Month: February 2015

King Solomon’s Ring.

Post author By Maria Yang, MD
Post date February 26, 2015

I often smiled to myself while reading King Solomon’s Ring by Konrad Lorenz. In this delightful book he shares stories of animal intelligence and character that humans often disregard. It reminded me of the botanical garden at UCLA.

The botanical garden at UCLA is not large, but it had tall trees with thick trunks and rugged bark, ferns with luxurious leaves that stretched along the edge of a small stream, and bright hibiscus flowers that beckoned butterflies and hummingbirds. Footpaths wound through the garden to quiet corners and pockets of shade. The garden offered respite from urban university life.

During my last year of college at UCLA, I helped with research projects in a behavioral ecology lab. One project I worked on involved scrub jays. They are related to crows, which means that they are intelligent birds.

Near the entrance to the botanical garden were two small chessboard-sized platforms, each on a post. This is where I did experiments with the scrub jays.

Prior to working with the birds, I prepared peanuts. Some peanuts I did not open; I merely painted them in one of four different colors. Other peanuts I opened, but took only one or two nuts out before gluing the shells back together. For some peanuts I removed all the nuts before gluing the shells back together. I also painted these manipulated peanuts.

Scrub jays can distinguish different colors. A bird will shake a peanut in its beak to discern how much food is inside.

I don’t remember the exact experiments, but this was the general procedure: I would place two peanuts, each a different color, on a platform. Scrub jays, their legs marked with rings, would appear one at a time to select a nut. Part of the task was to see if scrub jays could learn what specific colors meant (e.g., “red peanuts never have nuts in them; green peanuts are always full of nuts”). Another part of the task was to see how quickly scrub jays learned to adapt to changing circumstances (e.g., “something is different—now the green peanuts are empty and the red peanuts have some nuts in them”). I spent about 15 to 20 minutes several times a week putting pairs of peanuts on the platforms. The scrub jays would land on the edge of the platform, look at the peanuts, pick up and test the peanuts, and then fly away to a nearby tree with a peanut. I scribbled down my observations and readings from my stopwatch.

I did this for several weeks, maybe a month. It was fun. (Scrub jays usually learned within two to three trials what different colors meant and could retain this information over time.)

Once my time at the lab was over, I still took walks in the garden. Scrub jays saw me enter the garden and followed me, often for over ten minutes. They flew from branch to branch, sometimes trailing behind me, sometimes flying ahead of me on the path.

This occurred for months after I had stopped leaving peanuts for them.

I took walks in the garden before I joined the behavioral ecology lab. Scrub jays never followed me around then. I can only assume that the scrub jays learned to recognize me and hoped that I would leave peanuts for them.

My experiences with the scrub jays pales in comparison to Lorenz’s work, but it felt both magical and eerie to see scrub jays following me around—always in silence and never too close—as I took walks in the garden. I can only wish that everyone will have such an experience at least once in their lives.

Education Funding Homelessness Observations Policy Systems

Asylums are not the Answer.

Post author By Maria Yang, MD
Post date February 19, 2015

The New York Times recently featured an op-ed from a psychiatrist, Dr. Montross, who argues for the return of the asylum.

I understand her frustrations: I have worked with homeless individuals in both New York and Seattle who, if they were in psychiatric institutions, would not have had to worry as much about their safety, getting food, or sleeping at night. Many of the patients I now see in jail should undoubtedly be in a psychiatric institution (though not necessarily for a long period of time).

However, I disagree with her assertion that we should return to the era of the asylum.

President Kennedy signed the Community Mental Health Act into law in 1963. The goal of this legislation was to move people out of long-term psychiatric institutions, such as state hospitals, and help them integrate into the community by enrolling them in outpatient services. This is what “deinstitutionalization” refers to.

The Community Mental Health Act, however, only provided funds for the construction of the community mental health centers. The law made no provisions to fund the services that would occur in these buildings.

What we see now—the “transinstitutionalization” of people with severe psychiatric conditions into homelessness and jails—is a consequence of this lack of funding and support for patient care services.

Think of it this way: A city wants to improve its public transportation system. The city passes a law that provides funds to buy a lot of buses. However, the law provides no money to hire and retain bus drivers. There is also no money to hire and retain mechanics for bus maintenance.

The people of the city are frustrated: “Our public transportation system sucks! The city should build a subway system!”

The bus system never got a fair chance.

We also moved away from asylum care for good reasons: Conditions in psychiatric institutions were often terrible. It was not uncommon for state psychiatric hospitals to have insufficient staff for the number of patients in the institution. In Alabama in 1970, one psychiatric institution had one physician for every 350 patients, one nurse for every 250 patients and one psychiatrist for every 1,700 patients.

Dr. Montross herself notes (emphases mine):

But as a result, my patients with chronic psychotic illnesses cycle between emergency hospitalizations and inadequate outpatient care. They are treated by community mental health centers whose overburdened psychiatrists may see even the sickest patients for only 20 minutes every three months.[2. Unfortunately, 20-minute appointments every three months for the sickest patients is also a common occurrence here in Washington.]

If that is the quality and quantity of care “the sickest patients” in outpatient settings receive, then of course “many patients struggle with homelessness” and “many are incarcerated.”

Dr. Montross calls for “modern” asylums, though it is unclear to me what incentives government has at this time to build and support institutions that “would be nothing like the one in ‘One Flew Over the Cuckoo’s Nest'”. Asylums from years past did not receive sufficient funding to provide adequate care. Current outpatient centers often do not receive enough funding to provide adequate care. (How much longer must we wait before this changes?)

To be clear, I do believe there is a role for asylums in patient care. There is a small segment of the population with severe symptoms who would benefit from care in an institution. I’m talking about people who keep trying to jump off of buildings because they believe they can fly. Or people who cannot stop smashing their heads against the wall because they are trying to dislodge the computer chip they believe is in their heads. Or the people who eat their own feces and literally cannot use words to explain why.[1. As I have noted before: If you do not believe that these scenarios actually happen, I encourage you to volunteer at your local emergency department.] These individuals can and do recover; they are not necessarily destined to spend the rest of their lives in an asylum.

We also now have interventions such as assertive community treatment, assisted outpatient treatment[3. Assisted outpatient treatment is controversial, though preliminary data support its use. You can read an admittedly biased summary about it here.], and supportive housing/housing first. There is evidence that these intensive outpatient services keep people in the community and out of psychiatric institutions. What would happen if government and communities supported these interventions?

Modern psychiatric services—in an asylum or elsewhere—will not be modern at all if there are not enough staff to provide care for patients. It also will not be modern if the staff do not receive ongoing training and supervision for the care they provide. It cannot be modern if administrators do not understand the work and are unwilling to provide financial, technical, and emotional support to the front-line staff.

We must get away from the idea that where people receive services is more important than the quality of those services.

Nonfiction Observations

The Golden Rule.

Post author By Maria Yang, MD
Post date February 13, 2015

People in the meeting room returned to their seats: The Governor was about to enter the room!

The judge, wearing a smart blue suit, rose from his seat. He fastened a button of his single-breasted jacket and ran a hand along both lapels.

An urgent whisper: “Are we supposed to stand up for him?”

The judge looked around: Nearly everyone had sat down, but a few were standing.

“I’m going to stand up,” he murmured. “People stand up for me.”

The judge adopted his best posture. The door to the room clicked open. The Governor walked in. Everyone but the judge was seated.

“Ladies and gentlemen, the Governor,” the seated host announced. The audience burst into applause.

Smirking, the judge sat down with haste.

“I guess I was the only one,” he mumbled.

Observations Reflection

Jewelry in Jail.

Post author By Maria Yang, MD
Post date February 6, 2015

When I started working in the jail, officers and health staff alike told me, “You will get more comments about your jewelry here than anywhere else in your life.”

I don’t wear much jewelry, but inmates—who are people, so let’s call them people—do notice and comment:

“Those are nice earrings.”
“Wow—what a pretty bracelet!”
“So you got a man, huh?”
“Hey, that’s a nice bracelet. What’s it made of? Is it real? Where’dya get it from?”

It is obvious in some conversations that the people in jail are assessing the value of my jewelry. In rare instances they might use their questions or comments to frighten or intimidate. (“I once stole a bracelet off of a woman that looked just like yours….”)

In most cases, people in jail blurt out compliments about jewelry. They’re just reacting.

Jail is a rough place: The one I work in is a concrete block. Many walls are coated with institutional blue, grey, or yellow paint. The floors and ceilings feature that speckled grey hue associated with pavements and cement trucks.

Everyone in jail wears a uniform: Inmates wear red uniforms. Officers wear black uniforms. Health staff wear long white coats.

Many things in jail are uniform: Meals are served at the same times every day. Meals are contained in uniform brown paper sacks. The food inside the paper sacks is often the same day after day. Inmates often stay in the same cells with the same cellmates and the same officers. There are few things for the officers and inmates to do as everyone waits for the time to pass.

The only shiny things people see are things associated with hostility: The glint of the steel handcuffs and waist chains. The dull finish of the chrome-plated shower stalls that offer just enough—but not complete—privacy. The glare of the fluorescent lights overhead. They’re not things of beauty.

When you’re in a place where everything is dull and uniform, sometimes you can’t help but notice different and pretty things. That bracelet, that ring, that necklace: Those are small items of beauty in a place where few things are beautiful… or are allowed to be beautiful.