Hello, my hope here is to provide some thoughts on current events, trends in mental health, and reasoned thinking about how all of us struggle to survive and cope with the complexities of living in this day and age. I hope to provide a perspective, infused with living a long life here in RVA, practicing psychiatry for 40 years, and grounded in some knowledge base/science. I hope it provides reasons to visit my website even if you may not be my patient. Sharing my perspective is a daunting enterprise, but I think it will be good for me to hone my writing skills and hopefully you will also find “pearls of wisdom” in these musings — Steve.
Please Read On (most recent at the top):
Keeping Perspective on Cognitive Decline as We Age
One of the difficult components of aging is the fear and reality of cognitive decline. There are the dreaded diagnoses of Alzheimer’s or dementia or simply “early cognitive decline” that strike fear into the heart of anyone who enters into the developmental stage of “Old Age.” I have so many patients in their 70s and now even 80s who worry about the status of their ability to think, remember, and find words. There are enumerable reports and even books written (i.e., Sanjay Gupta’s Keep Sharp: Build a Better Brain at Any Age) about how to beat this phenomenon or at least keep it at bay. We know that good eating habits, exercising the mind as well as the body, staying interpersonally engaged can all be components that we need to integrate into our aging process to stay healthy and cognitively sharp.
We also, however, need to keep a perspective on this struggle, and try to focus on what age confers to us. I am forever grateful that at 73 years of age, I have reached a point in my life where emotional stability seems to be at a pinnacle. I may struggle to find a word, a name, or even remember the content of a movie I saw just last week, but when it comes to feeling emotionally liberated, it has never been better. I can get out on a dance floor and flail to my heart’s content and really could care less how I look, whether I’m appropriate, or even if I look like a silly old man. I can enjoy things without struggle to ensure that I am acting proper, or respectful, or even foolish. There is in this measure the potential to be my best self, my authentic self, and my truly engaged and present self.
We used to see the elderly as wise and cultures throughout the millennia have revered shamans, chiefs, and even grandparents. It isn’t their cognitive sharpness or their facile word-finding skills, but rather their accumulated experiences that living a long life provides. There can be an emotional steadiness, an ability to not get swept up in crises, and the willingness to ground others in the reality of the moment and help others keep perspective. I have repeatedly intoned my current status as one of the "wise old men” who need to speak up. We have so much still to offer and embracing this as a component of aging is to find a skill set that is immeasurably useful and critical in our culture. Politics aside, we now have a President who is older than almost everyone. It may be that he needs to step aside after his current term, but from my perspective, he has provided leadership that is wise and informed by his vast years of experience. There are legitimate concerns that we need to pass the mantle to a younger generation that may will better understand our cultural and institutional needs. However, for many thoughtful citizens of our country, his role in bringing us back to order and understanding has been truly comforting. Not everyone who ages bring this emotional maturity to the table (examples to go unnamed), but wisdom requires setting aside personal biases and yielding the floor to younger people with skill sets that we can’t hope to achieve. There is a selflessness that is better achieved with accumulated experience and knowledge that only living long and fully can provide.
My message to all who are struggling with aging and the reality of physical and cognitive decline, take heart: you can still be your best self, your wise, self, your emotionally grounded self who can give to those younger the needed stability and assurances that life is an endless series of challenges, struggles, and loss. But it also is filled with joyous encounters, exciting opportunities, and authentic love and caring that will fill the souls of those around you and provide needed perspective. You can truly provide solace and comfort when needed. Hurray for getting old!
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What About Benzodiazepines?
I recently did a musing called “What About Cannabis?” and I have begun to think about the other ubiquitous, still legal, but frowned upon player in the pharmacologic armor we bring to the table: benzodiazepines.
Benzodiazepines are a class of drugs to include short acting agents like alprazolam, intermediate acting agents like lorazepam and diazepam, and longer acting agents like clonazepam along with numerous sleep aids. They do have the potential to be addictive which implies the development of tolerance requiring increasing doses to relieve symptoms and as a result, there are countless tales of those who have so suffered. Withdrawal is complex and abrupt cessation can lead to seizures in some cases. There are reasonable concerns about their impact on cognition and memory. Alcoholics can become cross-addicted. So, admittedly, it should seem like a treatment of last resort when placed in this context.
But what about the vast majority of patients who do not get addicted and whose use is prudent, measured, and carefully monitored? I am mostly hopeful that the patients I treat with benzodiazepines are in this group. Throughout my career, I have watched and participated in the evolution of psychiatry from an analytic-, systemic-, and relationship-bound specialty to one in which pharmacology reigns supreme — and change has been truly astounding. I am a huge advocate for all the advances the SSRI’s, the SNRI’s, the atypical antipsychotics, the mood regulators, the psychostimulants, and yes! — the BENZODIAZEPINES (BZP), all of which I have offered my patients. In addition, I also advocate for informed and relationship driven therapy, EMDR, cognitive/behavioral intervention, and consistent exercise as vital components of any treatment effort.
I first prescribed benzodiazepines at a time when we did not know about all of the complex problems that can accrue to those taking BZP’s. We knew their addictive potential but were so utterly taken with their efficacy. If you know anyone who has panic attacks and watch them struggle with non-medical strategies to stop it versus taking an alprazolam, which has a rapid onset of action and quells symptoms miraculously (as some patients describe), few would choose the non-medical route. I might add I have profound respect for those who do achieve this non-medical control, but many of my patients started their journey using meds that convinced them they weren’t dying.
I do not want to enumerate every disorder for which a BZP can be useful, nor do I want to suggest that I am that conversant in the pharmacokinetics or neurotransmitter specificity of BZP’s anymore than I could be that specific about which atypical does what. It is not an easy language for me and I doubt at this point I want to invest in more learning in that vein. However, I am conversant and can enumerate countless patients with restless legs whose intake of clonazepam nightly allows them to sleep and allows their partners to continue to be in the same bed (which would seem to be a good tradeoff from my perspective). I know that taking a bit of lorazepam gets socially phobic people out of the house, or an elevator phobic on an elevator, or over the bridge, or whatever. It works, and in the long run may only be a pathway to a journey that ends drug free.
But what if the journey doesn’t end? What if you’re one of those people whose anxiety is just not helped by “baseline” agents like SSRI’s, SNRI’s, buspirone, gabapentin, etc.? What if your anxiety disorder persists in the face of everything tried? What if you need to take 2 mg of clonazepam a day to keep smiling, take care of your child or grandchild, and get to work? Yet to have this perspective and embrace it seems as if I’m facilitating “bad practices” at this point in our evolution of the rights and wrongs of psychiatric practice. Recently I have had a number of new patients seeking me out as they have been restricted from or weaned off BZP’s that they have taken for years. They are miserable and have now been labeled “drug seeking.” We could argue that it is their recovery from the addiction and that their systems will take years to re-equilibrate, or we could presume that it effectively treated their neurobiology for years. Someone taking 1 mg of Lorazepam in divided doses daily, and who has taken the same amount for 10 years, is not an addict. I agree it is not everyone’s story, but it is a lot of people’s stories.
I used to worry that because I so firmly believed in the efficacy of psychostimulants for ADHD, that people came to me because they know I was very comfortable prescribing these agents that have transformed so many of my patients. I've been mindful I didn’t want to become an “Adderall mill.” Now I am worrying that I will be perceived as a “BZP mill.” In reality, I make every effort to be a responsible clinician who listens to their patients and counsels them and shares in their life transitions, prescribing agents that provide quality and depth to their experiences. I am owning my belief that I am a good doctor when I relieve suffering and if it takes prescribing a BZP every day to do it, I'm not going to feel bad about it. So I will continue to muse and speak up when I think we need a more balanced understanding and perspective on how we practice our craft. I don’t want to feel like I’m a bad doctor prescribing these agents, and if any of this sounds naïve, I always welcome feedback. [JULY 2022]
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Doctors and Their Mental Health: What Gives?
Inspired to muse after reading an excellent piece by Seema Jilani, MD published as an OPED in the April 1, 2022 New York Times called “Doctors Face a Stigma Against Seeking Mental Health Care.” She provides a perspective on this issue that was new to me but also got me to thinking about whether it’s consistent with my experience and if so, what are the forces that make this so. While I have physicians in my practice, it is not nearly as frequent as one might predict. After all, it is a career path loaded with stress requiring a level of emotional entanglement with our patients that expectably should lead to not infrequent trouble. So why do not more step up to get help.
The factors are multiple and Dr. Jiliani offers a perspective that is compelling and has merit for some sector of this group. But it seems to me inherent in any effort to genuinely seek mental health care one has to offer oneself up. There is a leap of courage, a leap of faith, and a leap across an enormous chasm between “all knowing answer man” to the realm of “what’s wrong with me?” Physicians imagine that they are special and as I have addressed in a prior musing (“Finding Your Doctor Voice”), in many ways they are. It’s a hard job when done well and even if done half-heartedly, still takes enormous energy. I am clearly privileged and honored to be part of this club and wouldn’t trade it for anything. Yet, it requires a kind of mindset of humble vulnerability while providing exacting and thoughtfully-evoked delivery. Doling out news that is truthful, but tainted with as much hopefulness as is appropriate for the circumstance, is like threading the needle over and over again.
So, it doesn’t take a rocket scientist to understand that when the rocket veers off course, there is something wrong at the controls. The problem with physicians is that their credibility, their livelihood, and their career entails staying on course, and so to own that you have veered off somewhere tantamount to annihilation. Obviously, I am overdramatic to make my point, but you get my drift. It is not such an easy place for a physician to go. Imagine your physician clinically depressed and when you need your chest listened to or your throat checked he is unable to muster the energy to get out of bed yet alone come into the office. How excited would you be about entrusting your care to that physician. So, we soldier on. We hope against hope that things will be better tomorrow. I’ll just have one extra cocktail tonight and that will relax me and help this hellish feeling go away. Or maybe I can get my partner to prescribe small script for some sleeping pills. Everyone colludes because without doctors to generate revenue the whole group suffers.
Own your vulnerability. Own as a physician that you are human and not above being caught in the eye of a mental health hurricane. You may be neurobiologically susceptible to depression, anxiety, or mood difficulties. It’s your genetics, stupid, not that you’re morally bankrupt and weak. Reach out to each other. Find other physicians to be your friend and own together your willingness to help and support each other in this spectacular enterprise called practicing medicine. And when that is not enough, be man enough to call for professional help and be ready to be that patient that looks to his physician for “answers.” [APRIL 2022]
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Barefoot on the Beach: Getting Grounded
I’m in North Carolina, walking on the beach at Nags Head — barefoot and grounded into the sand. It is said that walking barefoot is really good for you and I am inclined to agree. Now that I am of an age where being conscious about balance exercises and other strategies to stay nimble are a prerequisite for survival, it is especially comforting to be able to walk out over the dunes and suddenly feel sole on sand. Sand walking challenges you in certain ways that no other hike does. Finding the right firmness, the right sand temperature, or dancing from hot to cold as the ocean is still alarmingly cold. The wave that suddenly washes over your feet and sends a jolt through you that is both inviting and distressing all at the same time. So, is it the walk on the beach or walking with a good friend or really both that provides grounding? Old friends have a way of grounding us too, so I don’t want to overvalue the sand. What does it mean to have yourself implanted directly on the earth and allow the core of the earth to come up through your being? To me, that is what grounding really means.
And why does grounding matter? When the world about us remains in such turmoil. When Supreme Court Justices have wives who invite insurrection. When Will Smith’s slap becomes more important than bombs falling on the Ukrainians. When gasoline prices begin to make us forget that global warming remains a critical priority and requires sacrifice now for the greater good. When the pandemic finally has relented to a degree and we can once again join with our fellow man. That is when we really need to get grounded. To imbed ourselves in the earth around us and envelop each other with warmth and kindness becomes an important mission. Grasp each other firmly from a position of connection to the earth. Respect its power and transmit energy that rises up to those around you. This all sounds contrived at the moment but musings have a way of gathering steam and go where they go. Do walk on the beach. Obviously privileged to have that opportunity but wherever you might find some level earth to ground yourself — barefoot, DO! The spring grass is especially beautiful right now (am always one to say that grass is a spring crop) and walking barefoot through it and grounding yourself to the earth is a good option. I like to envision that if I catch the earth’s vibration just right, it aligns my spirit and keeps me from veering off course.
My Sunday religion it seems. Connecting with the elements on a warm spring day at the beach. Not much one for organized religion, but truly imagine that our spirits require alignment and rejuvenation. Don’t neglect yourself and value the importance of getting quite literally grounded. Forget the metaphors. Forget the platitudes. Get your bare feet firmly planted in the sand, in the grass, in the dirt, or wherever you might find connection to the earth. And when the grounding won’t take hold, it is a signal that you need to reach out and ask for help. [APRIL 2022]
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FRIENDSHIP AS A SKILL-SET
Back into the musing mode after reading David Brooks OP-ED in the New York Times today, “The Secrets of Lasting Friendship.” It made me take stock of my circle of 5, then 15, then 150 “friends.” As it happened, I was lunching with two of my friends in the inner circle. It happens I am on a quest to broadcast my voice in some manner as I am truly committed to the idea that “Wise Men Need to Speak Up.” These two are graciously involved in my endeavor and truly seem to want to help me make my voice heard. The lunch, originally motivated by my efforts to move into Twitter and to “tweet,” ended up doing that, but as well reflecting on friendship and how it worked for us.
One of these friends is the role model for friendship. Cultivating and sustaining connection by reaching out, keeping track, and being effortlessly non-judgemental. She is now a 30-year friend and I have marveled at this capacity throughout and aspire to her standards of friendship. It also evolved into my vision that making and nurturing friendship is a “skill set.” Over and over again my message to the reluctant, isolated child/adolescent is that social acumen is learned and requires developing skills that are as important as history, english, or math. They need to think of it as a subject that they are not particularly good at, but need to develop these skills in order to survive in the world. I suggest that they need to work at this and learn about appropriate social interaction such as taking turns listening, putting aside your own needs when a friend is in distress, reaching out when you are hurting, and laughing at all the stupid things you do together.
So yes, it helps each of our adaptations to have good friends and to appreciate the power of the loving connection. But right now, it also seems we need to learn how to be friends as a group of citizens who share this fragile planet. We need to make sure that our “territory” is safe and that we cultivate caring for each other in these difficult times. During COVID-19 we have retracted our circle typically down to that 15 or so close friends who we trusted to be safe and who we knew shared some particular values. We are now at a juncture where we can think about the other 135 people and really engage our more extended family. I would suggest that we all need to step up and think about caring for those in our circle, beyond only those who provide more immediate comfort and solace. We owe it to each other to put a value on thoughtful connection and work at sharing some piece of yourself for the greater good. Hurray for friendship in all its dimensions and kudos to David Brooks for stimulating and bringing attention to this all too important “skill set." [MARCH 2022]
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Funding Schools Appropriately
Back to musing after reading another op-ed piece in Monday’s New York Times “The Pandemic Showed that Schools Aren’t Made for All Kids” by Jessica Grose. I was left with a sour taste in my mouth as it documents the issues and problems with the public school system but provides little insight into how we got here or what can be done about it. I for one think service in a public school system is one of the most profound contributions to our culture and we have to start with a salute to all our brave teachers, their assistants, principals, guidance counselors, and the whole team of mental health professionals who “grind out” IEP’s. These Individual Educational Plans are required for any child identified as having a disability and the specific strategies for accommodations that will allow that child to learn. When done right, it is a labor-intensive process.
I would agree that the pandemic might have thrown a spotlight on this issue, but it was also an extra-ordinary time in our culture for everyone and throwing our school system under the bus for its often misguided and confused response to it is not entirely fair. As a child/adolescent psychiatrist who has worked “in the field” shepherding parents and their children who are “atypical” in whatever way through the public school system, I have a keen sense of what amazing responses and what unique strategies can be arrived at with proper diagnosis and advocacy. This last point is especially telling as without a strong advocate a child has limited opportunities to get the gamut of services that would be ideal. My impression was that most of the anecdotal stories that Jessica Grose relates today have parents who are strong advocates.
What about all the other kids whose families cannot accommodate or understand or have any clue that their child is different or struggling. Even when they do, they often feel blamed and misunderstood and see the effort to secure a better education for their child as a burden on their time, their emotional bandwidth, and their resources. Teachers and all of their allied professionals have to teach and serve these children as well. I am so grateful that I have two amazing nieces who have taught middle school for years, but whose lifestyles have been profoundly upgraded in one case, by marriage and in the other by working as a waitress or safe home attendant to augment their meager salaries. What can we do to drive brilliant young people into this career that is so critical and so essential to the welfare of society. You can make as much money or more at an Amazon fulfillment center which is a job that is hard and I am respectful of those who work there, but you leave it at the door and “punch off the clock.” You don’t have to cram in one more IEP meeting, or grade one more paper, or politely listen to one more parent blaming you for failing their child.
This has all been happening for years and I have watched, mostly helplessly, as we “blame” our school systems for all their shortcomings, but then when budget time rolls around insist that they need to use their resources “more wisely” and underfund an already burdened system. No one likes to pay taxes, but this is one area where we have to step up and invest as if our lives depended on it. These are the children that have been brought into this world and their precious education and development can make all the difference in terms of the trajectory of their lives. Let’s not just bemoan the families and children who are impacted by their special needs, but rise up and tackle the problem of funding, respecting, and cherishing the educators who battle every day in the trenches and give their all to the cause. [MARCH 2022]
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Can Parenting Foster Self-Worth?
Inspired to muse after reading a compelling OP-ED article in Friday’s New York Times, “There’s More Than One Right Way to Raise Kids” by Jessica Grose. I haven’t been tuned into her writing before, but now I surely will.
I am forever struck when I deal with a child and his parents are in the room describing their struggles, my effort first and foremost is to legitimize their views, validate their emotions, and then set about trying to understand a particular child. Too often parents see their children as a reflection of themselves rather than as independent spirits steeped in your genetics and in your thrall. They are on their own unique developmental trajectory and you are at best participant observers in this process. It is a fairly frightening perspective to many as it requires letting go of control and imagining that you can change or alter patterns, traits, or behaviors you find objectionable. I am not arguing for giving up on structure and discipline, but that in getting there you recognize you are cultivating civilized patterns of being. It is a great gift to your child to facilitate civilizing them as it will be forever a skill set that they can put to good use. However, recognize that even as you are teaching them appropriate behavior, they are responding to your guidance, your emotional tone, and your status in a very unique and personal way. It comes out as tantrums, isolation, fears, or tears but they end up in my office seeking “answers.” I was trained in an era when we looked at child and family development as the crucial guiding beacon that informed our understanding of a child. We chronicled symptoms but we did not find some narrow diagnostic window in which six of eight facets have to be met before “full” criteria can be assigned. I am truly bemoaning the loss of child, adolescent, and family development as such a huge player in how we understand children as they grow and parents as they develop skill sets that they never dreamed they could muster.
Parenting is the most complex of tasks and when done inside of a marriage with all the complexities of two adults living, working, and creating lives together, it provides another window into your child’s world. Co-parenting children in two households leads to a whole other set of challenges that can make it easier or harder depending on your capacity to tolerate and respect each other. Finding your sync with your child is so critical. You have to be able to have those moments of pure, unadulterated pleasure and heartfelt love to anchor you when they are behaving like little monsters. Bridging back to that emotional engram will allow you to “take a breath” or whatever can bring emotional calm back into a tense moment. Your anger is a signal that your precious angel has crossed a line….your line at least….and it requires intervention. Be advised that everyone’s line is different. It depends on culture, traditions, religions, your experience of being parented, and on and on. Be comfortable with your line and honor it so that your children may come to honor it to. I am a white, privileged male who has lived a long good life so far, so clearly my bias is that the line be described with words, there is thoughtful processing in your interchange, and rational notions imparted. But that methodology only applies to a fairly small sector of the global population.
With that in mind, I would venture to say that parenting can provide a clear avenue for fostering self-worth. Building the complex skill set of parenting is worthy of a PhD. You don’t just work on this dissertation for a few months or even a few years. You live it every moment you breathe, in every waking hour and even in sleep infused in your dreams. Bravo to parenting. It really needs to be celebrated and you need to feel a sense of honor and purpose that you are brave enough to soldier your progeny through these difficult times. I am so respectful of all of my friends who are parents and grandparents and appreciate all of the beautiful souls that have come into my life over the years of our friendship. Rest assured there is no one path to parenting as Jessica Grose so aptly describes. I am indebted to her for inspiring me today and helping me to remember that the parents and children that I am honored to help can find solace in her words and stimulate me to be a better doctor. [MARCH 2022]
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Finding Your Doctor Voice — What it means to be a DOCTOR.
I’ve been thinking these days about what it means to be a Doctor. I have come to a stage in my career when taking care of patients consumes less of my time which opens up spaces to muse about various issues. I am particularly struck these days with my isolation as a psychiatrist/physician during these last two years of COVID-19. The trend had started long before. When I moved to Richmond in 1989 we had a robust psychiatric community and The Richmond Psychiatric Society (RPS) was my entre into that world. Having spent a decade of my early career as a community-based psychiatrist with a large Jewish Philanthropic organization in New York City, I was based in a community of colleagues, learned integration of disciplines, team meetings, child/parent training programs, and the vicissitudes of mental health struggles in a big city. It was my daily work and I did not have to seek out any kind of gatherings.
Richmond beckoned as the right garden zone and I began my career here now 40 years of age. I hadn’t trained here so had only two connections of colleagues I trained with at The Menninger School of Psychiatry. But there were these monthly meetings of the RPS where we would go to some fairly fancy hangout likely paid for by some drug company so they could bend our ears for a few minutes. It was during a time where we were naïve about marketing, when we still thought we were “above being influenced” even though now we know that research consistently confirms that it does. Nonetheless we gathered. Sometimes 40 to 50 people and for me this was a place where I was amongst my own. I was a fly on the wall which tended to be my style, but I slowly meandered into relationships with so many of those that came regularly. I didn’t befriend a lot of them beyond this venue, but many continued to be part of my life for some time. I don’t think I realized it at the time but physicians tend to be on the spectrum of snobbish and we do imagine we are special. What I have come to realize is that being a physician does make us special. Good physicians learn to speak with authority hopefully delivering it in a style that is palatable and grounded in some effort to connect emotionally with our patients. Nonetheless “with authority” catapults us into this realm where we have to deliver the goods explicitly and thoughtfully. It’s hard! But most of us come to embrace it as something that confers privilege and honor just by being one of the class. Most admittedly, it is a good gig and I feel so fortunate to be part of it.
I think learning to speak with authority is one of those things that we get better at the more we do of it. Finding your voice as a physician surely is a process and I would like to think I will get better at it even at this point in my career. I have now digressed sufficiently to set the stage for my view of what has become of those opportunities to gather as physicians. The RPS no longer really exists or meets. As our generation of physicians aged, a few stepped up, but then no one stepped up. I don’t really know the process of how it all came to this, but for me it is difficult to conceive that there is no longer this opportunity for growing and evolving physicians/psychiatrists to go and get this profound sense of connection to their colleagues. I emphasize that this happened long before COVID-19 got us, as it was truly on life supports in its last few years. But for me it continued to be a place to gather, to see the new Mental Health Clinic at VCU School of Medicine, even to earn CME’s. It was very rich. We often heard from our own Richmond/VCU colleagues. Sharing their research, their passion, marketing their skill set, and opening it up for the give and take of good discussion.
It is incredibly sad to think that this is no longer a venue for me to latch on to. But I truly hope that maybe there can be some kind of “Phoenix rising from the ashes” phenomena. I can’t do it, but I can assure you I will do my level best to come to the meetings. Everyone is stretched. Raising kids is demanding and job duties are overwhelming. Nonetheless, I would hope you could prioritize gathering as physicians. It may have a whole new twist to it and maybe I am so out of touch there is already some venue where this happens. Owning your role as physician and “voice of authority” is a way we can make our medical systems better. I believe strongly that there is a key role for physicians in our healthcare delivery systems to also learn to speak with authority. Learn how to challenge the numbers system and the crazy metrics they have on you. There was a time when physicians held enormous sway in our hospital systems and served as a brake on corporate malfeasance and outright fraud. Sit with your colleague and talk about the burden of “speaking with authority.” Own that it is hard but that your role is crucial and can be part of healing our broken healthcare system. I am of privilege and of course all of my experiences with healthcare needs are met with gusto. But otherwise the average Joe/Jane is way over his/her head trying to navigate the system to get his/her needs met.
This whole topic of thought/musing has been grounded in a relationship with my younger colleague, an ER physician who has become my neighbor and now my friend. He regales me with stories of his ER world and can always pull this marvelous reframing out of his hat to hurry along the patient who shouldn’t really be there while telling the patient who should be there some dire news. You are the “buck stop." How many scenes in how many shows do we see an expectant family/next of kin waiting for the doctor to come out and “speak with authority” to a traumatized grief-stricken family. It does make physicians special. But own that you need support, shared experiences, down-time with other physicians away from the hustle and bustle of your work lives. Please find some way to resurrect these “dinosaur” organizations that served my needs as a mid-career physician so effectively. But if that’s not possible “show me” some other venue — some other way, some strategy for continuing to find my VOICE AS A DOCTOR and to speak with even better COMPASSIONATE AUTHORITY. [01/27/2022]
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What About Cannabis?
I am increasingly perplexed and challenged by the aftermath of legalizing marijuana in the Commonwealth of Virginia. Patients are now actively inquiring about Cannabis concerning what are its uses and is it an option in regard to managing emotional struggles?
Let me start with a basic and intrinsic challenge in this process. There are no good random controlled placebo driven studies when it comes to cannabis. As such there is no good evidence base from which to provide guidance to our patients. Anecdotally we know that there are many individuals who purport that cannabis eases anxiety, facilitates sleep, keeps people focused, etc. But the evidence base is not yet available and regrettably it appears unlikely that this will eventuate. There is no “money to be had” in relationship to “proving” the efficacy of cannabis, as the sources of supply are so diffuse and “easy”. Anyone in the state of Virginia can grow up to 4 plants on their property and there is no longer a vested interest from pharmaceutical companies or even a drug cartel in “proving” its efficacy.
As such, we are in a position of trying to provide guidance and understanding when we do not have an evidence base. So, since the evidence base is lacking, do we simply ignore this agent as a viable intervention, or do we find some strategy that is thoughtful and informed to the degree that is possible. I would propose that this is what we must do as it has become an ubiquitous part of our culture and our way of coping.
I have always suggested to my patients that alcohol is disinhibiting and often a very bad “drug” for people who have problems with impulse control and already struggle to “rein in” their emotions, esp. anger. It is likewise problematic that cannabis for some late adolescent (esp. males) can be a sink hole that perpetuates mindless preoccupation with video games and similar genre. But I am also aware of individuals who suggest that a bowl of cannabis before bed allows them to sleep through the night without significant hangover, that it eases anxiety according to some, and that for others it contributes to focus and concentration. Clearly there is a differential response from one individual to the next. There are strains of cannabis that are different inducing unique responses in different individuals. In this measure there are issues intrinsic to the individual (perhaps neurobiologically determined) as well as different responses to different strains of the drug. Just as with all medicines for hypertension, diabetes, and elevated cholesterol, there are those that impact people positively and those that are problematic and create adverse side effects.
I would wonder is it better to take an Ambien or Lunesta tablet to facilitate sleep than a bowl of cannabis. I know that in some individuals Ambien leads to a kind of “blackout” during which they eat, have sex, and even drive and have no recollection of this happening. Is this risk more worthy of tolerating than not having the evidence base for cannabis? Is it better to take a drug like Adderall for focus, if someone has a reasonably positive experience with cannabis for its similar impact. Certainly, there is no appetite suppression, sleep disruption, or even aggravation of mood with cannabis that there can be with psychostimulants. Anxiety tends to be a very complicated emotion and while many report aggravation of anxiety states with cannabis, there is clearly a group of individuals who report relief from anxious states with cannabis.
I am concerned about the pulmonary impact of “smoking” cannabis, but there are now edibles that get ingested through the gastrointestinal tract and do not impact lung function. We know that in adolescents, cannabis can impact brain development and contribute to cognitive difficulties. This could be a concern with adults as well. This is the data we don’t have and what makes offering advice and direction difficult.
Nonetheless, I contend that as physicians and especially psychiatrists who specialize in human emotion, we must confront the complexity of cannabis. It is not only an agent that can be misused and abused, but an agent that can have beneficial and salutary effects for some. When it comes to cannabis, how to arrive at a realistic and measured position is a growing dilemma. It clearly deserves attention and thoughtful dialogue among all who struggle to help individuals find comfort, solace, and healing for their emotional ills. [JAN 2022]
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Emerging from the Shadows
Thinking about what it now means to be vaccinated and ready to emerge from the shadows. We have learned and heard a lot about safe behaviors, masking, social distancing, and all of the things that have kept us safe this last year. Now we must learn something about emergence, a kind of rebirth as it might be envisioned. Just as we constricted our lives (although it was in one fell swoop) we have to slowly emerge, re-engage, and make contact with each other in a more intimate way once again. Human nature requires such contact for us to live harmoniously amongst each other. So for me the process has begun.
Last Wednesday night was the eve of my 2 week post-2nd vaccine. Supposedly 14 days to achieve maximal effect. (Moderna is 95% effective!!!) There is almost nothing that happens in medicine where those are your odds. People have every right to question what they put in their bodies. But I assure you in the scheme of things, ALL OF US have put so much junk in our bodies that is so much knowingly worse than this. So, I’m a believer. (I do add the protest that until recently science was not considered a “belief system”). So in the backyard of a neighbor this week celebrating a birthday and able to enter the backyard and HUG the birthday man and then proceeded to hug 2 others. I confess, I’m a hugger and sometimes struggled pre-Covid with making sure I was not stepping on physical boundaries, but with my closest of friends — come-on! I then enjoyed a whole evening sitting closer to people and not being afraid.
I can be called out for not adhering to all of the social distancing parameters which we are encouraged to do even post-vaccine, but I also think we need to give some voice to moving back towards some norm of warmth in our connections and friendships. I promise to be selective and prudent, but just as schools need to reopen, we need to be able to re-engage with our family, our friends, and our trusted associates. I am fortunate to belong to a group of society that has embraced all the necessary rules. I had one event in my living room this winter on Christmas allowing my friend Scott into the inner chambers as he was alone on that special day, but that was my one incursion into risk. This past Friday I had good friends both vaccinated come and sit by the fire in my living room. I felt so liberated. I won’t have anyone in, but I think it’s ok to evaluate your “prudent” risk and go for it.
I have been preaching a bit about the responsibility of having been chosen for vaccination. It is at this moment, a privilege and an honor to be this group. Who would think that old age had such advantages. I do confess mine came via being a medical professional, but I do fit this “old” group as well. Now we wise old folk will need to lead us out of this social isolation and back into the world of engagement and connection. It is our charge, so to speak, while we still listen to Dr. Fauci and follow precautions that are reasonable in public and when you don’t know your players. But I contend we need to take our risks and chances with our family and friends and begin to repair our tarnished souls that have endured separation and loneliness to save our way of life. Now we need to save our way of life by taking life back. Remember, IT TAKES A VILLAGE. [FEB 2021]
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The Challenge of Maintaining Political Neutrality in a Mental Health Practice
It would seem now is an especially good moment in our history to address the subject of political neutrality. Ever since I was initially trained in psychoanalytic psychotherapy, the concept of the therapist as a neutral screen has been part and parcel of my understanding of what makes for good treatment. The patient can project onto this neutral therapist any and all kinds of feelings and thoughts without fear of censure or judgement. To have been trained to give nothing away in regard to your own feelings and thoughts is an amazing experience and took years of challenging supervision to achieve (or at least approach achieving). When I really functioned as a therapist, this made a great deal of sense to me and I didn’t ever question the wisdom of maintaining this “frame” as critical to the healing process.
Now, however, I have become a doctor, in as much as I diagnose, search for understanding, and often prescribe treatment. Mostly we think of this as prescribing medication, but we also prescribe exercise, better eating patterns, safe sex, and sleep hygiene to name a few. We know what makes people heal emotionally and we impart this wisdom as a basic axiom of our service and care for a patient. If you’ve gone this far with intruding so directly into an individual’s life, isn’t it a logical leap to then also prescribe “appropriate relationship interaction” and/or “appropriate ways of contributing to society,” and “rational belief systems?” As we venture into this terrain, the water gets exceedingly muddy. There are myriad reasons why an individual patient may have a political viewpoint that seems “mindless,” “simplistic,” “irrational,” and “self-centered.” Some patients crave a simple solution. They struggle to deal with complex variables that have to be thought through and metabolized and instead prefer an assured vision of what’s right and what’s wrong. The zone of grey is too frightening and generates enormous anxiety. It’s not dissimilar from any belief system/religion. Believing in “a savior” has been part and parcel of many of our experiences growing up in this country. Belonging to a movement or being part of a political vantage point can serve identity and stabilize internal distress and confusion. This sounds somewhat pompous as I read it, as I think it disrespects the enormous complexity that just surviving in this day and age entails. There are ardent believers all over the political spectrum and I’ve encountered closed minds on both sides of the spectrum. Political identity can be an extension of the self and finding comfort in the group is a human propensity. We are driven to relationship and to attachment if we have had a modicum of nurturing in our years. If not, then sociopathy rules the roost. Most sociopaths do not seek mental health treatment at least voluntarily.
So, back to the wisdom of maintaining political neutrality. Much as I would like to “educate” and “steer people” towards “my reality”, it is not my place as a physician and healer to make this my charge. My role has to be helping people achieve a sense of safety and comfort in their world, whatever shape that might take. That isn’t to say we don’t “intervene” to prevent self -harm or harm to other people or even engaging in illegal behaviors. We don’t turn a blind eye to child abuse or elder abuse or any kind of abuse. That is altogether another realm of concern and beyond the scope of what I would call political priorities and beliefs. These are foundational and no more amenable to my “judgement” than a belief in Jesus, Allah, Buddha, or whatever God someone embraces. They form and serve identity, security, and stability for that individual. Tampering with this is a dangerous enterprise for a physician and one that requires steadfast thoughtfulness to resist this temptation. EVEN NOW.[Jan. 2021]
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Whatever Happened to Honor?
I haven’t really “mused” in a long time and really need to be more diligent about it. Today, I'm inspired by the expected/unexpected passing of Justice Ruth Bader Ginsburg. She was a truly remarkable civil servant and served our country and our courts so admirably through her long career. I know I am a partisan, white and privileged, but I am also a United States citizen who grew up in an era when we actually came together and honored our fallen heroes. I was just 14 years when Kennedy was assassinated and even though my family was thoroughly Republican, we sat mesmerized for several days as we churned though our national grief and honored this young President who had tried to lead with such enthusiasm. Our affiliations on pause we were brought together in a shared unexpected grief to give honor to his service and his sacrifice. It has a way of binding fear and irrational emotions that truly serves a useful adaptive strategy for surviving as human beings. There are untold other heroes and ordinary citizens that I have come to honor over these last 56 years since that first event rocked our country back in my adolescence.
So now I work to honor Ruth Bader Ginsberg. So lucky to be walking the beach in North Carolina and watching the ferocity of the ocean rumbling into shore. Thinking of this small “titan” who inspired us all with such courage and moral commitment. Trying in my own quasi-spiritual way to thank her for coming into our world and doing her best to make her mark in a meaningful and virtuous manner. Then into this serene beautiful picture of normative grief and intimate honoring pops an intense fear of her death being used for political and cultural gain. We were so intent on preserving “our” seat that we hoped against all hope that she would survive November. We couldn’t even let her die with dignity and when “her time” called her. Again, I am not so much trying to justify my proclivities (although the fear is born of that) but trying to keep holding on to the notion that as a nation we need to honor her service. We should not at this point already be encumbered by “what’s next,” but to truly mourn and grieve her passing. Is it not honorable to do this? What has happened to our nation that we cannot take the time to do this. What about honoring her dying wishes that the next president (be it Trump or Biden) appoint her successor. Is it not honorable to play by the same set of rules that got established 4 years ago in the wake of the Merrick Garland nomination. Do we not want our children to understand what honor is all about?
Likely I am a naïve elder citizen, but I can’t help but hope that HONOR at this moment in time reigns supreme (no pun intended). I feel it is my duty as a physician, as an emotional healer, and as a fellow citizen to stay grounded, to value virtue and honesty, to teach our children that in spite of our differences we share a belief system that gives due justice to ALL, and to recognize that with national grieving of our fallen heroes we bestow on each other all the best that we have to give. [Sept. 2020]
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I was heartened to see that the American Academy of Pediatrics has issued a strong position statement firmly denouncing the use of spanking (or any corporal punishment) or verbal shaming or humiliating children as a discipline technique. I urge you to follow the link here to that article that articulates the sound thinking and reasoning behind this position statement. See AAP News, Nov 5, 2018; "AAP policy opposes corporal punishments, draws on recent evidence" author: Robert D. Sege, MD, PhD, FAAP https://www.aappublications.org/news/2018/11/05/discipline110518.
However, I do think it behooves us to ponder on why spanking has been so ubiquitous and broadly used over time, especially those of us from a generation where it was common place. In so doing, I think it provides a context for moving on and relinquishing what we now know has negative short, and long term consequences.
When I read recommendations around discipline it is all very cognitive and “heady.” It is methodical, measured, and so neatly contrived. There is not usually much about feelings or affect except as a coda to suggest that all parents get angry at their children so “don’t feel bad if you do.” It is my contention that affect is a critical component of delivering an effective “lesson” about danger, inappropriate behavior, or willful oppositionalism to your children. There has to be a kind of “sit up and take notice” or “I mean business” component to the intervention which is where parental anger along with raw fear can be recruited. I now think most children (and clearly every developmental stage is a bit different) barely look up from their devices when their parents are droning on with an elaborate sensible set of explanations or prospective consequences. Their attention has to be hijacked emphatically if the intervention is to be meaningful. I think this is why spanking has seemed so effective to many parents because it instantaneously works at grabbing attention.
So that leads me into thinking about “grabbing that attention” in some less traumatic way. I have rules in my office and expectations about how children behave. Believe me they know it when parents are helpless to get them to comply. It requires my recruiting my own anger and frustration in a no nonsense kind of way. They may not always get it the first time, but is infrequent that children come back for a 2nd visit and don’t remember. They may be a little afraid at first, but many of those kids grow to really respect me and even like me after a time. This is not to suggest that what I do is even remotely connected with the challenges of parenting (esp. a difficult or developmentally challenged child), but it is by way of promoting affective and real anger responses that are developmentally appropriate. I often coach adult patients on “finding their angry voice” which means not screaming histrionically or irrationally exploding in anger, but learning a more measured, but certain way of speaking our anger. In the same way, I think parents have to find that “angry voice” that is just at the edge of threatening that creates a real memory engram in children’s psyche. There has to be both a thoughtful cognitive delivery but joined with an affective valence that “marks” the experience. After all, you are not only working to deal with whatever momentary battle is being played out, but trying to help a child integrate and internalize something that they can call up the next time. When it happens again you can thoughtfully and directly remind them “let’s not have to replay the unpleasantness” from yesterday or last week, and if there has been a true affective marker laid down in memory, they will get there quite easily. Ultimately we hope they can internalize and then own more appropriate behavior. My mom, who utilized corporate discipline in an extremely sparing way, used to go to the kitchen drawer where the pancake turner was stored and rattle the drawer open forcefully. That sound was all it took for us to shout — ”I’ll be good, I’ll be good!” There was a juxtaposition in our memory of her meaning business, so we knew the instant that drawer rattled we had crossed the line —her line — and so we remembered to "be good" without her ever using it again.
How to make this work is clearly a complicated enterprise, but I think it’s important to transcend purely cognitive strategies in meeting out discipline and learn to harness and embrace the anger and frustration that comes with the territory of parenting. Parenting classes can be useful, but psychotherapy can be a useful tool in the service of better embracing and channeling anger. Freud spoke of the “id,” the “ego,” and “superego.” Still meaningful constructs for us to understand the complexity of our own psyche and how healthy development guides us toward integration of all of these components. Slight digression here, but have to get my salute to Freud in here somehow!
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Whither Family Therapy
My retirement has opened up channels for thinking about things that used to seem second nature but have become dusty and under appreciated. One of the things I was so enamored with in the 1980’s was Family Therapy. We didn’t have the medical tools we have now (before SSRI’s and Atypical Antipsychotics) and we were more or less forced to apply other models for understanding and recovery. However, it was so easy to be seduced by the power of drugs (and they truly are powerful) and then imagine all the interventions heretofore were naïve and uninformed. It made me really embrace neurobiology as an essential component of healing that as a psychiatrist I was in a perfect position to deliver. I feel I became proficient at it and was ultimately a good diagnostician and good medical provider. Psychiatrists owned their roots as physicians and became once again “legitimate.” Now, more than ever, I truly see that it is really only part of the picture. Weaving child development and family dynamics into any families presentation is so enriching. So many parents feel hamstrung by all the knowledge base that has been disseminated so thoroughly through the Internet, Print Media, and the ubiquitous Broadcast TV. They learn not to trust instinct and common sense in favor of expertise. It sets up strange dynamics in families that begin to influence things in a negative manner.
I really want to give a shout out here to the efficacy of family therapy. There was a time when we gathered all the players in the family together and just talked with them and tried to understand how they ticked. We figured out that parents were easily split by children, by their parents, by their own internal conflicts and remnants from their own experience of being parented. We understood that child development was a separate thread that wove its way through the family system. We didn’t pathologize or categorize behavior but really tried to figure out its meaning for the system. We understood paradoxical interventions as a way of capitalizing on the adaptive components of any particular “symptom.” We were likely overzealous in our belief that altering the family system lead to change in an individual’s psychopathology. But it still held value and contributed to more adaptive functioning, the goal of most of our efforts with both medical and non-medical strategies.
I’m not sure what this means for my practice now. As I ease out of the world of insurance reimbursement, I realize that a lot of my thinking was influenced by the apparent efficacy of medical intervention as perpetrated by the insurance carriers and the pharmaceutical industry (a whole other discussion). Medicine pays for a lot of salaries: sales reps, researchers, pharmacists, and all the support staff that their products require. That said, I would be the first to acknowledge that SSRI’s literally changed the landscape of managing anxiety, depression, and obsessive rumination. It is truly transformative for individuals and it gave me great comfort to see such impressive “results.” But people are embedded in systems: the family, our colleagues at work, our neighborhood, our community, and on and on.
When one of the cogs in the wheel is altered it effects how the wheel rolls. Recognizing this is critical in coming to terms with how change in the individual gets integrated into the broader system. Having an anxious wife who is suddenly not nearly so anxious, changes a husband’s role from a necessary agent of comfort and perspective to what? It’s so critical to understand that this upsets the marital balance and a new equilibrium has to be found. Children who walk on pins and needles around an anxious parent, no longer have to do so, but may be mystified that old scripts are no longer necessary to follow. Giving voice to all of this is part of what family therapy is about.
As I meander my way through this stage of re-invention, I want to salute all of the pathfinders in family therapy, like Minuchen, Bowen, Whitaker, Haley, and my original mentor at the Menninger Foundation, Art Mandelbaum. I want to bring more of this understanding back into my practice and be something more than a prescription pad. I do think more than most psychiatrists I have used this lens to evaluate and treat most of my patients over the years. Nonetheless, I think it needs to be more than noise in the background, and I am hopeful of integrating this more into my new practice. Hopefully others will find the courage to step out of the expected frame and insist there is a system complexity that needs to be evaluated and treated right along with individual psychopathology.
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There was a wonderful op-ed piece in today’s (April 23, 2019) New York Times by David Brooks on Rituals and their role or lack thereof in our culture. He advocates for upping the ante on rituals as a part of tradition, custom, and the creation of meaning in our lives. I often talk to my patients about rituals in family life as having a centering and grounding purpose. So many rituals are tied to religion which is great, but for those not inclined to express or believe in this, it creates real gaps in family life in the observance of ritual.
Having just “observed” the confluence of Easter and Passover this year when the dates were so intricately tied together, I was struck by the convergence of Christian and Jewish ritual into one weekend celebration. I am a spiritual human being, but not especially religious per se. Yet I so enjoy the ritual of Passover and all the centuries of tradition that flow into it. Over all I find Jewish ritual to be almost intoxicating. Having been raised in a traditional Christian household whose church was community based and people oriented, but had drummed much of the ritual that you might find in Catholicism out of its practice. I treasure and value this experience which was not filled with guilt and shame as I think it helped to solidify values in a very honest and sincere manner. BUT, I am so inspired by the ritual of other religions. I worked in an Orthodox Jewish Community Mental Health Center when I first started practicing psychiatry in New York City now 40 years ago. It was here I honed my understanding of Judaism and all its ritual. At first, I was a bit incredulous with the primitive way it treated women, and while it is still a concern, I came to find all the rules and strictures so helpful to the people who lived it. It can be so comforting for people not to have to think about or decide everything for themselves. Getting swept up in the expected mode of being helped so many of that community stay sane in a time of real upheaval and social change in the City. Granted it tied people in knots at times, but I came away from my 10 year encounter with the Orthodox population with a profound respect for its culture and ritual-filled focus. Here in Richmond I had the wonderful experience of being a partner in a practice with a brilliant Jewish man who shared with me all of his experiences in a highly reformed synagogue. I watched his children at their Bar and Bat Mitzvah, I sat at the Passover table, I heard him complain mightily in the midst of the fast at Yom Kippur, shared in the joy of Rosh Hashanah, and observed his daughter’s marriage under the Hoopa. It tied his family together in a way that was cherished and beautiful to experience.
So many families in this era, however, do not have these rituals. Nothing to tie children to tradition or something that is bigger that any of them. I think it tends to nourish narcissism and isolation……two very bad trends in our culture and as such in family life. Birthdays have ritual but it is very self-focused. Christmas has become a pagan exercise in giving and getting. Graduations provide some level of ritual, but little kids are now “graduating” from Kindergarten with elaborate parties. It just doesn’t seem the same. I don’t have a good answer, but I think it behooves parents to think about how they build in some kind of ritual. I had a ritual with my younger sister’s children that when they turned 13 years, they would get on the plane in Sioux Falls, South Dakota and fly to Richmond where they would spend a week with Uncle Steve. It isn’t complex but it helps children advance and yearn for another developmental stage that provides some autonomy and independence. Learning to drive and getting a license can be a family ritual. Celebrating the first time your child can vote provides ritual, but might also create a climate of expectation as to their role as citizens of this city, state, nation, world. Every parent must find these moments of shared vision and experience that provides a framework that is solid, immutable, and reassuring especially as young people struggle with confusing expectations and a sea of possibility that can be daunting if your internal structures are in flux. Children/and more so adolescents often scoff at these efforts and will/can belittle one’s efforts, but they really don’t know what’s good for them (a common theme in my advice about parenting). Don’t be daunted by their rejection and ridicule. As we often say, “they will thank you some day.” It can be as simple as taking a moment with just you as parents and all your children on their birthdays (when the gifts have been opened and parties done) to sit with them and say “seriously” what joy it was when you came into our life and what your life means to us is so important for who we are as a family. Without you we would be missing (whatever that child’s magic or special skill set might be). Without you we wouldn’t look forward to our nightly snuggles and being able to read and teach you. Obviously this cannot be “canned” but has to be your ritual for expressing your love and affection for this child who you gave birth to or adopted or whatever place they have in your life on their day. My parents developed what I now see as a ritual that Friday night was “kid’s night.” We got to pick the menu for our stay at home evening and then all played games together of our own choosing. Granted times were much simpler, but it still holds sway as one of the unique things we did as a family together. To this day when we get together we play games together in this fiercely competitive manner that owes its roots to that Friday night ritual. (And I still beat my sister at Scrabble most of the time!).
I urge you as parents to work at creating ritual in your family life. If it is religiously grounded that is in some ways easier and clearer to embrace. I would contend, however, that creating your own personal family rituals may ultimately have more power and meaning to your children that they can identify as unique to their own family. It makes one feel a sense of unique grounding and belonging in that essential web of connection that gives us all the best possible start in life.
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When Families Lose Their Dog
I have had the recent experience of having 2 different families lose their dog under very different circumstances. I have been struck with my own reaction to the losses, but also have given witness to its impact on each of these families.
Lucy was a golden retriever who lived next door to me and after 13 and ½ years developed an untreatable sinus cancer and had to be put down. She was one of those dogs that was loved by her family and who had a special place in my heart. She seemed genuinely fond of me and would even whimper and bark when she was in the back yard and could hear me or sense me in my garden on the other side of the fence. I was impressed with the way that the family joined together to all attend to her final moments and they all had a chance to prepare, say their goodbyes, and even take pictures the night before it happened.
Riley was a Westie that was part of a good friends’ family but who died in a horrific freak accident in which he drowned in a neighbor’s pool. The circumstances are not what’s important here, but the sudden and inexplicable loss is what has been so profoundly impacting. No chance to prepare, to say goodbyes, to reflect on the wonderful life he lived and how much meaning he had for not only the family but those people who saw him daily and lived life with him. The loss seems immeasurably more difficult under these circumstances. It is impossible not to attach blame and express anger and rage fulsomely when it occurs in this way. Yet, in the end it is still a loss to manage, to process, and to hopefully come out the other side. The goal being to recognize all the good feelings he generated and what meaning he had to so many people even if ultimately his life ended in an “untimely” manner.
How families cope is clearly impacted by the reality of loss, but the circumstances are even more compelling. Dogs have so much more meaning and are so integral to family life than they were when I was growing up. They are not “children” obviously, but in many ways, they are a much more critical part of the family than not. We had a “mutt” in our family growing up whose name was Freckles. I am almost embarrassed to think now how we treated him and how he was just a “dog”. When it was time for him to be put down, my older sister was given the task of taking him in as she was least connected and emotionally involved. I can’t even believe now that she was in later high school, but took him away and we never saw him again. She shouldered this task heroically, but we hardly even acknowledged how difficult this might have been for her. I can’t remember any kind of ritual or way in which we as a family even noted the event. I am not confessing, per se, but rather I think it was not atypical of dog owners in the past to not attach such meaning to their role in a family.
Back to now and the loss of these dogs. They both provided a kind of solace and companionship. Coming home was not to an empty house, but to a dog wagging their tails, yapping/barking in excitement, and providing amazing comfort. Every family member was on equal footing. No one was “younger” or “older” or “more accomplished at this or that.” Everyone had an equal stab at the affection and care they provided. Grieving this loss can be profound and intense. It no longer seems inconsequential, but is a real hole in the fabric of a family’s composition. Neighborhood walks no longer occur in the same way. Rituals of care and routine are gone. It just seems important to underscore that these is an intensity of grief that is important to respect and honor. It takes time to grieve and to heal from loss. For children it may be the first exposure to death and loss. It is both a challenge and an opportunity for you as parents to teach them about grieving. Is there a “doggie heaven,” why did this happen, struggling with tearfulness and watching you as parents show compassion and grief in your own way. If you are not blinded by your own grief, it can be an opportunity to model emotional expressiveness. It can in some ways prepare children for more profound losses such as grandparents, friend’s parents, even other children.As fellow travelers here, it is incumbent on all of us to be sensitive to how these losses impact in real and measurable ways. “It is just a dog” can so trivialize what for many is the loss of one of their most immediate and tangible connections. Be respectful of people needs to both talk about it and other moments be silent. I often think of grief as like waves on an ocean beach. The emotion washes in and overwhelms us and then it washes out and things are just fine. You might catch someone who has lost their dog when the waves are in or out. Just because it is out, doesn’t mean it won’t come washing back. Obviously, there are more profound losses that we all experience, but I hope that I can increase sensitivity to the real impact the loss of a dog can have on family life. Even as just a friend and neighbor to these 2 dogs, it has impacted me in ways that I really didn’t conceptualize previously. It adds another dimension to my understanding of just how important dogs can be in maintaining the fabric of family life.
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School's Out: Now What??
I’ve been listening to parents talking about the end of the school year and it is always interesting to hear the range of concerns, worries, excitement, and relief that this seems to generate in families. In our highly scheduled and structured lives, helping children, adolescents, and parents make the transition out of the school year into the summer can be a complex task. It provides both opportunities and challenges that if thought through will ease this experience for everyone involved.
First and foremost, you have to survive the end of the school year. This may mean studying for exams, getting make up work done that has been avoided until there is no more time to avoid, or confronting possible failure and need for summer school or even repeating a grade if necessary. All of this can be fraught with anxiety as parents sometimes work harder at this then their children. This is a whole other topic and I will not elaborate here on managing this struggle. You as parents see the consequences of inaction more clearly than your adolescent might. Because of this last push, everyone may feel exhausted and even dispirited by the time the school year comes to a close. There is also a propensity for teachers and students to be depleted by all of the demands on them administratively as well as hopefully all parties desire to reach a “successful” close to the year. SOL’s may be completed and suddenly there are days of movie watching or other “fun” activities that one envisions as a kind of “marking time” until the official end of the school year. There are graduations to be celebrated which entails a whole other level of effort and engagement. The complexity of the school year ending is wide and varied. Endings may be experienced very differently by each individual.
Because of this push and the effort entailed, parents and students my approach the last day with glee that they are now “free” and unburdened of further challenges. Yet, I would protest that it is not a great idea to simply let your structures and expectations come crashing down without thought or planning about the needs that children have. While I strongly advocate that children need some free time and opportunity for “down” time, I also think in our current culture too often this means sitting in front of screens and passively engaging in trolling the internet, watching You-Tube blips, or being consumed by Netflix shows, etc. Reflecting back on another time (my youth) it provided opportunity for free play, joining neighbor kids in self-directed activity, and creatively managing time. No one “structured us”. We created our structure and with some bias, I think this had great advantage from a developmental perspective. Mother’s shooed children out the door early in the morning and other than eating and bathroom breaks, we played outside. Obviously, this was another era in which safety concerns were not as challenging and knowing all the neighbors was a common experience. I do understand it is different now, but how to recapture some of this free-spirited play and allowing children opportunities to be creative remains a critical task. Too often I hear that children feel “bored.” They look to the adults in their lives to provide excitement, interest, and amusement. They are passive in this process. When adults take over and lay down structures externally without engagement, it only promotes this outcome.
From this follows my recommendations that children (and adolescents) should be engaged directly in planning for the summer. They need to generate ideas of what might interest them, what camps or learning programs might be available, how they see the balance between structured activity, down time, family vacations, summer jobs, and long hours of sleeping (esp. for adolescents). Often times, there will be push back. Obviously, more push back from older adolescents. Setting clear expectations about “meaningful” activity is critical. Sketching out a calendar of the summer can be useful. Getting them to work with you on what they can do and when they can do it is essential. Parents typically have a calendar of their own, but I think it is important for children to see this in black and white too. Engaging them builds ownership of the planning and when the time comes for some activity. They will resist less about getting up in the morning to get to a camp, weathering the storms of disappointment if an activity does not meet expectations, or finding that whatever they chose is “too hard” or feels “just like school.”
Obviously, some of the planning has to be done earlier than NOW. Special camps fill up, parents work schedules have to be coordinated, custodial parents yield weeks of time to the non-custodial parent, financial resources may be limited, etc.. There is no one right way to go about this, but putting some thought into the whole of the summer can be an opportunity for families to “develop” together. Sitting down with everyone involved, particularly in divided households, can be enormously beneficial. Children who see the buy in from both parents are grateful. It provides modeling for cooperation and developing flexible strategies that may require everyone stretching themselves in some way. Ultimately if all involved family members are truly engaged there is more success in reaching the planned outcome.
Truly balancing down time and engaged time can be a complex enterprise. Too much engagement can be stifling. Too much down time can corrupt children’s capacity for growth and learning “non-academic” but critical life lessons. In the end there is no one right way. Every parent and every child need to find “their” way. In the long run what is critical is not letting these opportunities and challenges slip away, but to be thoughtful in addressing the task, whatever the outcome. Summer vacations in this measure simply provide more grist for the developmental wheel. Good luck.
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My Child is Gay, Lesbian, or Transgender—Now What?
This week marks the 50th Anniversary of the Stonewall riots which was a turning point in our cultures march towards acceptance of divergence in sexual orientation and/or gender identity. For those parents whose child identifies in this way, it can be an arduous and challenging journey to figure out how to respond to and integrate this reality into family life. I chose not to recapitulate in this forum all of the research and data that has emerged in regard to solidification of sexual orientation and gender identify at a very early age, but rather focus on the emotional process of coming to terms with whatever reality your child brings to the table. I think it important to set religious and cultural values aside in this discussion as I would prefer not to be an advocate for any one frame of reference, but rather think as a clinician when I am confronted with families facing these concerns.
Clearly times are very different now than when I completed my specialized training in Child and Adolescent Psychiatry, now more than 40 years ago. AIDS had not even reared its head, transgender was a term that was esoteric and remote, words like “binary” and “cisgender” where not even part of our vocabulary, and same-sex marriage would have been unthinkable. To see this evolution of thought, belief, and science change so dramatically in this time has required a sophisticated and challenging process as one deals with (primarily) adolescents and parents around this struggle. Bullying campaigns to some degree have been an effort to protect sensitive and “weak” children from oppressive and scary experiences with their peer group. While not all children who are bullied have sexual orientation or gender identity issues, this is a group particularly targeted by their peers at least from a historic perspective. As such, many parents have already had some experience with their particular child being targeted as “different” or as we might now say “non-conforming”. More parents have a knowledge base from which to react and help their children who may be coming to terms with who they are.
It may be a bias, but I think there is an almost universal desire on the part of parents to hope your child is solidly heterosexual. This is not from a values standpoint, but rather with knowledge that their road may be more complicated, challenging, and filled with a level of emotional intensity that their journey may require. While we have come a long way in terms of general acceptance of divergence, I believe it is still a harder road for them to travel. Who would want that for their child. I lay that groundwork, as I think it is important for parents to be accepting of their own disappointment that they/their child will have this more difficult journey. How to bind this disappointment is the ultimate challenge in helping your child come to terms with who they are. I remember so clearly that when my nephew came out to my sister when he was in his early 20’s by telling her he was dating a “man’s name”, she took a deep breath and said: ”What would I say if it was a woman? I’d ask about her, find out who she was, how they met, how long they had been dating”. She then tried to do just that with his boyfriend. I always thought she was so incredibly cool about how she handled it. I recognize this is very different if your child is 12 or even younger when dealing with transgender issues as well. Keeping you cool and striving not to be reactive or overwhelmed emotionally is particularly challenging. I know that developmental contributions are not so much considered anymore, but we used to mark adolescence as a time of experimentation, trying on different identities, sometimes to shock, other times because that is in the nature of the development of identity. In this measure, not all children/adolescents who assert they are gay or transgender hold these identities into adulthood. That is not to engender “wishful” thinking as I think it is not the usual trajectory, but rather to appreciate that your negative responses can drive all of this underground and make it an even more compelling direction for some. We know that adolescents will sometimes do exactly what their parents forbid them to do……just to be contrary. I still adhere strongly to a developmental model and at times this may put me at odds with the current thinking that identify is “always” set from a very early age.
My adage is to be cool and measured in your responses to these developments. That your child feels safe enough to talk to you and reveal themselves to you should be considered a great tribute to your parenting. It becomes more complicated when kids are “outed” by friends, siblings, or (hopefully not) violating their messages, emails, or other social media accounts. Knowing that you know can be a cumbersome issue if not dealt with in some open and meaningful way. Letting children know that you love them unconditionally at these moments becomes critical. Providing some space for open discussion and inviting them to talk and to share these struggles is immensely important. Helping them to see that you can accept who they are and where they are headed will go a long way towards their journey becoming less arduous and fraught with conflict. Understand that while they may seem self-assured, typically there can be shame and self-doubt that pervades their sense of self. They may harbor the same biases and prejudices that much of our culture has expressed for so many years. I emphasize that it is a process. They are processing and coming to terms with this and you too as parents will process and come to terms with it. This typically takes TIME. It is a seldom a one moment in time kind of enterprise. It may have to be digested again and again, hopefully with greater clarity and comfort as TIME passes. Don’t be disappointed if it takes you TIME as a parent. As long as you have the ball on the end game, i.e. acceptance of your child for who they are, you can take as much time as you need. Parents can find support with therapy, with organizations such as PFLAG (Parents, Families, and Friends of Lesbians and Gays) or other community-based institutions (even religious organizations and schools). Don’t be shamed by your need for guidance and support. It is not always comfortable and may even challenge your own belief systems.
I strongly advocate against recruiting others to “change” or “dissuade” your child from this reality. Conversion therapy is no longer condoned by most professional organizations, at least in the state of Virginia. Conversion therapy again and again has been shown to be ineffective in its goal and contribute further to a child’s sense of shame and guilt. You can be real and upfront with your own struggles with it, but always in context of doing whatever you can to make your journey towards acceptance the priority. It behooves no one to shame your child or make them feel less than whole. Transgender youth pose a particular challenge for many parents as it is still less understood, accepted, and still stigmatized. Nonetheless, you can express your reservations and concerns in a thoughtful way, without further traumatizing them. You can empathize with their struggle without solving it for them. It is especially here where professional guidance and help may be critical.
If you’ve behaved poorly and emotionally, be strong enough to own it and say “I was wrong”. Just because you messed up initially doesn’t mean you can’t still “right the wrong”. Own that it is a hard issue….one that you weren’t well prepared for but now you will do everything in your power to make it up to them. Share with them your journey and be comfortable that is a process for you as much as for your child. While they may not be ready to immediately forgive you, it will start you on the road to that endpoint. Modeling evolution of thinking, feeling, and belief is enormously powerful contribution to your child’s development. Evolving is a good thing.
This is in no measure a comprehensive guide, but rather my usual musings on a topic that has particular resonance this week as Rainbow flags fly and Proudly Gay, Transgender, or Lesbian comes at us from all corners of the media. I underscore that you will be traversing complicated territory as you do your best to help your child feel comfortable with who they are. Root out issues of self-blame. We are certain that it is not parenting that creates divergence, but rather divergence is rooted in neurobiology that is a given as much as one’s athletic prowess, intelligence, and stature. It is compassionate parenting, however, that can make this journey a less arduous one for your child.
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