Author: Maria Yang, MD

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Education Lessons Nonfiction Reflection

Uncomfortable Thrill.

When I walked through glassware sections of stores as a child, my body buzzed with distress and delight. There were only two ways to ease this anxious discomfort:

  1. Fling my arms out and knock over all the glass to see, hear, and feel the pieces shatter; or
  2. Keep my arms tightly by my side and ensure that nothing above the soles of my shoes touched any objects in the store.

I always chose the second option. The urge to fling my arms out to knock over crystal and glassware has diminished with time. If I’m honest, though, the uncomfortable thrill persists.

That same uncomfortable thrill pulsed through me when the loaded guns rested in my hand.

It didn’t matter that I received a private didactic (with a white board![1. The white board didactic included four rules: (1) All guns are always loaded. (2) Keep finger off trigger until ready to fire. (3) Be aware of target and what’s behind it. (4) Don’t point at anything you’re not willing to destroy.]) about gun safety from someone I know and trust (who also happens to work as an emergency physician). It didn’t matter that we were at a pistol range where safety was paramount. It didn’t matter that I had close supervision for my first experience in shooting firearms.

The paper target revealed that my initial shots were the most accurate; the subsequent shots often drifted farther and farther from the target. Maybe my hands and arms suffered from fatigue. Maybe my uneven breathing made my body needlessly tense. Maybe my safety glasses got too foggy from perspiration.

Maybe it was the National Geographic article about a young woman’s face transplant due to a self-inflicted rifle wound that I had read just the day prior. Maybe it was the imagery of the assassination of President John F. Kennedy and the later murder of Lee Harvey Oswald that I saw at The Sixth Floor Museum.

Maybe all the stories I remembered from my work as a psychiatrist freaked me out.

Maybe it was all the stories I never heard or have yet to hear.

It happens so fast: Finger is off the trigger. Finger then rests on the trigger. Finger flexes.

BANG!

The bullet is gone. My body lurches with the recoil. The bullet casing bounces off my shoe. I only see the puff of pewter smoke when I lower my arms.

  • How much time passed between the time she loaded the gun and when she fired it at her chest?
  • Did she hesitate before she put her finger on the trigger?
  • How many times did he try to pull the trigger before putting the gun down?
  • Did he ever put his finger on the trigger before he pulled the barrel of the gun out of his mouth?
  • Did she ever touch a gun before the day she tried to kill herself with one?
  • Did he imagine what the BANG would sound like within his skull?

The power of the weapons spooked me.

My hands weren’t shaking, but my fingers could not push the 9mm bullets into the magazine. My hands felt weak.

More than once I walked away, pulled the safety glasses off my face, wiped the sheen of sweat off my forehead with my forearm, and then jumped up and down several times.

I never felt any urge to turn the guns on myself, though the uncomfortable thrill reminded me that I could. Others who are unable or unwilling to resist that uncomfortable thrill could indulge that urge, whether against themselves (more common) or against others (much less common). The uncomfortable thrill may not feel so uncomfortable when one is intoxicated. Or angry. Or hopeless.

It could happen so fast.

Yet, I quickly recognized the appeal behind shooting. Guns are tools. The anatomy and mechanics of firearms are interesting. Learning how to aim and hit targets with high accuracy is satisfying and rewarding. Achieving mastery over such powerful tools is thrilling.

I am grateful that I had the opportunity to learn how to shoot pistols. It was fun, though I must confess that it was not as fun as I had anticipated. Thoughts of death and injury from suicide rarely left my mind, which added elements of stress and sadness. Jumping up and down and taking deep breaths could only do so much.

The power of guns freaked me out. It was only the next day that my body finally stopped buzzing with distress and delight.

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Uncategorized

I Won’t Analyze You.

“Oh, you’re a psychiatrist? I hope you won’t analyze me!”

I never know what people actually mean when they say that upon learning that I work as a psychiatrist.

I think they’re[1. I can’t remember an instance when a woman said to me, “Oh, you’re a psychiatrist? I hope you don’t analyze me!” The men who offer that response are almost always trying to make someone laugh—me, them, the people who are observing the conversation.] saying, “I hope you’re not going to spend our time together trying to discern my flaws.” Nobody wants people to seek out, highlight, and exploit their vulnerabilities and faults, so I can understand that. Of course, that’s not what psychiatrists do.[2. Unfortunately, there are psychiatrists who focus on discerning and amplifying individual vulnerabilities. This is abuse of power and is not limited to psychiatrists.]

Anyway, let’s just take the statement at face value—that people hope that I won’t “analyze” them—regardless of what the underlying concern may be. Let’s also assume that when laypeople say “analyze”, they mean “do the things you do when you’re working as a psychiatrist”.

I cannot speak on behalf of all psychiatrists, but let me assure you: If you and I meet in a non-clinical context, I won’t “analyze” you. These are the reasons why:

1. It takes a lot of energy to “analyze” someone (a.k.a., “do the things psychiatrists do when they’re working”). When I’m working, these are the things I’m attending to:

  • What is the person saying? What words does he choose to express himself?
  • How is the person saying what she want to communicate? What is the tone of her voice? What nonverbal signals are present?
  • Is what this person is saying congruent with what this person is doing? What about his facial expressions and other physical movements?
  • What are the underlying or recurrent themes behind what this person is saying and doing?
  • What are the underlying assumptions the person has about himself? How are these underlying assumptions manifesting in what he says or does?
  • Is this person avoiding certain ideas or perspectives? If so, what are some possible reasons?
  • How did these ideas and behaviors come to be? Were they helpful or lifesaving in the past, but are now causing problems for the person? How do these thoughts and behaviors help this person now?
  • Is there something else going on that might explain this person’s thoughts and behaviors? Maybe this isn’t psychological; this might be a medical problem or related to substances (prescribed or not).

While attending to those tasks, I’m also:

  • Doing all the nonverbal stuff—often with intention—to let the person know that I’m listening
  • Saying things and doing nonverbal stuff to help the person feel both physically and psychologically safe in disclosing information to me. If I don’t receive accurate data from someone, I cannot help them as much as I possibly could.
  • Tracking the conversation and putting mental bookmarks in places to either revisit later during this dialogue or in the future (is this the right time to ask that question? how about now? should I phrase it differently now?)
  • Making mental notes of the important details I need to put in my note later
  • Gently (or more assertively, as the case may be sometimes) steering the conversation with questions and comments to make sure I get as much relevant information as possible, given the current circumstances (amount of time, condition of the individual, setting that we’re in)

All of these actions—not always visible, but definitely happening—require active listening, which means I shouldn’t space out.[3. When I’m working, I shouldn’t space out, but I have. The goal is zero instances of spacing out. Still working on it.] I need to be present and focused. We all know when someone isn’t paying attention to us.

When I do speak, I try to ensure that every sentence serves a purpose.[4. When I’m feeling more ambitious, I try to ensure that every word I say serves a purpose. Sometimes that makes me sound pedantic or brisk, which often makes people feel uncomfortable. I learned early on that most people feel more comfortable with a psychiatrist who is a human being, not a psychiatrist who could be a robot.] Sometimes I ask questions when I want to make a statement; sometimes I say nothing, even though the individual may want me to fill the space with something (reassurance? confirmation of inaccurate ideas? answers that no one has?). I’m frequently generating hypotheses and testing them (is this person experiencing paranoia, or would he say more to another colleague? if this person intoxicated, or is there a medical issue present? does she actually want to die, or is she feeling powerless in the face of adversity?), while trying to show empathy and kindness.[5. Kindness is often associated with warmth. However, people can demonstrate extraordinary kindness without warmth. Consider people who put themselves in danger to protect others. Warmth is often absent there, but kindness overflows.] I don’t want to come across as an automated flow chart.

All of that—and more!—is happening when I’m doing clinical work. That takes a lot of energy. If I don’t have to use that energy, I won’t.

2. I don’t know how to “analyze” people. Upon hearing the word “psychiatry”, some people conjure up images of New Yorker cartoons with couches and stodgy psychiatrists sitting behind them. Psychiatrists and other mental health professionals usually go through extra training to learn psychoanalysis. The tradition of “analysis” goes back to Freud and, well, I’m not a fan.

Now, to be clear, there are some ideas that stem from psychoanalysis that I think have some value (for example, Malan’s text on psychodynamics offers interesting and, at times, useful perspectives on symptoms and behaviors). However, I don’t think everything boils down to love and work. Or sex and violence. I don’t think women are envious of men because men have penises. I think we all probably have an “unconscious” or “subconscious”, but I can’t prove it. I also don’t think the unconscious/subconscious is simply an arena where good and evil, depravity and virtue, and other polarities are constantly duking it out.

My disdain of psychoanalysis stems, in part, from cultural reasons. Freud and his buddies came from Western Europe (particularly Austria and Switzerland). America is a product of Western European ideas, and while I was born and raised in the US, I was raised by people who were not. I was inculcated with Confucian, Buddhist, and Taoist ideas. The psychologies of these traditions don’t refer to constructs like ids, egos, and superegos. They instead focus on filial piety, the importance of community over the individual, harmony as a paramount virtue, and the reality of suffering. These manifest more between, rather than within, individuals.

3. I’m not my job. Yes, I have been fortunate enough to go through medical and psychiatric training and do the work that I do, but that’s just one aspect of who I am. In my youth, psychiatry was not a part of my identity. If I am lucky enough to live long enough to retire, psychiatry will be something of my past. This is just a long phase of my life.

So, rest assured, I won’t analyze you. If I ask you questions, maybe I just want to get to know you.

Categories
Lessons Medicine Nonfiction Reflection

On Gratitude.

Expressers significantly underestimated how surprised recipients would be about why expressers were grateful, overestimated how awkward recipients would feel, and underestimated how positive recipients would feel.” – Undervaluing Gratitude: Expressers Misunderstand the Consequences of Showing Appreciation

The past 30 days have been unusual because of the number of professional gestures of gratitude I’ve received:

  • I received a clinical faculty award from psychiatry residents for my teaching efforts.
  • An hospital administrator contacted me in my professional capacity; she later revealed that she was a former patient of mine and thanked me for our time together.
  • A former patient contacted me to let me know that she is about to start law school, something she did not think she could ever do. She attributed her change in perspective to our time together.

These gestures are deeply meaningful to me. At a time when arguments, conflict, and discord seem to dominate our collective consciousness, how refreshing it feels to receive thanks!

As I do not work in an academic medical center, I never expected to receive a teaching award. While I do some teaching for the residency, I have limited exposure to the trainees. That the residents even thought of my name for the ballot is meaningful. In my professional role, I have the privilege of teaching topics related to psychiatry to a variety of audiences—community members, attorneys, judges, case managers, nurses, social workers. Praise from students, though, is of greater value to me than praise from judges and others who have similar social status. As one of my more precocious medical students once commented, “I should know what a good teacher is, since I’m a medical student and many people teach me….” It makes me grateful for the teachers[1. I believe that literally everyone you encounter in life is a teacher. Sometimes you don’t want to learn what they have to teach you, but that doesn’t dilute the value of the lesson. And sometimes the best teachers in our lives aren’t identified as “teachers”.] in my life who have helped me develop my teaching skills.

Similarly, it is always a delight to receive thank you notes from past patients. Even though I often cannot remember the names of people who were under my care in the past, I recall how many of them taught me how to improve my skills in listening, using plain language, and applying interventions—medications or otherwise—to improve their health. I also recall the shame, fear, and suffering that they shared with me… and how, sometimes, I screwed up and gave them reasons to distrust me in the future. Sometimes I did better. Sometimes I think I did better when, in fact, I did not.

My boss (who is not a physician) recently gave me some feedback: “Maria, you’re hard to read. I usually can’t tell how you’re reacting to something.”

I laughed. “You’re not the first person to tell me that,” I said before continuing, “Like, when I was a fellow in New York, I had supervision with an attending (a physician) and, for whatever reason, I burst into tears because I was upset. To his credit, he didn’t freak out. He, a native New Yorker, sat with me and commented in that direct way that New Yorkers are known to do, ‘I had no idea you were so upset. You should know that you don’t show any signs that you’re upset.'”

After my mom died, I have put more effort in expressing my emotions. (To be fair, though, most of the expressing happens in words, not in my face.) Most of these expressions are of affection and gratitude. It sounds dramatic, though it is true: We never know when people will leave our lives, whether from death or other reasons. As noted in the opening citation, we might not think that what we say has much impact on others. However, expressions of affection and gratitude, at least, cause no harm and, at best, are emotional gifts that strengthen social bonds and foster harmony.

There is value in expressing displeasure, too. Sometimes people need to know that we’re upset, that we feel distress with current circumstances. Though it might make us uncomfortable, expressions of displeasure can ultimately strengthen social bonds and foster harmony. Sometimes we must travel the difficult path, even if it means that we will travel alone for a bit.

I am not old, but I am also not young. I am grateful to have the opportunity to work as a psychiatrist and to teach others the little that I do know. I am grateful that you, dear reader, have made it to the end of this post. Thank you.

Categories
Consult-Liaison Lessons Medicine Nonfiction Reflection

On Suicide.

I still feel a little anxiety whenever I ask someone about suicide.

I have no fear when asking The Question—“Have you been thinking about killing yourself?”—but sometimes I find that I’m not breathing while I await the answer.

What if this person says “yes”?

This anxiety persists even though it’s literally part of my job to ask this question. Despite having asked this question thousands of times, I still feel a twinge of unease whenever it is time to ask. I still feel nervous even though people have answered “yes” when I’ve asked The Question. I still wonder if my interventions will be effective despite knowing that I have helped people choose to live.

I still have to remind myself that it is a blessing if someone tells me, “Yes, I’ve been thinking about killing myself.” It means this person trusts me enough to share this information with me. It means this person has faith that I’m not going to freak out. It means that we can talk about death, what it means to this person, and why suicide seems like the best option. It means that there is hope that the conversation will lead to a discussion of other viable options.

It means that, in this moment, this person is willing to live.

During my training, I had several teachers who would offer gentle correction to people who said, “I feel suicidal.”

“‘Suicidal’ is a thought, not a feeling,” they would offer. “What are the emotions that are leading you to think about suicide?”

That snippet looks condescending and contrived on the screen. When said with skill, it steers the conversation to areas that can lead to change.

It is hard, if not impossible, to change emotions with willpower alone. Consider all the unseen things that can shift your emotions:

  • a fragrance that resurrects a memory from your youth
  • the sound of stranger’s voice that reminds you of another person
  • the feeling of the sun on your skin after a dark winter

Emotions are powerful. They can promote certain thoughts or drive certain behaviors. Sometimes emotions feel so overwhelming that, to cope, we have thoughts that death is the best option.

“Do you want to die? Or do you want to feel different?”

Whenever I learn that someone has died from suicide, I recall five specific people. Three of them tried to kill themselves while under my ongoing care:

  • one arrived in the clinic with long, bleeding lacerations on the both arms
  • one had spent hours on top of a tall structure, debating whether to jump off
  • one missed an appointment and I somehow knew that something had happened; this person used a friend’s gun and shot a bullet through the chest

Two of them did kill themselves:

  • one jumped off of a tall bridge
  • one took an intentional overdose of alcohol and methadone

There are people who I have worked with in acute settings—crisis centers, jail, emergency departments, medical and psychiatric hospitals—who tried to kill themselves, but never told me. There are people who have killed themselves after I met them, but I haven’t learned of their deaths.

I don’t think about the five people frequently, but they cross my mind from time to time. I hope the three are living lives they believe are worth living.

I say prayers for the two who are deceased, but the words of my prayers come from a language that has no shape or sound.

To prevent suicide, we must be willing and able to talk about it. This doesn’t mean that anxiety, fear, and discomfort are absent during conversations about death and dying. Talking about suicide does not increase the likelihood that people will kill themselves. In fact, these conversations often bring relief; it offers a perspective that frequently differs from the one that predominates in our heads.

The onus to broach this topic should not be solely on the person who is thinking about suicide. If we ever sense that people we love are not doing well, asking how they’re doing and learning more about what’s on their minds shows that we care.

When people are thinking about suicide, sometimes the best way we can help them is to let them know that we see them. We want them in our lives. And that may be how we can help them choose life.

Categories
Nonfiction Reflection

On Dignity.

There were about nine of us waiting to cross the street. Several were Asian; there were also a few black and brown men.

A van approached the curb to turn. It was one of those vans with a back door that slides along a track. That back door was wide open, even though the van was in motion. As it pulled closer, we saw that there were three young white men seated in the back. They were wearing shorts and sunglasses. Their legs were spread wide, occupying the space with confidence.

The young white man seated closest to the open door called at us as the van passed:

“… ching ching ching chong ting ting tong tong…”

The man of color next to me swiftly raised his arm and made a gesture with his hand. The young men in the van saw this gesture and shouted their musical slurs in a higher pitch in response.

“What? That still happens? Are you kidding?” she exclaimed.

“Well, yeah,” I said, perplexed. “The last time this happened to us was about three or four months ago.”

“But we’re in Seattle. And there are so many Asians here, on the West Coast. This really happened to you?”

These are probably the same people who see the color of your skin and say terrible things to you, I thought. Why are you surprised?

He and I had never met. He knew that I was conducting a clinical interview with someone else, but kept talking at me, anyway:

“… stupid f_cking whore, that’s what you are, you think you’re better just because you’re in a white coat, but you’re a f_cking whore, a c_nt, you should go finger f_ck yourself and die, you stupid f_cking whore…”

Sometimes, I can’t help but laugh with amusement at the racism and sexism lobbed at me. Like that one time I was eating an egg custard in Chinatown in New York City. I was leaning against a brick wall, enjoying an afternoon treat; Asians of all shapes, sizes, and ages walked past me. A non-Asian man saw me from across the street, stopped, and shouted, “CHINK!” before resuming his stroll.

… but… but… you know we’re in Chinatown, right…?

Other times, like this most recent instance of the open van, I feel more troubled. I wasn’t fearful for my safety when the van sped past, though I was aware how things could escalate. I wasn’t going to stop doing my work when the man insisted I am a “f_cking whore”, though I wondered if others agreed with him, but just kept silent.

It’s toxic and it’s tiring.

People want and deserve a basic level of dignity. It doesn’t cost anything to be civil, to be humane. Why some people sacrifice humanity and civility to assert higher status, I don’t know.

Would these young men in the van have sang their racial slurs at me if they knew I spoke perfect American English? What if they learned I am trained as a physician? What if they learned I work in a jail and helped out someone they knew? What if they found out I like the same cookies they do?

Would the man who insisted that I am a “f_cking whore” have cared if I was able to help address his health concerns? What if I interacted with him in a way that was better than his past experiences with people in white coats? What if he and I shared the same concerns about the rising rents and gentrification in Seattle?

When groups of people—complex, complicated, multifaceted humans with thoughts, hopes, talents, and dreams—are reduced to a single trait, it’s easy to denigrate and dismiss them.

When our nation has an elected leader who reduces groups of people to a single trait—“rapists”, “[they] all have AIDS”, “grab them by the pussy”—then other ignoble acts don’t seem so bad. To be clear, indecency and baseness obviously existed before the current President. The expectation for public discourse, though, is now at a different set point.

Is it really that bad when someone repeatedly says “Konnichiwa!” to you in a sing-songy voice, even after you tell that person that you’re not Japanese? I mean, it’s not like that person was trying to ban all people of the Islamic faith from entering the United States.

Is it really that bad when someone says, “Wow, you speak English really well!” upon meeting you? That seems like nothing when the President got on stage and mocked a citizen with a congenital condition.

A close friend of mine provided counsel to me many years ago when I expressed distress to him about a personal issue.

“You don’t have to work on this problem every single day,” he said. “It’s a complicated problem that does not have an easy solution. It’s okay to take a break. It’s not like anyone can solve this problem quickly.”

When we grow weary from complicated problems like racism, sexism, incivility, and dehumanization, we must remember that it is okay to take a break. Not an indefinite break, but a break. It’s not going to make an enormous difference if you take a week off from fighting racism; that’s been going on for centuries. Stepping away from your efforts to stop dehumanization for a little bit doesn’t mean you’re weak; it just means you can rest and recuperate so you can sustain this work for the upcoming years.

Things often don’t change as fast as we want them to, but that doesn’t mean that they won’t change. We must maintain our own abilities and willingness to show humanity, civility, and kindness to ourselves and others. Only when we do that can we hope and work to ensure that everyone experiences dignity.