Author: Maria Yang, MD

Categories
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.

Categories
Medicine Systems

Balloons.

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.

Categories
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.

Categories
Consult-Liaison Education Medicine Reading Reflection Systems

The Challenge of Going Off Psychiatric Drugs for Psychiatry.

Here are my initial reactions to the New Yorker’s The Challenge of Going Off Psychiatric Drugs:

Which populations are most likely to receive large numbers of psychiatric medications?

The woman described in the article comes from a family of money and privilege. These individuals (and families) have both the time and money to seek out psychiatrists who practice “precision psychopharmacology”. These psychiatrists then order complicated medication regimens that ostensibly address and “correct” neuroreceptors. As a consequence, people end up taking multiple medications.

There are also individuals who do not have money or privilege, but are subjected to psychiatric services due to the concerns of the public. They may be behaving in ways that endanger their own lives or the lives of others. As a consequence, they receive medications—sometimes willingly, sometimes through coercion—that aim to reduce certain behaviors. If one medication doesn’t reduce the behavior, then more are added.

What these two populations have in common are (a) the lack of clarity around diagnosis, which often stems from (b) missing information about the person and the context in which s/he lives.

I completely agree with Dr. Frances’s comment from the article:

[There is a] “cruel paradox: there’s a large population on the severe end of the spectrum who really need the medicine” and either don’t have access to treatment or avoid it because it is stigmatized in their community. At the same time, many others are “being overprescribed and then stay on the medications for years.”

The meanings of diagnosis and treatment, particularly medications.

Some people feel relief upon learning that their symptoms belong to a diagnosis, that what they have is “real”. Others don’t want the “label” of a psychiatric diagnosis; they are not damaged human beings.

For various reasons (e.g., the current primacy of biological psychiatry, insurance reimbursement, psychiatry’s seeming inferiority complex within medicine), treatment in psychiatry is often focused on medications. This is not ideal. Medications are a biological solution, though our understanding of the biology of the brain and mind remains limited.

In the meantime, doctors recommend that people take pills. Some people view pills as a necessary intervention to keep them healthy and well. Some people view pills as a shameful reminder that there is something wrong with them that will never improve. The more pills someone has to take, the more potent the reminder that they are beyond hope or repair. Some people view pills as an external validator of their pain and suffering: “Someone else believes and understands my pain and these pills remind them and me that my pain is real.”

The pills may not be treating what psychiatrists think they are treating.

The problems with psychiatric diagnosis.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) focuses only on the “what”, not the “why”.

It doesn’t matter why someone has a depressed mood, takes no pleasure in work or play, can’t sleep, won’t eat, and feels hopeless. The underlying reason could be the cardiologist’s realization that he should have pursued his dream of becoming an architect… or it could be the threat of eviction after losing one’s job.

This affects the way psychiatrists gather a history from people seeking care. Instead of learning the context behind one’s symptoms, psychiatrists now focus on whether certain symptoms are present or absent. What matters more is that she feels paranoid, not that the paranoia started when she learned that her father was molesting her sister.

To be clear, there are some instances in which the underlying “why” doesn’t matter. If someone is terrified of flying on a plane, there are treatments (e.g., exposure therapy) that can help people tolerate plane rides without getting into the reasons why this fear appeared in the first place.

In other instances, though, the “why” is often relevant. Since our understanding of the biology of the brain and mind are limited, we don’t know if the biological properties of Medication A are more useful in military veterans who have fought in combat or if those of Medication B are more useful in women who experience major depression after the birth of a baby. Even if evidence suggests that medications aren’t the best treatment for either population, it is often the easiest intervention to deliver. This is due to the context and underlying “whys” of the health care system.

All of the other psychiatrists.

It’s true that there is scant evidence about how to taper and stop medications. It is a shame that psychiatry, as a field, has nothing to say about deprescribing. The scientific literature has plenty to say about adding medications, but nothing that extols the virtues of taking them away. There are risks to stopping medications, yes, but why are psychiatrists unimpressed with the risks of starting them? In this way we have failed not only the people who receive care from us, but we also fail the people who step in to help in our absence: Other physicians, nurses, family members, friends.

When I consider the psychiatrists I have worked with with, many of them have helped people come off of medications. They work with their patients and go through the trial-and-error process together. While they may not work in ivory towers of acclaim, they are still doing the work of helping people make informed choices about their care so they can lead healthy and meaningful lives. These are the quiet anecdotes that will never make it into the New Yorker.

Psychiatry as an agent of social control.

This is not the first time I’ve written about psychiatry as an agent of social control.

What does it mean that “antidepressants are taken by one in five white American women”? Is this a reflection of white American women? Or a reflection of the society and systems that want to contain white American women?

What does it mean that African- and Latinx-Americans are more likely to receive diagnoses of psychotic disorders? Is this a reflection of these populations of color? Or a reflection of the society and systems that want to contain these populations?

Perhaps there needs to be a “Challenge of Going Off Psychiatric Drugs” for the field of psychiatry. To be clear, there is definitely a role for medications in the treatment of psychiatric disorders, though: first, do no harm. When The Royal We have more humility about what we do and do not know, and exercise more care in current pharmacological tools, then perhaps getting on or going off of psychiatric drugs won’t be a “challenge”.

Categories
Medicine Nonfiction Seattle

Questions After a Suicide.

To my knowledge, three people who were under my care killed themselves.[1. Additionally, three people who were active patients of mine tried to kill themselves. Then there are the people who have killed themselves, and I am simply unaware that they have died from suicide.]

The first was a young man—late 20s, maybe?—who I met while I was a psychiatry intern. He was hospitalized in the psychiatric unit where I had just started my rotation. I did not have the opportunity to get to know him well. Our paths crossed, at most, for two days. He had a diagnosis of schizophrenia. I can conjure up his face in my mind, though I do not remember his name. He didn’t blink much. While his face did not betray fear, he often looked uncomfortable.

I don’t know how many days he had been out of the hospital before he died, though I think it was within a week of his discharge. He jumped off of the Aurora Bridge (before a suicide prevention fence was installed) into Lake Union in Seattle.

The second was a man in his late 40s who had repeated visits to a crisis center. He did well in college and earned a law degree. His career as a lawyer was cut short due to problems with depression and alcohol. From there he became homeless and destitute. He had a diagnosis of major depression. Some professionals thought he had a personality disorder.

He was smart and sarcastic. While he was often critical of everyone around him, there were moments when he was self-effacing. After we had worked together for a few months, he commented that he liked “debating” with me, though I suspected that arguing was the only way he knew how to interact with other people. On the rare occasions when he took a break from his self-loathing, he considered how his life could change. He didn’t drink as much alcohol now as he once had, but it still helped him forget his shame and regret.

When I learned that he had died from an overdose of methadone, I knew immediately that he had intentionally killed himself. He had no history of using opiates, but he knew how, with or without alcohol, they could end his life. Over a month had passed between our last conversation and his suicide. When I learned of his death, I asked him—as if he could hear me—why he didn’t come back to the crisis center. He knew that he could.

I have not forgotten his name. Earlier this week, I saw his name in a newspaper. It wasn’t him, of course; the name belonged to an author who was promoting his book. I hadn’t seen this name elsewhere before. It made me wonder if my patient was saying hello.

This past week, I learned that a third person who was under my care killed himself. He was in his 20s, smart, and funny. When his symptoms were active, he was very ill. In the minutes to hours leading up to his death, was he experiencing a resurgence of his symptoms? Or was he mulling over how his illness could impact his life in the future and decided to impact his life first?

The last time I spoke with him, we talked about how his condition did not define him. His identity wasn’t solely his illness. We talked about the things he wanted to do in the future and how he could accomplish those things.

The person who called me to tell me the news heard my breath catch in my throat.

Death, while uncomplicated in some ways—it’s a permanent cessation of all vital functions, the end of life—our attachments make it complicated in other ways. We have so many questions that will forever go unanswered. We wonder where the dead go. Does a part of them persist outside of our memories? And for those who kill themselves, what happened? What got in the way of them asking for help? What made death the best option? What made them believe that the rest of us could not or would not understand?

The end of a life never just impacts the individual who died. The ripples spread far and wide. We search for words to describe our grief, but language fails us.