy told me, she was wilted there, in the seat beside her daughter. Saying words in effort of trying to be understood, she spoke, and she cried. At some point, Marcy realized she thought that if she didn’t go trick-or-treating with her kids, it meant she was a let-down. She wasn’t a good mother.

Not only was she someone who gets tired too easily, she was also a flake.  

Marcy threw out a few options; how to make this right for them. Then her mind opened up and processed these. She saw her inner beast let shame go. Something better in her said that she would give what she could, and discharge the rest. 

Marcy, in talking it out with her daughter, made herself vulnerable to what brought her shame. In that, she let the truth surface that she was, actually, not “a piece of crap,” after all.

Building on what our living experiences are, rather than disenchanting, they are healing. The easy fantasy that comes from comparison, from fabricated idealism, and from the personalizing of it, is destructive. We can be resilient by building on real experiences. We can be present and connected both to ourselves and others.

Brene Brown speaks on wholehearted living:  “It’s about the willingness to be imperfect, to be vulnerable. It’s about the courage to wake up in the morning and acknowledge that no matter what gets done and what doesn’t get done, that I’m enough, and that I’m worthy of love, belonging, and joy.”

Halloween will be a reminder to me of Marcy letting shame go, not identifying with the thin logic of her own self-inadequacies, and of getting into the living of it. That’s courage. That is brave.

Self-Care Tip: Start exploring where your shame is, and let your real experiences speak toward your belonging and self-value.

 

Question: In what areas of your life do you feel like you are not enough?

What has helped you discover your reality?

Please tell your story! We need to hear from you. Keep on!

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What are you Living for?

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“Latest Banksy Graffiti”

Why do you get out of bed every morning? To go to work? You think, “Life i is about working and then, someday I’ll die.” Are you living to go to school? Perhaps a student for life, the best is to gather and gather. A klepto of information.  Ma skzwybe you live, instead, to stay home and not leave. That can be worth it. Leaving home feels like going to one’s death for many, in fact, with anxiety.

Is what you are living for, worth “living for?” Why didn’t you kill yourself last night?m I’m not asking for “13 Reasons” or glamorizing suicide in any way, like it ois, unfortunately, being done in the media these days. I’m just asking. (Straight face. Eye contact.) Why?

Suicide is increasing, this year up by ~30%. It’s sad but I’ve heard the ignorant say, “When our world is being overrun by humans, this is just one more way to improve population management.” Why anyone would say that, let alone to a psychiatrist, speaks toward the unfortunate person saying it more than anything. Even so, these are the people that contribute to our cultural stigma and sentiment, like the wrong colloid for growth. This stigma is best diminished by peer-to-peer influence. Your voice; you speaking up is the painting over the foul-language graffiti. You speaking of your own journey with suicidality or any related diseases changes the ignorance into empathic knowledge. 

We are in the mental health equivalent to the industrial revolution. Fortune. We are wealthy in mental health treatment options. Bling! Bling! It wasn’t too long ago when we were trusting depression medical therapies to crude agents bulky, and bluntly stunning our neuroreceptors. These were a big stick coming down on a flower.

Think of the cart and horse transforming into the automobile; course into sleek and refined; slowly moving and grossly impacting changes, contemporarily working rather as specific rapid responses. Now remember your parent, or mine, who never had the opportunity to receive a treatment that would work in a matter of weeks, and without turning her/him into a zombie-blimp.

A child stands there going through his own vasovagal experience, scared and confused while watching his favorite person in the whole world performing like a broken toy. The child tries to make sense and restabilize their once clarified existence. The parent goes through this at first for about six months and then somehow “gets better.” Was it the prayer that worked? Was Momma finally able to “pull through it?” Was it because the child’s behavior finally became “good enough” to please God who then condescended to make his momma better? Momma does well for another 2 years. She’s connected. She’s filled with purpose. The memory turns into something like, “Boston’s worst winter in fourteen years;” briefly print-worthy and then thankfully, not much more.

Then momma is again dark, hopeless and staying in bed whenever she can. The child, Teddy, is now a preteen of ten. This comes back, like finding another letter from his cheating dad’s girlfriend under a magazine in the back of the closet where his golf clubs are. And instead of six months, Momma’s change lasts about two years. (Can we even call it a “change” when it lasts two years?)

The amorphic improvement comes again though, like a miracle, but who can trust it. Miracles aren’t gotten in vending machines after all. I We can’t buy them with a paycheck.

Sadly, as Teddy feared, another some many months later, Momma drops again. This time she plummets rather than drops, into a drunken, more terrible condition. For longer, and the boy is now a teen. He at first appears more calloused. Yet, if questioned, he will show his grief and bewildered young self, just there behind a gentle touch, or a cluster of inquiring kind words. He loves her well. Why can’t she love him? Moms who love their kids will get up in the morning. They’ll shower and they’ll talk. They don’t write suicide notes or leave their son’s to find them half conscious when they get home from school. Not mom’s who love their kids.

Our moms, yours and mine in the seventies, didn’t have the privilege of taking treatments that worked or worked well, and rapidly. We are so blessed. How to grasp the immense difference in our Age; this Age of mental health revolution.

Now a little boy sees this change in his favorite person in the world. She is fortunate enough to receive medical treatment, and within weeks is “back to myself again.” This little family escaped years of decomposition by the ravaging damages from brain illness. 

My grandma, Elsie Louise, (isn’t that a great name!), was washing her laundry in a new machine that decreased her labor by many hours. One day, when she was daydreaming about her young handsome husband, or maybe it was the chicken she lost to the fox, when she screamed, jerking out from a terrible pain in her hand. Her fourth finger was gone. She lost it, pulled off by the twisting force of the machine’s internal grips.

Now we place our laundry in a closed lidded box we just walk away from. We don’t even think about the appendages we are allowed to retain. We don’t imagine the privilege. 

In psychiatry, it is like this. The treatments we had generations past were better than none. But, enter now into 2018, and we don’t realize how good we have it. We forgot most of the print-worthy stories back then. Not to use the treatments from this revolution, is going back to the darker ages of medicine. The treatments save lives. They bless. They make us rich in life. Bling! Bling! Look at your wealthy character. Healthy.

Why are you still alive? Whatever you answer, fight for that. Take advantage of the mental health revolution and live well.

Questions: What are some stories of those you have loved who missed out on mental health treatment? What are some stories of those who did not? Where is the difference?

Self-care tip: Speak! We need to hear you. You are painting over the foul-language graffiti of ignorance!

Keep on!

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False Thoughts about Getting Healthy

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Think of walking in a rainstorm. Your clothes and hair hang heavily. They provide no protection. They offer no remedy. You take a hand towel out of your bag and try to mop up your icy wet face. Wring it out and continue to wipe. 

This is like choosing to do all the psychosocial efforts in your life, but missing the biological. Until you treat the underlying illness, much of our efforts to heal are like using a hand towel to dry off in the rain storm. We think that we can get better without medication. Or, we may reject other treatment options, like ECT or TMS. We think false thoughts. 

It’s not healthy to take pills. 

I’m better than that. 

All I need is God. 

My parents would be upset, so I shouldn’t. 

If my work found out, I’d lose my job. So I shouldn’t. 

THC is better. 

Exercise is better. 

Some of these are entirely false. But some are just partly false, encased in a disconnected truth. This “rain and the hand towel” idea is not an analogy meant to minimize or bring shame to those who choose not to engage in treatment. It is not meant to talk down. Please forgive me for the crudeness and limitations. It is just meant to crack open this idea.

Yesterday, Louise commented that her physician told her taking sertraline, or Zoloft, was like taking “a vitamin for my brain”. That clicked for her! Vitamins were ok.

Question: How has your physician helped you get past not wanting to take treatment? How could your provider do better with this?

Self-care Tip: Allow healing with medical treatment for medical disease.