psychiatry

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Personal Boundaries

Think of personal boundaries as the barriers we set with others to demarcate which of their behaviors towards us are permissible and which are not. Personal boundaries can encompass the following categories: intellectual, physical, emotional, social, and spiritual. My patients who have difficulty knowing and setting their personal boundaries usually lack self-worth or adequate role models from whom to learn these skills. Some lack both.

I lacked both. Growing up, my father crossed boundaries with me and my mother couldn’t maintain any for herself or me. This became my blueprint for life. I was an object that existed first to please my father and later to please others. I did not see any inherent value in myself. It set me up to live and repeat the torturous cycle of poor self-worth, inability to set boundaries, bad decisions, poor self-worth, and on and on.

Fortunately, this is no longer the case for me. These days, my self-worth is strong. I know my boundaries. I set my boundaries. No exceptions. My decisions are better. I can take care of myself and others.

It took much pain and practice to get to this point. And now that I’m here, I want nothing more than to help my patients on their journeys towards healthy self-worth and boundaries.

It takes time, I tell my patients. Generally, we start by identifying family patterns that may have contributed to their ongoing struggles. Then we see how they might be repeating these patterns in their current lives. Next we figure out what their boundaries should be and how they might begin to set them. Setting the boundaries requires assertiveness (being able to verbalize their true thoughts, feelings, wishes, and decisions) and the ability to tolerate the negative feelings that initially accompany not doing what they think other people want. We discuss how they can practice these skills in the here and now of their lives.

There are times when my patients can grasp the theories we discuss, but have a difficult time stopping their own cycles of poor self-worth, inability to set boundaries, and bad decisions. In these cases, involving their families or significant others can be helpful. Sometimes the patients end up repeating their cycles in their therapeutic relationship with me, and on some of those occasions I may have to set strong boundaries with them to role model appropriate behavior. And in order to avoid enabling the cycles that keep them stuck, I might even have to stop treating them. During our final session, I remind them that they are worthy and that it is imperative that they work on knowing and setting limits with others so that they can nurture their own self-worth and sustain and nurture their most important relationships.


Anxiety Sucks, but Trump Could Use Some.

I don’t normally wish a psychiatric disorder on anyone, but I wish Trump had Generalized Anxiety Disorder (GAD). See then he’d overthink everything instead of being so brazen. Then he’d get stuck on thinking and thinking and thinking about how other people viewed him. His anxious brain would force him to attend to other people’s feelings before his own. I’m convinced that a Trump with GAD would be a toned down more empathetic human being.

But, for most people afflicted with any of the anxiety disorders, especially kids and teens, life is extra challenging.

A major component of anxiety disorders is overthinking. So when presented with a situation, a youth with anxiety disorder will automatically and effortlessly come up with every possible cause and effect of said situation. If the situation is dangerous, than this overthinking is a good thing. A biologic, rewired brain, protective thing (Anxiety disorders like PTSD can develop after or during exposure to adverse experiences such as abuse). But when the situation is no longer dangerous and it’s just plain old life, the overthinking is detrimental. It prevents the youth from being in the moment, developing their complete identity & positive self-worth, and making good decisions. They end up trapped in an endless loop of negative automatic thoughts, feelings, and behaviors based on what they perceive will keep others happy even if they harm themselves or someone else. Here’s a common example of overthinking that teen girls tell me about in the office: “I was at a party, the parents were out of town. And the guy I was kind of dating wasn’t there. This popular boy started talking to me. I used to like him so I was all giddy inside. Anyway, he gave me a beer and I didn’t really want to drink it but I did. He started touching me and it was cool at first. But then I wasn’t sure. I tried to move his hand away, but he was like, ‘Come on, I’ll be gentle. Don’t give me blue balls.’ I told him I had a boyfriend but he said ‘he doesn’t have to know.’ I knew that was wrong but he kept trying to convince me. I’d never had sex before and I didn’t want to but I couldn’t say no. If I said no he would get mad. He’d tell everyone I was a loser. He’d hate me and then everyone would hate me. So I let him. Hey, I’d rather deal with it than risk having him mad at me.”

Woah, right? But that is how powerful anxiety is. It makes youth do things their rational selves wouldn’t do.

In addition to overthinking, anxiety disorders can also make youth hold the opinions of others as definitively true. They have difficulty creating thought and feeling boundaries and are often unable to cling to rational thoughts of themselves. And this can have tragic effects. A common example of poor thought and feeling boundaries that teens tell me about: “The kids at school teased me about being fat ever since I was in second grade. It was so bad. I didn’t tell anyone. No one helped me. I even started making fun of myself. I hated what they said but I hated myself more. I started skipping meals. Exercising in my room at night. By the time I got to high school, I was binging and throwing up everyday. I still got teased. Nothing I did made me lose weight. I couldn’t stop thinking about what a worthless piece of shit I was. Am. I wanted to die. I tried to kill myself a couple of times…”

In med school and residency, I’ve gotten top notch training on how to help kids and teens with anxiety disorders. But more than that, I have an anxiety disorder and I’ve come to understand how it almost destroyed my life—this has made me passionate about helping anxious youth find their way through the quagmire of overthinking. And I practice what I preach. I practice being mindful and in the moment. I practice doing cognitive behavioral therapy on my automatic negative thoughts. I get enough sleep. I eat regularly. I exercise regularly. I don’t partake in social media. I try to work on expressing my true thoughts and feelings in the moment even though it takes everything inside of me to do so sometimes.

My latest battle is not internalizing the harsh negative online reviews people have posted about me as a psychiatrist. Things like, "I didn't like her at all" or I'm "unprofessional." My personal favorite, I'm "the worst psychiatrist." Luckily, these days I can fight off the anxious overthinking that tries to make me ignore all the evidence that points to the opposite of their disapproving opinions—that there are more positive reviews online than negative, that reviews shouldn’t really matter at all because I know in my heart that I give my all to my patients in every session (even if that means pointing out things that they don’t want to hear since I know this will give them a better chance of truly healing), that I don’t just do fifteen minute medication checks, that I will not prescribe medication unless it is medically necessary, that I insist on family therapy if indicated because youth don’t exist in a vacuum, that I do intensive talk therapy with youth with the goal of making them assertive, self-confident, and able to utilize a myriad of coping strategies to recover from—and/or live with at a manageable level—whatever psychiatric disorder(s) that plague them. All that and I’m not Trump.

Three Simple Rules That Can Have a Life-changing Impact on Kids and Teens

My teenager looked over my shoulder as I finished typing the first draft of this blog post. She proceeded to roll her eyes and mutter, “Ugh. This is our household.”

I smiled a satisfied smile to myself because, yes, this is our household.

Outside of my household, I’m a child and adolescent psychiatrist and I have the privilege of guiding young people through individual talk therapy to help them overcome mental health issues such as anxiety, depression, eating disorders, post-traumatic stress disorder, reactive attachment disorder, etc. Sometimes there are also complex family dynamics at play that require specific family interventions such as parent education or family therapy.

Over the years of doing individual child and adolescent talk therapy and family therapy, I’ve found that without a certain baseline, non-negotiable structure at home, therapy isn’t as effective or lasting. Because without this basic structure, it is that much more challenging to navigate the muddy waters of mental illness and that much more challenging to even begin to negotiate normal social, emotional, physical, and/or intellectual developmental tasks. Without limits and rules at home they may become even more entrenched in their mental illness. And a lack of boundaries doesn’t just affect youth with mental illness. It can negatively impact any young person.

So what is this baseline, non-negotiable structure I recommend? It’s three simple rules for children and adolescents that parents can enforce.

  1. Social media and screen time - 2 hours a day maximum, but less is better.

  2. Uninterrupted sleep time - 9-10 hours each night.

  3. Family meals - eat together as often as possible.

I apply these rules to my own tween and teen. I recommend the rules for all youth in general, as well as for the youth I treat. Let me give you a bit more detail on each rule.

Social Media and Screen Time

More studies are coming out about the detriment of social media and prolonged screen time. The bottom line is that excessive electronics isolates and prevents youth from learning about normal face-to-face interactions with people, which are an important part of development and happiness. The worst case scenario regarding isolation is that it is a risk factor for suicide. But being plugged in for two or more hours a day can also lead to a significant increase in suicide risk factors.

When youth have their heads buried in screens they are not self-reflecting or thinking independently. It’s not their fault that they want to stare at all the dazzling images and words on their screens. See youth do not have fully developed abstract thinking so they are more vulnerable than adults to being swayed by what flashes before their eyes. That’s also why they are more susceptible to peer pressure. So they see these fancy, filtered images and words and they may become convinced that they have to look and behave that way. They may think they have to get a certain amount of comments and likes to be worthy. They may engage in excessive texting or messaging that doesn’t allow them to learn the nuances of social communication (facial expressions, tones in voice, etc.). They may be vulnerable to online bullying. They may be constantly thinking they are missing out. They may live through their screens instead of in the moment. All of this can impair their ability to move through the normal stages of social, emotional, and intellectual development.

Incidentally, I quit social media. My tween and teen are not allowed to have social media. I figure I should practice what I preach, right?

Sleep

Poor sleep in youth can lead to negative outcomes such as struggles in school, car crashes, and/or depression. Numerous studies have shown that 9-10 hours of uninterrupted sleep is optimal for youth, especially teens because they are in an intense stage of physical, intellectual, and emotional growth.

It is helpful to remove all electronics from their bedroom at bedtime (except a good, old fashioned alarm clock) because teens will often surreptitiously use these devices in the middle of the night. They are not bad for doing this. Testing boundaries is part of normal teen development and it is up to parents to set and enforce the limits to help guide and teach them.

Most kids will not happily go to bed early, my kiddos included. They will most likely complain and fight it. They may also panic because they haven’t finished their homework. But in the long run, sleep is more important. Parents can rest assured that despite what their youth say, setting strict bedtimes helps with brain development and teaches youth to make more efficient use of their time. It may even bring up the issue of cutting back on extracurricular activities if there really isn’t enough time to get homework done. This raises another issue—that youth need time to be bored to help with their normal emotional and intellectual development. But that’s for another blog post.

Eating Meals As a Family

In this day and age of being overscheduled, I cannot overemphasize the importance of eating meals together as a family. I recommend decreasing youth activities if this will allow for more meals together. That’s how important it is. Eating meals together, especially dinners, teaches kids about face-to-face communication. It also can lead to better family relationships, improved nutrition and enjoyment of food, boosted grades and vocabulary, decreased depression and stress, increased ability to bounce back from bullying, improved overall mood, and fosters a positive outlook of the future.

As a side note, there is a trend in our society to eliminate more and more types of food from our diets. The science behind this “purer” eating is not crystal clear. There are many factors besides food that contribute to overall health and longevity.  Still, it is not uncommon for people who don’t have medical reasons for dietary restrictions to cut out all meat, gluten, dairy, sugar, etc. For adults, this is a personal choice and I’m not addressing that right now. But children and teens have different nutritional needs than adults and it can be dangerous for youth to be eating “pure,” “clean,” vegan, or some other restrictive diet unless they are properly monitored by a parent who can make sure they are getting enough calories, protein, vitamins, and minerals. Chronic lack of these nutrients can lead to medical problems and organ damage.

A typical example I see in my practice is the teen girl athlete who restricts her food intake and then doesn’t get enough calories to maintain her high activity level. She loses weight and stops having her period. Contrary to what some people think, it isn’t normal for a girl athlete to not have a regular menstrual cycle. Also parents need to be aware that restrictive diets can be a guise for eating disorders. In fact, "healthy," restrictive eating is the most common trigger for eating disorders in teens that present to my office. Eating disorders are complex and can have devastating consequences, including death.

If the family does not have long established exclusionary food preferences or practices (such as for religious or diagnosed medical reasons), I recommend that youth not be allowed to suddenly follow any restrictive diets. They can make up their own minds when they are eighteen but until then parents can protect them by normalizing inclusive, structured eating- regular meals and snacks, normal portions, preparing and offering a variety of foods, not making negative comments about certain foods, ingredients, or bodies. This makes it less likely that the youth will have disordered eating when they grow up. This makes it less likely that the youth will link food with control and self-worth. They will be more likely to grow up with the understanding that food is simply fuel and nourishment, not a means to happiness, and most certainly not who they are.