Tag:

psychology

Grief In Repeat

{Upland, California}

Upon driving into my garage coming home from work this evening, I suddenly burst into tears as the garage door slowly closed behind me. I haven’t felt like myself at all this past week. I tried my hardest to discern the reason for my melancholic mood and pinpointed a series of events that occurred after the subject of death was brought up during my therapy session this past weekend. The subject of terminal illness and inevitable death is never an easy one, even as a physician who had to pronounce deaths in the hospital wards and was educated on how to talk to patients about advance directives (Do Not Resuscitate/DNR), hospice, etc. We all have triggers that may occur randomly during our day that may unleash suppressed feelings that go deeper beyond whatever triggered us in that present moment. A patient once told me that hamburgers made her sad because her deceased father cooked them all the time at family gatherings. For others, something as simple as a hamburger triggering profound emotions may sound ridiculous, but we must be empathetic to each individual because none of us know of the history, context, or meaning that a symbol (such as hamburgers) provided in a person’s life.

My initial trigger was watching the movie Furious 7 last week. Now, I know that millions of devoted Paul Walker fans (including myself) were profoundly impacted by his tragic death, but the uncontrollable amount of tears that I shed was far too disproportionate to the mild attachment I had for the actor. Since everyone I knew who watched the movie admitted to shedding tears, I didn’t think much of my emotional response at the time. But, during my group therapy session, I was extremely angered about an unrelated topic, and again, I couldn’t figure out the reason why. Leaving my therapy session in a pissed off mood, I contemplated quitting group because I didn’t want to be a part of anything that made me feel angry and unsupported. I looked at my phone and started scrolling Instagram to distract myself from my emotions, and stopped incessantly scrolling once I came across the picture below, which my sister posted for National Siblings Day with the following caption:

It was always the four of us. Although we’re all grown up with separate lives, we will always have the same love for each other, and share the same values that our Lola and Lolo (Grandma & Grandpa) taught us. My latepost In honor of ‪‎siblings Day 4/10 and my lolo’s birthday 4/7. I love you all. I miss you Lolo & Lola.

Last week was my grandfather’s birthday. The theme of losing such a devoted and integral part of a family is the theme that resonated most with me about the movie. And watching the ending somehow re-opened the wound in my heart that I experienced when I first received news that my grandfather passed away from cancer thirteen years ago. I continue to re-experience feelings of grief each year around his birthday and this year is no exception. I wrote about my grandfather’s influence and my difficulties coping with losing him in previous blogposts (here, here & here). Last week, a few of my patients discussed their own grief, which is always a hard subject to process. I always do my best to provide them with as much support as possible because I know what it’s like to feel isolated, angered, and confused by a complex mixture of emotions.

I used to want to believe that “time heals all wounds,” but one of my inspiring readers modified my perspective of the statement to make it more accurate: time may help make the grief a bit more tolerable. Grief never goes away, but rather is re-experienced in different, sometimes confusing ways. But, just like the goal of the movie, I try to shift my focus from sadness to embracing my grandfather’s strength and legacy. I can already feel the wound close a tiny bit as it starts to repair itself yet again.

April 15, 2015 16 comments

Personal therapy

Let Go

written by freudandfashion

{Ventura, California}

Several of my readers know how much I struggle with self-care and criticize myself on days that I feel less productive (I wrote about the subject here, here, and here). I’m starting to let go of the guilty, judgmental thoughts, which I’m sure are ingrained in the minds of many others like myself who’ve spent most of their lives incessantly working towards a degree and busy career. Last month, I disclosed to one of my patients that I sometimes sit on the couch and watch tv for hours on days I feel exhausted and overwhelmed. I regretted telling her the information because I realized my attempt to make her feel less guilty about doing a similar “lazy” regimen was really an attempt to validate my own actions of simply resting on my days off. I realized how much I still need to work on letting go. I need to let go of the pressures, demands, guilt, and self-criticism.

Well, I’m happy to report that I went to the beach this week, strolled, and stared out at the water as the surfers rode the waves. The thought of rushing home to answer emails popped up in my head a few times, but I surprisingly allowed myself to let the thoughts go. I’ve been working on this process of self-care for years, but I’m making progress. And that’s all that matters (no self-criticism involved).

What activities of self-care did you incorporate this week? I hope you all have a wonderful, relaxing weekend!

April 10, 2015 12 comments

Psychiatry

Teaching Influence

written by freudandfashion

{Malibu, CA}

Current thought: I’m glad I turned out to be a decent psychiatrist.

I remember being an eager medical student during an internal medicine rotation and asking a consulting psychiatrist the reason he diagnosed two of my elderly patients with schizophrenia. I anxiously awaited his response (Note: I highlight the word elderly because diagnosing schizophrenia at such a late onset in life is rare) and he gave me the most nonchalant, dismissive response: “because they’re having hallucinations.” He got up and walked away before I could ask him any more questions. Well, Mr. Psychiatrist, if I knew what I know now, I would’ve told you back then that you were a horrible doctor because you did not even talk to my patient nor put any thought into your diagnosis, nor care that giving a frail 70-year old woman excessive doses of antipsychotic medication might actually make her worse (excessive doses of antipsychotics may increase risk of confusion, oversedation, and pneumonia in the elderly population).

The accumulation of my experiences working with various attending physicians (aka supervising physicians) have shaped the way that I practice psychiatry today. One of the first lectures I attended during my psychiatry residency was about the emphasis of humanism in mental health, which was a concept that was markedly different than what I observed during internship (I had made the decision to switch to a different residency program after internship). I remember feeling ashamed during the lecture because I recalled how I used to write orders for “B-52’s” (the nickname for a cocktail of medications given by injection for acute agitation; a chemical restraint) so frequently and unhesitatingly during internship. Needless to say, that lecture set the tone and confirmed that I made the right decision to change training programs. My whole perspective and approach to psychiatry changed by working with the most caring and compassionate psychiatrists, therapists, and nurses. I obviously recall interacting with a few terrible psychiatrists, which actually turned out to be a useful learning experience: I learned how NOT to practice psychiatry. So, if you are interested in pursuing a career in the mental health field, I hope that you train with amazing supervisors, remain open-minded (psychiatry is not so clear cut as reading the DSM 5, our diagnostic manual), maintain empathy, and remember that each individual/client/patient has a story.

The greatest compliment that I’ve received from several of my patients is also a sad reality about the spectrum of practitioners in my field: “You’re not like any psychiatrist I’ve met before. You actually try to get to know me.”

March 25, 2015 36 comments

Lifestyle Personal

Thankful Thursdays – Time Off

written by freudandfashion

{Fairfield, California}

Time off from work couldn’t have arrived at a better time. It has been awhile since I wrote my last “Thankful Thursdays” post (see previous ones here and here), so I think it’s appropriate to write one given my current state of mind (which is more relaxed and centered). My vacation started off with a quick, last minute trip to visit my family in northern California, which is usually my preferred travel destination each time I get the urge to feel more rooted and have the need to reset. During a stroll with my sister, I realized the grassy hilltops are gorgeous landscapes that I’ve taken for granted ever since my family first moved to the area when I was in junior high. For some reason, the lush hills appeared immaculate and majestic this time around. I enjoyed reuniting with family visiting from the Philippines, tasting my mom’s traditional filipino dishes, and playing card games with my cousins and siblings. I truly savored my brief stay.

Currently, I am sitting in a hotel lobby located in the flourishing city of Scottsdale, Arizona. I stare outside at the backdrop of pristine mountains, pale blue skies streaked with thinly layered clouds, and adobe fountains and fixtures at the forefront. Everything seems extremely tangible – from the texture of the furniture to the warmth of the sun hitting my face. While attending a conference, I am also aware of the numerous psychiatry and neurology residents here preparing to take their board exams tomorrow, as they lay out by the pool with heads buried in flashcards and exam prep books.

“I remember being in your same position two years ago,” I said to one of the girls who studied while lounging on the chair next to me. All I could remember from that day two years ago was memorizing the diagnostic criteria for various psychiatric diagnoses, the treatment for alcohol and drug withdrawal, etc. I never would have imagined noticing the simplistic, yet characteristic details of the locale like I am able to observe now. Fortunately, I passed the horrific test, yet I reflect on the past and a part of me wishes I was more mindful of the details from that experience. However, as the saying goes, “better late than never.”

Photo by Marlon Santos

March 12, 2015 6 comments

Personal

Weekend Reflection

written by freudandfashion

{Ventura Pier, CA}

In order to take charge of my life after a stressful week, I made the decision to temporarily cut back on certain responsibilities. In the past, I rarely said “no” to projects or other opportunities, however, as I mentioned in my last post, I’ve been extremely overwhelmed and need some time to regroup. Though it’s difficult, especially if you’re someone who people rely on (especially if you’re the caregiver type), setting boundaries with people and activities is a healthy way to cope and manage your life. I’ve never met anyone who devotes a huge percentage of their energies on work and everyone else BUT themselves without getting burned out. However, if you have mastered the art of life balance, please message me. I’d love to know your secret.

Hope you’re having a wonderful weekend filled with relaxation and self-care!

March 8, 2015 19 comments

Personal therapy

Numb

written by freudandfashion

I honestly didn’t want to write a blogpost today. The main reason being that I’m not in a peppy mood, but why should blogging only be about happy thoughts when reality is that human beings experience a full range of emotions?

My current emotion = numb. I participated in a suicide debriefing at work today, which is a meeting where we review a recent suicide, process grief, and provide support for staff members involved. I have been open about my feelings surrounding patient loss (here, here, and here), and experiencing this sort of numbness is somewhat new to me. The intellectual part of me feels inclined to look up research articles to find meaning behind this numbness, however the emotional side of me lacks motivation to perform the work. We may sometimes experience a mixture of confusing, unfamiliar emotions, which may contrast from what one might perceive to be normal or expected. But that leads to criticism for feeling a certain way. How nice would it be to have freedom to be yourself and feel a certain emotion without being judged?

Yesterday, one of my newer patients wanted me to tell her where her anxiety is coming from and I replied, “I’m actually not sure, but perhaps you have an idea what might be triggering it?” My patients often expect me to identify the reason behind a specific emotion, but I find it difficult to formulate my thoughts without the patient’s own input. If I switched roles right now and sat in the patient chair and the psychiatrist asked me where I think my numbness is coming from, I’d say “I feel too overwhelmed and there’s no room for extra stress in my life.” (Then, the light bulb goes off in my head). I have too much going on in my mind and don’t have the reserve to tolerate more emotions at this current moment. Hence, feeling numb. Now that I think about it, feeling numb isn’t much different from the hours I spent watching House of Cards last night (Note: it’s out of character for me to watch that much tv on a regular basis). Either way, I am trying to avoid some unsettling feeling that I’m not quite ready to process. However, I’m bracing myself because I know the time to process the difficult emotions will eventually come. Until then, I still have two more seasons to watch.

March 5, 2015 20 comments

Personal Psychiatry

Casual Fridays – Join the Cause

written by freudandfashion

I started blogging during psychiatry residency training a few years ago not only because I needed a creative outlet, but also because I felt lonely and isolated living in a new town without an established support system. I initially coped by laying on the couch watching excessive amounts of television, but then the idea to start a blog popped up in my mind. Since I rarely shared my feelings with colleagues and supervisors, imagine how embarrassed I felt when my medical director told me that he read my blog! He said that he learned far more about me within minutes of reading a few blog posts compared to the last few months since I joined their program. Since I never felt comfortable enough to verbalize my thoughts nor struggles, I realized that my writing provided a necessary outlet of expression. Over time (through my training and participating in both group and individual psychotherapy), I let down my guard, however, it’s still a significant work-in-progress (ask the members in my current group therapy cohort). However, my experience allows me to empathize with my patients, especially when they describe the difficulties of discussing their issues with others.

The purpose of my blog has been to create an openness to discuss mental health, so I was excited when I came across the conscious clothing line, Wear Your Label, which shares a congruent mission: to create conversations around mental health and ultimately end the stigma. Each garment creates a sense of connection and empowerment by emphasizing positive messages in each piece. For example, their “Stuggle vs. Strength” tee (worn in photo) highlights the co-existence of both strength and struggle, for, the “most valiant strength develops through times of struggle.”

Many organizations, advocates, social media forums, etc, are rising with the same goals in mind of providing support, education, and resources to prioritize mental health. However, each one of us can contribute to this goal simply by opening up about our own individual struggles. That way, none of us ever have to feel alone.

February 27, 2015 6 comments

Psychiatry therapy

Therapy Pet-Friendly Guide

written by freudandfashion

I learned about the concept of service dogs early on since my dear aunt has a guide dog (which I featured in one of my blog posts here). In my practice, I am often asked about the process of making a beloved pet an emotional support animal (ESA) or a psychiatric service animal (PSA), so I thought it might be helpful to share info for those who are interested. And as a side note, it wasn’t until I wrote this post that I realized the differences in nomenclature, for “therapy dog” (a dog trained to provide comfort to people in hospitals, nursing homes, and other institutions where their services are needed) certification has its own set of guidelines that you can refer to here. Therefore, for the sake of this post, I will limit my discussion to PSA and ESA.

Psychiatric Service Animal (PSA):

The 2010 Americans with Disabilities Act (ADA) regulations define “service animals” as dogs that are individually trained to do work or perform tasks for people with disabilities.
- a dog trained to perform tasks that benefit a person with psychiatric disabilities = a “psychiatric service animal”
  - examples: calming a person with PTSD during an anxiety attack, reminding individuals to take medications
- Miniature horses may also be included under this definition, however, there are four assessment factors that facilities may use to determine whether or not miniature horses are permitted
How do you get your dog to qualify as a service animal?
- In my research, I was surprised to find that registration for a service dog is not required, nor are special vests, tags, or harnesses required to be worn (though many utilize these as a way of identifying them).
- Almost anyone can train a service animal. In order to be protected under federal and state law (I know this to be true in California, but please check with your respective states), the only requirement is that the dog must be individually trained to benefit the person with the disability (Bronk v. Ineichen). Otherwise, if the owner fails to demonstrate their dog’s ability to perform the trained task, it is considered a crime of misrepresentation.

Emotional Support Animal (ESA):

An ESA is any type of animal (not just limited to dogs) that can provide comfort to a person with a psychiatric disability. Training to perform a specific task is not required [1].
ESAs are not protected the same way that service animals are protected when it comes to access to public places (restaurants, buildings, etc).
Will your ESA be allowed to stay in your home even if your housing complex has a “No Pets” policy?
- The answer is generally yes, however, the details are a bit more complex so I suggest checking out the answer to this question here starting on page 5.
What is required for your pet to qualify as an ESA?
- As mentioned above, the animal must provide comfort as therapeutic benefit for a verifiable disability.
- For situations pertaining to housing or travel, a note from a physician, therapist, or other qualified medical professional should indicate the animal’s provided benefit for the person’s disability.

Helpful Resources:

I like to print out information for my patients, so I bookmarked the following link from Disability Rights California (still quite useful even if you live in a different state) as it provides simplified, yet comprehensive information on the topic: Psychiatric Service and Emotional Support Animals.

For physicians, mental health clinicians, and other qualified medical professionals, the link above also includes useful sample letters to use as a guide when writing notes for your patients.

Notes:

See Majors v. Housing Authority of the County of Dekalb (5th Cir. 1981); Housing Authority of the City of New London v. Tarrant, (Conn. Super. Ct. Jan. 14, 1997); Whittier Terrace v. Hampshire (Mass. App. Ct. 1989); Durkee v. Staszak (N.Y.App.Div. 1996); Crossroads Apartments v. LeBoo (City Court of Rochester, N.Y. 1991)

February 26, 2015 9 comments

Psychiatry

Valentine’s Day Healing

written by freudandfashion

{Malibu, CA}

Oh, the chatter of couples reserving a spot at their favorite romantic restaurants, enamored significant others shopping for the ideal gift, beloved partners plotting the perfect engagement proposal, top hotel ballrooms fully booked for weddings…all Valentine’s Day festivities sound so dreamy, however the majority of the nation’s singles probably want to vomit.

Since I’ve been writing about grief in my recent posts, I curiously looked up existing research on psychological aspects related to relationship breakups. I found a few interesting studies and figured I’d share what I learned especially since National Singles Awareness Day is fast approaching:

1. Up to one-third of active Facebook users go on the social networking website to “Facebook stalk” their exes. I’m sure many of us have experienced how difficult it can be to avoid ANY contact with our exes soon after a breakup (previous research has shown continued contact offline to be associated with poorer functioning post breakup). Well, a study conducted by Dr. Tara Marshall showed Facebook stalking to be even WORSE for recovery post breakup! Those who de-friended their ex showed greater personal growth, which suggests that the best chance for healing a broken heart is to avoid them both online and offline.

2. There is hope in breaking up, at least in terms of developing personal growth. Another study led by Dr. Tara Marshall examined the association of attachment styles (see below for my attempt at a simplified explanation of this theory) as predictors of personal growth following romantic breakups.

One attachment style involves those who grew up in an environment where the caregivers were inconsistently available nor responsive. As an adult, they tend to be clingy and require excessive reassurance especially when they feel insecure and unsafe in the relationship. Therefore, after a breakup, these highly anxious individuals developed heightened distress, which ultimately led to greater self growth. Why so? Perhaps experiencing high distressing emotions acted as a catalyst to promote self-reflection and growth.
In contrast, when someone grows up in an environment where the caregivers were never around nor available, then as an adult they grow up to be highly self-reliant and mistrustful of others. Therefore, after a breakup, these individuals aim to restore their self-sufficiency and take on the role of parenting themselves. In this study, they were found to exhibit low amounts of distress and less personal growth likely due to experiencing little motivation to change as a result of the split.

3. Changes in your brain activity occur after a breakup. One study published in the American Journal of Psychiatry (2004) conducted brain scans and found altered brain activity in women actively grieving from a recent breakup. Therefore, you’re bound to experience some changes in emotions, especially sadness, and there’s a scientific reason to account for this.

Thought of the Day: Ready, set…stop stalking your ex! (at least until you’ve healed and moved on. I admittedly get a kick out of Facebook stalking my exes every once in awhile as well).

February 13, 2015 21 comments

Psychiatry therapy

Shock and Denial

written by freudandfashion

I review the 5 Stages of Grief with my patients all the time. Yet, no matter how many times I review them, nor how many patients or people I lose in my life, experiencing these stages never gets easier nor avoidable.

Stages of Grief:

Shock/Denial
Depression/Sadness
Anger
Bargaining
Acceptance

The following was written last week:

Today, I shall focus on shock/denial. Why focus on the shock/denial stage? I received a call from the medical examiner (aka coroner) today. I hold my breath each time I answer my office phone in fear that the medical examiner’s office is on the other line. The worst sentence to hear upon answering the phone is “Hi doctor, this is (insert name here) from the medical examiner’s office.”

My biggest fear became a reality today, yet again.

Currently, I am in the shock/denial phase and I’m coping by intellectualizing (a defense mechanism that many of my colleagues employ to deal with difficult news; mostly because I’m more comfortable processing the loss clinically rather than emotionally at this point, hence, the reason I am focusing on writing a blog post that teaches the stages of grief), carrying on with work, and going about my day, with the occasional few tears and blank stares when I have downtime. These moments of sadness are periods that I try to avoid, especially after glancing at my fully-booked patient schedule. According to the medical examiner, “cause of death is not known, the toxicology results are still pending.”

Each and every one of us go through this phase when we experience loss. I blogged about the subject of grief recently when I lost a patient to suicide two months ago. I am aware that my demeanor is currently “off” because I’m quite tense and impatient right now as well. I might be going through the motions of a regular day, but in no way am I taking this loss lightly. I know the anger stage will approach soon. For me, the worst stage is sadness/depression because I generally want to isolate and hide.

The following was written today:

One week has passed since hearing the tragic news about my patient. I enter the clinic, greet my usual “good morning” as I observe everyone going about their busy day as normal. I enter my office and suddenly have a desire to punch my computer as it takes forever to reboot. I settle for slamming my palm against the keyboard instead. Note that this is my usual morning routine, minus the angry/”I wanna punch something” part. The anger stage is here.

I see my first few patients and notice a decline in my usual empathetic statements, my mind drifts more frequently, however, I remain fully aware of my thoughts and am able to re-focus. The 20 minutes that I have with each of them is their designated time and I must not let my grief impact any medical decision. I take my lunch break and run into one of the therapists, who was also involved in my deceased patient’s care. I decide to open up about the struggle I’m having today, in hopes that we can provide comfort and support each other during this difficult time. Instead, I get a remark that pisses me the hell off, or at least that’s how I interpreted her curt comment. I essentially wanted to tell her she was an insensitive idiot and to f*** off, but I held my composure. I normally wouldn’t be bothered by such a comment, but I’m clearly more irritable than usual. I let it go and tried to have compassion for her especially since she might be grieving as well, or thought that perhaps she’s a cold witch and doesn’t care, then thought that perhaps I misinterpreted her comment. Perhaps I feel that nobody understands, and maybe no words can make me feel better at this moment anyway.

February 5, 2015 23 comments

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