Boxes and Boundaries
Many years ago, a wise therapist gave me some excellent guidance in how to stay sane while parenting a teenager. “Set up a box of boundaries for her, then let her bounce around inside that box and become who she is meant to be.”
Hmm….I remember thinking…what should these boundaries be? All I had to do was think about my own teenage years to come up with a good solid box, a way to keep her safe and healthy. School was obviously on one side of the box: an expectation to attend regularly, study hard, and get as good grades as she was capable of getting. Then there were home expectations: chores, pet care, nightly dinners, and participating in family life. We made her play board games with us, which she would complain about, despite the fact that she beat us 99% of the time, and still does even to this day.
The other two sides of the box melded into one another: drugs/alcohol, and her social life. I secretly got away with a lot when I was a teenager, probably because my good grades and athletics gave the illusion that I never got into any trouble, which was far from the truth. So, I knew how to sneak out of the house, how to make it seem like I was somewhere that I wasn’t, and how to pretend I was fine when I was under the influence of…something I wasn’t supposed to ingest at that age. For my daughter the expectations were clear: no drugs, no smoking, no alcohol, no risky behaviors that would end her up injured, in jail, or pregnant.
One way I accomplished this was to ask her for a list of all her friends, their cell phone numbers, their parents’ names and phone numbers, and their home addresses. This was prominently displayed on the frig. I would call other parents to verify they would be home while a bunch of teenagers were staying there overnight. Often times her friend’s parents would tell me I was the only one that called to check. I did not care if it upset my daughter. My job was to be her parent, not her friend, right? With the help of this box of boundaries, as well as her own common sense and internal drive, she made it through high school without a scrape (that I know of…), and once she went off to college, it was up to her to set up her own box.
I have thought about this box of boundaries often in the last six years since becoming an attending physician. I often imagine my patients are also in a type of box of boundaries that I have set up for them as they are recovering. As an inpatient stroke rehabilitation physician my boundaries or expectations include therapy, medication compliance, stroke education, and avoiding drugs/tobacco/alcohol. My patients are expected to participate in three hours of therapy five days a week, including physical therapy, occupational therapy, and speech therapy. If they refuse to participate, they are either discharged to a skilled nursing facility, or home with their family. I treat my stroke patients with medications that are designed to prevent further strokes and also prevent known complications that can occur after a stroke. Most of the time patients are agreeable, as they are often a bit shocked and depressed over their new impairments, and never want to have a second stroke. There is also an expectation that my patients attend a stroke education class, to learn about the underlying mechanisms for stroke, as well as the known risk factors, many of which are lifestyle based. I have had several patients change their diets as a direct result of that class. The fourth side of the box is the counseling I provide regarding tobacco, alcohol, and drug use, and the risks associated with using these substances. Ironically, this is much like the conversations I had with my daughter when she was growing up.
In the beginning of my career, I would often feel responsible if one of my patients had another stroke, as if I did not do the right thing in taking care of them. For any of my patients that made a conscious decision to keep smoking, or drinking, or eating unhealthily, I felt as though I had failed as a physician, much as I would have also felt a failure if my daughter was not able to accomplish her academic, athletic, and career goals. But am I really responsible for my patients’ outcome, or my daughters for that matter? I provided the best care possible, and then my daughter and my patients bounce around in the box of their lives, becoming who they are meant to be, with me cheering them on from outside their box.
The professional stress associated with my job got exponentially higher in the last year. Not just because of COVID patients and all the fear associated with the pandemic, but also because of increased workloads, pressure to do more with less support, pressure to get better patient satisfaction survey results, and pressure to see more patients so that our hospital system can bounce back from the financial strain of the pandemic. This increased stress has forced me to take an honest look at my life. I am slowly learning how to discover and find my own box of boundaries, in order to maintain my physical and mental health.
I am deciding who and what to allow in my life, what I want to do in my time off from work, what activities really feed my soul, and what I can let go of. Healthcare providers have a tendency to be self-sacrificing, to put themselves last, and neglect their own health due to both external and internal expectations of what it means to be a healer and a physician. I have realized, in order to stay strong and healthy, in the same way I wished for my daughter to grow up healthy, and my patients to regain their health and function, I need a box of boundaries!
The edges of my box are still morphing, but can be roughly shaped by my home, my work, my social relationships, and my “non-negotiable” healthy choices. I have finally found my physical home, the place that has become my sanctuary, right next to a wetland full of bird song, windows opening to the sun and wind, stunning sunrises over the brown mountains, quiet alcoves to think, write, and read. I have set boundaries at work, deciding to not take on any further administrative roles so that I can focus on direct patient care, which is my true love. I limit the number of patients I admit, and I always try to finish my work at the hospital, keeping my work and home life as separate as possible. I have started forming new friendships with others that are on a similar path: healers, writers, dreamers, artists, hikers, photographers, and nature lovers. I spend quality time with my husband Ronando, gardening together, cooking, and reading to each other in the evenings.
But the most important side of my box of boundaries is my “non-negotiable” edge: those things that I do every day in order to fill up my battery so that I can continue to take care of myself, my family, and my patients. For me, these things include at least eight hours of sleep, exercise, meditation, eating healthy, avoiding alcohol or addictive substances, writing, and connecting with others who really know and support me. Finally, after fifty years on the planet I am figuring out what the boundaries of my box are, while learning so much about myself as I bounce around the inside, becoming who I am meant to be.