Author: Maria Yang, MD

Categories
Public health psychiatry

Killing and Mental Disorders.

Though over three years have passed since the start of the pandemic, we on Earth have yet to escape the specters of death and destruction. With murderous tragedies large and small happening around the globe, one might wonder, “All these people who are killing other people: There must be something wrong with them. Do they have a mental disorder?”

The Diagnostic and Statistical Manual, now in its fifth, text-revised edition, provides this definition for “mental disorder” (emphases mine):

A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.

Let’s consider some examples:

The man who shot 18 people in Maine. There are accounts that he has heard voices in the recent past. It is unclear if these voices were related to his threats to carry out a shooting at a military base. Reporting suggests that these two events resulted in a psychiatric hospitalization.

If we assume that he is still experiencing now the symptoms he had over the summer, he has a disturbance in his cognition (hearing voices) and behavior (use of a firearm to kill other people). We don’t know if the voices have caused him distress. He is certainly experiencing major disability at this time, as it seems that he has no social connections at this moment and he isn’t able to engage in activities such as work and leisure. He has demonstrated socially deviant behavior that, at least the way it is reported, is related to a dysfunction inherent to him.

Thus, it seems likely that this man who has killed 18 people in Maine has a mental disorder.

The Long Island Sex Killer. This is the man who allegedly killed 11 women between 1996 and 2011 and put their remains on Gilgo Beach. This man worked as an architect in New York City, was married, and had children.

It is debatable if he had a clinically significant disturbance in his thoughts, emotions, and behaviors: No one in his life seemed to notice any disturbances. For 15 years he presumably didn’t exhibit concerning distress or disability, as he was able to maintain multiple roles in his life with success. No one knew of his socially deviant behavior until he was caught.

Under this framework and given what has been shared, the Long Island Sex Killer does not appear to have a mental disorder.

People fighting in wars. This can include a military attacking an opposing nation-state, an organization attacking a nation-state, or a nation-state attacking an exclave.

We’ve already encountered a barrier: Mental disorders, by definition, only occur in individuals, not populations.

So let’s broadly consider the leadership of these populations, such as elected officials and others with high rank and authority. Propaganda obscures whether any of them are exhibiting disturbances. Note that their followers would not interpret their leaders’ thoughts, emotions, and behaviors as disturbed. Any distress the leaders express is related to their rage towards the enemy. Anyone showing disability would likely be removed, as this would be construed as a vulnerability. Attacking the enemy is not socially deviant behavior. (Resisting such efforts is.)

Leaders who order the killing of other people, in this framework, do not have mental disorders.

(As you already know, those fighting and harmed in wars are at higher risk of developing mental disorders. It is unjust that once someone demonstrates disturbances, distress, and disability due to war, the consequences of a state action land solely on individuals who must bear the psychological burdens and stigma.)

So, if mental disorders are not the underlying reason why people kill other people, then what is?

(Evil?)

(If it is evil, that is not something psychiatrists can treat.)

Categories
Consult-Liaison Reflection

Killing and Suffering.

To become a doctor, one learns how to prevent disease and death. To do this, one first must become acquainted with them: What happens? What does disease and death look like? sound like? smell like? What are their textures and patterns? What shifts over time, until the patient has no more time left?

As medical students learn what disease and death look like, they witness human suffering. Many students are unprepared for this. The tears that physicians in training shed are not from recognition of the mechanisms of disease and death. They cry because of the human suffering that surrounds them, that submerges them.

We don’t cry because we recognize that the proteins in the coagulation cascade aren’t reacting fast enough. We weep because there is so much blood everywhere. We see how pale their skin is, hear their rapid heartbeat on the monitor, and feel the coolness of their skin.

We see the contortions of their loved one’s face. We hear them scream, their sobs escaping their throats.

If we cry when we witness the suffering of one or two human beings, won’t we still cry when this happens to multiple human beings who are infected with a pandemic illness?

What if the cause of death isn’t a disease, but is instead a person? How do we then react?

Some psychiatrists recently shared the mental model of projection to explain why people kill others. Briefly: Projection is an unconscious process. People generally don’t think of themselves doing “bad” things:

  • I would never hate people because of their religion.
  • I would never treat people differently because they are poor.
  • I would never deny someone a place to live.

… even though they may have fleeting thoughts or impulses that align with these.

In projection, someone will “project” negative thoughts and impulses onto someone else and deny that they themselves ever have them:

  • I’ve done the work and I don’t have implicit biases. That guy, though, hates anyone who belongs to that religion.
  • I’m open-minded and understand that people who are poor are still people. That person, though, thinks poor people are all lazy and stupid. Just a bunch of moochers.
  • Of course everyone deserves a place to live. That guy, though, thinks some people deserve to be homeless. He thinks they’re all criminals and deserve to die.

In projection, we (unconsciously) don the gown of righteousness. We can do no wrong. Our intentions and motives are pure. In projection, we (unconsciously) coat The Other Person in the rags of depravity. They are evil. They only want to do bad things.

We are nothing like them. We could never be like them. They could never be like us. Anything we do glows with virtue. Anything They do is wrong.

We crush cockroaches underfoot because we are nothing like them and could never be like them.

How different are They from cockroaches?

We can’t test for projection. This is supposed to be an entirely unconscious process. (If we were conscious that this were happening, we would (should?) be horrified. We could not tolerate this and would take steps to stop it.)

I don’t discount the idea of projection for killing, but because there is no way to validate it, this is not the first explanation I go to. There are also a lot of steps: I’m a good person, you’re a bad person, you’re so bad that I don’t think you’re a person anymore, so killing you isn’t actually killing a person.

The dehumanization that comes from neglect is more compelling to me than the dehumanization that comes from projection. Indifference can cause more harm. It can be a conscious choice.

It’s not that I think you’re subhuman or an animal. I just don’t think about you at all. Torturing and killing an animal, even a cockroach, means that I at least thought of you as something that can react. If I don’t think about you at all, then you already don’t exist. And what sort of reaction could you possibly have if you don’t exist?

What harm could torture, rape, and murder have on nothing? If you don’t exist, then I’m not killing anyone in hospitals and schools. There are no children. I’m just flattening buildings.

You don’t matter. You have no matter.

People, like you and me, weep around the world.

A man cries for his son who will not live to start school because of the cancer in his brain. A son cries for his mother who died in an accidental plane crash. Someone cries for a friend of 60 years because their heart stopped beating.

Death from disease and the random events of life already causes suffering. Do not cause more suffering by killing other people. You will not only destroy others, but you will also destroy yourself.

Categories
Homelessness Reading

Down and Out, On the Road.

It took me a couple of months, but I finally got through Down and Out, On the Road: The Homeless in American History (first mentioned in this post). Here are the main points I took from the book:

“Down and Out” refers to people who live in impoverished urban areas. More specifically, people who live on “skid row” are “down and out”. (The term “skid row” likely originated in Seattle. As noted in both the Underground Tour and Beneath the Streets Tour in the Pioneer Square neighborhood, tree logs cut from the hills were pushed down Yesler Way towards the waterfront. Logs skidding down Yesler Way led to the name “skid row”.) These days, “skid row” typically refers to centers of poverty in cities where homeless people often reside. This is paired with…

“On the Road” refers to people who were homeless and, in trying to search for work, rode the trains. They often did not ride in the train, but rather on or under the train. These same individuals might reside in “down and out” areas upon arriving in a city. During the 1800s, people who were homeless were often associated with riding the rails than living in skid rows.

The term “the jungle” has been used to describe homeless encampments for nearly 200 years. In recent years here in Seattle, “the jungle” has referred specifically to a large encampment tucked under many trees in an undeveloped area near Interstate 5. This “jungle” was also notorious in the local press for violence (and was subsequently razed, though it seems that there are evergreen efforts to revive it). Over the past 200 years, people who had no place to live set up camp in forested areas (“jungles”) outside of urban centers, which developed into communities.

Cycles of romanticizing and vilifying homeless people are not new. People with no place to live are poor. Because the working class recognized how similar their struggles were with people who were homeless, they were (and continue to be) consistently more sympathetic, empathetic, and generous to them. Other classes, though, have swung between perceptions that people who are homeless are harmless—perhaps even charming (see Norman Rockwell) to lazy, deviant, and dangerous. (Other indicators include The Way It Is and Mr. Wendal, both excellent songs.)

Homelessness is a consequence of poverty. When I first received the book, I confess that I was dismayed to see in the index that “mental illness” is mentioned on only four pages of this ~250 page text. Kusmer, the author, provides a compelling historical account that various systems, including government policy (or lack thereof), economic forces, and cultural values are the chief drivers that lead to people becoming poor. Poverty is a major risk factor for homelessness. (I know this from my own anecdotal experience: Most people who are homeless do not have a severe psychiatric illness like schizophrenia. People often develop psychiatric symptoms because of homelessness. Even if every single psychiatrist in the nation worked with people who are homeless, homelessness would persist: There are plenty of people who are unhoused who do not need psychiatric treatment. They need a place to live and ways to have money to pay for living expenses.)

There was a federal program to address homelessness! Homelessness has been and continues to be a nationwide problem (regardless of the size of the US throughout time) that requires a federal response. The Federal Transient Service (FTS) was the first (and only?) federal agency in US history whose goal was to aid people who were homeless and unemployed. It started in 1933 and only lasted two years, in part because it seemed “successful”: The number of homeless people dropped, so everyone thought the problem of homelessness was solved. FTS funds were swept to support public works and Social Security. (In theory, public works and Social Security seemed like better investments to prevent homelessness.)

The disproportionate number of homeless people who are Black is not new. This is another legacy of slavery. A number of minority populations (e.g., Native Americans, Mexicans, women) suffer from homelessness because of policies and practices related to economic and class exclusion.

Down and Out, On the Road: The Homeless in American History was published in 2002. My sense is that the author, when viewing the current state of homelessness in the US, would continue to argue that the forces that contribute to poverty remain the primary driver of homelessness. I think he would continue to view mental illness and substance use as distractions and not significant causes of homelessness. (To be clear, I don’t think he’s discounting psychiatric conditions as contributors to homelessness for specific individuals, particularly since psychiatric conditions, both directly and indirectly, can pull people into poverty.) I appreciate how he ends the text:

The compulsion to stereotype the homeless as dependent and deviant turns the poorest Americans into an abstract “other,” separate and inferior from everyone else. Although their problems are more severe, however, destitute people living on the streets and in homeless shelters are not so different from the rest of us. They never have been. Any genuine effort to end homelessness must begin with a recognition of that essential truth.

Categories
Blogosphere Medicine Systems

Brain Snacks.

It’s a short post this week, though the links will take you to nutritious brain snacks (or hors d’oeuvres, if you identify as classy):

24 Hours in an Invisible Pandemic. This is an excellent example of data visualization about the experience of loneliness in the US.

26.2 to Life. This documentary is about the San Quentin Marathon. The athletes are inmates at the San Quentin prison. The course is 105 laps around the prison yard. (The virtual premiere is this weekend.)

30 Days of Healthcare. Dr. Glaucomflecken’s series of short videos about the US health care system is accurate, devastating, and, when it can be, amusing.

We Are Not Just Polarized. We Are Traumatized. This long essay is provocative, thoughtful, and worth the time to read. (Side commentary: The term “trauma response” is a relatively new phrase and, as far as I know, isn’t rooted in robust psychological or biological principles. I worry that the usage of “trauma response” may also dilute the experiences of people who meet formal criteria for the diagnosis of PTSD.)

Categories
Nonfiction

A Guessing Game.

To keep the watermelon from rolling off the platform, I placed the bag holding it between my ankles. My fingers tapped words of grief into my phone while I waited at the International District/Chinatown light rail station. Around ten of us were waiting for the next train.

“Ni hao?” A male voice was asking me this tentative question. My head tilted up; who was talking to me? He waved at me, a smile on his lips.

“Ni hao?” he asked again, taking a few steps towards me. Without waiting a beat, he continued, “Are you Chinese? Am I right? Wait, let me guess: Filipino.”

Reader, my mind was worn and my body was weary. How should I have responded?

I look East Asian because, yes, I am Chinese American. That is something I cannot and do not wish to change.

I didn’t want to talk with him or anyone else. My heart was heavy with sadness.

He was also talking at me. Did he actually want to have a conversation? or simply the satisfaction of winning a guessing game?

My eyes remain fixed on his while I did the calculations. If I answer this stranger’s question, he will probably continue to talk. If I respond with snark, he might get mad. (That he wasn’t giving me the space to speak warned me that he might be impulsive. If he genuinely wanted to know my ethnicity, he could have asked me directly. In English.) Either way, we’d both be contributing to an interaction, something I didn’t want.

So, I said nothing, tilted my head back down at my phone, and resumed my text conversation with myself.

Reader, what do you think his reaction was?

“No, no,” he said, coming closer to me. “You’re wearing yellow sneakers and I’m yellow, too, I’m Filipino.”

I kept my eyes fixed on my phone and continued creating words, letter by letter.

“Oh, come on,” he whined, still approaching. “Don’t withhold from me!”

I started a new paragraph on my phone: a guy on the platform just started talking to me, greeted me with a “ni hao”

“You’re a BITCH!” he shouted. My peripheral vision spied that he was standing to my right, less than an arm’s length away.

Reader, what should I have done?

There were other people on the platform. A petite woman, who also appeared East Asian, was standing about six feet away from me to my left. She kept her eyes on her phone. There was also a handful of people on the opposite platform.

Pigeons fluttered between the rafters. Tiny feathers floated down onto the track.

don’t look up

he could hit you he’s close

don’t move

stay

“Fuck you,” he snarled.

Then, he started walking away. A few steps in he turned back and screamed, “FAGGOT!” He sauntered down the platform.

The only visible movement from my body was in my fingers: explained that it was the yellow I was wearing and he was yellow, too. When I continued to ignore him, he started calling me names

When the train arrived, I looked up. I got into a traincar and leaned against the opposite doors. He got into the same traincar and sat down about ten feet from me.

When the train started moving, he made small talk with people wearing jerseys for the visiting baseball team. He greeted them in English. They talked about the visiting team’s city. He told them to have a good time.

Was that really the same person?

I got off the train. He exited the train, too.

After waiting for him to board the escalator, I remained far behind him and watched him leave the station. Unsure of what to do next, I again chose stillness: I loitered in the station for over five minutes before I fell into the shadows directly behind a group of people around my age.

He had disappeared into the city crowds.

Part of the reason why I ask my colleagues, regardless of credential, to call me “Maria” instead “Dr. Yang” is because of events like this. Outside of the work setting my status automatically regresses towards the mean. People like this shouting man reveal just how low some think my status should be.

Like elsewhere in the country, events continue to occur in Seattle that show how much contempt some people have for Asians. The esteemed Wing Luke Museum was recently vandalized. The man who smashed multiple windows with a sledgehammer offered this explanation for his actions: “The Chinese are responsible for all this, they’ve ruined my life. … That’s why I came to Chinatown.” I don’t know who this person is, though descriptions of his speech suggest that he may have psychiatric symptoms. That offers no consolation. (I don’t think the use of racial slurs in of itself reflects mental illness.)

This isn’t the first time that someone has given me unwanted attention because of my ethnicity. (Presumably this was more about my gender, though this event nicely illustrates intersectionality). It won’t be the last time, either.

I don’t think of myself as a victim. What has changed, though, is that I walk through the world with greater vigilance. When I initially took up running, I did so to improve my aerobic fitness. These days, I want to maintain the ability to run a 5K so I can run away for self-preservation.

I think it is mostly luck that the shouting man did not strike me. Had he hit me, I would have been injured. I don’t feel great about my decision that day to remain rooted and still while ignoring him. However, I also believe that any other choice I could have made to limit our interaction would have had a similar result.

I don’t owe anyone my attention, just as no one owes me theirs.

But, such is the creeping toxicity of racism: You don’t actually know when you should be worried, so you always worry.