From Dr. Fortuna’s column on Addictionblog.org from January 8, 2016: “A featured article from Dr. Lisa R. Fortuna, MD, MPH, expert on teen addiction who helps outline mental health issues for parents. Here, she considers the research on the social and neuro-developmental factors related to teen substance use disorders and mental health, and translates that into everyday language and practical recommendations.”

http://drug.addictionblog.org/adhd-and-teen-smoking-what-parents-should-know/

I am a Latina who identifies as Afro-Latina, at least that is what a young woman recently pointed out to me. She asked me if I was Afro-Latina, she has asked me if I have ever straightened my short curly hair. I had to answer yes that I identify with my connection to the African Diaspora. Yes I have straightened my hair in the past. I feel a bit liberated from that now (just not my choice to do so anymore). But what I take away from the encounter is that racial identity, and all that potentially means, does matter in the child and adolescent psychiatrist’s office. We live in a society where it is often suggested that if one focuses too much on race then one is racist. The young girl asking me questions, her peers, youth in this country are experiencing challenges as well as making sense of their racial identity.

The aggressive societal message is that people of color should get over it and stop focusing on race. The scientific community is clear that race is a social construct. But a powerful social construct it is indeed.  Children identify race pretty early on. A preschooler will often notice if they are brown and others are not. They will ask questions about why there are differences in skin color, and when they begin to receive messages that are suddenly negative about race and color then it starts to be a real and tangible issue. We each have a variety of social locations. We identify with gender, socioeconomic status, sometime a faith tradition, ethnicity etc. Race is clearly among these and it is a very intimate and powerful identification because it does mean so much in society. How we relate to the societal construct of race in our communities makes a difference in our integrity. Then there is racism:

Racism–a belief or doctrine that inherent differences among the various human racial groups determine cultural or individual achievement, usually involving the idea that one’s own race is superior and has the right to dominate others or that a particular racial group is inferior to the others.

Well that has a whole set of other implications for the well being of children. The fact that we have to declare that Black Lives Matter says a lot about the messages youth of color are living with that suggest to them that certain lives don’t matter as much…that their lives are not valuable.

Sometimes I find myself walking into my office needing to hold together a youth who already depressed has to bear media messages like, “all Mexicans are rapists”, or has to see black churches burning down or black young boys shot down in the middle of the street. We may not even speak all of that out loud right then and there…but it is there and can’t be ignored.

What does that mean for the well-being of our children?

What does a child psychiatrist like me do with that reality? What do we all do with it?

Speak the truth and listen to the truth. We need to be honest about the realities of the racial injustices that are present in our society. It is not a color blind society and youth know that –so let’s be open and real and allow them to ask the questions and bear the truth with us.

Understand that racial injustice, racism can have the power to make us sick. Science shows that racism may be implicated in heart disease, depression, anxiety, low birth weight babies born to African American women.  If anyone says racism and oppression can’t be poisonous and deadly then reconsider.  Joaquin Luna was only 18. The senior at Juarez Lincoln High School in Mission, Texas, dreamed of going to college. But since he was in the country illegally, that was nearly impossible and so he killed himself. How many young people of color drop out of school due to a combination of poor educational systems and a sense of just wanting to give up because it seems that no one cares? Human rights and dealing with social justice issues is part of good medicine. Being real and truthful and listening to the good, the powerful and the ugly realities of race in America is part of our work as those who care, wish to heal and to bear compassionate and transformative witness to what our young people face, and what we all face. In the end we have to declare that we won’t tolerate and stand by while our children are being moved to despair… we’ll show it in our practice, our actions, our commitment to join them in the truth.

When evening had come, Jesus said to his disciples, “Let us go across to the other side.” And leaving the crowd behind, they took him with them in the boat, just as he was. Other boats were with him. A great windstorm arose, and the waves beat into the boat, so that the boat was already being swamped. But he was in the stern, asleep on the cushion; and they woke him up and said to him, “Teacher, do you not care that we are perishing?” He woke up and rebuked the wind, and said to the sea, “Peace! Be still!” Then the wind ceased, and there was a dead calm. He said to them, “Why are you afraid? Have you still no faith?” And they were filled with great awe and said to one another, “Who then is this, that even the wind and the sea obey him?”

I include Christian scripture in this blog this time because I feel I need to speak from my tradition and faith in these moments. The killing of nine people in Charlestown, in a church, in the name of hate is painful. But hate is not the last word. It does feel as if we are perishing. But death is not the last word.

A saw a friend and colleague of mine at an event tonight. She let me know that a young man she had been trying to have me meet so that he might get help since she was sure he suffered from traumatic stress and he was having such a hard time…that young man was one of the first to be murdered this year in Boston. It does feel as if we are perishing. But I have to remind myself, death will not have the last word. I won’t be afraid and I will persist through my faith.

Put in the most practical terms we have to act. If you reader are a person of any faith, if you are a humanist, if you are in any way someone who cares about humanity and what is good and right, I ask you to dig deep and consider the following as some possible and important action.

1. Join others in speaking against racism, hate and the oppression against any human being.
2. Join others in demanding better gun control legislation. I don’t want any more dead kids!
3. Speak up for the provision of a good education system, which is made available to all.

Help that be the choice instead of supporting the proliferation of prisons and the feeding of the prison pipeline (disproportionately fed by people of color and the poor).

4. Say no to legislation that disproportionately favors the already privileged and further disenfranchises everyone else.
5. If you are a health provider in mental health or other field of healing…don’t prioritize the financial interests (of our health system) over your vocation to serve your community, your patients our kids.

In the storm that we are in, act with love and justice… hate be still!”

I speak not for myself but for those without voice… those who have fought for their rights… their right to live in peace, their right to be treated with dignity, their right to equality of opportunity, their right to be educated.

~Malala Yousafzai

My objective for this blog is to offer both clinicians and consumers some practical information, especially as it relates to helping young people struggling with behavioral health problems. This is the blog of a child and adolescent psychiatrist after all. But more and more I am hearing both from my colleagues and patients that they are very interested in a deeper purpose and meaning of our clinical work together. What comes up more and more is the question of where the spiritual or the more deeply meaningful enters into our practice and clinical relationships.

So today I want to consider one concept I have found meaningful for healing and practice, which is the idea of dignity. A simple definition of dignity is the state or quality of being worthy of honor or respect. My question in response to this definition is, who is not worthy of dignity? Noble Peace Prize winner Malala Yousafzai says it clearly in the quote above. So many individuals, especially young people, go through life without voice or without being treated with dignity. Yet, those who work in the area of conflict resolution know that it is very hard to heal relationships if the parties involved cannot honor each other’s basic human dignity. Those of us who work with trauma know that one’s core sense of dignity and integrity is harmed by violence, abuse and neglect. The Christian baptismal vows in fact call us to uphold and protect the dignity of all people. Can we think of any major violence, discrimination or social injury which does not have harm to human dignity as a central part of the problem? The Black Lives Matter movement is about justice but it is also about upholding human dignity. The movement for civil rights for sexual minorities is an issue of justice and dignity. And when dignity is upheld and we witness it, these are often the most moving moments in our lives. When we see dignity reclaimed in the consultation room this too is moving and transformative. So my five pointers for upholding the dignity of another in the consultation room (even and especially with young people):

1. Listen to and hold each story for the sacred reality it is, with compassion. Being truly listened to and truly seen is central to our dignity.
2. Believe in the wisdom for healing that each person possesses. As clinicians we can offer a lot of good advice and expertise, but we do not by any stretch of the imagination hold all the answers available in the room. Sometimes we do not think a teenager or child to be wise…but think again.
3. Perceive the whole person, not just the broken and hurt, but the complete person who does not need you to change them but needs you to honor what they strive to be. Sometimes that means listening to their songs, or worries, or ideas, or even noting their acting out. But listen to it, be deeply aware of it.
4. Walk (even run) with them. One of the interventions I respect a lot is one where counselors run with adolescents and children and they train for a 5 K race, or even a half marathon. This is a community-based intervention, but it speaks to the power of doing, being and achieving together so as to offer an opportunity for growing into one’s full potential, and being heard and witnessed on the way. (SOLE TRAIN HERE)
5. Respect, honor and create a space where your own humility makes space for the dignity of others. If as clinicians we can let go of our own rigid expectations and actually open up to the unexpected and the possibility, be open completely to outcome…then we are upholding the dignity of those who sit before us.

It brings up yet another quote, this one from The Rev. Dr. Martin Luther King Jr.  “All labor that uplifts humanity has dignity and importance and should be undertaken with painstaking excellence.” Let us undertake that labor with painstaking excellence.

Some of my picks this week for resources and examples of practicing and upholding dignity:

Sole Train

Boston Runs Together is a free, non-competitive, long distance running program based at Boston Public Schools and Department of Youth Services. In Sole Train, teens from Boston neighborhoods, many of whom have never run before, train for and complete a half marathon or 5-mile race.  In the process, they find their place in a supportive community that celebrates them and helps them discover just how far they can go.

https://www.trinityinspires.org/sole-train/

Creating safe space for GLBTQ Youth: A Toolkit

http://www.advocatesforyouth.org/storage/advfy/documents/safespace.pdf

Because I am a priest and a psychiatrist I spend a lot of time discerning the meaning of things. The past two weeks have been filled with a lot of news stories about discord, violence and hate.  A lot of this very bad news has to do with racism, divisions, greed, and power. I only have to bring up Ferguson, Baltimore or ISIS and you know the kinds of stories I am speaking of. These things bring me to two questions: How do we raise up our young people to be healthy in body, mind and spirit in a world that upholds such violence? How does our world contribute to the development of anxiety, depression, and traumatic stress in our young people?

Today one of my parishioners asked me, “What can we do to help our kids make it in this world?”

It is an important and challenging question that I have had to try to answer either at the coffee hour after church service, in my consultation office when seeing a patient and their parents, or when investigating a new intervention that might help young people with depression or trauma.

Although these are all big questions, I have at least  learned a few things over the years through my clinical practice, research and ministry about what helps young people stay healthy (or what helps them heal if needed) in mind, body and spirit. Here are my top 5 learnings of what helps young people:

1. Having someone in their life that is absolutely crazy about them, loves them unconditionally and lets them know it

2. Having a sense of community and true belonging

3. Developing compassion for self and others

4. Connecting to ones heritage and traditions while also embracing new ideas and diversity (Includes biculturalism, multiculturalism) 

5.  Developing a sense of a greater good and commitment to something bigger than oneself  (spirituality, justice, connecting across differences).

I have found that these five core areas are very important for emotional health and development.

Here are some links of some examples of youth living into these principles and adults supporting them on the journey:

These Baltimore Teens Aren’t Waiting Around for Someone Else to Fix Their City, 

http://www.motherjones.com/politics/2015/04/baltimore-teens-police

La Puerta Abierta/ The Open Door—a program for clinical excellence and belonging for immigrant youth

http://icfamwell.org/content/about-la-puerta-abiertathe-open-door

Youth Engaging Compassion

https://sites.google.com/site/youthengagingcompassionorg/

What are some of the ways we can engender these types of experiences and opportunities for growth and healing in the lives of our young people?

As I write this, I am at an international conference in which the primary topic is dual disorders–meaning the  not so infrequent clinical situation in which someone is suffering from both a mental health and addictions problem at the same time. The medical field understands dual or co-occurring disorders to be harder to treat than when there is one disorder. Adolescents with co-occurring mental health and addictions, have an even harder time in school then if they had one disorder, have more problems functioning and take longer to get better. To be frank, I think a lot of psychiatrists don’t like to ask about the addictions part of the problem because they are not sure what to do about it. For the patient or client, there is often shame or discomfort about sharing information about their addiction, or they are just not ready or sure how to. So, addictions and dual disorders remain unspoken between doctor and patient. Here are 5 things we can do about that:

1. Your pediatrician or primary care doctor should be screening for substance use or other risk behaviors regularly. 
2. All child and adolescents psychiatrists should assess for both mental health symptoms and substance use disorders in their first sessions with adolescents and older children and continue to monitor and offer information.
3. The doctor should ask about substance use without judgement, asking the patient about both what they find positive and negative about using drugs or drinking. Knowing both sides, negative and positive, helps with discerning motivation for change and brings to light the ambivalence we can all have about change.
4. Ideally, treatment offered should address both disorders in an integrated fashion (both together).
5. All of us should remember that both psychiatric disorders and addictions are both treatable, and people often do get better. It can take a while to see change and often only after a series of attempts, lapses and relapses but recovery is possible.

If we can talk about it then we can work on it. 

Child psychiatrists are physicians trained in child development, pediatric mental health disorders, talk therapy and medical care for children and adolescents suffering from a range of mental health problems: depression, anxiety, psychosis, neurodevelopment disorders such as Autism Spectrum Disorders. There are not enough child and adolescent psychiatrists to serve all of the needs of the US population of pediatric patients with psychiatric disorders. However, mental health and behavioral disorders are among the most prevalent and disabling health problems faced by young people. As a Latina, bilingual psychiatrist I also am one of a few child psychiatrists in the country who can serve Spanish speaking children and families. But to be honest, I wish we had more child and adolescent psychiatrists in the country to serve all of the young people who need care. I also believe that child psychiatrists should not have their practice limited to providing pharmacological treatments (medication), as is the trend, but given the opportunity to offer integrated care (therapy, family and other interventions that may also include medications if needed)  for helping children and adolescents.

I want to welcome you to this blog. I hope you visit frequently. I hope to offer you some helpful information that I share with you from my experience as a practicing child psychiatrist who has worked in diverse settings and with many families for over 15 years.  Families, youth and medical providers often have many questions about  mental illness or behavioral health problems in children. I can’t offer you specific medical advise but I hope we can enter in a dialogue about the challenges, and opportunities for better addressing the needs of our children especially the most vulnerable.

Peace,

Dr. Lisa