Month: January 2019

Answers Unknown.

Post author By Maria Yang, MD
Post date January 27, 2019

The chief complaint was belly pain. He described the pain as both dull and crampy. It came and went, but bothered him the most on the same night of each week.

The notes from the primary care doctor show a thoughtful search for the underlying cause. There were comments about activity logs, blood tests, and imaging studies. Months later, it remained a mystery: He still had belly pain. The investigations did not reveal any physical causes for the aches in his abdomen.

When I asked him if he had pain anywhere now in his body, he looked at me, blinked, and then looked away. He remained mute.

The first note in the medical record was a standard template for vaccinations related to overseas travel. This international adventure would be a distant memory by the time the discomfort in his gut brought him back to the clinic.

His trip to the distant land was unhampered by children. Over ten years would pass before they were born.

I didn’t ask him about his family. I knew that they now had restraining orders against him.

The next entries in the medical record describe a different person: He no longer had concerns about belly pain. The primary care doctor in the public health clinic wrote sympathetic notes about his skin infections and paranoia. The social history noted that he was no longer in contact with his family, but did not offer any reasons why.

Physicians and nurses are trained to ask questions that are inappropriate in social settings (e.g., “Have you been passing gas?” “When was your last period?”). There are also questions that we never think to ask: We don’t believe the people under our care would ever do something so inappropriate.

Did he develop belly pain because he literally could not stomach what he was doing to his children?

Maybe I only imagined that he nodded when I asked him about spiritual distress.

Could spiritual distress look like schizophrenia?

Could guilt and shame look like schizophrenia?

Could efforts to mimic schizophrenia look like actual schizophrenia?

Could a desire for a reduced punishment look like schizophrenia?

I gave him pencil and paper. “If you’d prefer to communicate through writing instead of speech, that’s okay. I’d like to know how I may best help you.”

His fingers grasped the pencil and paper for a few minutes. He looked at the floor. He then returned the pencil and paper to me before walking away.

What Makes America Great.

Post author By Maria Yang, MD
Post date January 20, 2019

After a long gaze at the different fonts and bright colors, my father, a Chinese man in his 70s, concluded in English, “The menu is different.”

“Yes, it’s new. Today is the first day,” replied the clerk, a Latina woman in her 40s. Standing next to her was a young Latina woman, perhaps not yet 20 years old.

“It used to be K5,” my father murmured in Chinese.

“Do you want what you usually get?” I responded in Chinese.

Though my father has an excellent grasp of English, the new orientation and colors of the fluorescent menu perplexed him.

“Yes….”

“Chicken legs, right? You want K1.”

My dad found K1, too, and nodded with approval. He directed his attention to the cashier.

“Can I please have K1?” he asked.

The older woman nudged the younger woman to show her how to enter this order. “Ask if he wants original or extra crispy,” she advised in English.

“Original or extra crispy?” the young lady parroted.

“Original,” my dad said. The older woman then began to give instructions to the young woman in Spanish.

“It’s her first day here,” the older woman offered. The young woman smiled sheepishly; we all smiled back at her. No big deal.

And so it went: Spanish behind the counter, Chinese in front of the counter, with English connecting the two sides, and people helping people in all directions.

This is what makes America great.

Policy Reading Systems

About that APA Statement on “Toxic Masculinity”…

Post author By Maria Yang, MD
Post date January 13, 2019

Several people asked me about the American Psychological Association’s (APA) statement about “toxic masculinity”. You can find the statement, which is actually a practice guideline, here.

I read the entire guideline. My reactions and opinions follow:

1. The title of the practice guideline is not “Toxic Masculinity”. The title is “APA Guidelines
for Psychological Practice with Boys and Men”. The word “toxic”, let alone the phrase “toxic masculinity”, does not appear anywhere in the document.

2. This APA practice guideline, like other clinical practice guideline, is a “statement[s] that suggest or recommend specific professional behavior, endeavor, or conduct for psychologists”. Psychologists are the intended audience. On page one of the document, it states:

These guidelines serve to (a) improve service delivery among populations, (b) stimulate public policy initiatives, and (c) provide professional guidance based on advances in the field. Accordingly, the present document offers guidelines for psychological practice with boys and men.

3. The introduction to the document includes a section of definitions. Language is how we communicate with each other, but, wow, can words get in the way. I suspect some readers had strong reactions to the definitions (and, perhaps, to the legitimacy of some of the words defined). And if those readers do not agree with the definitions (or question the validity of the words themselves), then the rest of the document will seem like a pile of poo.

My guess is that the phrase “traditional masculinity ideology”, tucked into the “masculine ideology” section, and the accompanying definition made some people clutch their pearls. I myself did not react one way or another to the phrase “traditional masculinity ideology”, which the APA defines as

anti-femininity, achievement, eschewal of the appearance of weakness, and adventure, risk, and violence.

This phrase has apparently been in use since 2007. This definition gets more attention later in the document, which may have caused the strands holding the pearls to rip, thus sending hundreds of pearls clattering to the floor.

So many words. So many opportunities to develop heartburn over words.

4. The practice guideline includes ten specific guidelines. Here they are:

Psychologists…

strive to recognize that masculinities are constructed based on social, cultural, and contextual norms.
strive to recognize that boys and men integrate multiple aspects to their social identities across the lifespan.
understand the impact of power, privilege, and sexism on the development of boys and men and on their relationships with others.
strive to develop a comprehensive understanding of the factors that influence the interpersonal relationships of boys and men.
strive to encourage positive father involvement and healthy family relationships.
strive to support educational efforts that are responsive to the needs of boys and men.
strive to reduce the high rates of problems boys and men face and act out in their lives such as aggression, violence, substance abuse, and suicide.
strive to help boys and men engage in health-related behaviors.
strive to build and promote gender-sensitive psychological services.
understand and strive to change institutional, cultural, and systemic problems that affect boys and men through advocacy, prevention, and education.

Lots of striving happening here.

While I can understand why some people might hurl spittle at their electronic screens at a few of these guidelines, most of them are reasonable and want to improve the well-being of boys and men. Don’t we want boys and men to successfully integrate various aspects of their identities? Who objects to helping men become better fathers? Why would anyone get upset about reducing the problems that boys and men are more likely to encounter in both behaviors and health?

4. I took the most notes for the first three guidelines:

Guideline 1: Psychologists strive to recognize that masculinities are constructed based on social, cultural, and contextual norms.

And this is where the pearls spilled all over the floor.

Recall that the APA’s definition of “traditional masculinity ideology” refers to “anti-femininity, achievement, eschewal of the appearance of weakness, and adventure, risk, and violence”. In this section, APA asserts that this ideology “can be viewed as the dominant… form of masculinity” that “strongly influences what” people in a culture assume is normal.

APA goes on to assert that this “dominant masculinity” has historically excluded men “who were not White, heterosexual, cisgender, able-bodied, and privileged”.

So many words in there that induce emotional reactions, right?

I argue, however, that this definition is fair. Let’s go through a thought experiment together:

In the United States, the image of a cowboy easily comes to mind upon hearing the word “masculine”. Picture a cowboy in your mind’s eye, if you will:

What color is his skin? Does he look like this or this?
When he is riding off into the sunset, who does he want to make sweet love to? Why was Brokeback Mountain so scandalous?
Did you even consider that your cowboy could be a trans man?
Does your cowboy wear glasses? hearing aids? a prosthetic limb?
And does your cowboy push the saloon doors open with bravado? Or does he brush off all the dust from his face and clothes, ensure that he has proper identification on him, and knock on the wall of the saloon?

APA never states that this definition of “dominant masculinity” is “toxic”. Instead, APA asserts that the “ideal, dominant masculinity is generally unattainable for most men”. As a consequence, men “who depart from this narrow masculine conception by any dimension of diversity… may find themselves negotiating between adopting dominant ideals that exclude them or being stereotyped or marginalized”.

Because it’s too hard to reach that ideal, “men not meeting dominant expectations often create their own communities”.

APA then recommends that psychologists work with individuals in their care to “become aware of how masculinity is defined in the context of their life circumstances”. More importantly, APA advises that “psychologists strive to understand their own assumptions of, and countertransference reactions toward, boys, men, and masculinity”. Because if I think Mr. Doe should be like a cowboy and refrain from crying after the death of his child, Mr. Doe is going to pick up on that, even if he wants to weep. And, thus, I’m a jerk and I’m not helping him.

Guideline 2: Psychologists strive to recognize that boys and men integrate multiple aspects to their social identities across the lifespan.

This guideline delves more into the intersection of things like race, age, sexual orientation, etc. and being a boy or man. And these intersections aren’t limited to these “social justice warrior” flavors: A man who has served in the military has a social identity that many others lack. Military service is its own culture and affects how men interpret and define masculinity.

As such, APA recommends that psychologists “working with boys and men strive to become educated about the history and cultural practices of diverse identities” and

[w]hile attempting to understand, respect, and affirm how masculinity is defined in different cultures, psychologists also try to avoid within-group stereotyping of individuals by helping them to distinguish what they believe to be desirable and undesirable masculine traits and to understand the reasons upon which they base these beliefs”.

This recommendation is easiest to understand through a lens of race or ethnicity (e.g., a black man or a refugee from Somalia), though has other applications.

Guideline 3: Psychologists understand the impact of power, privilege, and sexism on the development of boys and men and on their relationships with others.

More words that have the power to launch spittle across the screen.

My overall read of this guideline suggests that the ostensible privilege that boys and men have can also trap them. If boys and men are trying to fit into a masculine ideal that is unattainable, and that masculine ideal includes behaving in ways that are intended to restrict resources and power from others, that pursuit impairs their abilities to have effective and meaningful relationships with human beings. This leads to suffering for all involved. This ties into Guideline 4:

Psychologists strive to develop a comprehensive understanding of the factors that influence the interpersonal relationships of boys and men.

The recommendation is that psychologists

can discuss with boys and men the messages they have received about withholding affection from other males to help them understand how components of traditional masculinity such as emotional stoicism, homophobia, not showing vulnerability, self-reliance, and competitiveness might deter them from forming close relationships with male peers.

For me, the punchline of the practice guideline is actually tucked in the section that defines “masculine ideology”. The last sentence in that section is:

acknowledging the plurality of and social constructionist perspective of masculinity, the term masculinities is being used with increasing frequency. (emphasis mine)

If there are multiple definitions of “masculinity”, and knowing that those definitions can change over time, even within the same person, then we can use those changing definitions to help improve the psychological and physical health of boys and men.

Do I think the moral fiber of our nation will disintegrate if a boy or man chooses to wear nail polish? No.

Do I want boys and men to stop trying to achieve things? No.

Do I want them to avoid risks and adventure? No. (Do I want them to avoid stupid risks and pursue noble adventures to make great achievements? Yes.)

Do I want boys and men to engage in less violence? Yes, because I want everyone to engage in less violence. I value cooperation over conflict… and that’s the only way we’re going to survive as a species.

Do I think men should feel comfortable crying in public when they feel heartbroken? Given what some (many?) of them have experienced, yes. I want them to know we don’t think less of them when they need help… because we all do.

The “anti-femininity, achievement, eschewal of the appearance of weakness, and adventure, risk, and violence” of “traditional masculine ideology” is not “toxic” or evil. There were assumptions behind that definition and it’s outstanding that we can now challenge those assumptions. It means that we’re growing and learning, and don’t we want people and societies to change for the better as time passes?

Education Nonfiction Reading

Books I Read in 2018.

Post author By Maria Yang, MD
Post date January 5, 2019

I know this post is late (i.e., “These are the things I did in 2018” posts usually appear in December), but perhaps some of the books I read in 2018 will make it onto your reading list for 2019.

Radical Dharma: Talking Race, Love, and Liberation. I didn’t know what to expect when I picked up this book. Because the authors are people of color, they bring a different perspective to Buddhist thought and practice. In some ways, this was a refreshing change from much of published the Buddhist literature (i.e., written by white authors, or written by Asian authors who seem to have a white audience in mind). The authors also share personal anecdotes about their journey in Buddhism that may resonate with readers of color.

The Nonviolence Handbook: A Guide for Practical Action. This was the most compelling book I read in 2018. This slim book offers both concrete suggestions about how to practice nonviolence in daily living and how individuals (often Gandhi) applied nonviolence principles in history. I found this book inspiring, challenging, and meaningful. It also reminded me that I should not take cooperation for granted.

On Tyranny: Twenty Lessons from the Twentieth Century. This book is definitely a “handbook”: It is small and to the point. The table of contents alone provide useful guidance on what we all can do every single day to support our democratic society. I appreciated that the book does not rely on fear alone; it empowers the reader to take action in the face of uncertainty.

Dreams from My Father: A Story of Race and Inheritance. This book pairs well with the next book (Hillbilly Elegy). Obama’s writing reveals a thoughtful and idealistic perspective. He wrote this years before he served as President and I found myself recognizing elements of his character as President in this book. It is a story of a man trying to learn about himself and his beliefs in a world that passes judgment on him because of his heritage and skin color. It also highlights the importance of his relationship with his mother.

Hillbilly Elegy: A Memoir of a Family and Culture in Crisis. I read this after Dreams from My Father and, in many ways, I felt like I was reading the same tale with different details. Vance also tells the story of his efforts to learn about himself and his beliefs in a world that passes judgment on him because of where he was born and raised. Vance, too, highlights the importance of his relationship with his grandmother. Because Vance and Obama have different political ideologies, these two books show how, despite our beliefs, we share more in common than we allow ourselves to believe.

Silence: The Mystery of Wholeness. I picked up this book with hopes of learning more about how to find or create silence in a world that seems full of sonic garbage. This was the most “woo woo” book I read all year. I often wrote question marks in the margins. I intend to re-read this book at some point; I may always find it esoteric. I found the ideas of different silences (e.g., the silence within our hearts versus the “big” silence of the universe; how silence is always with us) useful for my own application.

The Girl on the Train. I rarely read fiction, so this was a treat. I picked this up on a public bookshelf for airplane reading. The story was engrossing, though I couldn’t help but think about the lack of coping skills the characters demonstrated. I also discerned the identity of the villain early on, so the “twist” not surprise me. The book nonetheless makes for fine brain candy.

Falling Leaves: The Memoir of an Unwanted Chinese Daughter. This book was also a selection for airplane reading. The intercultural issues of the memoir are familiar to me and the storytelling is satisfactory. This memoir seemed to lack the depth of self-reflection as seen in the Obama and Vance memoirs. I wanted to learn more about how she grew and understood herself as an individual as a result of her experiences with her stepmother.

Silence: The Power of Quiet in a World Full of Noise. This was yet another effort to apply more silence in my life. This text is similar to other works by Thich Nhat Hanh, though does comment more on cultivating silence within (which, in some ways, paired nicely with the Sardello book above on silence). Did I learn anything new? No. Did it nonetheless bring me comfort? Yes. This book was another reminder to me that we often have to generate our own silence, particularly when there is a lot of noise “outside” that we cannot control.

Trauma Stewardship: An Everyday Guide to Caring for Self While Caring for Others. I read this in anticipation of a talk from the author, Laura van Dernoot Lipsky. Many of the examples in her book come from her previous clinical work in Seattle, so the book felt particularly familiar. The book offers validation to all of us who work in clinical settings. I was hoping for more commentary on how we can adjust or shift systems to better support people who work in human services; the book focuses chiefly on what the individual can do. I also hoped that the book would offer a more evidence-based framework for these individual interventions, though also appreciate that there are spiritual aspects of trauma work that are difficult to measure. Laura is a compelling and energetic speaker. You can watch her TED talk.

Extreme Government Makeover: Increasing Our Capacity to Do More Good. I received this book from a colleague, who received it from the author for free! (My colleague and I both work in local government and when she asked him if he could provide the books at a discount for the staff, he sent a stack of books to us at no charge.) The major premise of the book is the reduction of waste: Reducing the amount of time between tasks (much of which is waiting, with no action happening); eliminating bottlenecks (e.g., where only one person is the “decider”); and minimizing processes that only serve to prevent lawsuits. I suspect that selection bias is at play, though: The people who choose to read this book are probably already aware of how to make things more efficient.

Here are all the books I started in 2018, but did not finish:

A People’s History of the United States. I’m actually over halfway through this book. I found myself getting angry while reading it, though, given the current context of the federal administration in the United States. Some of the events described in the book were similar to the ideas coming out of the current White House. I like reading and don’t need to experience more anger than necessary. I do want to finish this book, just not now.

The Making of Asian America: A History. I found myself getting angry while reading this one, too, so I put this one down. I like that the author discusses the experiences and events of different Asian groups, as, indeed, Asians are not all the same. I will get back to this one, too.

The Art of Memoir. I want to write a book, and that book is a memoir. Writing is already difficult, but the writing for this memoir presents particular challenges. I hope to learn from the mistakes and experiences of others. However, reading about memoir writing takes time away from actual memoir writing. Sometimes we fool ourselves into thinking we need to learn from others when, in fact, we just need to do the work.

The Gifts of Imperfection: Let Go of Who You Think You’re Supposed to Be and Embrace Who You Are. I had never read a book by Brene Brown, though I enjoyed listening to Krista Tippett interview her on the podcast On Being. The book is like a personal cheerleader, which is fine, though that’s not what I needed or wanted.

Good Prose: The Art of Nonfiction. I enjoy reading good sentences. I continue to strive to craft clear, meaningful sentences because I want to write stellar stories. As I noted above, though, sometimes we just need to do the work.

Chinese Culture and Mental Health. While Western psychiatry is getting better at acknowledging the role of culture in the manifestation of thoughts, emotions, and behaviors, it still ain’t great. This book is an academic textbook, so while it is informative, it isn’t the most exciting reading. I will finish this one, too, though it may take a while.

How to Measure Anything: Finding the Value of Intangibles in Business. I picked this up primarily to help me think about my clinical and administrative work in a different way. I have already learned interesting perspectives about measuring seemingly immeasurable things in the first quarter of the book. This book requires a level of concentration that I often did not have by the end of the day. This is a book I want to finish, but it will take time.

If you want to share with me what books have changed your life for the better or made you think about the world in a different way, let me know (e-mail, Twitter, Facebook).