"Setting a boundary does not mean you’re an asshole."

Real self-care with Pooja Lakshmin

Last week, I wrote about reading Pooja Lakshmin’s Real Self-Care at the hair salon and underlining every other passage because Pooja’s book effectively explodes most popular notions of self-care. Real self-care is not self-optimization. It’s not escapism. It’s not achievement. Real self-care does not exist outside of us and it is not for sale. In other words, many of the things we’ve been trained to view as self-care, while sometimes being pleasurable (baths are nice!), have nothing to do with the hard, careful work of identifying internal values and making life adjustments based on a clear understanding of those values.

Dr. Pooja Lakshmin is a psychiatrist who specializes in women's mental health and and perinatal psychiatry. She’s also the founder and CEO of a women's mental health community called Gemma, which she co-founded with Dr. Kali Cyrus and Dr. Lucy Hutner. I’ve learned so much from her work, and I’m thrilled to share our chat with you (a week late because REAL SELF-CARE).

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Sara: How did you come to focus on self-care in your work?

Pooja: Real Self-Care has been the culmination of about a decade of professional and personal experience. I have spent thousands of hours taking care of women who are struggling with things like despair, burnout, depression, anxiety, and importantly, I've also experienced my own failed wellness journey in my twenties where I dropped out of my residency training program, got divorced, moved into a commune in San Francisco that was focused on the female orgasm, and basically blew up my life because I believed that this commune was an external wellness solution that would fix all of my problems.

This experience taught me the hard way that there is no “solution” outside of yourself. And anybody who is trying to tell you that there's a simple or easy solution is usually trying to sell you something.

After leaving the commune (which turned out to be a cult), I went into my own psychoanalysis. I was on the couch three times a week for years trying to grapple with how I fell for this cult, and whether I was meant to devote myself to wellness or to mainstream medicine, and ultimately, I came to understand that my place is in mainstream medicine, so I finished my training, joined the faculty at George Washington University, and started my own private practice.

From there, I started to consider the role of self-care both in my own life and in the lives of my patients. I wrote a piece in 2018 for Doximity, called, “We need boundaries, not self-care,” directed to an audience of women physicians, in response to industry-wide resilience trainings and mindfulness trainings that were happening in medicine as a solution to the burnout of healthcare workers.

And that piece really just took off, after which I started my Instagram account, which led to me writing for The New York Times. This all made me realize that I had a real point of view about self-care, and I wanted to share it.

Sara: A big part of the book is focused on boundaries, your central argument being that one cannot develop a self-care practice without first reckoning with boundaries. I feel like boundaries get a bad rap, as if boundaries are indicative of a person's selfishness or boundaries mean the person doesn't care or isn't being a good friend or isn't showing up for you the way you want them show up for you. And I think boundaries are generally misunderstood, especially as they pertain to self-care. Can you talk us through boundaries and their connection to real self-care?

Pooja: It's funny because if you scroll Instagram, every other meme is about boundaries and every other therapist is talking about boundaries. So on one hand, it's everywhere. And on the other hand, it's actually the hardest thing to put in place and I do think you’re right that in some senses boundaries are misunderstood. I think part of this misunderstanding stems from the fact that almost all therapy terms, when they’re disseminated across social media, are bound to become diluted and misunderstood.

Sara: So what is a boundary and how does a person create and utilize a boundary?

Pooja: From a clinical standpoint, the people that are the most kind and the most supportive are people who actually have learned to set compassionate and firm boundaries. I'm sure that we both can identify a person in our lives who never sets any boundaries. And often this is because they’re terrified of being called selfish or being viewed as a bitch or being talked about behind their back as being difficult. That same person also is very likely to be oozing with resentment and anger. And like, it's bad vibes!

When I first came on the faculty at George Washington University, my mentor, who’s now one of my good friends, Dr. Lisa Catapano, took me out to lunch, and she was like, Pooja, one piece of advice that I have for you is that you don't have to answer your work phone. Lisa was like, You can let your phone go to voicemail. And then you can listen to the what the person wants, and then you can respond. That made me realize that a boundary is in the pause, right? If this was a patient who was running out of their Adderall that very day and needed an immediate refill, that would be something I could decide to act quickly on. But if this was someone from the front desk calling to notify me about some non-urgent paperwork, I could decide to act on that a bit later. The point is, not answering the phone gave me the power to decide.

A boundary is taking the space to stop, think, and feel, and understand what you need and what you want. And then you have three choices. You can say yes, you can say no, or you can negotiate. And negotiating is an interesting word. Because I think we often imagine the corporate world or a business setting when we think about negotiations.

But in reality, the majority of the negotiating we're doing in our lives takes place in our personal lives. With our families, our friends. Like, what time is a good time for the party? Where are we going to celebrate Thanksgiving this year? All of this is interpersonal negotiation.  

And if you’re an anxious person, or the type of person that likes a sense of control, it is definitely more work to wait for a response or to state what you need and then wait for the other person to react. It can feel much easier to just respond either “yes” or “no” versus entering into negotiation. With negotiation, you might have to wait a few days, or discuss something a bit more, and that can all feel uncomfortable. Especially for moms in our culture, we’re so overburdened, we want to check as many things off of our to-do lists as possible.

But setting a boundary does not mean you’re an asshole. It means you’re centering real, honest communication. I think of it as putting more of yourself into your relationships. We live in a culture that doesn’t prioritize honesty. We live in a culture that prioritizes fast forward motion. So to ask a question or to step back and consider something for a bit longer might feel like we’re somehow “holding up a process.”

Also, boundaries are not brick walls. I like to think of them as mesh nets. They’re about understanding what you need and what the other person needs and investing enough in the relationship to come to a place that feels good.

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Sara: And why are boundaries so critical to self-care, and why are they so hard to utilize?

Pooja: Putting boundaries in places means having to trust that your relationships can withstand discomfort. People in your life not used to setting boundaries are gonna be like, Oh my God, why is Pooja being so difficult?

Sara: Or why doesn't she care more about my feelings?

Pooja: Right. So it requires a degree of emotional regulation and a capacity to tolerate discomfort. These are real skills that we all have to cultivate and work on. And boundaries are such a big part of the book because in order to understand your own needs, you first have to take back some space and energy for yourself. You have to understand that you and your needs are separate from other people emotionally and energetically.

Sara: I love how in the book, you really walk through the very explicit process of getting to know your own values and your own goals.

Pooja: I noticed that after my patients set up boundaries in their lives, they often didn’t know what to do with the extra time that opened up as a result. So I created an exercise called the Real Self-Care Compass. The compass is actually not focused on goals; it's focused on values. It's kind of pulling back from the idea that we have to have some sort of specific task or thing that we want to achieve in order to pursue self-care. It’s more like, What are the ways of being that feel most important to you? Once you get clear on your values, you can work to embody them. Real self-care isn't just a thing that you do or something to check off the list. It's actually a way to be. It's a verb, not a noun.

Sara: I so appreciated how you make these concepts more accessible and knowable by offering the questionnaires and quizzes as concrete ways for readers to tap into essential truths. I’m the type of person who can pretty readily intellectually understand why internal values are important, for example, but I’m also quite likely to do nothing with that knowledge without some guided prompts. So I found the framework included in the book so helpful.

Pooja: I like to think it’s a self-help book for people who typically roll their eyes at self-help. Because sometimes these types of exercises can be quite cringe, you know? But I hope people can approach this book in whatever way works for them. Some people might get really into it and take a bunch of notes, while others might simply meditate over the book’s contents for several weeks.

Here’s an example of the types of guiding questions you might find in the book. How would you plan your ideal dinner party with $200? And how would that look different than how your friend would plan a dinner party with $200? This doesn’t sound like an obvious way to understand your internal values, but you’d be surprised at how such questions will indirectly lead you to greater understanding of internal values.

Sara: And you also point out that your internal values might change throughout life - this isn’t a one-and-done situation.

Pooja: Not at all, and it was really important for me to be honest in the book about the fact that I’ve made mistakes, and I’m continuously falling off the wagon of real self-care. Real self-care is an ongoing process within each transition in each phase of your life. I am a self-described workaholic. I continually have to remind myself that I don’t want to be the type of person who exalts productivity. It’s not easy. And I don't want the message to be like Oh, just read this book, and everything will be fine. This is hard stuff. I want my book to be the type of book that you revisit throughout life. There’s no full stop to real self-care.

Sara: It is like spiritual exercise in a way. Like, it's not as though you go for a run one day and say to yourself, Okay, I'm all done with exercise for the rest of my life.

Pooja: When it comes to mental health, I think we’re resistant to doing more work, right? I spent a whole chapter in the book talking about how the game is rigged for women and for moms. It is so unfair that it's on us to keep doing this work. But we live in an oppressive structure and an oppressive society, so if you're not doing this type of internal work, then you're just absorbing so many terrible, toxic messages and expectations. I think most people understand that in order to be physically healthy, you probably need to find some time in your week to exercise. Which again, is really hard, right? We need to make a similar commitment to our emotional lives.

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Sara: I think so many women and mothers think of self-care as a “girls’ weekend,” or whatever. Like, Finally, I'm getting away from the kids. I need a break or I’ll crack. It’s very much fueled from a state of desperation and panic. And then as soon as the escape is over, you’re flung onto the same roller coaster.

Pooja: Escapism is a type of faux self-care, and when I’m talking about faux self-care, it’s usually something you can buy, whether it’s a product or a retreat or a trip. It’s a noun, whereas real self-care is a verb. It's an internal process. It's not something that you can buy. It's not something you can check off the list. I referenced Greg McKeown’s great book, Effortless, where he distinguishes between methods versus principles. A method is something concrete; it works for a specific period of time, but it only serves one particular function. Whereas a principle is something you can apply over a wide range of time. This shows up in my practice when a mom will come and say, Before I had kids, I’d go to yoga three times a week, but I can’t find the time anymore, and I feel like I’m failing self-care. Or I know I should meditate, and I have a meditation app on my phone I never use and I’m failing self-care. It’s this constant tyranny of faux self-care that makes you feel as though your inability to attain perfect self-care is your fault. But this just means that you haven't yet assessed your principles in order to find a new method that makes sense for this particular season of your life.

I also want to clarify that no one should feel ashamed for taking pleasure in escapism. We all need it sometimes! But once you leave the retreat or the trip, once you return home, your real life is just as messy as it was when you fled. The decisions never stop.

And to be clear, most people can't afford these types of escapes, right? But let’s look at escape on a smaller scale. Let’s say we want to go to Starbucks so someone else can make the coffee. We tell ourselves that the Starbucks latte is a treat we deserve, but the Starbucks latte is doing nothing to actually change any of the problems in your life, or to change any of the larger systems wielding power over our lives.

Sara: Can you talk about self-care as a competition with yourself? This really resonated for me - the idea that there’s always a better version of me I can aspire to be.

Pooja: In the book, I share the story of a patient who was meticulously tracking her self-care. She tracked her running times, she posted selfies from yoga. There’s nothing wrong with running or doing yoga, but we have to ask ourselves what we’re getting from these activities. And if the thing that you're psychologically trying to get is competition or escape or efficiency, then it's not actually nourishing you. It's not actually fulfilling the function of real self-care.

Sara: I think this relates to the differences between hedonic wellbeing and eudaimonic wellbeing, which you write about in the book. Like, sure, it feels good to get a massage. It feels good to enjoy a glass of wine with friends. But these activities aren’t the same as internal, eudaimonic wellbeing. Can you talk about this?

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Pooja: So eudaimonic wellbeing is built around the idea that when your behaviors and your activities are aligned with your internal values, that's when you have the most sustainable sense of fulfillment and contentment. Whereas hedonic wellbeing is focused on pleasure or happiness. I equate hedonic wellbeing with relief and eudaimonic wellbeing with meaning. Many of my mom clients say they spend so much time managing their families but don’t derive a clear sense of meaning from their families. And the research backs that up. There was a big study done on moms which determined that the more unequal the division of cognitive labor is in a household, the more likely a mother is to look around and feel like it's all meaningless. So it’s the disconnection from meaning that’s the real problem.

And meaning is different for everybody. You have to make your own meaning. And when you try to put on somebody else's meaning or somebody else's values, that's when you will find yourself feeling lost.

Sara: I think this is why real self-care is so hard for so many of us because especially in the US, we are taught to buy our identities and buy our meaning. We're not taught to prioritize our internal values or to model a life around those values. We are taught how to buy a face mask, we are taught how to adhere to western beauty ideals. And when it comes to finding meaning within mothering – that’s intrinsically difficult just because mothering requires so much doing and managing. It’s easy to get bogged down by all the doing and not be able to find any deeper meaning within it.

Pooja: I think the fear is that if you were to let meaning lead, then you would blow up your life. And blowing up your life doesn’t work. I did it! In the book, I include various questions and exercises to more easily identify your internal values, because this book is not about me telling you what to do. It’s just presenting you with different questions to consider. And I think some people are afraid they’ll bump up against a scary answer to some of these internal questions. But you don’t have to do anything with an answer that feels scary. You can just sit with it. For months. For years. It's up to you what you decide to do.

I wrote a piece for The New York Times last year over Mother's Day that was all about maternal ambivalence. And of course, the comments were just fucking terrible.

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Sara: I mean, how dare you be publicly ambivalent about motherhood!

Pooja: I think for women who maybe lost a decade to becoming mothers, to come out of that and look around and really talk to yourself – it can be a very fragile place. So the message is not to throw everything away and start over, but to consider your relationship to the components and people in your life. How do you interact with your roles in life? What do the parts of your life symbolize for you? What do you need to radically reshape your relationship to over time?And I think that's why this type of work is so hard and powerful. It's like this middle ground of accepting that you are constantly still having to engage with toxic consumerism, extractive capitalism, white supremacy, you name it. That’s the world we live in. How do we hold onto ourselves while also figuring out how to engage with modern life at the appropriate volume level?

Sara: Can you talk about how real self-care naturally bleeds into community care?

Pooja: I spend a lot of time thinking about the connection between our personal decisions and our own personal healing, and how we advocate for change to larger systems. The most revolutionary part of the book for me are the stories from patients whose self-care practices led to changes in wider structures. There was the patient who had to take a mental health leave because of her OCD and ultimately started a group in her company to support other folks who have mental health issues. There was the patient who was pissed that her husband had never taken paternity leave for the birth of their first child. And for their second child, her husband asked his company for leave, which they approved, which ultimately impacted his coworkers who came after him. And all of those community-wide ripple effects started from and individual saying, I'm allowed to ask for more. I'm allowed to think about myself, I'm allowed to engage in different conversations and think about my needs in a different way.

Sara: And I'm allowed to say no, right? Can you talk a bit about the roots of self-care?

Pooja: Real self-care has always about reclaiming power. The first notions of self-care stemmed from 1950s’ inpatient psychiatric units. It was all about empowering patients to make decisions about what they ate, or how they wanted to exercise, and things like that. It was about people having ownership over their own wellbeing, even inside of an institution where they didn’t choose to live. And from there, the nursing community considered self-care in reference to compassion fatigue. And then primarily Black activists and queer activists started evoking real self-care as a kind of rallying cry for a political movement. We all know the brilliant quote from Audre Lorde about self-preservation being self-care. And that's really what brought self-care into the cultural conversation and the zeitgeist.

Interestingly, in the US, immediately following the presidential election in 2016, Google searches for “self-care” peaked.

Sara: I wonder why!

Pooja: And now, of course, the age of social media has commodified self-care as something aspirational. And because of our ailing American healthcare system, it’s no wonder that the latest prettily branded vitamin promising to relieve anxiety is going to resonate with social media users. It's so much easier to click “buy now” then to call your insurance company and try to get reimbursed for your out-of-network therapy sessions (which is how I pay for my own psychoanalysis). You used the word “desperation” earlier, and I think that’s right. We are desperate and we don’t know where to turn.

With Gemma, I set out to provide a resource for people trying to navigate the broken systems of mental healthcare, social media, and wellness. Gemma is essentially a master class for women’s mental health. You can take classes, have conversations, we have WhatsApp threads, we have a Substack,

Therapy Takeaway

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Gemma is a community of women asking questions facilitated by mental health experts because we all know that you can't just throw people in a Facebook group and expect something good to happen. But Gemma isn’t therapy. It's not medical care.

Sara: But it's also not a crystal infused water bottle! This just points out the need to find creative workarounds because the system is completely flawed and broken and totally inaccessible for many of us.

Pooja: I do want to distinguish between the limits of real-self care and more serious mental health issues. As a psychiatrist, it’s really important to me that I don’t over-promise with this book. If you’re looking for solutions, it’s so important to know what real self-care can give you and what it can't. And I'm really open in the book about seeking treatment for my own depression and anxiety when I left the cult. I was nearly suicidal. When working through the principles of real self-care, it’s going to be much harder if you have an undiagnosed anxiety disorder, or if you have undiagnosed clinical depression. Real self-care is less a solution and more of a barometer. So if I have a patient who has a history of depression, and maybe they're on meds, or maybe we’re doing therapy, or maybe both, and they start to notice that it's more difficult for them to turn down the volume on their inner critic, or they start to notice that every time they set a boundary, they end up wanting to spend a day in bed because they feel so guilty about setting the boundary, that's a sign for us that we need to look at our treatment plan and make adjustments. So while real self-care is a helpful component of mental health, it’s not the be-all solution that will fix everything. When it comes to true wellness, magic pills do not exist.

Thank you Pooja!