You Can’t Sit With Us. What the Mean Girl Effect has on Mass Shootings

“You Can’t Sit With Us!”

The recent tragedy in Thousand Oaks has invoked a heated and polarizing debate about gun control, even within my own family. I have people that I love and value dearly on both sides of the political spectrum, they are all good people, they’re all intelligent, they all essentially want the same thing: protection and safety for their families and themselves. The difference is in ideologies of how to get there.

I was having a conversation with my dad about the matter, and a trait he has (that I like to think I inherited to some degree) is really being able to see a disagreement from multiple vantage points. We got into the same impassioned conversation that I’m sure millions of people were having across the country: what role gun control and what role mental health treatment plays in stopping these senseless massacres. Our conclusion came to an agreement mirroring the nature vs. nurture question, and the answer being that “it’s both.”

He asked me a poignant question after we agreed on this, asking about what the root of the problem was. I came to a very simple conclusion:

We need to stop being horrible to each other.

I’ll stop a subset of people right here who will say “People need to stop being such damn snowflakes” or something of the sort. This is not one dimensional in that the “mean girls” have sole responsibility for every violent action that happens. A huge part is also being able to accept that others have differing opinions, views, and beliefs from us, and that’s okay. We also need to be able to accept criticism and accept that we are not the entity the world revolves around, and that we are all capable of fault.

I’ve talked about “internet autism” in previous posts, but it is applicable here too. On whatever platform, may it be Twitter, Instagram, SnapChat, Facebook, whatever, you will likely find a plethora of comments: You’re ugly. You’re a bitch. Go kill yourself. Slut. Drink bleach. You’re a waste of space. Everyone hates you. Your mom should have gotten an abortion. …. etc…etc…etc….

My point is not to say that people saying mean things to a person in some way excuses or justifies a person committing a horrible crime. My point is rather that we, as a culture, have fostered and fertilized an environment (in many areas/ in many people) of anger, hate, exclusion, and intolerance. My point is that yes, we need to figure out some common sense gun laws that at the same time protect the second amendment, but also ensure people who purchase/own firearms are competent to do so. Another piece is mental health treatment and eliminating the obstacles people face in seeking treatment (I’ve had patients come in for initial evaluations [especially kids/adolescents] that have been waiting weeks/months to be seen). This really is only the tip of the iceberg, in that by the time most people are sitting on the couch in my office they have been struggling with whatever issue it is for a long time…it has now just gotten to the point where it is unmanageable and they are at such a point of distress they are willing to get help.

Psychiatric treatment is no different from any other medical specialty whether it be family medicine, oncology, neurology, etc. in that preventative care, or early treatment are going to have the best outcomes.

But why is there such an influx in the need for this treatment? There is no easy answer for this, but it goes back to a few key factors: from an early age we need to be teaching and learning emotional intelligence and distress tolerance, learning how to deal with failures, adversities, and unmet expectations (the snowflake argument), while also not subjecting each other to mental torture. It’s easy to say that millennials are being overly sensitive on the surface, but this really is the first generation that has been exposed to 24/7 notifications from their classmates and peers, often receiving sentiments similar to those mentioned earlier.

There have been numerous studies showing the effect negative experiences such as insulting/negative talk have in comparison to positive talk. This has been shown on many things from plants to pitchers of water and the outcomes are pretty astounding. It makes sense if a person is told something enough, odds are they are going to believe it.

Sometimes all it takes to change someone’s life is a smile or a kind word. If you’re not able to do that, at a minimum don’t be a jerk. More often than not if someone has a need to put others down it’s likely because of some insecurities/perceived inadequacies, or unresolved emotional issues the perpetrator is experiencing.

The truth is we can have great gun control laws, we can even have great mental health care, and these things will likely make a difference, but the reality is we’re not going to get very far without kindness and compassion for each other.

Recently when the Dali Lama was speaking at UCSD he was asked how he dealt with difficult people or was abe to continue expressing compassion for them. His answer was simple but remarkable, “I think of them as my fellow human being.” He went on to describe what an amazing thing it is that out of all times we could be living, out of all the matter we could be, as humans we’re sharing this planet as the same beings, and that as humans, largely, we all have the same objective and are just trying to get through our day, rarely are we meaning intentional harm to another person. As different as our life circumstances may be, we have this in common: we’re all human beings just trying to live our lives. So he said in unpleasant situations he reminds himself to think of the other person as “my fellow human being.”

It’s something that seems so rudimentary, but it really can be profound. I found myself in a day of the grumpies driving home from work in gridlock and saw a car going around and cutting in front of dozens of other cars all patiently waiting to move down the freeway. My mom was sitting next to me in the passenger seat and watching this happen, and I let her know what a jerk i thought the guy was for purposefully using an exit lane to cut in front of dozens of people in traffic.

Later that night talking with her I reflected on how bad I felt about getting so frustrated. I thought about it and realized how I had no idea what was going on in that person’s day. Maybe his wife was giving birth to their first child unexpectedly and he was trying to get to the hospital, maybe he just got laid off from a job he loved and his family was depending on him to provide with, maybe his best friend just got served divorce papers and he needs to go talk him off the so to speak, ledge, we just don’t know.

In psychology there is something called Maslow’s Hierarchy of Needs. This model tells us that love and belonging are some of the most basic needs a person has aside from food, clothing, and shelter. Whenever a violent act occurs it comes into question if the person was mentally ill. When most people think of this it’s in terms of whether the person was psychotic or not. However that’s not the case. No one who can go into a school, bar, movie theater, etc. and murder innocent people can be mentally healthy. They may have the capacity to understand what they are doing, or be in touch with reality but there is clearly something wrong with the individual’s thought process, impulse control, and/or other executive functioning. This goes back to the importance of early intervention in mental health, to identify, assess, and treat this.

This is clearly a complicated, emotional, and political issue with no easy answers. I think the solution is a combination of common sense gun regulations, better access to mental health treatment, but also starting to just be nice to each other.

I have many patients who participated in the school walk-outs following the Thousand Oaks shooting, and I think this made a powerful statement. However, my challenge to any kiddo who participated in these walkouts, to any adult who has participated in the debate on gun control or mental health treatment to just actively engage in the simple act of being kind to each other. Think about what you say or type, insulting or berating another person accomplishes absolutely nothing, being kind on the other hand can change the whole dynamic of our culture.

The Opioid Epidemic and Substance use, What’s it All About?

Recently, I was at a concert with some friends, I noticed the floor was slick, and warned my best friend, “Be careful, the floor is really slippery, don’t fall.” Within five minutes I reinforced the sentiment that my parents should have named me “Grace,” a joke they have made since I was a small child. I slipped, fell, and ended up fracturing my fibula and required surgical repair. This resulted in having to reschedule my planned trip to Thailand. So, being relatively immobile, in a fair amount of pain, and having pain medication and addiction being frequent topics of recent conversation, I figured this would be a good opportunity to explore opioid use and the controversial topic of naloxone/Narcan.

Over the last few years there has been a pretty heated debate on whether Narcan should be more readily available for people suffering from opioid addiction and/or their friends/family members. So what’s the problem, and what is naloxone?

Naloxone is an opioid antagonist, meaning it is something that counteracts the action of opioids. Opioids are substances like heroin, oxycodone, hydrocodone, etc. that bind to specific receptors in our brains. A benefit of opioids is the binding of opioids to these sites results in pain relief, however danger comes because this can result in a sense of euphoria which can trigger a very intense reward system in our brains thus potentially leading to addiction/abuse/misuse.

Basically naloxone acts as opioid “police” or “bouncers.” Imagine opioids as underage kids at a wild party, the job of naloxone is to round them all up and boot them out. Naloxone is often used for rapid opioid reversal in an emergency situation (kind of like an antidote). Since an opioid overdose can cause respiratory depression and coma it can be deadly, naloxone can reverse the action of opioids and prevent these lethal outcomes.

So what’s the controversy? There has been a push to make this medication readily available for people with substance use disorders and/or friends/family members to have on hand so that it may be administered in case of an overdose. Some argue that making this medication readily available will only encourage people to start or continue using opioids because the risk of overdose would be significantly reduced. Now, everyone is certainly entitled to his/her own opinions and beliefs, however to me this seems very similar to arguments that we shouldn’t have sex education, make contraception available, or administer the HPV vaccination to children because “it will only encourage them to engage in these behaviors.” In my belief, the more education someone has on a matter the better informed they are and thus make more educated/informed decisions and multiple studies support this.

This gets a little tricky in regards to substance use because the decision making/reward system parts of our brain are exactly what gets affected by substance use. Most frequently overdoses occur in a few situations: 1. a person has been using a substance, tolerance has developed, as a result of continued use, higher doses of the substance are required to get the desired “high” a person is seeking, or 2. a person has been using a substance, he/she sustained some period of sobriety and relapse, using the same amount of substance in question, however since there has been time without use of the substance some of that tolerance has gone away (meaning it won’t take as much to get the same high), the body gets overwhelmed and overdose results. Now this doesn’t mean it’s impossible to overdose on the first use of a substance, or that there aren’t some people who may try a substance because there is some kind of perceived safety net, however in my professional experience this is not the majority of cases.

So what should you know about Naloxone?

It is an opioid antagonist a.k.a. it is the opioid police. Imagine the chaos of people fleeing a party and getting put into a police car when the cops show up.
It is unpleasant, uncomfortable chaos. When naloxone comes on board, it basically displaces all the opioids from where they have bound which is UNCOMFORTABLE. One reason opioid use is so hard to kick is the withdrawal. Naloxone essentially makes a person go into instant withdrawal, which is NOT FUN.
There is no “high” with naloxone. There is no intrinsic reward that comes from naloxone use. If anything, say someone hypothetically was experimenting with opioids knowing he/she had this perceived safety net, the sheer discomfort of this instant withdrawal would in itself likely be a deterrent from future use.

One of the most important things I hope to leave people with is a better understanding of substance use. Generally speaking, people do not start using/abusing/misusing substances when things in his/her life are going fantastically. The majority of times substance use is a maladaptive coping mechanism used to numb some kind of intolerable emotional pain. What I frequently remind family/friends of is THIS IS NOT AN EXCUSE, rather an explanation of behaviors.

So why do some people become addicted and others don’t? This is a complicated question with no easy answer. However there are physiological changes that happen in our brain when we use substances. It may start as “Hey this feels good, and helps me get away from the **** going on in my life right now” which we can call ‘impulsive behavior’ a specific part of the brain is activated in this process. However when it shifts to compulsive behavior ‘I need this to get me through the day and you are going to be in massive suffering/you are going to die if you don’t get [substance, A,B,C,D, etc.] an entirely different system in our brain is activated.

Ok, so what flips the switch from impulsive to compulsive? A bunch of different things. However one of the most important seems to be social supports. There have been animal studies that have animals both exposed to addictive substances. One with a very uncomfortable environment with limited supports, the other with a significantly more supportive environment. While the subject in the supportive environment may try the addictive substance, the same kind of dependence doesn’t occur. This is not to say this is the only factor, but it is a key one.

There was a stand-up bit I saw YEARS ago where the comic poked fun saying “Alcoholism is the only disease you can get yelled at for having.” Every once in a while I need to let this sentiment sink in and resonant with me, and something I will tell you is that it makes me angry. It makes me angry at what a poor job we do of educating others on substance use, and treating it as what it is, a psychiatric/physiological condition that should be treated with the same understanding, compassion, and concern that any other kind of medical condition is instead of as a ‘character defect.’

It may be easy for people to scoff at this and continue to lack compassion, but what I would say is if you are able to exert enough energy to have contempt or distain for people suffering from these conditions and say “Well why don’t you just go get help?” Why don’t you just get a job?” I challenge you to earnestly speak to someone or the family member of someone who has been struggling with a substance use disorder.

Does the woman now addicted to heroin who was eight years old when she was shot up with heroin for the first time and forced into prostitution by her dad deserve public ridicule or disdain? What about the (wo)man who spent years of his/her life sending and receiving gunfire in war zones who comes home and ends up finding his/her only escape pain medication prescribed to treat injuries he/she sustained? What about the doctor or the lawyer who comes home after days on end of shouldering the emotional burden of each and every one of his/her patients/clients and can find no solace outside of a whiskey bottle? Likely we don’t see these people the same way we do the indigent person downtown carrying all of his/her worldly belongings in a shopping cart. However it’s relatively rare for someone passing these judgements (out of distain, discomfort, fear, or whatever) to actually speak to these people like the actual living, breathing human beings they are. If we look at the actual science and neurochemistry that is involved in addiction there is absolutely no question this is an actual disease, not a character defect, and we need to start treating it as such.

My opinion is that I have seen more than enough people struggle with addiction in both my professional and personal life. Narcan saves lives. It is something that is INCREDIBLY uncomfortable to be administered during an overdose, people do not get a high off of it, people don’t feel good after using it. Withdrawal is something so uncomfortable and so powerful that it is a perpetuating factor in addiction… going into instant withdrawal is not desirable. Remember, people go to EXTREME lengths to avoid symptoms of withdrawal.

My final question or thought would be, if a medication is available to save the life of a person with a potentially life threatening condition why would we not make it available? If it was your child/sibling/significant other/friend/etc. who was struggling with an addictive disorder and had the possibility of dying of an overdose, would you not want something available to save his/her life?

Please, comment, share, subscribe, ask any addiction/mental health questions! I


f you or someone you know is experiencing a mental health/substance use condition contact the national mental health and substance abuse hotline
SAMHSA’s National Helpline – 1-800-662-HELP (4357)

13 Reasons Why Our Kids are Depressed,Anxious, and Suicidal (Side A)

With the recent release of season two of the Netflix original “13 Reasons Why,” along with the recent tragic shootings I have had more and more parents and patients asking about depression and suicide, especially among children and adolescents. One of the most common questions parents ask me is how or why his/her child (relative, kid’s friend, etc.) is depressed and/or anxious, feeling the child is “too young” to be experiencing this and it is “just a phase they must be going through.” It’s a confusing and difficult experience for both the child suffering and for all other family members to go through. I want to start with the reassurance that depression, anxiety, bipolar disorder, psychosis, or most other mental health disorders are completely possible for children to experience.

So, why? Why are our kids depressed, anxious, and committing suicide, and what can we do to address these issues, prevent, or treat them?

  1. It is very rarely (if ever) that one single issue is the root cause. Many parents feel extreme guilt if their child experiences any of these conditions feeling that they “passed it down” or there is something they could have “done better.” It is more likely a combination of genetic, “chemical” (biologic/physiologic), and environmental factors. Frequently I describe this to my patients or their parents as a bridge relying on supports. One support being disrupted (i.e. genetic factors) will likely not cause the entire bridge to collapse, however the more supports you start taking out (environmental, biological, etc.) the less stable that bridge becomes, and the risk of collapse arises.
  2. Social Media. There is an amazing phenomenon that happens when we get engrossed in social media: We get depressed. More and more research is demonstrating that there is a correlation between the use of social media and depression. When we use social media we see a carefully edited, curated, photoshopped version of a life people want to show us. It is not reality, but it’s difficult for us, especially kids, to register this. We start to compare our lives to what we are seeing on Instagram, Snapchat, or Facebook, which makes our lives seem pretty lame. We wonder why we can’t look like that, or have those awesome clothes/gadgets, why we aren’t on vacation in some amazing location. When we start to compare ourselves to others it is very easy for a mood disorder to creep in or worsen. However what we see is not real life. I don’t know many people who post photos of themselves washing the dishes, or taking the garbage out. I always recommend limiting screen time. Yes, your kid will be mad and probably yell and cry and scream what an awful parent you are for doing this, let me assure you, you are not. It is ok for your kid to be mad at you! Let me reiterate that: IT IS OK FOR YOUR KID TO BE MAD AT YOU. The initial battle may not be pretty, but I see it countless times that both parents and the child/adolescent report almost an instant improvement in depression or anxiety if his/her cell phone or social media use is restricted.
  3. Bullying: This goes right along with the social media factor. When we are online/via text we do and say things that we never in a hundred years would say to someone’s face…so why do we feel comfortable doing it online? There’s another interesting issue we develop with more screen time, I’ve heard it called “Internet Autism.” Meaning when we cannot hear or see a person we are unable to pick up on the social/human cues, and we stop thinking of the person we are speaking to as a genuine, living, breathing human being and more as an object.
  4. Diet: This is a hard one particularly for teens who may be stubborn, but it is crucial. Think about it, when any of us live off a diet of Chili Cheese Fritos,  Snickers Ice Cream Bars, and Dr. Pepper (which I will admit was my standard throughout junior high and high school) and stay up all night binge watching the latest Netflix show we do not feel like we are at our prime. We deplete ourselves of crucial vitamins and minerals that directly effect mood (Vitamin D, B Vitamins, Omega-3’s are huge).
  5. Exercise: Exercise really does help stimulate all of those “feel good neurotransmitters” that regulate our mood, so even if it’s for 20 or 30 minutes getting some exercise WILL help. Again, another thing that we see related to increase use of social media/screen time, increased sedentary lifestyles.
  6. Sleep Deprivation: Most of our kids are on some kind of device until they go to sleep, if not falling asleep next to them or with them on. The light these devices omit suppresses our body’s ability to produce/release melatonin, which is crucial to regulate our circadian rhythm. Also, when we’re tired our body wants us to have energy and looks for the easiest source of this. This is why when we’re dead tired we tend to find ourselves eating more, and eating foods high in carbohydrates or processed foods that are easily broken down for our bodies to use as energy. Then we get into a horrible on-going cycle with reason four.

Obviously this is a very difficult and complex subject and there are many more factors in kids developing mental health disorders, which we’ll leave for Side B.

So what are some warning signs of depression or risk of suicide?

  1. Anger: Depression/anxiety often presents as anger in children and adolescents, so if it seems that your kid hates everything from their teacher to the spaghetti that’s on the table, or seems to argue about any and everything this may be something to explore.
  2. Withdrawal: One symptom of depression is something called anhedonia, which is the inability to enjoy things that we typically would. A kid who refuses to come out of there room or is uninterested in seeing his friends may be struggling.
  3. Dark thoughts: Recurrent thoughts about death or harming themselves is a fairly obvious red flag, but pay attention to the music he’s listening to, what they’re writing about, jokes he’s telling, what kind of movies he is watching.
  4. A sudden drastic change in friends or appearance. A drastic change in appearance may be a way for someone to express he is not happy with who he is or is trying to send a silent cry for help in an attempt to get more attention. A sudden change in friends may also signal anger (frustration/arguments with current friends or disinterest in them).
  5. Suddenly developing a really good mood or become overly generous. This may seem counter-intuitive but if a person is contemplating suicide and make the decision to follow through with this, in some ways it may be a source of relief. Giving away possessions may be seen as generosity, but may be part of a person’s preparation for suicide.

What do we do? There are clearly no easy answers, limiting screen time, good nutrition and sleep are fairly intuitive (albeit not always easy interventions to implement) but perhaps the most important piece of advice I can give is: talk to your kids, if something seems wrong, ask. There has been a kind of myth or fear that asking someone about suicidal thoughts will give them the idea or motivation to do so, which has been proven many times to just not be true. One of the biggest concerns my kids/adolescents report when they come to see me is that they feel misunderstood, invalidated, or unheard, whether it be by peers, their previous mental health provider, or their family.

“I wouldn’t say a single word to them. I would have listened to what they had to say, because that’s what no one did.” –Marilyn Manson