Policy Reflection Systems

Belonging in Psychiatry.

I recently finished reading The Art of Community: Seven Principles for Belonging by Charles Vogl. He starts the book with this definition of “community”:

a group of individuals who share a mutual concern for one another’s welfare.

He continues:

[A community] is distinct from a group whose members may share ideas, interests, proximity, or any number of things but lack concern for one another.

He argues that communities (as he defines it) have “shared values”, “membership identity”, “moral proscriptions”, and “insider understanding”.

The American Psychiatric Association (APA) held its annual meeting this past week in San Francisco. I did not attend.

I have never been a member of the APA. There was a time when I took some oppositional pride in this, though I was aware of how this attitude is problematic: I cannot help change an organization if I do not join it.

Why do I resist the APA, even though it is the organization that represents the work I do?

This excellent post over at Slate Star Codex captures many of my reasons: All of the pharmaceuticals! The overt and covert intersections with politics (which can lead to overmedicalization of life and underrecognition of psychiatry as an agent of social control)! And while I know that there are members of APA who care about people, families, and communities that experience severe psychiatric symptoms (e.g., schizophrenia, bipolar I disorder, co-occurring mental health and substance use disorders), I’ve never gotten the impression that these are priority populations for the APA.

If we use Vogl’s definition, the APA, to me, doesn’t feel like “a group of individuals who share a mutual concern for one another’s welfare”.

Maybe professional organizations aren’t intended to be spaces where people have mutual concern for the welfare of others.

In the past I wondered if my lack of affinity for APA had to do with how different my clinical practice is compared to other psychiatrists. There are other psychiatrists who work with people living on the streets and do housecalls for people who live at or near the poverty line… but we are few and far between. I live in the largest county in Washington State. There are hundreds of psychiatarists here. Yet I know of only two other psychiatrists who share my work experiences!

Consider emergency physicians. They all work in generally the same setting and thus have similar clinical practices. I don’t know the membership of their professional organization (American College of Emergency Physicians), though it at least seems that their specialty organization is more cohesive and united. Because their clinical practice is more uniform, perhaps it is easier to have mutual concern for the welfare of their fellow physicians.

Meanwhile, how much does my work have in common with the private practice psychiatrist who provides psychoanalysis? I’m just trying to get the guy who lives outside due to relentless paranoia to look at me long enough so I can say hello in a manner that won’t scare him off.

A few years ago a local psychiatric association contacted me. They anticipated an upcoming vacancy in a committee involved in government relations.

During the phone call, I learned that most of the members were psychiatrists in private practice. The leadership expressed a desire for the association to get more involved in government affairs (e.g., local and state legislation). Because of my role in local government, they highlighted the value I could contribute to the association.

“You’ll have a lot of influence,” they said several times.

They also commented that they were trying to increase the diversity in their organization. In addition to the “influence” I could bring, I could also bring my non-white, non-male self.

By the end of the phone call, I said that I wanted time to think about it. What I actually thought about was the responsibilities I had to myself versus those I would have to the organization. I cannot help change an organization if I do not join it. Could I bring issues related to underserved communities to the association? Would the membership find these issues compelling? Would they have interest in legislation that did not focus on their own patient populations?

A few weeks later, I told them that I wouldn’t join. This decision stemmed chiefly from the substance of the work. However, it was also a reaction to their recruitment methods: They thought I would respond favorably to an appeal to my vanity. “You’ll have so much influence!!!” Perhaps the corollary to that was that my influence would help get stuff done, but the emphasis was on the vast amounts of influence I could wield over the group. That didn’t interest me.

And while I did appreciate the blunt commentary about how my participation would help increase the diversity of the association, it made me tired just thinking about it. Increasing diversity doesn’t just mean increasing the amount of color in a photograph. There’s a lot of work in introducing and maintaining various perspectives in a group. I didn’t want to be the only person responsible for that simply because of my non-white, non-male status.

The association certainly had concern for its own welfare. I wasn’t convinced that the association members had concern for mine.

To be clear, this doesn’t mean I’m great.

At least once a week I wonder if I would be more effective in my medical director role if I were involved in more associations and groups. What if I could bring the “forces” of the local medical society and psychiatric association to my job? What if I could use my status as a medical director in government to influence the priorities of these organizations? Would my “success” in each sphere be greater?

What responsibilities am I shirking? I believe one function of government is to convene people so we can figure out how to collaborate with each other. How many opportunities am I missing to improve the community because I am not participating in these other organizations? If I really care that much about underserved populations, don’t I have some responsibility to persuade these organizations to support initiatives that will serve the the underserved? Isn’t there more strength in numbers?

What would it be like if I shared and coordinated ideas, plans, and concerns with these big organizations with large audiences instead of here on my blog?

This has been true from the very beginning: I am a reluctant psychiatrist. I was never supposed to become a psychiatrist.

But, for reasons known and unknown, people experiencing psychotic symptoms feel comfortable talking to me.

So, here I am, working as a psychiatrist.

And, perhaps because of my affinity for complex problems, this is also why I am more comfortable working at the boundaries of fields. Yes, it is possible that the APA will create and disseminate the cure schizophrenia.

I doubt it.

I don’t think a pharmaceutical product will cure schizophrenia. But, at the intersection of nutrition science and psychiatry we can maximize the likelihood that pregnant women will have access to foods that will decrease the risk of their babies developing schizophrenia. At the intersection of legal systems and psychiatry we can reduce (if not eradicate) the use of solitary confinement so that jails and prisons do not worsen psychiatric symptoms. At the intersection of education and psychiatry we can teach kids and their parents skills to better cope with the adversity that life throws at all of us.

I will continue to struggle with joining APA and other organizations. But I already know that I’m not alone. Those of us—and not just psychiatrists—who care about the welfare of people with severe psychiatric symptoms are already part of a community. Sometimes we’re just harder to find.

Medicine Systems


I worked with someone (not a physician, but that doesn’t really matter here) whose title was “assistant director”. He and I quickly recognized that we worked well together: His head brimmed with big visions and ideas, whereas my head brimmed with plans as to how to make those ideas manifest in the actual world.

“He’s like a bunch of balloons,” I quipped to a colleague. “He’s got a ton of ideas—shiny, bright balloons—but he needs someone to hold all the ribbons to keep them from floating away.”

“Do you think medical school trains us to become managers or leaders?” my colleague asked. Someone several rungs up on the organizational chart had convened a supervisor training; one of the major points of discussion surrounded the differences between “managers” and “leaders”. One suggested generated a lot of wondrous “ooooh”ing: Managers ensure that the ship is running properly; leaders ensure that the ship is going the right direction.

“Managers,” I responded. “Particularly once you get to internship.” Interns are learning on the job how to diagnose and treat medical problems in actual human beings with all the complicating factors of life: Pregnancy, poverty, rare diseases, under- or over-involved family members, a health care system that can prioritize profits over patients.

“Really? I think medicine teaches us to become leaders. By the time we are attendings, we have to hold the entire context of a specific person in mind while ensuring that junior staff learn skills—the technical stuff in addition to the bedside manner stuff—that do not result in harm to patients.”

“Yeah, I agree with that,” I said after a pause. Only upon further reflection I was able to articulate that physicians are often “stuck” as managers because we are often too busy doing clinical work to exert influence and demonstrate leadership on the systems in which we work.

Sometimes it is the system that gets in the way of us doing all the things we want and should do.

Though I am more likely to be the person holding the balloons than the actual balloons, Big Thoughts still trickle through my mind:

  • What if the public mental health and substance use disorder systems worked from the assumption that people will get better and no longer need services? What if we built a system where people didn’t get stuck in it?
  • What if the ratio of “case management” to “treatment” was flipped in the public mental health and substance use disorder systems? What if people received effective treatment sooner? Would people then need as much “case management”?[1. To be clear, case management is important. The public systems are complicated and confusing. Case managers can help people navigate their way through and hopefully out.]
  • What if various skills—emotion regulation, distress tolerance, effective communication, relating to others, self-reflection—were automatically included in prenatal care and continued post-partum?
  • What if various skills—emotion regulation, distress tolerance, effective communication, relating to others, self-reflection—were included in school curricula for every grade?
  • What if designated leaders and managers of clinics, hospitals, and other health care entities included more clinicians (of all stripes) and people who receive services there? What if it were routine for health care entities and regulators—particularly Medicaid and Medicare—to solicit and implement ideas from clinicians and people who receive services?

I agree that systems—whether formal or not—need both managers and leaders. I also agree that the most effective managers and leaders do not rely upon their hierarchical positions to promote change and improvement; they instead cultivate and nurture interdependent relationships throughout the system. After all, in health care, our primary goal is (or at least should be) to help others.

Consult-Liaison Education

Most People Do Okay Most of the Time.

Because May is Mental Health Month, I was asked to present information about mental health to a lay audience. This is both an exciting and daunting task. I imagine it’s like asking someone to talk about fish. There are so many kinds of fish! They live in many habitats! Some of them look more like snakes than fish! There are so many directions to go.

I have given a “psychiatry 101” talk to many non-clinical audiences in the past. While reviewing my notes, it became clear that, while this presentation offers useful introduction, the underlying message is that psychiatry focuses on pathology. (This is a common theme in medicine: Doctors are often much better at looking for and finding things that are wrong than at pointing out and supporting things that are going well.)

So, here are three things about psychiatry that don’t focus on pathology:

People are resilient. I remain amazed with the capacity people have to take care of themselves and others when everything is falling apart.

Even though the majority of people experience terrible trauma—war, rapes, natural and unnatural disasters, etc.—most of them will not develop post-traumatic stress disorder. Most people at some point will experience heartbreaking grief following the death of a loved one, but the vast majority will not develop major depression or complicated grief.

People go to work, take care of children, and support their friends despite hearing disturbing voices, thinking about suicide, and feeling unsafe in public. They find ways to help themselves that have nothing to do with formal psychiatric interventions: The man hearing disturbing voices might put on headphones and play the same song over and over again. The woman thinking about suicide might sign up for an extra volunteer shift at the animal shelter so she is around other people. The military veteran might sit in the rear corner of the movie theatre.

Most people do okay most of the time.

It’s okay to not feel good. The goal of feeling happy or serene all the time is an impossible goal. Everyone at some point thinks disturbing thoughts. Just because it seems like everyone else is happy or serene doesn’t actually mean that they are happy or serene.

While our thoughts and emotions may seem illogical at times (“why am I thinking about that?” “why do I feel this way right now?”), that doesn’t mean that something is wrong. Sometimes your thoughts and emotions are treasure troves of information: Your internal experiences give you information about the person you’re talking to, the situation you’re in, and what your next steps should be.

The definitions of psychiatric disorders are not solely limited to “not feeling good” or disliking an emotional experience. Sometimes we don’t feel good. Sometimes that lasts longer than we want. But that doesn’t mean you have a terminal emotional illness.

Most people do okay most of the time.

Behaviors serve a purpose. We all do things that other people think are weird. The spectrum of weirdness is wide, but, if we are lucky to learn more, we can find out the basis behind the behavior.

Why doesn’t she speak up more? Because she believes that no one will find her remarks helpful.

Why won’t he wear anything other than sweatpants? Because he wants to spend his money on fancy cars.

Why won’t she stop smoking methamphetamine? Because it helps her stay awake at night so the men won’t rape her.

Why does he apologize all the time? Because, as a child, he learned that if he apologized a lot, he might be able to stop his father from beating him.

Why does he say things like, “I know a lot about wind” and “I know more about drones than anybody”? I mean, who knows. Is this the only way he knows how to interact with other people? Have these sorts of boasts helped him succeed in the past in relationships and business deals?

The definitions of psychiatric disorders are not solely limited to “doing weird things”. If we do certain things that help us or get things that we want, we will continue to do those things. Sometimes we continue to do those things even when they no longer help us as they once did. But that doesn’t mean you have a terminal psychiatric illness.

Most people do okay most of the time.