Consult-Liaison Observations

Status Game Strategy.

How do you introduce yourself when you greet people, particularly those you don’t know?

Yes, your answer might depend on who you’re meeting. But what’s your general approach?

I try to emanate warmth: I make eye contact and smile. I do what I think will make the person feel comfortable. I listen and try to speak less than the other person… unless it becomes clear that the other person wants to listen more and speak less, too.

This strategy has worked for me: It helps me form and maintain relationships. This approach has produced few, if any, negative consequences.

Some people use a different strategy when they interact with others: They assert their superiority. They say things like they have “one of the great memories of all time” and “I went to an Ivy League college… I’m a very intelligent person.”

The other way to assert superiority is to denigrate others, such as commenting that others are “weak”, “lightweight”, and “fake”.

This, of course, is a status game. Who has higher status? Who should have higher status? And if I should always have higher status, how can I make sure that everyone around me recognizes that?

Sometimes people use this status game strategy because it’s the only way they know how to interact with other people.

Maybe they learned long ago that the people in their life only paid attention to them when they said something that asserted their high status. People only took interest in them when they said things like, “I’m a very rich person.” The attention of others makes them feel worthy, seen, and valued. It’s nice to have a lot of money, but some people crave a wealth of attention.

Asserting high status, though, becomes a vicious, reinforcing cycle. After a while, people won’t care when they hear things like “I’m a very rich person”. They’ve heard that before and won’t react the way they once did. So it escalates: Soon, these individuals have the best memory, the highest IQ, and the best words.

Even though these statements are false—and verifiably false!—it doesn’t matter. Remember that outrage and indignation are still forms of attention. And some people are never satisfied with the amount of attention they receive.

This status game strategy works for some people: It helps them form and maintain relationships. For whatever reason, it has produced few, if any, negative consequences.

There are other ways, of course, to interact with people. However, it takes time and practice to do something different. Why change what you’re doing if it’s worked for you for so many years?

People who behave this way don’t need our pity. Pity doesn’t help anyone. One wonders, though, what happened to them in the past. Despite being over 70 years of age, they still don’t know how to interact with people without elevating themselves or putting others down.

Education Homelessness Medicine Nonfiction Policy Systems

People Get Better.

“What?!” he exclaimed. “Are you serious?”

“Yeah,” I replied, puzzled.

“That’s… amazing.”

“Yeah, it is.” I paused, finally realizing that he had never heard me talk about this before. “It actually happens a lot. People get better. People get better all the time.”

When I first met him, he screamed at me, his face red, spittle flying from his lips. He refused to believe I was a physician.

“Women can’t be doctors! They can’t!”

He did believe, though, that televisions could control his thoughts.

“They know what I think! When they start talking, they control what I think and what I say and what I do!”

He drew a swastika that covered the entire wall of his jail cell.

“Yes, I believe in white supremacy! But I’m not part of a group!”

He accepted medications on his own. First, the yelling stopped. Then, the swastika disappeared. Drawings of cute farm animals took its place. Within a few weeks, he greeted me with a smile.

“Hi, Dr. Yang. How are you doing today? I hope you’re well.”

He invited me to sit at the small table next to the kitchenette in his apartment.

“You want anything to drink?”

“No, thank you. How are you doing?”

“I’m okay. What do you know about the Mediterranean diet? I want to try that. I want to lose some of this weight.”

After discussing the merits of vegetables and lean proteins as they related to heart health, he leaned back in his chair. He then blurted, “It’s been six months since I smoked a cigarette.”

He never smiled when he shared his accomplishments. His condition prevented him from doing so. I smiled for him.

He resumed musing about dietary changes. I mused about how far he had come: Just 18 months ago he was living on the streets, often snarling at strangers and the voices that only he heard. He came to the attention of the police when he chased a young mother pushing her baby in a stroller. He threatened to beat them with the metal pipe in his hand. The police thankfully sent him to the hospital for care.

“Thanks for seeing me,” he said as he walked me to the door. The voices hadn’t completed disappeared, but he could ignore them now. “I like steak and potatoes, but I’ll try the leafy vegetables.”

He used both hands to smear his own feces on his arms, chest, and belly. He applied toothpaste to his elbows and his knees. I asked him why.

“because it’s protection it’s protection against all of you I shouldn’t be here I’m fine I’m not sick you don’t understand who I am they all know who I am you would be scared too if you knew who I am people know me from way back—”

He began howling at the door.

Within days of him receiving medications, all of that stopped. His jail cell was clean. He took showers. He never spoke of what happened. Neither did I.

I was taking a walk a few months later when I heard someone call, “Hey, Dr. Yang!”

I turned around and saw a group of men in uniform working. This man, suited up like his colleagues, waved at me and smiled.

I couldn’t help but smile—this is fanstastic!—but felt a twinge of embarrassment. Did he know that he had called me “doctor”? What would his coworkers think?

First do no harm. I waved back.

“Nice to see you, Doc,” he continued. “I’m doing good.”

“I’m glad to hear that. Take care of yourself.”

“I will, Doc. Thanks.”

People get better. The science hasn’t yet generated interventions that guarantee that everyone will get better. Furthermore, some people who could get better can’t access care due to barriers related to finances, policy, and other systemic factors.

Until then, we must share both stories and data (try this, this, and this) that people get better. It is amazing, but it shouldn’t be surprising.

Homelessness Lessons Nonfiction Observations Reflection

What Would It Be Like to Say Hello?

My first memory of encountering a person who appeared to have no place to live was during my first year of college at UCLA. A man was sitting outside a mini-mart, his legs crossed and his hair long. He looked tired and his clothes had stains on them. Feeling pity for him, I went into the mini-mart and purchased a turkey sandwich on wheat.

“Here,” I said as I handed him the sandwich. I beamed with Warm Fuzzies for Doing a Good Deed. “Take this.”

Because I expected him to thank me for My Act of Generosity, I was dumbfounded when he started yelling at me with contempt: “A sandwich? I don’t want that sandwich. I don’t like turkey and I have an allergy to gluten. If you really wanted to help me, you’d buy me a meal at an all-you-can-eat place. What am I going to do after I eat a sandwich? I’ll still be hungry. At least I can get another plate of food at an all-you-can-eat restaurant.”

“Okay,” I said, my cheeks burning with shame. He had a point: All hungry people prefer all-you-can-eat food to what now looked like a pathetic turkey sandwich. I took the rejected sandwich back to my dorm room.

My dining companion and I were seated at a long table that looked out a large window. Across the street was a man who we often saw in the downtown shopping district. He often carried a unrolled sleeping bag on his shoulder while talking and growling to himself. His clothes were soiled and too big for him. The soles of his shoes were falling apart. He didn’t have a beard, only uneven facial stubble. His eyes were light and his face was dark from smears, smudges, dirt, and dust.

“He doesn’t look well,” I said to my dining companion. The man was sitting on his rumpled sleeping bag on the sidewalk while engaged in an animated conversation… with no one. Sometimes he leaned back against the side of the building and puffed on a cigarette.

“I wonder when he last ate,” I wondered aloud.

“Why don’t you buy him something to eat?”

“Because he might not want that. Some people feel shame when people just give them food. They don’t like that other people think that they don’t have enough money to buy food for themselves. And I don’t even know what kind of food he wants. When we’re done eating, let’s go over there and ask him.”

As we approached him, his posture was relaxed and he was about halfway through his cigarette. His clumpy hair was falling into his eyes and everything he was wearing was soiled. He was engrossed in a conversation, occasionally making a point with his right hand.

“Excuse me?” I asked.

He continued talking.

“Excuse me?”

He stopped talking, turned his head, and looked at me. He remained still as the swirls of smoke from his cigarette defied gravity with ease.

“Hi. Do you want some food?”

Another tendril of smoke dissolved into the night before he answered: He shook his head no.

“Are you sure?”

He nodded yes.

I smiled and waved good-bye. I heard him resume his conversation as we walked away.

In retrospect, I should have introduced myself and asked him for his name. And I wonder if, next time, he will be hungry and accept an offer of food.

Sometimes we believe people are so different from us. How could there be anything similar between that guy talking to himself and sleeping on the street and me? What do I have in common with that guy wearing dirty clothes and carrying a sleeping bag around?

Well, we all share the wish to be treated with dignity. We want people to acknowledge us, our presence, our existence. We want people to see us as equals, not less than. We want people to show us respect, to see us as people who have worth.

Maybe you see someone in your daily commute who sleeps outside or doesn’t seem to have any money. Maybe it’s someone who sits against a wall with a sign asking for help.

What would it be like if you said hello that person? Or made eye contact with that person and smiled? What would it be like to acknowledge that person as a person? What’s gotten in the way of you doing that in the past? What is the worst thing that could happen if you tried that? What’s the likelihood that your worst fear in this situation would come true?

What would it be like if we said hello to everyone in our communities? Because aren’t these individuals who sleep outside and talk to themselves part of our communities?

Funding Homelessness Nonfiction NYC Policy Reflection Seattle Systems

God’s Work versus Meaningful Work versus Value.

Every now and then, when some people learn what kind of work I do, they say, “You’re doing God’s work. Thank you.”

They mean well, so I accept the compliment, though I also tack on, “I also like what I do. It’s meaningful work for me.”

So many of the people I see, whether in my current job or in my past jobs working in other underserved communities, have a lot going on that psychiatry and medicine cannot formally address. One example is housing. It is often an effective intervention for the distress of people who don’t have a place to live, though housing is not something physicians can prescribe. However, there are individuals who are eligible for housing, but do not want to move into housing for reasons that do not make sense to most people. For example, in New York I worked with a man who would spend his days sitting in front of the building where he once worked before he became ill. He talked to himself and burned through multiple packs of cigarettes. He did not recognize how soiled his clothes and skin became with time. At night he disappeared into the subway tunnels and rode the trains. He did not want to move into an apartment until he was able to get his job back, even though he hadn’t worked there in over ten years. With time (nearly two years!) and unrelenting attention, our team was able to persuade him to try living indoors. He eventually accepted the key and moved in.

There are other active conditions that I do not have the skills to treat: Sometimes it’s institutional racism; sometimes it’s multiple generations of poverty. Both prevent people from accessing education, housing, and other resources. Do some of these individuals end up taking psychotropic medications due to the consequences of these systemic conditions? Yes. Do I think they’re always indicated? No.

Most of my jobs have been unconventional: I worked on an Assertive Community Treatment team that often provided intensive psychiatric services in people’s homes. I worked with a homeless outreach team and did most of my clinical work in alleys, under bridges, and in public parks. I worked in a geriatric adult home and saw people either in my office, which was literally the storage room for the recreational therapist’s stuff, or in their apartments if they were uncomfortable seeing me in the storage room. I was recruited to create and lead the programming for a new crisis center whose goal was to divert people from jails and emergency departments.

And now I work in a jail.

As time progresses, it has become clear to me that I have not had the typical career for a psychiatrist. I like that. However, I often also feel out of touch with my colleagues. I believe that they are all trying their best, but they don’t have the time to see how systems end up failing the most vulnerable and ill in our communities. They work in the ivory towers of academia and don’t seem to realize the dearth of resources—financial, administrative, academic—in the community. They work in private practice and don’t seem to realize how ill some people are and how we need their expertise. They work in psychiatric hospitals and seem to believe that some of these individuals will never get better when, in fact, they do.

Because much of my work has been outside of the traditional system, I consider myself fortunate that I have been able to escape the box of simply prescribing medications. Many of the individuals under my care do not want to take medications. Their desire to not take medications, though, doesn’t stop us from working with them. We meet them where they are at and remember that they are, first, people. As we are in the profession of helping people shift their thoughts, emotions, and behaviors, we believe that there will come a time—maybe soon, but maybe not for weeks, months, or years—that something will change. Just getting someone to talk to us becomes the essential task. This is true whether someone is in a jail cell, living in a cardboard box under a bridge, or residing in a studio apartment.

Should systems pay psychiatrists to do this work? Maybe it’s not “cost effective” because of its “low return on investment”. After all, this task of “building rapport” means psychiatrists aren’t working “at the top of their licenses”. If a psychiatrist is able to get people to talk to her and help them shift their behaviors, whether or not that involves medications, does that have value?

Does the psychiatrist’s efforts have value if it helps the “system” save money?

Is there value if it reduces the suffering of these individuals who have had to deal with police officers, jails, and living on the streets due to a psychiatric condition?

Perhaps my idealism blinds me. One of my early mentors in New York City often said, “I want the guy who lives under the Manhattan Bridge to have a psychiatrist who is as good as, if not better than, the psychiatrist who has a private practice on Fifth Avenue.” I couldn’t agree more.

Observations Policy Reflection Systems

Pondering the Purpose of Policies.

What’s your policy on wearing pants?

We all have a personal policy about pants. My policy is that I shall wear pants on all days unless (a) I am attending a special event where a dress or skirt is indicated or (b) it is a hot day and I must wear something professional, so a dress or skirt is the cooler option.

Hang in there with me. This isn’t actually about pants.

I’ve been chewing on the purpose of policies. Much of my work life is dedicated to the creation and amending of policies for a system.

It makes me feel disappointed to see that policies often cater to the lowest common denominator. They seem to solely focus on preventing undesired behaviors and outcomes. It’s almost as if policies are written for those people or organizations, whether they exist or not, with the worst intentions.

Policies aren’t inspiring. They don’t talk about what could be or what we should strive for. This might be why we find policies tedious to read.

A colleague pointed out that, yes, policies are for the lowest common denominator because people often have the worst intentions.

“Think about the Ten Commandments,” she said. “Like ‘Thou shalt not kill’ and ‘Thou shalt not steal’ and ‘Thou shalt not commit adultery’. Those are really basic things, but we need them. Those are policies to help us get along.”

Indeed, those religious prohibitions are not inspiring. What if we rephrased them? What if we said “Thou shalt honor life” instead of “Thou shalt not kill”? Doesn’t the idea of honoring life inspire more creativity and joy than a fearful instruction to not kill?

I think my colleague would reply that people need explicit directions. A exhortation to honor life does not guarantee that people will stop killing.

In his book Practical Wisdom, Barry Schwartz laments how policies can affect our abilities to do the right thing the right way. If we rely on policies, we ignore the nuances of the situation and stop thinking. When we stop thinking, we lose our wisdom. We end up looking to policies to prevent the worst thing from happening. The prevention of the worst thing, however, does not equal the creation of something better.

Call me naive—you won’t be the first—but I believe that, for most people, they meet the expectations you have of them. If you have high expectations, people will often meet them. (To be clear, there is a balance: Most expectations must be realistic. If they aren’t, people become demoralized.) It’s meaningful to people when they realize that someone believes in them when they may not believe in themselves. High expectations are frequently a form of respect.

(Perhaps I am straying. A significant difference between individual expectations and policies is the relationship. Relationships between people rely on invisible things like trust, hope, and respect. Relationships between organizations rely on visible things like contracts, memoranda, and policies. We often don’t feel like we have total control over what we do as individuals. How can an organization, comprised of potentially hundreds of people, control its behaviors to meet the expectations of another organization without those invisible connections?)

Someone on Twitter recently commented that policies should reflect the morals of the organization. I like that. If policies focus on documentation requirements and payment arrangements, but say nothing about the quality of services, what does that say about the organization? Does a mission statement have any meaning if the policies and procedures do not align with the stated mission? If the policies only comment on how to prevent the worst thing from happening, why would anyone expect extraordinary quality from the organization?

Perhaps I need to reframe, for myself, the purpose of policies. Policies help prevent bad things from happening. That’s good. Prevention is underappreciated: It’s difficult to measure things that didn’t happen. The difficulty in showing that less bad things happened, however, doesn’t mean that the activity of prevention is worthless.

It’s not an “either/or” issue. Policies prevent bad things from happening, which is valuable. But, as I noted above, preventing bad things and creating better things are two different activities. We don’t want to focus our energy on just preventing bad things from occurring. We must also create new things, or we otherwise will not progress.

The primary reason for my personal pants policy is comfort, though there are professional implications, too. Much of my work in the past involved talking to people in atypical places: Sometimes I’d have to step over puddles of mud to talk to the man living in the park; sometimes I’d have to slip between towers of yellowed magazines to reach the elderly woman seated on her bed. These days, wearing pants makes it less likely that male inmates will make unwelcome comments about my legs. Pants prevent bad things from happening to me.

My other clothing policy is to wear bright colors or patterns to work. People—colleagues, patients, strangers—often comment on the shirts I wear, frequently while smiling. That helps build rapport and connections, even if they are initially based on something as superficial as polka dots on a shirt. These relationships, though, often help create better things and situations for us all.