Author: Maria Yang, MD

Categories
Consult-Liaison Education Medicine Public health psychiatry Reading

What is Mental Health? (01)

To try to answer the perennial question I ask myself (“what am I doing?”), I recently read this 2015 article, What is mental health? Evidence towards a new definition from a mixed methods multidisciplinary international survey.

As a psychiatrist1, do I treat mental illness? What is mental illness? What is mental health?

The paper comments on the ambiguity in the definition of “mental health”:

Mental health can be defined as the absence of mental disease or it can be defined as a state of being that also includes the biological, psychological or social factors which contribute to an individual’s mental state and ability to function within the environment.

Upon reading this I recognized that I define “mental health” according to the second definition, “a state of being…”. This also explains why I internally bristle when people say “mental health” when they actually mean “mental illness”. (Example: The Lancet Commission on ending stigma and discrimination in mental health.)

Figure 2B, the Two Continua Model, resonates with me:

There are people with diagnoses of significant mental illnesses who have “high mental health”. (If we’re going to be picky about words, I’m not sure that I like grading mental health as “high” or “low”. Maybe “well” versus “unwell”? It is more common to hear “I’m physically doing well,” rather than “My physical health is high.”)

Consider the person with a diagnosis of schizophrenia who has been hospitalized multiple times in the past. However, now they go about their lives and only make contact with their healthcare team every few months for routine check-ins.2

Then there are people with no diagnosable mental illness who have “low mental health”. Consider the many people who felt psychologically unwell during the Covid pandemic.

I started doodling to try to determine where psychiatry should intervene along the axes of mental illness and mental wellness:

I have yet to come up with any convincing answers. This doodling did offer clarity, though:

My professional interest has been the diagnosing and treatment of (often severe) mental illness. There are many reasons for this. One compelling reason is that the severity of symptoms makes it unmistakable that professional intervention is warranted.3

Only after years had passed did I recognize that this worldview is why I chafed at some requests patients brought to me early in my career. I once went through an entire diagnostic interview with a guy who worked as a game designer. Nothing came up; according to the Two Continua Model, he had neither a mental illness nor low mental health. Only at the end did he reveal why he had sought care from a psychiatrist: “My girlfriend takes Prozac and it made her more creative. I thought that if I take Prozac, that might make me creative, too, which can help me with my work.”

My goal was to diagnose and treat a mental illness. His goal was mental enhancement.

Are these two goals mutually exclusive? I don’t think so, though I want to noodle on this more.

The history of psychiatry holds these two goals in tension, too: On one end are the state psychiatric hospitals (also called asylums) where some people with severe symptoms (or not) were held (warehoused?) prior to the elimination of these institutions. On the other end are the psychoanalysts, where the typical patient was “a college-educated, upper-middle class professional who paid for service out of pocket.”

More to follow as I continue to wonder what I am doing.

  1. It was never part of The Plan to become a psychiatrist. This is part of the reason why I ask myself the perennial question, “What am I doing?”
  2. When asked, “What is your best life?”, no one responds, “I want to spend as many precious moments of my existence in hospitals and clinics.”
  3. A choice quote from the paper that highlights why I personally like clarity about where professional intervention is warranted: “Lots of things can cause people problems—poverty, vices, social injustice, stupidity—a definition of health should not end up defining these as medical problems.”
Categories
Medicine Observations

H/ours Lost.

Most people in ten countries lost an hour of time between yesterday and today in the name of Daylight Saving. (Nearly 30 nations in the Northern Hemisphere will lose an hour by the end of March.)

Among the many who woke up at a later clock time today are the seven million or so Americans who have dementia. They opened their eyes and their gazes passed over the clocks in their worlds. The faces of those with dementia may have matched the faces of analog clocks: Flat, blank, lacking emotion.

There were fewer sparks of electricity this morning in these brains speckled with scar tissue. Amyloid plaques and tau tangles are the remnants of neurons that once vibrated with vitality. The hues of their hair have faded to gray; the gray matter of their brains continues to disappear.

When they looked at their cell phones, they may have forgotten that their phones automatically adjusted the time at 2:00am. The steps of logic are missing from these brains; the staircases of reasoning have crumbled. When someone mentioned “Daylight Saving”, they sprang forward with their praxis memory, similar to “muscle memory”: They can no longer explain the steps to search the internet on their phone, but their fingers reflexively swipe and type.

Their aged fingers tapped out the word “time”, trusting that Google would orient them to this moment.

Except their query was unsuccessful. With the decay of the gray matter in their brains, their abilities to give and hold attention, to notice details, have also deteriorated. Their single word question didn’t go to Google; it went into a text message:

Time

And then again, since Google did not respond:

Time

Daylight Saving Time may have stolen one hour of our time, but dementia has stolen hours and ours from us.

Categories
Observations Reflection

Mental Habits.

We got on the topic of nightclubs.

“I’ve never been to that nightclub,” I said.

“Yeah, I’ve never seen you there,” The Person replied, before adding, without any malice, “… you seem like you’d go to the Wildrose.”

I couldn’t help but laugh. That allowed the moment to pass, a question to leave unanswered.

The Wildrose is a lesbian bar in Seattle. (It’s apparently the oldest lesbian bar in the US.)

The Person’s error wasn’t about my sexual preferences; it was that they thought I go to nightclubs!†

What impression do you have of The Person?

Would your impression change if The Person is:

  • a man?
  • a woman?
  • the teenage child of a friend?
  • a stranger over the age of 70?
  • a white person? a non-white person?
  • a straight person? a queer person?
  • my boss?

As much as we try, we can never really get away from ourselves. We all think we view the world through relatively impartial lenses. Then we encounter people and situations that trigger our mental habits.

Like viewing the world and the people in it through the lens of sexual preferences.

Or believing that blog posts are only worthwhile if they resemble articles.

† Long-time readers know my opinions about dancing.

Categories
Lessons

On Mental Endurance.

Although “mental endurance” is more wordy than “grit”, I prefer the extra syllables. “Grit” sounds difficult and uncomfortable: Jaws clenched, the jagged surfaces of molars grinding together, or granules of sand scratching the surface of your eyeball.

“Grit” also suggests firmness and unyielding. It doesn’t matter what the conditions are: I will not change my strategy or tactics. I will not bend, even if I might break.

“Mental endurance” offers more flexibility. There is room to breathe. Maybe you can keep more enamel on your teeth.

When Things Are Hard, how can we unclench our jaws? When we run psychological marathons we did not sign up for, how can we keep moving without falling down from exhaustion or heartache? How can we practice and manifest mental endurance?

Build and commit to routines. If the word “ritual” is more pleasing to your ear, build and commit to rituals. This includes the essentials of eating, sleeping, and other healthful activities. (Without a basic foundation, any type of endurance is hard to achieve.) Creating and sticking to routines brings comfort when most things seem out of control. Rituals help us feel like we have agency over something. To start, the less profound the ritual, the better:

  • Make the bed every morning.
  • Always say “thank you” to the bus driver, even if they don’t make eye contact with you and look like they’re grinding the enamel off of their teeth.
  • After you put your kids in the car and shut their door, make a point of taking three full breaths before you get in to drive.

No one has to know what your routines are or the reasons behind them. Maybe you run because you actually want to run away from your problems. Maybe you watch the same video on YouTube before bed because it increases the chances that you will fall asleep. Maybe you behold the cereal in your bowl and say thanks to all the nameless people who transformed and transported the cereal to you.

What matters is that you created a ritual. You’re choosing to do it. Within is freedom and power.

Pace yourself. Or, it’s okay to take a break. When Things Are Hard, we often want to get through All Of It as soon as possible. Who wants to feel psychologically uncomfortable?

However, the logical conclusion of this approach doesn’t make sense: Life is hard. If we want to get through the Hard Stuff as fast as possible, that means we should try to get through life as fast as possible. This is impossible. (Puberty over in 24 hours! bone fracture healing in five minutes! grief resolved in two seconds!)

Yes, there are often external pressures: The boss wants us to do something. The kids have a need that only you can fulfill. There isn’t enough money to deal with The Thing the way you’d like to deal with The Thing.

It’s okay to take a break. If you were able to think your way out of this problem, you would have already thought of the solution. Spending 30 minutes thinking about something else is nothing when you spend hours dwelling on The Thing. Your mind will welcome the break, too, because it needs it. (Epiphanies seem to arrive when we give our mind a break: showering, doing our laundry, etc.)

Talk with people you trust. Many burdens are not meant to be carried alone. If someone is able and willing to help lift the burden from your mind, or at least shift it so you can adjust your psychological grip, not only are you blessed, but you are also letting someone help you. Sometimes our grip is so tight on The Thing because we insist on bearing it ourselves. (What would it mean if we let someone help us? Does it mean that we’re weak? unreliable? a failure?) Olympians and chess grandmasters all have coaches and esteemed colleagues. Amateur chefs share their dishes with tasters and amateur writers share their words on blogs. While it may be true that no one in your social circle has been through what you’re going through, that doesn’t mean that they are useless. Support, attention, and care from others has value. It’s okay to unclench.

Remember that everything changes. Things may not change as fast as we want them to, but everything changes. What feels intolerable now will one day be a memory. We ourselves change because of The Thing; our values will shift and we will make different choices. With heartbreak, we might ultimately discover more love flowing through our lives. Instead of the friction associated with grit, there can be a softening, a light, gentle expansion of our hearts. There is room to breathe. Our bigger hearts will buoy us forward for whatever changes await us next.

Categories
Uncategorized

Hello Again.

Hi. I feel some obligation to apologize for my lack of posting here over the past three months (!).

Challenging Events happened in the last two months of 2023. Things settled down. (Let us not forget, though, that stability is an illusion.)

Now that my adrenal glands aren’t squirting out large volumes of adrenaline, I’m starting again. Getting started is often the hardest part. (What should I write about? Do I have anything to say that hasn’t already been said? Am I sending signals or simply generating noise? Am I making useful contributions? etc.)

My goal today is simply to post something. (Prior to the onset of Challenging Events, I was crafting a post brimming with self-righteous outrage about my patient’s inability to get a prescription for generic nicotine gum filled. That post is forthcoming.) Hang in there with me as I crack my knuckles to reacclimate myself to writing posts again:

I’ve moved to a different newsletter service. If you’re reading this in your e-mail, that means you’re already subscribed to my newsletter. (I hope you don’t mind that I migrated your e-mail address over to Buttondown without telling you.) If you’re reading this on RSS or on my website and would prefer to receive posts in your e-mail, please feel free to sign up here. (If you do use RSS, I use and recommend CommaFeed.)

I don’t use any social media platforms anymore. One of the unintended benefits of Challenging Events is that I stopped using Twitter/X because I didn’t have the will or energy to. Twitter/X may have stopped using me, too: As of this writing, I am not able to log in to Twitter/X. Oh well (and good riddance).

The Omnivore app has helped me read more. Instapaper was letting me down and Pocket had too many bells and whistles for my taste. The Omnivore web and mobile apps are visually appealing, easy to navigate, and a pleasure to use. (The ability of Omnivore to sync with Logseq is also wonderful.)

The Friends of Big Bear Valley live eagle cam is worth your time. Big Bear Bald Eagle Live Nest – Cam 1 is the live webcam; the channel has video summaries of the eagle pair.

I am still trying to learn how to play Go (well). I first learned how to play Go literally decades ago and remain a perpetual student. The Way to Go tutorial (…) is pretty good.

Lunar New Year is nearly upon us. The Year of the Dragon starts on the new moon on February 10th. I wish you, fine reader, good health, safety, and prosperity.