Giving Thanks After Thanksgiving…How an Attitude of Gratitude Will Change Your Life

The last of the mashed potatoes have been scraped from the Tupperware, the can shaped cranberry sauce somehow looks even more like a science experiment as the gelatinous blob splatters in the trash can. Every remnant of Thanksgiving is gone.

Are we still thankful?

For many, the spirit of giving, kindness, and joy lasts through December. Suddenly when the last string of tangled lights has been placed back in it’s designated box to collect dust into until next year, we seem to pack that sense of joy, gratefulness, and compassion along with it.


I thought about this as the stuffing, pumpkin pie, and green bean casserole rumble in my stomach. It’s easy to be grateful when we’re reminded to be. Now, I don’t think this is because humans are innately selfish or ungrateful. I reflect on the countless sessions I’ve had with patients and many stressors, obstacles, traumas, and heartbreak fill our daily lives. Something I find myself echoing to many patients when they express shame, or even guilt about seeking treatment is that: we live hard lives. It can be argued that many of those stressors are ‘first world problems’ and they might be, but it doesn’t make them any less real when we experience them.

We live in a world where we’re expected to work harder, work longer hours and to be constantly connected to our jobs. We’re inundated with carefully curated photos that convince us that everyone but us lives the perfect, magical, happy-at-all-times lives. Heavily edited and filtered photos cover our screens, and tell us no one else has wrinkles, or cellulite, or blemishes. We see nothing but smiling picture perfect families that tell us we must be awful parents because our kids would never wear those disgusting saccharinely sweet matching pajama sets, let alone smile together in the same picture.

All of these stressors don’t disappear during the holidays, however at this time went tend to be more generous and patient, often we donate more of our time and money. Most people at some point during the holiday season will sit around the table with loved ones and share something we’re thankful for. The calendar turning to November doesn’t magically change the stressors and challenges we have, however one thing is different. We are essentially forced to reflect on what we have to be thankful for, whereas the rest of the year we don’t often have similar prompting.

Our perception and thoughts are powerful things. Our thoughts and beliefs are much like the old saying “birds of a feather flock together,” or “like attracts like.” The more negative or irrational thoughts we have, the more they seem to multiply, the same being true for positive thoughts.

One trick that I like to teach patients is how the change of a very simple word in our thinking can alter our entire perception. Changing “have” to “get” can completely change the context and our thinking of a situation.

Flipping, “I have to go to work today,” to “I get to go to work today” elicits a very different feeling. It makes me think of something my dad said years ago while he was working a job that came with some pretty severe stressors, “I might not like my work, but if I didn’t have a job, I’d sure want this one.”

During the holiday season we’re literally told to ‘give thanks’ or ‘be thankful’ hundreds of times. I find the happiest people are the ones who think of something to be grateful for the instant their feet hit the floor in the morning.

So give thanks this holiday season, and enjoy the festivities, but especially if you’re struggling with any kind of mental or emotional pain, I invite you to accept the challenge of starting every day, this holiday season and beyond, with something, no matter how small, that you can be grateful for.

You might find it’s not as hard to face the work day, your kids aren’t as exhausting, you may just feel better about yourself and life overall.

And with that… I’m thankful for you reading this 😉

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.

Let’s Talk About Sex(ual) Assault

With the recent Supreme Court appointment, and the #metoo movement sexual assault has had a light shown on it in a way that we have never seen before. This have been very polarizing issue with people both cheering that women are finally speaking out against their attackers, and others saying “It’s a scary time for boys.”

Sexual assault is probably the most common cause of trauma I see patients seeking treatment for in my practice. There are countless others who are seeking treatment for various other reasons that report some form of sexual assault at some point in their lives. One criticism of victims who have come forward is “Oh if it really happened they would have said something earlier.” “They would have reported it.” I can tell you from working with countless victims of sexual assault, (men, women, and children) this is just without a doubt absolutely, positively, 100% not true.

I cannot tell you the countless number of patients who tearfully tell me their story and conclude with a cathartic cry saying that was the first time they had told anyone about the incident. I always ask if the assault was reported and (excluding cases regarding children) I could probably count on both hands the number of people who had ever reported it to police. Out of all of these people I can think of maybe two or three who’s attacker was ever prosecuted.

When I ask these victims if there was something that stopped them from reporting this, there is almost always some variant of “I was afraid what people would think,” or “I was afraid no one would believe me.” Another common thing that happens is that victims blame themselves. “Well I shouldn’t have been at that party,” “I shouldn’t have let myself be alone with him.” As a result victims often don’t seek any kind of mental health treatment, which often leads to significant mental health issues down the road.

So what happens when a person experiences a trauma? Each person may respond differently, but frequently what happens is over-activation of a part of our brain called the amygdala. The amygdala is often referred to as “the fear bean” (if you were to look at the structure that’s kind of what it resembles) and one of it’s functions is that it kind of serves as an alarm system. When we experience a trauma the amygdala sounds the alarm, when it does this it basically sends out very intense excitatory signals, warning us to be on high alert. Now trauma does not effect everyone in the same way for a variety of reasons (biologic, environmental, genetic, etc.) but frequently it results in some kind of anxiety disorder and for victims of sexual assault this commonly manifests as Post-Traumatic Stress Disorder (PTSD).

We hear a lot about PTSD related to service members and deployments, but it is important to remember that this can affect anyone who has experienced a trauma. This may present in a person as frequent distressing memories, or dreams of the trauma, re-experiencing the trauma (feeling that you are back in that traumatic situation), amnesia about an important aspect of the trauma, heightened startle response, irritability, sleep disturbances, among many other symptoms (American Psychiatric Association, 2013). This affects a person’s daily life in many ways. Imagine re-experiencing the assault every time your significant other touches you, being afraid to go to sleep due to fear of having another nightmare, or going into a panic when you hear footsteps behind you.

We spend so much time teaching and warning girls and women about precautions to take to keep themselves safe. I think it would be pretty rare to find a woman who at some point hasn’t been advised to or warned:

“Don’t ever let your drink out of your sight.”

“Don’t wear headphones or at least take them out of one ear when you’re jogging.”

“Make sure you park in a well lit area.”

“Don’t drink something you haven’t seen made in front of you.”

“Stay in groups if you have to walk somewhere at night.”

“Carry your keys in your hand so you can use them to protect yourself.”

“Don’t talk on your phone or be unaware of your surroundings when you’re walking somewhere alone.”

These are just a handful of warnings that, like I said, I’m sure every woman has heard. And the truth is we spend so much time teaching and instilling these warnings for one reason. We believe and know that it is completely possible for someone to be assaulted. Think about it, is there any other kind of event we give so much warning to? I can’t think of any. We give these warnings because we know this is not out of the realm of possibility. So why do we act like it is when someone speaks up?

We need to start fostering a culture of not condemning victims when they do report an assault so that when it does happen people are comfortable speaking up immediately, not living in fear or blaming themselves for years, and then being questioned or mocked when the courage to speak up does arise.

Something that I always try to leave my patients with who have been victims of sexual assault is acceptance that what happened is not their fault. It doesn’t matter what you were wearing, it doesn’t matter if you were drunk, it doesn’t matter if you’ve had some kind of sexual relationship with the person before. It. Is. Not. Your. Fault.

If you or someone you know has been the victim of sexual assault and needs help contact the National Sexual Assault Hotline (800)-656-4673

Body Positivity: What it is, What it isn’t, and How to Get There

Over the last few years body positivity is something that has been getting a lot of attention. Supporters of this movement have the stance that this helps improve a person’s self esteem and overall wellbeing, and reducing judgment. However there is also the thought that this puts people in danger of ignoring larger health problems. So who’s right? Both, well, kind of.

When I explain body positivity to patients I describe it as loving and accepting yourself for where you are currently at. This doesn’t mean you get to put blinders on and ignore any health issues you are experiencing. It is rather that accepting of you where you are at. Feeling guilt, shame, or anger towards yourself certainly will not resolve these issues. Let’s take a step back and look at our body in a different way. Imagine your body as a car. Let’s say for whatever reason, you hate this car. If you have negative feelings towards it it probably won’t be a priority to take it to the car wash, you may not care that there’s trash strewn about, it might be easy to ignore that maintenance light. What happens? The car further deteriorates. Now imagine your dream car. Do you treat it the same way? Probably not. You probably will ensure maintenance is kept up, take it through a car wash, maybe even put premium fuel in it.

We cannot take care of something we don’t value, and our bodies are no exception to this.

Valuing ourselves means valuing our bodies and this is something we need to start prioritizing in childhood. I got started thinking about this earlier this month when I was getting a massage. Ok, so the best way I can describe this message was an hour of being pinched, tickled, and poked. It was awful. I hate to admit this, but it took me a lot longer than it should have to speak up. While laying on the table I remembered having the thought “Why am I not saying something? This is in no way enjoyable. You are paying for this come on.” I realized how ridiculous it was for me to be valuing the feelings of a person (who I was paying to perform a specific service) over being uncomfortable with something that was happening to my body. We need to start instilling this from a very young age; if your child does not want to hug a friend/relative/whoever he/she does not have to! When we force or pressure our kids into things like this it starts a thought process that your body is not as valuable as someone else’s feelings/wants/needs.

Traveling is one of my big passions, and I like to think it is something that helps me think on a more global level and fuels the fires of curiosity. So when thinking about all of this I began to wonder about different things that affect the perception of our body’s value. Thailand is one of the most (if not the most) infamous areas for sex tourism/sex trafficking/sex work, etc. I began to question how having this be such a prominent part of a culture affected people’s sense of self worth. How do people involved in these industries perceive and feel about themselves, how do others view the individuals working in this industry? I’m so excited to say this is something I will be fortunate enough to explore at the end of September, so check back to see what the experience is all about!

Tips for Adopting a Body Positive Mindset

1. Place a sign, post-it note, whatever on your mirror with a positive message for yourself. I love having people put something like “Hello, gorgeous” up. This is helpful for a few reasons. One being that it starts your day with a positive thought about yourself. It begins to make you feel comfortable with thinking/feeling/accepting nice things about yourself. The more that we practice this, and replace negative self talk with these thoughts the more second nature it becomes.
2. Focus on health and wellness not numbers. We can get so tied up in wanting to hit that magic number on the scale that sometimes we neglect what is more important, overall health. If you start treating your body like that brand new car I talked about earlier, guess what happens? We start putting higher quality fuel in, we’re more attentive to regular maintenance (exercise, time to de-stress, etc.) and we overall perform at a higher level.
3. Adopt an attitude of gratitude. An exercise I commonly have patients struggling with this do is body mapping. So either draw or list it out, head to toe write something that you like about each body part. If you cannot think of something you like about a particular body part write something that you can appreciate about it (eg. you may not like your stomach but you can appreciate that it houses organs that digest food to nourish you).

Just remember, you deserve the same love, kindness, and compassion you give to others, so be kind to yourself!

Mental Health in Mexico

It seems that the topics of deportation and the matter of separating parents from their children has been everywhere lately. This made me want to explore (setting aside any arguments about the legal/political issues associated with this on either side) what is this really doing to these kids, these families, and what kind of mental health treatment is available in Mexico for these people? How is mental health treatment approached in Mexico?

So what really happens when a child experiences a trauma like being separated from a parent? Childhood is when a lot our core beliefs, patterns of thought, and coping skills develop. This is a time that really sets the stage for how we relate to others and the world around us. A trauma like this certainly could lead to depressive, anxiety or trauma related disorders as well as problems with attachment. When a trauma like this happens it may lead the child to view the world as an unsafe place, have difficulty trusting others, develop feelings of inferiority, or have difficulty establishing their own self-identity. It would not be unusual for the parents in these situations to  develop extreme feelings of guilt, hopelessness and subsequent depressive, anxiety, or trauma related disorders. Personality disorders, especially Borderline Personality Disorder are also very strongly related to unhealthy attachment and fear of abandonment. The cultural importance of family puts these individuals at even higher risk.

I wondered if providers had been seeing an increase in people seeking mental health treatment specifically related to these issues. So I went down to Tijuana’s only psychiatric hospital, Hospital de Salud Mental de Tijuana and met with some of the providers to learn about the treatment and perspective of mental health in Mexico. While the providers I spoke with said they may have seen a very modest increase in hospitalizations/treatment specifically related to these issues it didn’t seem to have the major impact I suspected it would.

There is still a fair stigma about mental health issues in the U.S. and the providers I spoke with felt there was a similar if not harsher stigma about mental health treatment in Mexico. This stigma often discourages people from getting mental health treatment, frequently a person may be afraid to tell his or her family there is a need to seek treatment, or may be actively discouraged to do so if it is discussed. Mental health conditions are frequently seen as something that should can be managed by religious or family support. This puts individuals experiencing a mental health condition in a very difficult spot and seemed to be the primary barrier to seeking treatment.

I toured the facility for about two hours while the doctors I met with patiently answered my 1,001 questions. About five minutes into the tour it hit me like a Mac truck, these people have it right. There were some stark differences in how treatment is approached and I started to take note of what we need to bring to the states.

1. Length of stay. The average length of stay for inpatients is about 2 weeks. That is the average, frequently stays are 3-4 weeks. I compared this to the inpatient units I’ve worked on where the average length of stay is probably 2-3 days. If someone’s length of stay is approaching a week administration usually starts to sweat. Why is this? The most basic answer is insurance coverage. Generally speaking an insurance company will only provide coverage for a psychiatric hospitalization if a person meets one of three criteria: they are an imminent danger to themselves, others, or are gravely disabled (cannot provide for basic needs like clothing, shelter, food, or water, due to a psychiatric illness). This means that people are generally not hospitalized until their symptoms are so severe it becomes a liability if not treated. What’s more, the minute a patient no longer meets this criteria insurance coverage stops (some really good plans may authorize a few additional days, but this is pretty rare). This basically means we are using inpatient treatment as basically a means to stabilize someone to the bare minimum level, or until they are no longer assessed to be a liability.

2.  Holistic treatment. This kind of goes along with the idea of what really is the purpose of treatment, to simply stabilize someone, or actually provide treatment of the symptoms. Most inpatient units in the states will offer things like group therapy, AA meetings, and maybe art therapy, these activities are fairly minimal and not the largest part of treatment. I was amazed to see at Hospital de Salud Mental de Tijuana they had displays of expansive works of art therapy done by patients, there were volley ball courts, a gym, yoga classes, even a garden that patients tend to and what is grown is used in the meals served that are specially planned by a nutritionist. We know that good nutrition, exercise, a sense of community and purpose are vital for our mental health and yet we put such a minimal focus on it.

3. Community outreach. As mentioned above the stigma about mental health treatment is prevalent across borders, these providers are rolling up their sleeves to fight it. They host meetings, and also visit schools and other community facilities to provide education about mental health to the community. Starting in elementary school these providers are actively working to change how the next generation perceives mental health.

I left the facility dumbstruck and with one thought. As providers, as a community and society we need to be better. I believe that the vast majority of providers do want to give the best care possible and heal their patients but become limited by administrative and financial barriers. like any other kind of medical issue, doing primary prevention is without a doubt the best thing we can do, we first need to start educating our kids about mental health treatment and  and we need to be better about community outreach. We also need to fight for the ability to actually be able to treat our patients instead of giving them the bare minimum level of stabilization. It’s up to us to talk to our legislators, and to push for expanded coverage of treatment. Let’s be better.