Mom: A Performance Review

Today is the day after Mother’s Day, and I feel like yesterday I was handed a kind of performance review of the job I’m doing. Anyone who regularly reads this blog probably knows that I believe the job of a parent is very important to all kids' long-term psychological wellbeing. I want to do the best job possible.

So how am I doing?

My two elementary school children brought home projects from school. (The middle-schooler just wrote a quick note, I imagine prompted by Dad, saying, “Thanks for being an awesome mom.”) Both younger kids, 3rd and 5th graders, were asked to fill in the blanks with the best things about Mom. These were traditional Mother’s Day school projects, designed by teachers who surely wanted Moms to feel loved and appreciated. I was pleased to see my children had written items like: “My mom always listens to me.” And “My Mom thinks everyone should be treated equal. She will be happiest when everyone in the world gets treated that way.” Top marks on those. But “My mom’s favorite hobby is… napping.” Really? I’m not sure that’s a fair representation of my day-to-day parenting productivity. Well, at least it didn’t say staring at her iPhone…

Maybe children aren’t the most qualified to write parents’ job performance reviews. After all, don’t many kids, especially younger ones, just believe their own family is normal, or even great? They describe what they see, without fully understanding the implications. (We’ve all seen the internet memes of kids who have drawn a picture with the caption, “My Mommy likes… drinking WINE!”) 

And of course teens aren’t much more helpful in reviewing performance. It can be hard to get teens to express any viewpoint at all about their families. (Although “awesome,” while not very descriptive, still seems pretty positive.) Teens have more to say when they have a complaint, but is their feedback objective? If we rely on our teenagers to tell us how well we are parenting, we might all conclude that we are the strictest, most controlling people on the planet. “Do you know that I’m the only kid in my grade who doesn’t have a laptop?” (Doubtful). 

Young adult children won’t be much help, either. They may be frustrated about the parents’ ability or inability to help support them, or homesick, or drudging through a long list of emotions about their childhood, trying to understand who they are and where they come from. By the time adult children can give objective, helpful feedback, the parents’ most important roles have likely concluded.

So, if kids can’t evaluate our job performance as parents, who can? Because heaven knows we need some honest feedback. Otherwise how can we improve?

Perhaps we each have to assess our own performance as parents. It’s impossible to be objective, but at least we can try to honestly note our biases. Here’s a simple 12 item job performance checklist for parents:

1. Are my kids getting all their basic needs met?

2. If I’m having trouble being a parent, am I asking for help?

3. Am I living by my values and adhering to them as often as possible?

4. Do my kids know with certainty that they are loved and cherished?

5. Am I tuning in to my kids often enough?

6. Am I here for my kids, or just for me?

7. Am I managing my automatic reactions so that I can be more reasonable when I’m tired, frustrated, or just having a bad day?

8. Am I guiding my kids in a direction I think they need to go (rather than just letting them wander aimlessly)?

9. Am I letting go enough, so they figure things out for themselves?

10. Am I communicating clearly so they understand me?

11. Am I teaching them necessary skills they will need for future stages of life?

12. Do my kids seem okay, and if not, am I figuring out how to help?

There are probably many more items a parent could use to assess job performance. What would you add?

Urgent Care for Mental Health?

When I first heard about the concept of an urgent care clinic for mental health, I thought it couldn’t work. What about the importance of the treatment relationship? Isn’t that the key to good clinical care? And besides, I had heard that the few urgent clinics that exist around the country have patients coming in and waiting 4 hours, or sometimes all day, just to be seen. Wouldn’t any mental health urgent care fill up, leaving the same access to care problems that existed before its inception?

At the same time, access to psychiatric services is becoming more and more difficult. The typical scenario for people seeking mental health care services in my community progresses as follows: 
1.    An unexpected crisis hits, so the individual in crisis seeks care at an emergency room or medical urgent care. A doctor or PA assesses the patient and may recommend hospitalization, but usually not. (Mental health hospitals provide care for a few days when necessary for safety. If there is not a safety concern, hospitalization is usually not the best option). The doctor/PA perhaps prescribes a Xanax like medication (probably not the best treatment for he problem, but available in the ER) and recommends ongoing care with a psychiatrist, but doesn’t know anyone who is taking new patients.
2.    The patient, hopefully stable enough to wait, calls around town and finds out very few psychiatrists accept her insurance, and many of those who do take her plan have full practices. She finally finds someone and schedules an appointment with psychiatrist’s office, but will have to wait 4 months for the initial evaluation.
3.    Uncertain she can wait 4 months; she reluctantly goes to her primary care physician (to whom she had not wanted to disclose the psychiatric problem, because she felt ashamed). The PCP starts a medication, but both he and the patient feel uncertain that they understand the problem fully and both would prefer the opinion of a specialist, which they must wait 120 days to hear.
4.    When she does finally meet with the psychiatrist, she finds that this person is not a good fit for her needs. He’s a specialist in PTSD and mostly treats veterans with medications only. He has 10-15 minute appointments. The patient is a 50-year-old woman with depression, and she wanted longer sessions with her doctor. 10 minutes is not enough time to get her concerns heard. She also preferred to see a female psychiatrist, but couldn’t find one who was taking new patients.

If, however, the patient above can seek care from a mental health urgent care center, the scenario can look quite different.
1.    A crisis hits and the patient seeks care at a same day appointment. She is assessed by a team consisting of a therapist and psychiatrist, and a treatment plan is developed which includes both short term psychotherapy and starting an antidepressant. She may also be referred to a group for psychotherapy.
2.    As part of the treatment plan, a long term strategy is developed for the patient’s continued care. Her choices for care include returning to primary care to maintain treatment once her symptoms are stable, having the mental health urgent care center facilitate an appropriate referral to a psychiatrist who provides the services she needs, or waiting on a waiting list with a community provider while the MHUC provides bridge care in the interim.
3.    The MHUC stabilizes the patient, decreases emergency room and hospital utilization, and offers a screening process for the patient so she can land in the right place for care.

And what about the 4-hour wait times? I think the answer is that we need more than just a few of these specialized urgent care centers to provide the necessary services. The problem has been that only a few small clinics offered walk-in assessments for mental health. Many of these clinics were state funded, and had limited budgets. When the clinic budget was used up, the walk-in services began to clog up and drop in quality. 

The answer will be to offer more options for walk-in care. To keep pace with the demand, the number of providers will have to increase over time. By returning patients to primary care when possible, using counseling professionals to fill in gaps, and focusing on the acute phase of treatment, I believe this can be achieved. Psychiatrists can offer consultation at the onset of an illness, and then allow other professionals to continue the plan later. Urgent care centers may be the best way to deliver specialty care in other fields as well (like orthopedics and internal medicine diagnostics), so that brief periods of consultation can then be followed by longer term follow-up in primary care.

Dear Single Mom, You're Doing a Good Job

My friend is a single mom. She called recently, stressed and overwhelmed, feeling like she wasn’t being “enough” of what her kids need. She has to work, to provide for her family, so she can’t always make it to the PTA meetings. She gets frustrated and impatient after a long day.

It’s not just single parents, parents in most circumstances face feelings of guilt and inadequacy. Your job as a parent is a sacred task, it’s ever changing, and you’ll never be capable of doing it perfectly. 

1.    You are only one person. You can’t do everything.
Whether you’re parenting partnered or alone, YOU are just one person. You can’t be everywhere, see everything, or do it all. Maybe your spouse, community, teachers, or neighbors are there to be your eyes and ears, but you’ll never be able to do everything. It’s just not possible.
Tips: Learn to ask for help, and lean on your support system. It takes a village! 
2.    You won’t be flawless.
If you are working hard to be self-aware and to be a great parent, you probably catch yourself making some mistakes. It’s impossible to be a flawless parent. You’re going to have bad days, or even make mistakes on good days. That’s just the way it is.
Tips: Don’t be so hard on yourself. You’re not perfect. None of us are.
3.    Your best is enough. It will have to be.
There will be days when you give it your all, and your efforts fall short. Maybe you tried to pull off a morning soccer match followed by an afternoon birthday party, and you showed up to the party dirty, late, and without a gift. That’s okay. Sometimes that’s just how it goes.
Tips: Don’t beat yourself up. Being a parent in not about perfection, it’s about being there with -and for- your kiddos, muddy shoes and all. Your friends will be glad you made the party. You can always drop a gift by later on.
4.    You don’t have to answer for the unrealistic expectations of others.
Just when you get your own inner voice under control, a voice from outside chimes in with a criticism: “My sister is a single mom, and she finds time to be her child’s room parent.” It doesn’t matter what others want or expect from you. Each family is unique, and you’ll have to structure your work-family-service life in whatever way works best for you and your kids.
Tips: Don’t worry what others think. Take care of you and your kids in the way that’s consistent with your own values and priorities.
5.    As long as you notice signs you need to grow and keep trying to learn, you’re doing well enough.
When I meet with families in my mental health clinic, I often hear moms or dads say, “I’m afraid I will be just like my own dysfunctional family.” But if you’re working on being the best parent you can be, and if you’re worrying about how to do better, then you’re probably doing fine. It’s the parents who aren’t willing to work on things that might be more concerning.
Tips: Just keep looking for new ways to grow. As long as you’re mindful of your successes and mistakes, your kids will have a good enough childhood life, and that’s all you can offer.

Being a parent it hard, but if you’re taking the time to read this, you’re probably doing fine. So give yourself a break and a little bit of credit, and embrace the joys and uncertainties of being a parent!

4-20

Today is 4/20, a day when pro-marijuana advocates come out in support of legalization efforts around the US to legalize. I’m a doctor in the state of Texas, and a psychiatrist. I’m in the field of medicine that treats addictions and PTSD. The DSM5 has added Cannabis dependence as a disease classification due to a growing body of research showing that it is possible to get hooked on pot, and simultaneously, evidence shows cannabis may be a viable medical treatment for several mental health disorders.

Meanwhile, the debate over medical marijuana has begun in Texas. Medical cannabis has many uses, many of them that might affect the patients I see every day: PTSD and anxiety disorders can be treated with cannabis. We have other effective treatments for those illnesses, so as a physician, I haven’t been compelled to lobby my legislature for medical legalization of cannabis to treat mental health disorders. 

But then I learned about the research on cannabis oil for childhood seizures from a fellow Texas physician, a pediatrician, who handed me an article and said, “Have you seen these numbers? This is amazing.” It appears cannabis oil can have miraculous effects on some childhood seizure disorders. There are medical journal articles with statistical analyses for the medical professionals, and & videos posted by parents of kids with intractable seizures to demonstrate for anyone who wants to search online and see for yourself. Desperate families of kids with terrible seizure disorders are trying to petition the legislature to offer them hope where there has been none.

Some of the kids who could be helped with medical cannabis have twenty or more seizures every day. The damage to their brains and bodies is unthinkable, and then there’s the toll on the family: the constant monitoring, the sleepless nights, the fear of serious head trauma from the next episode, and the fear of a seizure that can’t be controlled, resulting in an untimely death.

The problem with a debate over medical marijuana is that it can quickly turn into a black and white, simple yes or no, partisan set of arguments. “Drugs are bad.” “Pot is safe.” My view on cannabis is not black or white, for sure.

I don’t want teenagers and young adults smoke recreational marijuana, or use any substance to escape reality. The association between marijuana use and the onset of schizophrenia worries me, and young brains as still forming, making them especially vulnerable to the affects of substance use.

But medical cannabis can save little lives. Children’s lives. So, I hope the Texas legislature legalizes medical marijuana. And I simultaneously hope your teenager (and mine) doesn’t choose to smoke it recreationally.