March 2016 – Maria Yang, MD

“Do you have any questions for me?” I asked. It’s how I usually close clinical interviews. It’s also a way to acknowledge how one-sided the interviews are.

“Will you go out on a date with me?” he replied. We were looking at each other through the window of his cell. His face was serious.

“No. Don’t ask me that again.” I want to be clear. There’s no ambiguity in that answer. “Do you have any other questions for me?” Even though I said no, I will still talk to you in my professional capacity.

He said nothing, but now he was frowning.

“Are you angry?”

“Yes, I’m mad. You said no when I asked you out on a date.” His cheeks were now red. He roared, “I HAVE SEXUAL NEEDS, TOO!”

“Good-bye, sir.” He was still shouting racial and misogynistic epithets at me as I left the area.

It’s not his request for a date that was noteworthy. That, unfortunately, has occurred before. It doesn’t happen often.

This is usually how these conversations occur:

SCENARIO 1: “Do you have any questions for me?”

“Will you have sex with me?”

“No. Don’t ask me that again.”

“Okay.”

And the subject never comes up again.

SCENARIO 2: “Do you have any questions for me?”

“Will you give me a blow job?”

“No.” (walking away)

“I’M SORRY, I’M SORRY, I WAS JUST KIDDING….”

These men usually apologize again the next time I see them.

SCENARIO 3: “Do you have any questions for me?”

“When I get out, I’ll take you to that burger place, I’ll buy you a burger and small fries, you can choose Pepsi or Coke—”

“Thank you, but no. That won’t happen.”

“But you can choose your own soda—”

If it comes up again, the requests are benign and may not make a lot of sense.

What made this man’s reaction noteworthy was his rage.

Nobody likes rejection. We all feel that visceral crushing sensation when we want something and we can’t have it. That crushing sensation is particularly harsh when we can’t have what we want due to arbitrary reasons. Like when a woman declines a date with a man.

This man and I had an interaction in a jail through the door of his cell. It was civil. To me it was a clinical interview. To him it may have been a nice and encouraging conversation. Something about the interaction made him feel comfortable enough to ask me for a date.

(Never mind the cues that indicated that such a request was inappropriate: He was in a jail cell. He knew that I worked as a physician there.)

The men in jail who have asked for dates or sex, though, recognized that they were not entitled to either. Sure, they could ask whatever they wanted. But, they also had the understanding that I could respond however I wished.

This man, though, was furious that I declined his request for a date. His reaction suggested that he could not believe that I had the gall to say no to him. How dare you say no when you were the one who asked me if I had any other questions? You started this. If my role as a physician was to help him, he had ideas as to how I could do that. Boundaries had blurred for him. He disliked that they had not blurred for me.

And, to be clear, this sort of behavior is not a function or manifestation of psychiatric illness. Some people with severe psychiatric conditions have extraordinary manners. Some people without any psychiatric conditions have vulgar manners.

If we look at the entire population of heterosexual men who are talking with a female psychiatrist:

Some (most?) men will never think to ask for a date or sex when asked, “Do you have any questions for me?”
Some men will think to ask that question, but won’t actually ask it.
Some (few?) men will actually ask the question (whether earnest or not), though will not react as this man did.

And, as unpleasant as this interaction was, he did use his words to express his displeasure with me. Would he have shared his thoughts with me had I not asked him if he was angry? There are all the ways this interaction did not play out:

He could have spit on the window (and if the window wasn’t present, his saliva would have landed on my face).
He could have hit or punched the window.
He could have reached through the open slot in his cell door and grabbed me.
He could have thrown something—wet or dry—at me through the open slot.

What would have happened if this interaction had occurred outside of the jail?[1. As I write often here, context matters. Some behaviors occur in jail because of the jail. When you are deprived of your freedom and must spend time in an uncomfortable place with limited to no privacy and nothing to do, you may find yourself behaving in uncharacteristic ways because you are angry or bored… or just because you can.]

He might have walked away.

He might have grabbed me to demonstrate his power and elevate his status.

He might have hit or punched me to express his rage.

He might have grabbed me and taken what he wanted.

Those of you who follow me on Twitter already know that I spent much of last week in Las Vegas. I attended the National Council for Behavioral Health Conference, “featuring the best in leadership, organizational development, and excellence in mental health and addictions practice.” Here are my reflections about the experience:

It was large. I have never attended a conference with 5000 other people. I already find Las Vegas overstimulating. Not being able to get away from thousands of people for hours on end was draining for me.

There were many sessions I wanted to attend, but could not. This, of course, was a function of the size of the conference. Humans, thus far, can only physically be in one place and mentally elsewhere. During this conference I often wished I could physically be in two places at once.

The sessions that most inspired me often had little to do with formal behavioral health. Nora Volkow, the director for the National Institute of Drug Abuse, gave a talk about the neurobiology of addictive behaviors. Did I learn anything new? No, only because I had learned this while in medical training. Did she present the information in an engaging and compelling way? Yes.

Charles Blow, an opinion writer for the New York Times, authored a memoir about his youth and past sexual abuse. During his talk he read from his book and shared his reflections about his experience. Did I learn anything new? Nothing obvious that would affect either my clinical practice or policy considerations. He won me over with his personal perspective, grace, and vulnerability.

Susan Cain spoke about introversion and leadership. Did I learn anything new? No, because I had already read her book. Was it nonetheless worthwhile to hear her speak in person? For me, yes.

The conference featured a large session called “Uncomfortable Conversations”. The intention was for Big Names in the field to discuss controversial topics. These included involuntary commitment, confidentiality laws that are specific to substance use disorder treatment that can interfere with clinical care, and the concept of cultural competency. Each pair, however, had less than ten minutes to discuss their issue. The moderator also seemed to speak more than each member of the pair. The session could have been thoughtful, though ended up feeling underdeveloped and unfocused.

Where were my psychiatrist colleagues? I understand that this is my own issue—after all, this was not a physician conference. The National Council, however, is supposed to be the leadership conference for community behavioral health. Are psychiatrists involved in leadership in community behavioral health? If not, why not? [1. As I have noted elsewhere: “Physicians, as a population, don’t advocate for ourselves as much as we should because we’re “too busy taking care of patients”. This is true. However, our busy-ness creates a vacuum where non-physicians step in and make decisions for us. We then express resentment that we have to follow the edicts of people who have never done the work. If we did a better job of regulating and advocating for ourselves, we might not be in this position.” Advocacy in this case is leadership.]

Only two “small” sessions I attended featured physician presentations. One involved the introduction of trauma-informed care into primary care settings. The other discussed a concrete integration of mental health, substance use, and primary care services. In both cases the physicians were family practice physicians. Which, to be clear, is fantastic. We must work across systems to provide good care for individuals and populations. I nonetheless felt both puzzled and disappointed with the lack of psychiatrist representation. [2. To be fair, Nora Volkow and several of the panelists for the “Uncomfortable Conversations” are trained as psychiatrists.]

There was a “medical track” meant for medical professionals. Few of those sessions discussed systems issues or leadership. I had planned to attend one that discussed guidelines for benzodiazepine use, though there was no room by the time I arrived. (One of my colleagues, a psychiatrist, later told me that many attendees were not doctors.)

The conference will be in Seattle next year. My colleagues and I are already discussing what we can present.

A lot of people want to do good. I often comment, “Life is terrible… and life is wonderful.” That people have done good work to help others and want to share what they learned in the process is remarkable. That people continue to strive to provide useful services to people who are suffering is humbling. That people are creating new programs to help solve problems, often rooted in inequality, a variety of disparities, and the randomness of existence, is inspiring.

When we have our heads down in our own work, we often forget that we are part of a system. Though I have critical opinions about the conference, I am grateful that I could attend. May we all seek inspiration and always learn from others.