Author: Maria Yang, MD

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Funding Homelessness Nonfiction NYC Policy Reflection Seattle Systems

God’s Work versus Meaningful Work versus Value.

Every now and then, when some people learn what kind of work I do, they say, “You’re doing God’s work. Thank you.”

They mean well, so I accept the compliment, though I also tack on, “I also like what I do. It’s meaningful work for me.”

So many of the people I see, whether in my current job or in my past jobs working in other underserved communities, have a lot going on that psychiatry and medicine cannot formally address. One example is housing. It is often an effective intervention for the distress of people who don’t have a place to live, though housing is not something physicians can prescribe. However, there are individuals who are eligible for housing, but do not want to move into housing for reasons that do not make sense to most people. For example, in New York I worked with a man who would spend his days sitting in front of the building where he once worked before he became ill. He talked to himself and burned through multiple packs of cigarettes. He did not recognize how soiled his clothes and skin became with time. At night he disappeared into the subway tunnels and rode the trains. He did not want to move into an apartment until he was able to get his job back, even though he hadn’t worked there in over ten years. With time (nearly two years!) and unrelenting attention, our team was able to persuade him to try living indoors. He eventually accepted the key and moved in.

There are other active conditions that I do not have the skills to treat: Sometimes it’s institutional racism; sometimes it’s multiple generations of poverty. Both prevent people from accessing education, housing, and other resources. Do some of these individuals end up taking psychotropic medications due to the consequences of these systemic conditions? Yes. Do I think they’re always indicated? No.

Most of my jobs have been unconventional: I worked on an Assertive Community Treatment team that often provided intensive psychiatric services in people’s homes. I worked with a homeless outreach team and did most of my clinical work in alleys, under bridges, and in public parks. I worked in a geriatric adult home and saw people either in my office, which was literally the storage room for the recreational therapist’s stuff, or in their apartments if they were uncomfortable seeing me in the storage room. I was recruited to create and lead the programming for a new crisis center whose goal was to divert people from jails and emergency departments.

And now I work in a jail.

As time progresses, it has become clear to me that I have not had the typical career for a psychiatrist. I like that. However, I often also feel out of touch with my colleagues. I believe that they are all trying their best, but they don’t have the time to see how systems end up failing the most vulnerable and ill in our communities. They work in the ivory towers of academia and don’t seem to realize the dearth of resources—financial, administrative, academic—in the community. They work in private practice and don’t seem to realize how ill some people are and how we need their expertise. They work in psychiatric hospitals and seem to believe that some of these individuals will never get better when, in fact, they do.

Because much of my work has been outside of the traditional system, I consider myself fortunate that I have been able to escape the box of simply prescribing medications. Many of the individuals under my care do not want to take medications. Their desire to not take medications, though, doesn’t stop us from working with them. We meet them where they are at and remember that they are, first, people. As we are in the profession of helping people shift their thoughts, emotions, and behaviors, we believe that there will come a time—maybe soon, but maybe not for weeks, months, or years—that something will change. Just getting someone to talk to us becomes the essential task. This is true whether someone is in a jail cell, living in a cardboard box under a bridge, or residing in a studio apartment.

Should systems pay psychiatrists to do this work? Maybe it’s not “cost effective” because of its “low return on investment”. After all, this task of “building rapport” means psychiatrists aren’t working “at the top of their licenses”. If a psychiatrist is able to get people to talk to her and help them shift their behaviors, whether or not that involves medications, does that have value?

Does the psychiatrist’s efforts have value if it helps the “system” save money?

Is there value if it reduces the suffering of these individuals who have had to deal with police officers, jails, and living on the streets due to a psychiatric condition?

Perhaps my idealism blinds me. One of my early mentors in New York City often said, “I want the guy who lives under the Manhattan Bridge to have a psychiatrist who is as good as, if not better than, the psychiatrist who has a private practice on Fifth Avenue.” I couldn’t agree more.

Categories
Observations Policy Reflection Systems

Pondering the Purpose of Policies.

What’s your policy on wearing pants?

We all have a personal policy about pants. My policy is that I shall wear pants on all days unless (a) I am attending a special event where a dress or skirt is indicated or (b) it is a hot day and I must wear something professional, so a dress or skirt is the cooler option.

Hang in there with me. This isn’t actually about pants.

I’ve been chewing on the purpose of policies. Much of my work life is dedicated to the creation and amending of policies for a system.

It makes me feel disappointed to see that policies often cater to the lowest common denominator. They seem to solely focus on preventing undesired behaviors and outcomes. It’s almost as if policies are written for those people or organizations, whether they exist or not, with the worst intentions.

Policies aren’t inspiring. They don’t talk about what could be or what we should strive for. This might be why we find policies tedious to read.

A colleague pointed out that, yes, policies are for the lowest common denominator because people often have the worst intentions.

“Think about the Ten Commandments,” she said. “Like ‘Thou shalt not kill’ and ‘Thou shalt not steal’ and ‘Thou shalt not commit adultery’. Those are really basic things, but we need them. Those are policies to help us get along.”

Indeed, those religious prohibitions are not inspiring. What if we rephrased them? What if we said “Thou shalt honor life” instead of “Thou shalt not kill”? Doesn’t the idea of honoring life inspire more creativity and joy than a fearful instruction to not kill?

I think my colleague would reply that people need explicit directions. A exhortation to honor life does not guarantee that people will stop killing.

In his book Practical Wisdom, Barry Schwartz laments how policies can affect our abilities to do the right thing the right way. If we rely on policies, we ignore the nuances of the situation and stop thinking. When we stop thinking, we lose our wisdom. We end up looking to policies to prevent the worst thing from happening. The prevention of the worst thing, however, does not equal the creation of something better.

Call me naive—you won’t be the first—but I believe that, for most people, they meet the expectations you have of them. If you have high expectations, people will often meet them. (To be clear, there is a balance: Most expectations must be realistic. If they aren’t, people become demoralized.) It’s meaningful to people when they realize that someone believes in them when they may not believe in themselves. High expectations are frequently a form of respect.

(Perhaps I am straying. A significant difference between individual expectations and policies is the relationship. Relationships between people rely on invisible things like trust, hope, and respect. Relationships between organizations rely on visible things like contracts, memoranda, and policies. We often don’t feel like we have total control over what we do as individuals. How can an organization, comprised of potentially hundreds of people, control its behaviors to meet the expectations of another organization without those invisible connections?)

Someone on Twitter recently commented that policies should reflect the morals of the organization. I like that. If policies focus on documentation requirements and payment arrangements, but say nothing about the quality of services, what does that say about the organization? Does a mission statement have any meaning if the policies and procedures do not align with the stated mission? If the policies only comment on how to prevent the worst thing from happening, why would anyone expect extraordinary quality from the organization?

Perhaps I need to reframe, for myself, the purpose of policies. Policies help prevent bad things from happening. That’s good. Prevention is underappreciated: It’s difficult to measure things that didn’t happen. The difficulty in showing that less bad things happened, however, doesn’t mean that the activity of prevention is worthless.

It’s not an “either/or” issue. Policies prevent bad things from happening, which is valuable. But, as I noted above, preventing bad things and creating better things are two different activities. We don’t want to focus our energy on just preventing bad things from occurring. We must also create new things, or we otherwise will not progress.

The primary reason for my personal pants policy is comfort, though there are professional implications, too. Much of my work in the past involved talking to people in atypical places: Sometimes I’d have to step over puddles of mud to talk to the man living in the park; sometimes I’d have to slip between towers of yellowed magazines to reach the elderly woman seated on her bed. These days, wearing pants makes it less likely that male inmates will make unwelcome comments about my legs. Pants prevent bad things from happening to me.

My other clothing policy is to wear bright colors or patterns to work. People—colleagues, patients, strangers—often comment on the shirts I wear, frequently while smiling. That helps build rapport and connections, even if they are initially based on something as superficial as polka dots on a shirt. These relationships, though, often help create better things and situations for us all.

Categories
Education Nonfiction Reflection

Primary and Secondary Emotions.

I used my left arm to stop the tears from rolling off my cheeks and onto the lotus root. Had I known that Act One of episode 597 of This American Life would make me cry to the point that I would have to wipe the snot from my nose multiple times with my arm, I wouldn’t have listened to it while making a lotus root salad for a party.

People warned me that my grief about my mother’s death would continue to fluctuate with time. It had been many months since I last cried; how was I to know that learning about the wind telephone in Japan would induce such a reaction?

Perhaps my grief wasn’t my own. My father’s older brother recently died.

“I’m glad I could help with the funeral arrangements for him,” my father murmured to me. “I went through all that just three years ago, so I knew what to do.”

I nodded. He sighed.

“He was my older brother. It was still a shock.”

I looked away. He didn’t need to see his daughter trying to hide the sadness from her face.

I first learned about “primary” and “secondary” emotions while learning dialectical behavior therapy. Marsha Linehan points out that there is

a distinction between primary or “authentic” emotions and secondary or “learned” emotions. The latter are reactions to primary cognitive appraisals and emotional responses; they are the end products of chains of feelings and thoughts. Dysfunctional and maladaptive emotions, according to Greenberg and Safran, are usually secondary emotions that block the experience and expression of primary emotions.

Some (corny) examples are helpful here:

Primary emotion: “All right! I did well on that test! I feel happy about my performance!”
Secondary emotion: “But wait! I still missed some items on the test. I feel ashamed that I felt so happy about how I did. It’s not like I got a perfect score.”

Primary emotion: “I can’t believe she did that! Who does things like that, anyway? I feel angry.”
Secondary emotion: “Maybe I’m overreacting about her. I don’t want people to think I’m a b!tch. I’m disappointed that I can’t control my moods better.”

Not much time has to pass between the primary and secondary emotions. In fact, sometimes people experience only the secondary emotion. The experience of the primary emotion gets lost, even though the primary emotion reveals useful information about the situation and how the person relates to it.

Infants and children experience and express primary emotions. We become acquainted with secondary emotions as we age.

Primary emotion: I feel sad about the death of my mother. I witnessed how her death affected my father, who lost his companion of forty years. There are things that only my father and I understand; we can’t talk about those things with anyone else because they just won’t get it. I feel sad that he is at that age where multiple loved ones are dying because their time has run out. I feel sad when I consider the loneliness he must feel at least some of the time.

Secondary emotion: God willing my father dies before I do: No father should outlive both his spouse and child. Of course I will feel grief when he dies. Will it be worse than the grief I felt when my mother died? What if it’s too much grief? What if I don’t have the mettle to tolerate it?

What will I do when my only option is to use a wind telephone?

Categories
Consult-Liaison Education Medicine Policy Systems

Online Screening for Depression?

Inquisitve reader Amy asked me if I had any opinions about online screening for depression. The British Medical Journal recently published a debate on this issue.

What an excellent question, Amy! I read the opposing arguments and these are my thoughts:

First, I see two different issues. The first is whether the 9-question Patient Health Questionnaire (PHQ-9) is an appropriate tool to use to screen for depression. The second is whether the public should trust Google to administer the PHQ-9.

Before I do delve into that, though, let’s take a step back and consider the purpose of screening tools. Screening tools help physicians figure out how much more we should learn about a person. For example, asking for a person’s biological sex is a screening tool. The moment I learn that the person before me is female, I will ask her questions about menstruation and pregnancy history. I’ll skip those questions if the person is male. Similarly, if a person tells me that he smokes cigarettes, then I will ask more questions about how much and how often he smokes, what he gets out of smoking cigarettes, and if he thinks smoking causes him any problems. This helps me assess potential risks to his psychological and physical health. It also helps me assess if he has any interest in changing his smoking behaviors. Screening tools help us sort and gather information to generate diagnoses and interventions.

The literature states that the PHQ-9 was developed both to diagnose and measure the severity major depression. The PHQ-9 was modeled after the criteria for major depression in DSM-IV. Thus, the problems with the PHQ-9 for diagnosis are the same as the problems with the DSM for diagnosis: Context is completely missing. The authors of DSM argue that the situation and underlying causes of major depression don’t matter; they state that the presence of certain symptoms determine whether the diagnosis applies.

Long-time readers know my refrain: Context does matter. Major depression is “comorbid” with many other psychiatric conditions, meaning that someone experiencing the symptoms of major depression often experience symptoms of other psychiatric conditions. For example, bipolar disorder, by definition, includes episodes of major depression. People with diagnoses of post-traumatic stress disorder (PTSD) and schizophrenia often experience major depression. Some people who take drugs, whether prescribed or obtained from illict sources, experience symptoms of major depression. Sometimes the symptoms of major depression are actually due to a medical condition, such as certain cancers, infectious diseases, or thyroid conditions.

There are several papers that make the case that the PHQ-9 is a useful tool in the screening for and diagnosis of major depression. Given that major depression is comorbid with other conditions, a positive PHQ-9 result is useful to help get people into care. A professional can then help clarify symptoms, determine possible diagnoses, and suggest treatment and other interventions. Recall that the purpose of diagnosis is to guide treatment.

Here is where we get into the second issue as to whether the public should trust Google to administer the PHQ-9. Most task forces agree that there is no point in performing screening tests if you can’t do anything with the results. If you can’t refer someone with a positive PHQ-9 result to a professional who can clarify diagnosis and provide treatment, then why bother? You’re potentially causing more problems and distress for the person seeking help. Thus, the question is whether Google will direct people with positive PHQ-9 results to helpful resources.

There is a shortage of psychiatrists and other mental health professionals in the US. One wonders if an online depression screening tool will lead people to believe that they are “majorly” depressed, when they are not. They will then seek services that are hard to find. If these individuals are able to get into primary care services, those medical professionals may not be able to determine if someone has depression because of bipolar disorder, or depression due to the recent death of a loved one. Wrong diagnosis often results in wrong treatment or overtreatment. Recall that we should first do no harm.

However, it is clear that people seek information about depression and other psychological experiences on the internet. The questions on the PHQ-9 can educate the public about the differences between major depression and having a sucky day. The more information and education we can provide to the public, the more empowered the public can feel about not only what isn’t going well, but also what they can do to improve their health and wellness. I do not view my work as a psychiatrist as a guild secret. The more understanding and communication we have in our communities, the more we can address our psychological health on individual and societal levels.

The other reaction I had to that BMJ debate was related to a comment that Dr. Duckworth made under “attitudinal barriers”. He noted that a “key reason may be that people with mental health conditions perceive that they do not need treatment. Studies show that they report attitudinal barriers to seeking care much more often than structural or financial barriers.”

I don’t see how the PHQ-9 is related to “attitudinal barriers”. Screening tests don’t reduce stigma. Sure, people may avoid treatment for depression because they don’t know that they are depressed. However, I suspect that more people avoid treatment for depression because of the stigma associated with psychiatric conditions and treatment. If we want to reduce and remove “attitudinal barriers” related to depression, we must help share stories that remind everyone that people with depression are, first, people. The PHQ-9 is not a means to that end.

I don’t know the workings of Google well enough to comment more about whether we should trust Google to administer the PHQ-9. Others with more knowledge about online security, marketing, and data mining can say more about whether Google will use PHQ-9 results for good or evil… or both. There are likely other unintended consequences that I don’t know or understand.

Thanks for the question, Amy!

Categories
Nonfiction Observations Reflection

A Thousand Years.

I recently had the opportunity to visit two places in New Mexico: Chaco Culture National Historical Park and the Very Large Array.

The Chaco Culture National Historical Park features now ruined pueblos that people built over a thousand years ago. Construction started on Pueblo Bonito, a structure that archaeologists believe contained over 600 rooms, around 850 AD! Additions and revisions occurred on Pueblo Bonito for the next two hundred years. There are ruins of other pueblos in the area; some of them are now crumbling walls that have succumbed to the eroding powers of the desert winds and blazing sun.

Petroglyphs and the orientation of these ruined pueblos suggest that the people who lived in or visited Chaco appreciated their relationship with the celestial universe. A sun dial, located on a butte that is no longer open to the public, reflects their observations of the equinoxes and solstices. People, then and now, witnessed the directional relationships the buildings have with the stars.

The Very Large Array, on the other hand, was constructed over forty years ago. The 27 enormous dish antennae, arranged in a Y configuration, sense radio waves coming in from the universe. These antennae function as a giant “eye” and funnel the signals they receive to a supercomputer. Scientists analyze data from this supercomputer to describe events that have occurred in the universe: Stars exploding, the birth of new stars, and the location of black holes.

The antennae are arranged in straight lines, which are in stark contrast to the curves and shapes of the surrounding mountains and clouds. Such straight lines do not occur in nature—even trees are not so rigid.

What if Chaco and the Very Large Array serve the same purpose?

What if Chaco was an effort to better understand the universe and what was in it? The Very Large Array gathers data from invisible radio waves; Chaco collected data from visible waves from the sun, moon, and stars.

If people excavate the Very Large Array a thousand years from now, what will they think? Will they look upon the Very Large Array with the same wonder that we feel when we look upon Chaco?

I have noted before that death is the great equalizer. It puts everything in perspective.

In a thousand years, who will know your name? That thing you’re worried about now: Will it matter in a thousand years? Your creations—children, music, writings, meals, home improvements, tweets, laws, relationships—what impact will they have in a thousand years?

To be clear, I am not saying that what we do now has no importance or value.

There are things we do now that have huge significance and meaning. Sure, that kind act you do today won’t enter the annals of history. However, that same kind act will make the world an easier place for someone who is suffering now. Maybe the melody of that song you wrote will fall silent once you die, though it brings joy now to someone who delights in music. What you do now may not last forever, but that shouldn’t stop you from doing those things. What you do matters.

And maybe the remnants of something you create will still be around a thousand years from now. If that is the case, consider how your creations can inspire and humble the people of the future. The mysteries that you want to understand now may still be mysteries hundreds of years from now.

Someone said this a thousand years ago, and someone else will say this a thousand years from now. This is a reminder for us all today.