Year: 2016

Categories
Education Nonfiction Policy Reflection Systems

A Review of the National Council for Behavioral Health Conference.

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.

Categories
Nonfiction Reflection

My Conflicted Relationship with Fried Chicken.

They are clear memories from my youth: After riding our bikes along the beach on warm summer mornings, my parents frequently picked up a bucket of Kentucky Fried Chicken. After we settled into our seats at the kitchen table, I always got the drumsticks and biscuits. My parents both preferred dark meat. My mom would take the cole slaw. My dad enjoyed the mashed potatoes and gravy. Chilled watermelon or papaya completed the meal.

A pot of tea was now on that same kitchen table. The wedding band was loose on my mom’s finger.

“You know why I got cancer?” she asked me in Chinese. Before I could say anything, she replied in English, “I ate too much Kentucky Fried Chicken.”

“No,” I blurted out.

“There’s too much grease in it,” she continued.

“No,” I repeated, now both amused and disturbed that she was attributing her lung cancer to Kentucky Fried Chicken.

“If I didn’t eat so much Kentucky Fried Chicken, I probably wouldn’t have gotten cancer.”

“NO.”

I repeated what the oncologist had told us: It was probably genetics. She was a relatively young, non-smoking, Asian female. Something about all that put her at higher risk of developing non-small cell lung cancer. The Kentucky Fried Chicken had nothing to do with it.

She looked away and sighed. Even though I had a medical degree, I was still her daughter and my statement was a child’s opinion.

“I’m not hungry, but I should eat something,” I said, wiping the snot from my nose with my arm. Less than an hour had passed since I had learned that my mom had died.

When we got home, we pulled the paper containers from the plastic bag and put them on the kitchen table. Tears were trailing down my cheeks and my chest still hurt, but I started laughing as I bit into the fried chicken from Ezell’s.

“I get a senior citizen’s discount,” my dad said, smiling. He put the red tray down between us and opened the red and white box.

“I’m glad,” I replied, smiling back at him. He reflexively gave me the drumstick and the biscuit. I handed him the mashed potatoes and gravy.

“Mmm,” he said between bites. “Kentucky Fried Chicken is good.”

“Mm hm,” I mumbled in agreement while chewing. I’m going to enjoy this fried chicken and cancer can go f-ck off.

Categories
Lessons Nonfiction Reflection

Racial Slurs and Hurt Feelings.

You could feel the air rushing out of her lungs and into your face if she was screaming at you.

“STOP CALLING ME A WHORE! I AM NOT A WHORE, YOU DIRTY N-GGER!”

No one, in fact, was calling her a whore.

“DON’T LIE TO ME, MOTHERF-CKER! I HEAR ALL OF YOU CALLING ME A WHORE! I HEARD IT, JUST NOW!”

Her best defense was a loud offense that included liberal use of racial and homophobic slurs. We winced and asked her to stop when the colorful epithets flew from her mouth. She glared at us, her face red and fists clenched.

Despite seeing her multiple times over the course of two years, she, up to that point, had never made any comments about my race. (I look obviously Asian.) Then, one day, with an audience of a dozen people:

“YOU CAN F-CKING GO TO HELL, DR. YANG, YOU F-CKING CHINK!”

As she stormed out of the building, I grinned and put my arms up in the air in victory.

It’s about time!

Some people immediately expressed their concerns (“I’m sorry she said that”; “Are you okay?”), the distress apparent on their faces.

“It’s okay,” I replied. “I consider it a badge of honor.”

“Yeah, but that still must hurt.”

I shrugged. I felt amused, not hurt. I didn’t need them to take care of me.

They, of course, had good intentions. There was just so much they didn’t know:

That one time when my parents and I were biking along a dry river bed. I was eight years old. Two young men, both white, began trailing us. They began to shout things at us that I didn’t understand. They didn’t seem friendly.

“Stay between your mom and me,” my dad instructed in Chinese.

“Don’t say anything back to them,” my mom added.

For the next half hour, they continued to follow us. They continued to shout things at us. They often laughed.

They followed us to the parking lot and continued to shout things at us as my parents loaded the bikes into the van. As my dad drove away, they threw something at the car.

That one time I was pleading again with my mother to leave the Girl Scout troop. I was nine years old.

“I don’t want to go anymore!” I said in English.

“No, you have to go. It’s a good activity and you learn how to get along with others,” she replied in Chinese.

“But I don’t fit in. I just don’t fit in!” in English.

“Of course you fit in. You go to school with the other girls, you know all of them, they’re all good kids—” in Chinese.

“That doesn’t matter. I don’t look like them, I don’t act like them, we don’t do the same things. I don’t like it. I don’t fit in!” in English.

Silence.

“You don’t fit in,” my mother said in her thickly accented English. There were at least ten girls in the troop. I was the only person of color. Her face was no longer stern.

“Okay,” she said. It’s a word that is used in both English and Chinese.

That one time when my parents and I were walking through a parking garage. It was a hot day and a convertible with its top down approached us. The group of white guys in the car shouted “KONNICHIWA!!!” at us; we could hear them laughing as they roared past.

“WE’RE NOT JAPANESE!” I shouted back. I was ten years old. My parents shushed me.

That one time when I used my fingers to briefly transform the Asian monolids of my eyes into something that resembled double eyelids.

That one time became multiple times over the course of several months. One day, I didn’t have to manipulate my eyelids anymore: My double eyelids remained stable. My eyelids sort of (but only sort of) looked like the eyelids of the girls in Teen Magazine.

I was twelve years old.

We all have ways in which we don’t fit in, in which we’re different. We all have also learned how to take care of ourselves when others antagonize us for being different. We wouldn’t be who we are today—for better or for worse—if we didn’t have those unpleasant experiences.

No, it didn’t hurt when she said the slur. Other things have hurt much more.

Categories
Uncategorized

Content for Consumption.

My father, a man approaching 70 years of age, told me about his recent explorations in pop music. This included an extended analysis of Macklemore’s Can’t Hold Us and commentary about why youth in Taiwan like Justin Bieber. However, I currently lack the creativity to craft a pithy post about that.[1. What I lack in creativity I make up for in alliteration.]

Since I am having difficulties generating content, let me at least provide some other content for consumption:

Manifesto of a Doer. It is reminiscent of Ze Frank’s Invocation for Beginnings, though without the profanity and… artistry.

Life in a Tiny Apartment. This is a collection of posts about making the most of and staying organized in small living spaces. She and I do not share the same aesthetic, though I do like her principles.

You To Still Die One Day. Because death is the Great Equalizer, puts everything in perspective, and “you are still going to die one day and there is nothing you can do to prevent it.”

Marmot Sings Mozart’s Queen of the Night Aria. No matter what my mood may be, watching this marmot sing an aria makes me laugh out loud.[2. Biggie Smalls feat. Thomas the Tank Engine also makes me laugh, but it is not safe for work or children.]

Categories
Policy Systems

Guns, Mental Illness, and Background Checks.

To my knowledge, I’ve only had one “long-term” patient attempt suicide with a gun. [1. I have worked with other people who have tried to kill themselves with guns. They usually report that these attempts had occurred years ago. Other people told me that they owned guns, but had no desire to kill themselves in the time we worked together. Still others owned guns and were struggling with ideas of suicide. Thankfully, we were able to work through this together and these people chose life. Then there are people who own guns and want to kill themselves, but share neither detail with me. I don’t know who they are because I either (1) never meet them in the first place or (2) I never see them again.]

This Person Who Attempted Suicide with a Gun did not show up for an appointment one day. For reasons I could not explain, I had great concerns that This Person had attempted suicide. After leaving several phone messages, I got a phone call from This Person, who was in the hospital.

“I swallowed a bullet,” This Person said.

“What?”

“I don’t know how it happened, but I swallowed a bullet.”

When I later spoke to This Person’s hospital physician, I learned that This Person had not swallowed a bullet. A bullet had gone through This Person’s chest wall, through a lung, and out the back.

I told This Person what I had learned.

“It was my friend’s gun,” This Person said. “I went over when no one was at home.”

The New York Times has a short article about “Why People With Mental Illness Are Able to Obtain Guns“. [2. While the title of this article, “Why People With Mental Illness Are Able to Obtain Guns”, is simply an accurate description of the piece, I still feel annoyed with it. I think my reaction is due to the pairing of “mental illness” and “guns”. There is no reference that most deaths from guns are due to suicide. Where are the articles that pair guns with other conditions? “Why People With Substance Use Disorders Are Able to Obtain Guns”? “Why People With Incurable, Painful Diseases Are Able to Obtain Guns”? “Why People in Financial Ruin Are Able to Obtain Guns”?] One reason offered is “Their Mental Health Records Are Not Accessible”. The author, unfortunately, does not provide much elaboration on this, which alarmed me. Just what records would the FBI National Instant Criminal Background Check System have access to? If it is accurate that about one in five Americans will experience any mental illness in a year, how much private health information will the FBI have access to?

The government released a document, “Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule and the National Instant Criminal Background Check System (NICS)“, that clarifies some of this. The summary from the document notes:

Among the persons subject to the Federal mental health prohibitor established under the Gun Control Act of 1968 and implementing regulations issued by the Department of Justice (DOJ) are individuals who have been involuntarily committed to a mental institution; found incompetent to stand trial or not guilty by reason of insanity; or otherwise have been determined by a court, board, commission, or other lawful authority to be a danger to themselves or others or to lack the mental capacity to contract or manage their own affairs, as a result of marked subnormal intelligence or mental illness, incompetency, condition, or disease. (emphasis mine)

Thus, three populations of people will have their “mental health records” accessible to the FBI National Instant Criminal Background Check System:

  1. people who have been hospitalized against their wills for psychiatric reasons
  2. people who are deemed by a court to be incompetent to stand trial, or the court ruled that they are not guilty by reason of insanity
  3. people who are deemed by a lawful authority to be a danger to themselves or others, or are “gravely disabled” (unable to care for themselves)

The summary adds:

The disclosure is restricted to limited demographic and certain other information needed for NICS purposes. The rule specifically prohibits the disclosure of diagnostic or clinical information, from medical records or other sources, and any mental health information beyond the indication that the individual is subject to the Federal mental health prohibitor.

This offers partial relief, though I still have concerns:

  • What is the “limited demographic” information? Name? Age? Sex? Race?
  • What is the “certain other information”? Country of birth? Political party registration? Contacts with law enforcement in the past year? Religious affiliation?

This Person who “swallowed a bullet” was ultimately “involuntarily committed to a mental institution”. Under Washington State law, This Person lost the right to own a firearm because of the involuntary detention.

As such, I generally agree with the three populations described above in the “mental health prohibitor”. There is data that argues that people who own guns are more likely to complete suicide. There is also data that argues that people are more likely to complete suicide in the first few weeks after discharge from a psychiatric hospital. I would not want This Person to purchase a gun and attempt suicide again.

However, This Person used someone else’s gun in the suicide attempt. Neither Washington State law nor this new Federal rule has relevance.

I don’t know what the answer is.

Increasing the amount of data in background checks may help reduce suicides and homicides. The current implementation, however, may only increase stigma for people with mental health conditions. We want to increase the awareness and acceptance of mental health conditions. We don’t want to increase fear.

It does not appear that banning guns outright is possible. I am also not totally convinced that an outright firearm ban would result in less gun homicides due to some of the reasons listed here. Would a ban on guns decrease suicides? Maybe, as states with firearm registration and licensing regulations seem to have less suicides.

As I have noted elsewhere, a psychiatric diagnosis alone does not explain why people kill other people, whether with guns or other means. Yes, there are sociopaths who kill people, but they are extremely uncommon. Does the mental health of a society affect and shape the mental health of an individual? Does context matter?

If so, how can we as a society help change the context?