Cole Weatherby, D.O.
Moontower Mental Wellness, PLLC
by Dr. Cole Weatherby on March 17th, 2015

Boundaries, boundaries, BOUNDARIES!
 
If you have spent any time on a therapist’s couch, you have probably been exposed to the psychological concept of boundaries. And, generally, I feel that any successful therapy should include an exploration of this concept. However, as is often the case with psychobabble buzzwords, boundaries have become clichéd, and I have seen some grimace and squirm at the mere mention of the dread “B word”.
 
Today I’d like to communicate my feelings on the fundamentals of boundaries, their importance, and how to make use of them in your life. Let’s start with a purely fictional example:
 
You have a friend named Marsha. Marsha is likeable enough in many ways, but over the years your relationship has become somewhat of a burden. When her name pops up on the caller ID, your pulse quickens, armpits dampen and feelings of dread ensue. Marsha has a tendency to push the limits of what you should be expected to do as a reasonable human being. She depends on you, and sometimes blames you in a way that feels unfair. You feel responsible for her. When she’s sad, you’re guilty; when she’s hurting, you’re afraid. When she asks you to do something for her, you know you have to do it, or she will “lose it” or fall apart. A 3-hour phone conversation is not unusual, and afterwards your pressure to say the right thing has left you feeling too exhausted to function…not to mention the appointment you had to miss to stay on the phone with her. Sometimes she yells at you. Marsha also has an annoying tendency to tell you what to do, and doesn’t take no for an answer. On top of all that, she really doesn’t like your other friends, or the fact that you’d rather hang out with them from time to time.
 
Yes, this example is extreme of a toxic relationship with poor boundaries, but I’d be willing to bet you have known more than a few Marshas in your lifetime, or found yourself in a relationship that felt at least a little bit like the one described. Before going further, I think it is important to emphasize that not all the blame in this situation is on Marsha (In fact, I’ll argue that only 50% is on her). She is who she is, and she actually might behave quite differently in other relationships, but the relationship with you is broken and painful. So, what is to be done?! How do you keep these kinds of relationships from accumulating in your life?
 
The only way I know of to help a relationship like this one is by building your boundary skills and putting them to use. Essentially, boundaries are the lines we draw between self and other. As I see it there are two main aspects to boundaries: 1. Recognizing who you are, what you stand for, and what you (or anyone else) shouldn’t tolerate, and being assertive about those things. 2. Allowing other people to feel their emotions without feeling responsible for what they are feeling.
 
But, before we go on to how to do that, let’s think for a minute about why it is so hard for you to do. Your difficulty setting boundaries arises primarily from four feelings: Fear, low self-worth/compassion, guilt, and guilt’s second cousin, obligation. Maybe you’re afraid that you’ll be rejected, or abandoned and forced into loneliness. Maybe you’re afraid that confrontation will just leave you feeling worse. Maybe you feel like you don’t matter enough to take a stand, that your own needs and feelings don’t matter as much as others. Perhaps a parent, friend or spouse blamed you for their negative feelings and you started to believe them. Or, you just tend to take on guilt for other people’s actions or feelings. Everyone who struggles to set boundaries has their own set of reasons this is the case, and this warrants exploration in your psychotherapy or personal self-exploration so that you can be less blind to what drives your behaviors and feelings.
 
Here are some general tips that I’ve compiled on how to set healthy boundaries:
 
  1. You don't cause other people to feel emotions. Emotions come from within. Your actions might play a role in how they are feeling, but you are not making them feel anything and shouldn’t be blamed for such. We should strive to be responsible to each other, not for each other.
  2. Ultimately your actions are the only thing you can control. You can’t control/change/fix other people even if it makes you very uncomfortable not to do that.
  3. Even people who are struggling can be told no. No matter how much pain someone is in, it is usually unreasonable for them to expect all their support from you alone. You can be there for people in need, but you have your own set of needs that are also important.
  4. You can care a lot about yourself and not be selfish. A good rule of thumb is to strive for 49% caring for others and 51% caring for yourself. You need to be healthy to be an effective person and this requires taking care of yourself and working to limit the number of draining relationships in your life. Few could fault you for caring about others almost as much as you care about yourself.
  5. Avoid telling other people what to feel or make them feel bad for feeling something. Respect their boundaries, and they might pay more attention to yours.
  6. Examine the characters in your life. Do any of them seem overly dependent on you? If so, think about what effect that is having on you and think about setting some limits on that.
  7. If you find that contact with someone in your life is leaving you feeling used, abused, disrespected, untrusted or less than, tell them about it. But, be careful not to blame them for your feelings or tell them what to do/not do, or you’re just as guilty as they are. The exception to this is if someone is abusing you. In that case the way to set a boundary is to say no and leave. For everything else, though,try the following:
    1. Use “I” or “Me” statements to let them know what you are feeling and what you aren’t okay with or what you want/need.
    2. Use the ABC equation: I feel ___A___ when you ___B___, and I would like ___­C___. Be as specific as possible.
  8. Remember that boundaries help others grow. People with dependent, borderline, narcissistic, etc. traits usually only get help when people in their lives set consistent boundaries. They must grow to understand that their behavior is unhealthy and unacceptable.
  9. The most extreme boundary enforcement is ending a relationship with someone who is causing you pain, but that is not usually the goal. You establish what your needs are and what you can’t tolerate, then communicate that and from there it is up to them to either honor that, or face the consequence that the relationship can’t go on.
  10. Boundaries need to be set and enforced. When you establish a boundary, make sure you know how far you’re willing to go to make sure the boundary is respected. This will probably be different for the particular thing you’re communicating about. For instance, some boundaries must allow for gradual change, compromise, or second chances, whereas others (e.g., those involving your safety) must not allow compromise.
  11. Sometimes your boundaries will cause others pain. In these cases, you must take time to make sure your boundary is reasonable and that if it does cause someone pain, does the pain lead only to injury, or possibly to growth.
  12. During a fight is very seldom the time to communicate boundaries effectively. It helps to present your boundaries in a confident, straightforward, non-blaming way and this is very hard to do when tensions are high. Get some distance from the fight, make sure the other person has calmed down, and then explain your boundary as clearly and calmly as possible.
  13. When in doubt, talk to people you trust about your boundaries. Make sure your “boundary advisor” is someone you respect as a good “boundary setter”. Seek their input when you are struggling with whether it is appropriate to set a particular boundary.
  14. Remember that as half of a relationship, you share half of the responsibility for things that happen in that relationship. Refusing to set a boundary is doing just as much damage as the other person who is mistreating you.
  15. If you feel unsafe setting a boundary, this is a VERY SERIOUS warning sign for a dangerous and abusive relationship. Get help before you or someone you love gets hurt. 
Establishing and enforcing healthy boundaries is not an innate human behavior. We aren’t born with any special ability to do this, and few of us have just the right set of circumstances during childhood to make boundaries come naturally. Improving this part of your life takes patience and very often reassurance and self-compassion. I strongly believe though that the more we are able to set and enforce boundaries, the stronger our sense of self becomes and the greater our chances are for peace and happiness in life.
 
Here are some resources that I have found helpful on this topic:
 
Out of the FOG support community
 
The DBT Therapy Skills Workbook
 
Self Compassion by Kristin Neff
 
Psych Central article on boundaries 
 
Codependent No More: How to stop controlling others and start caring for yourself by Melody Beattie
 
 
 
 

by Dr. Cole Weatherby on January 28th, 2015

Mindfulness-based practices are some of the most helpful tools for coping with stress, anxiety, depression and pain. There is ever-expanding scientific evidence to support the effectiveness of meditation and other mindful practices, and my own clinical experience strongly supports its usefulness.
 
I have been mindfully meditating for the last decade, and have found the practice to be soothing, enriching and a source of balance when things feel most unbalanced. I have the opinion that any person struggling with emotional distress can benefit from mindfulness meditation. Given that this topic is such an interest of mine, I could easily overwhelm you going on and on about the various theories and issues related to mindfulness, but what I’m trying to communicate in this post is a few of the basics of mindfulness and give you some links and resources to get you started with your own practice. For current patients, if this is not something we have discussed, feel free to ask me about it the next time we meet, as I’m always happy to help you along the process of developing your own mindfulness practice.
 
Mindfulness can be simply defined as non-judgmental awareness of the present moment. In mindfulness meditation, one will focus on some aspect of the present, e.g. breath, sounds, thoughts, emotions, bodily sensations, etc. During this process, it is very common to be distracted by various things besides what you are intending to focus on. In mindfulness practice, the key is to calmly acknowledge and accept whatever is pulling you out of focus and bring your attention back to whatever it is you are focused on. Formal mindfulness practices can be as short as two minutes and as long as hours. I differentiate “formal practice” from the concept of mindfulness, which can be applied to life in a number of ways. 
 
Several things seem to happen when mindfulness is done regularly. There have been a number of discoveries in the field of cognitive science in the last several years about what meditation does in the brain. There are several brain structures affected by mindfulness practices that are key to emotional regulation and stress tolerance. Amygdala function is profoundly affected by meditation and regular meditation can even decrease the size of the amygdala. I encourage anyone with emotional problems to learn about the amygdala and what it does for/to us. It is beyond the scope of this post to go into, but I’ll just say that it plays a hugely important role in your emotional response to various thoughts, memories and other stimuli, especially when it comes to your fear response.
 
Mindfulness practices also increase activity in the prefrontal cortex (PFC), which helps decrease emotional reactivity. Over time, this allows your emotions to be less triggered by various things that life throws at you. Mindfulness practices also involve strengthening non-judgment and compassion, two of the most key ingredients to a more balanced and healthy mind.
 
Here are some links for free guided mindfulness meditations and a few links to books that I feel are particularly helpful for someone wanting to incorporate mindfulness into their lives:
 
Free mindfulness

UCLA Free guided meditations

Excellent books on various mindfulness topics
 
Mindfulness Based Stress Reduction Workbook
 
Full Catastrophe Living by Jon Kabat-Zinn
 
The mindfulness and acceptance workbook for anxiety
 
Mindful way through depression
 
Mindfulness meditation for pain relief - audio
 

by Dr. Cole Weatherby on May 14th, 2014

I am writing today to address an old rumor about brain chemistry and mental illness that still seems to be hanging around. For some reason that I can't fully comprehend, though I am pretty sure it has to do with some clever antidepressant marketing and the way that science is often communicated to the “general public”, some time in the late 90s people started to discuss the "fact" that mental illness is caused by chemical imbalances in the brain. And, it was suggested that giving a medication (namely, antidepressants) could balance your brain chemicals out, thus curing your mental illness. It is confusing where this "conclusion" arose, though I can assure you it was not from science, or psychiatry. In fact, the American Psychiatric Association (APA) never stated anything of the sort, and they are the ones who labor in committees of experts for days and days to come up with "consensus" ways of communicating scientific information about mental illness to the public as a whole. Now, don’t get me wrong, I don’t think everything the APA does is correct, but in this case I think they were.

There is some new research in this area that is very interesting, and we'll get to that in a bit. But, for the most part, the only clue that brain "chemicals" are involved with depression, anxiety, mania, psychosis, etc. comes from observations of what happens to various animals (including us) who are exposed to drugs that alter the levels of said chemicals. For those of you with a scientific background, you are probably already thinking, "Hmm... That sounds like a correlation that does not necessarily imply causation, and says nothing about what occurs in a natural system", and you would be exactly right. Knowing what happens when an unnatural level of a chemical is introduced to a living system, says little about what effects that chemical has in it's natural state. As for causation-- that can really only be understood if the mechanism is understood. And, even now, with all the sophisticated means we have developed to study functional neurophysiology, the mechanism is quite poorly understood.

The chemicals in questions are the monoamines, primarily serotonin and norepinephrine. It does seem to be the case that having low levels of these molecules in your central nervous system and in certain parts of the brain predisposes you to have difficulty with mood regulation and anxiety. However, there is no proof that the deficiency of these molecules is the cause of depressive episodes, manic episodes, anxiety, psychosis, etc. The reality is much more complex— an interplay between genetic differences in how our bodies produce and regulate those chemicals important in our mood system AND our psychological makeup that develops over the course of life experiences.

Another argument against the “chemical imbalance” stance is that antidepressants don’t tend to “restore” normal levels of monoamines. They actually cause very high, abnormal levels that sometimes (slightly more often than placebo) has a therapeutic benefit for depression, anxiety, mania, etc.

I mentioned some interesting new research. Functional imaging techniques (mostly f-MRI) allow researchers to look inside the brain at how different types of neurons and regions of the brain are functioning in response to various conditions. There is evidence that neurons in regions of the brain responsible for emotion (and those dependent on monoamines) function less well in people with mood disorders, and the functioning can be improved by some of the existing pharmaceuticals. Also, there is now evidence that epigenetic changes (changes in gene function and expression due to external factors) may occur in the setting of childhood adversity that alter the way our monoamine receptors function later in life. This is the missing link that will help us understand how “psychological” factors can impact the functioning of brain cells.

It is also important to note that in a system where serotonin is not well-produced, or is not functioning properly, neurons don’t grow/repair/connect as well, due to the neurotrophic, or nerve cell growing, importance of serotonin. So, we have every reason to believe that child abuse/neglect/bullying and all forms of hate, cruelty, emotional stress and trauma that we encounter has the ability to affect the growth and repair of brain cells.

To summarize, it is not a chemical imbalance that causes mental illness. Emotional illnesses do seem to be caused, at least in part, by a poorly functioning monoamine system due to both genetic and epigenetic factors and by an impaired ability of brain cells to grow, connect and repair. Are these changes in nerve function fully responsible for depression, insecurity, self-doubt, attachment issues and low self-esteem? Perhaps, or perhaps there are aspects of our psyche that cannot be reduced to changes in nerve function and chemical concentrations. Resolving this issue will no doubt continue to challenge the limits of human understanding for the rest of our existence.



by Dr. Cole Weatherby on May 1st, 2014

I have to say I thought this day would never come. Austin is one of the greatest cities in the United States (IMHO) and one of the weakest in mental health resources. One of the key areas in which we have been lacking is in emergency mental health resources. For the past decades, those in the midst of a mental health crisis were often stashed in an emergency room for days awaiting a psychiatric inpatient bed, or made to endure the long and stressful process of navigating the admissions department of an inpatient psychiatric hospital-- which are nearly always at or exceeding capacity. Wait times could be more than 8-10 hours in some cases, and in the instance that you didn't need inpatient care, but had a serious psychiatric issue that required attention, there was no help available to you unless you already had a psychiatrist who was always on call (a rarity this day and time). 

So, I rejoice at the news that on April 29th, 2014 Seton opened a psychiatric emergency room at University Medical Center Brackenridge. Now, if you are experiencing a psychiatric emergency, you can simply go to Brackenridge (located at 601 E. 15th St.), get on the elevator to the 2nd floor and step right up to the Psych ED intake window. AND, this is not just a way for people to get into an inpatient psychiatric hospital, though that might happen if necessary. Patients in the Psych ED will be triaged, evaluated and in many cases treated and discharged home. It remains to be seen how smoothly this process will work, and one can certainly expect it may take time before the Psych ED becomes a "well-oiled machine" of delivering healthcare. But, Seton seems very motivated to make this a top-notch facility.

For those of you who have faced the nightmare that is a psychiatric crisis, I think you can rest a bit easier knowing that this resource is available. Austin has had nothing like it, and getting psychiatric help has been an arduous, frightening and sometimes traumatizing experience. This seems to be a big step in the right direction. I encourage you to share this news with others so that more people in Austin and surrounding areas know that there is a place to get this kind of help if one is in need.

BTW, I have no financial relationship whatsoever with Seton or Brackenridge. I am a sometimes lecturer and psychotherapy supervisor to some of the psychiatry residents who work at that facility.

Here are some links to news stories:

KXAN

Community Impact

Seton

More on this to follow once I get a look at the Psych ED first hand.

by Dr. Cole Weatherby on April 30th, 2014

I am going to start making an effort to communicate some of my thoughts on mental wellness. The planned audience is current and prospective patients, other psychiatrists and therapists, those interested in mental health in Austin, TX, and anyone else who happens by. I am constantly coming across fascinating articles and other information that I think could be helpful to share. I also hope to do this as a way of organizing and expressing some of my own thoughts about human psychology.

I am fascinated by the inner workings of the human mind and by human behavior, and also skeptical and cautious in my use of information. I am also an open-minded person and am fascinated by complementary and alternative approaches aimed at combating illness and supporting health and healing. I am hopeful that the process of sharing and teaching in this way will encourage my own growth and education, which I see as a lifelong endeavor.

A note for my patients: I anticipate writing from time to time about various emotional issues, common stressful life events, and important issues involved in the process of practicing psychiatry and psychotherapy. It is possible that you might read a post here that reminds you of something you expressed or that occurred in session. The purpose of this blog is not to publicize your psychotherapy. And, if I ever get the feeling or feedback that is happening, I will immediately delete a post that makes you uncomfortable. That being said, keep in mind that just because what I talk about might remind you of your issue, I would not be commenting on it if I didn't think it had broader implications or universal applications to many people. In fact, it might not be your issue at all. I will never post anything that violates your confidentiality, nor will I communicate things here that I wouldn't communicate to you in session. Please approach me if you have any problems at all with this.





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