Author: Maria Yang, MD

Talking About Suicide.

Post author By Maria Yang, MD
Post date July 8, 2017

I was recently asked to speak at a community event about youth suicide. Several young people in the area had killed themselves in the past few months to years. This was an opportunity for the community to learn and talk about suicide and suicide prevention.

My role was to provide a professional perspective on and information about suicide in young people. There was also a panel of people between the ages of 16 and 19 who shared their perspectives about suicide. The youth panel was the most compelling aspect of the evening.

The audience was comprised entirely of adults. Most were probably parents; others were adults who often interact with young people, such as school administrators and police. The youth panel encouraged the audience to talk to the young people in their lives about death, dying, and suicide. The panel also spoke about the importance of showing that they, as adults, care about young people. They shared their experiences in how talking about suicide with their peers has given others hope and saved lives.

One girl shared an anecdote that involved a teacher who inspected the wrists and arms of students prior to a test. He wanted to ensure that students didn’t have accoutrements on their arms that could contribute to cheating. This girl said that she felt anxious about rolling up her sleeves because of the scars on her wrists and arms from cutting. What would her teacher say or do?

When he inspected her arms, he undoubtedly saw the scars. His response? “Okay, good. Nothing on you that will lead to cheating.” And that was it. He never spoke to her about what he saw; he never asked her how she was doing or what the injuries were on her arms.

What did she take away from that? “He cared more about whether I was cheating than about me staying alive.”

The fresh candor of young people inspired some adults to comment on their own perspectives of suicide. One man, hands stuffed into the pockets of his jeans and voice deep and gruff, shared, “I’m a veteran. I also come from a generation of men who just don’t talk about suicide, even though a lot of veterans come home from war and commit suicide.”

The contrast was striking: The young people sat on the stage, the lights on their faces, and spoke about death and suicide without fear or self-consciousness. The adults sat in the shade of the auditorium and shifted with unease, gasped with sadness, or shook their heads when they heard the youth talk about their peers dying.

I do not believe that there was anything anomalous about this group of young people. Youth want to talk with adults about death, dying, and suicide. They want relationships with parents and other parental figures where they can ask questions, share their worries, and learn how to navigate the difficulties in life so that they can live another day. They also are sensitive to the burdens that adults already experience; sometimes they don’t share their thoughts, worries, dreams, and fears with us because they don’t want to cause us more distress. Because they automatically assume that any conversation about death and dying will cause distress in adults.

I created a short handout with suggestions about how to talk about suicide with young people (hint: these suggestions work with adults and older people, too). It also has phone numbers to call, online chats to access, and websites to view for more information about suicide prevention.

There is no evidence to support the fear that talking about suicide—particularly in a thoughtful, caring way—will increase the likelihood that people will kill themselves. In fact, talking about suicide directly can help people change their minds about taking their lives.

Here’s the requisite link to the National Suicide Prevention Lifeline, which is an excellent and literally lifesaving resource. However, I encourage all of us to talk with each other, within our own communities—even if it is “only” the community within our homes—about death, dying, and suicide. We don’t have to talk about it all the time; we don’t have to ask each other, “Are you thinking about killing yourself?” every day. The more comfort we have with talking about how we are doing, what we’re thinking about, and what death means to us, the more we can support each other when the difficulties, problems, and failures in life occur.

Observations Reflection

It’s Okay to Get Angry.

Post author By Maria Yang, MD
Post date June 22, 2017

It was my first job as a physician. I was 32 years old.

In that job I functioned as a psychiatric consultant. Thus, while I had clinical expertise, I didn’t have formal authority at any of the places I worked.

I can’t remember now what exactly happened: Someone said or did something that vexed me. It made me worry about how staff might (mis)treat patients. But who was I? I didn’t work for that agency; I was only there two days a week.

“I don’t feel like I can say anything,” I sighed to my boss.

My boss took a sip from his drink and leaned forward on the table.

“Maria, it’s okay get angry,” he said. “Sometimes you need to let people know that you’re angry.”

When we’re young, we often don’t believe that we can contain our anger. And, in some ways, that’s true: We don’t contain our anger because it is unfamiliar to us. There are different flavors of anger: Sometimes it simmers just beneath the surface of our skin while the flames roar in our ears. Sometimes it explodes and tears, words, and fists fly from of our bodies. When we’re young, these flavors are novel and strange: What is happening? What am I supposed to do with this? It’s empowering and overwhelming and frightening all at the same time.

We also don’t believe that we can contain our anger because we often don’t know how. It’s a skills deficit. Our anger propels us to do different things because anger is uncomfortable. We say (or scream) things. We break things. We cry. We bury it within us. We focus the energy of anger into other things. We avoid it.

As we age, we get to know our anger because it keeps coming around. There’s no way to avoid it, though that doesn’t stop us from trying. Most of us recognize the different flavors over time; we even learn what flavor we prefer.

Many of us also learn that our anger won’t destroy us. The sharp edges of anger cause us pain, yes, but we know that the edges will become dull and the pain will recede. That never happens as fast as we wish; we grumble with annoyance and impatience as the days, weeks, months—maybe even years—pass. The anger burns, but its flames do not kill us.

We also learn that when we share our anger with others, whether we intend to or not, we often make ourselves vulnerable. Those who must work or live with us learn what our buttons are and how we react when they press them. Sometimes our distress makes them laugh at us. Indeed, there are people who will use the vulnerability within our anger against us. Many others, particularly those who care about us, learn more about who we are and appreciate us more, despite our anger.

Not only does our anger let other people know who we are, but it also tells us who we are, too. Sometimes we don’t like what we learn about ourselves when we’re angry. Other times, our anger reminds us and reaffirms what we value.

And sometimes you need to let people know that you’re angry so they learn what matters to you.

Informal-curriculum Nonfiction Reflection

Bias.

Post author By Maria Yang, MD
Post date June 4, 2017

“I’ve been alive for too long,” he sighed. “I will be 200 years old in two months and four days. I was born in 1817, you know.”

“200 years is a long time,” I replied. While he wasn’t 199 years old, the wrinkles around his eyes, the knobbiness of the knuckles on his hand, and his slumped posture made him look older than his actual age.

“I’m an angel,” he continued. “I do what I can to help people, as that is my mission from God.” His thin frame quivered as he coughed into the crook of his elbow. “God sent me down from heaven 200 years ago. People are drawn to me. Animals are drawn to me. They know that I can help them. I give away my food, I give away my cigarettes, I give away my marijuana. God gives me instructions about how to best help people.”

“Would you miss God’s voice if it went away?”

The Angel bit his thin lip before responding. “Maybe.” He looked worried.

“You seem to appreciate the guidance,” I said, though we both recognized that I was actually asking a question.

“Sometimes God says helpful things,” the Angel answered. “Sometimes… not.”

He shared that sometimes demons speak to him, too. They whisper and shout amidst his thoughts, pointing out how his efforts are useless, that no one cares, that there is no value to his life.

“What has stopped you from killing yourself?”

The question had barely left my lips before he answered, “It’s a sin.”

The cases of beer helped to mute the voices of God and the demons, which often became a cacophony when the light of heaven was gone. No, he didn’t think that the beer was hurting his liver; maybe it was even helping it.

“I didn’t get the hepatitis from drugs,” the Angel offered. “I wasn’t feeling good, I was sick. The doctor tested me and said I had hepatitis. He told me that I had to tell anyone I was having relations with. When I told the lady I was seeing at the time, she said, ‘You got that from me.’ I wish she had told me that sooner. I would’ve used protection if I had known that.”

The Angel didn’t know when he was getting out of jail. We discussed what treatment would best help him. When I asked if he had any questions for me, he shook his head.

“Feel free to come back any time to talk,” he said with the same polite manner he showed for the half hour we spoke. He bowed his head.

You can look up an inmate’s charges on the internet. It’s public information. You won’t learn what specifically happened that resulted in the arrest, but you will learn the alleged reason for why the person is in jail: Robbery. Assault. Failure to appear for court. Theft. Domestic violence.

I don’t seek that information before I meet my patients in jail. If patients start sharing their understanding as to why they’re incarcerated, I stop them. My duty is to the patient, not to the court or the attorneys.

When I first started working in the jail, I looked up the charges for all of my patients, as that information has the potential to help with clinical care. What I saw quickly dissuaded me from doing this on a routine basis.

It is uncommon for a man of the Angel’s age to be in jail. Yes, he was reporting and demonstrating psychiatric symptoms, but they alone did not explain why he captured the attention of law enforcement. Why would a man with his gentle manner and feeble condition be in jail?

Failure to report: sex offender.

The Angel had two convictions: One for Rape, the other for Indecent Liberties With Forcible Compulsion. These occurred years apart.

“Sometimes God says helpful things,” the Angel answered. “Sometimes… not.”

Informal-curriculum Lessons Medicine Nonfiction Reflection Seattle

Crossing Streets.

Post author By Maria Yang, MD
Post date May 28, 2017

I didn’t mind that I had to wait to cross the street. The yellow-white light of the Spring sun shimmered in the infinite depths of the lapis lazuli sky. The afternoon breeze lifted the fragrance of sweet flowers over the concrete and fluttered the short sleeves of my summer blouse.

Then I heard a man. He seemed to aim his voice, full of gravel, towards me.

“WOOOO WHEEEE!” He chuckled. “Lawd have mercy!”

ignore him don’t turn your head ignore him don’t look ignore him stay still

My peripheral vision saw his tall figure approach me before I heard him: “Doctah!”

okay he is probably talking to you take a breath

I turned. Though his pants, tee shirt, and jacket were all too large for his frame, it was a stylish look on him. His baseball cap was on backwards and pinned his dreadlocks away from his face.

“How you doin’?” he greeted, his smile revealing several missing teeth. He extended his right fist, a wordless invitation to extend my fist for a bump.

“So what are you supposed to do when you see your patient out in public?” We all looked at the professor with great expectation.

“What do you think?” (Of course a professor of psychiatry would answer a question with a question.)

“Well, you want to respect the patient’s privacy, so you probably shouldn’t say anything.”

“But what if your patient sees you first? And says hi?”

“It seems rude if you don’t say hi back. But if your patient is with another person, that could get awkward fast. What if the other person says, ‘How do you two know each other?'”

“I’d probably go out of my way to avoid my patient. I’d cross the street or something.”

“But that’s weird, too. Your patient might wonder why you’re avoiding them.”

“Or my patient might appreciate that I am keeping the boundaries clear.”

“If my patient said hi to me first, then I would probably say hi back and then try to get away as soon as possible.”

“What do you think they do in smaller communities? Doctors and patient see each other all the time when they shop for groceries and stuff.”

“That might be embarrassing: I don’t want my patients seeing me in sweats when I’m shopping for food.”

“Why are we assuming that patients would want to talk with us in public, anyway?”

The group reached a consensus: If you see your patient, but your patient doesn’t acknowledge you, don’t acknowledge them. You have a duty to keep things confidential. If your patient says hello to you first, be a person and say hello back, but keep it superficial and brief. And the next time you see each other, ask the patient how s/he would like to proceed in the future if you two run into each other again.

“I hope I never run into my patients,” someone mumbled.

The most memorable patient run-in I’ve had in a public setting occurred on a bus.

I was sitting in the back half of a double-length bus. Most of the seats were occupied and a few people were standing in the aisle. The grassy trashy odor of marijuana wafted from the rear of the bus. A young woman, who was under my care several times at a crisis center, and a young man boarded the bus. She saw me first.

“Hey! Doctor! How you doing?” she shouted at me. I nodded back at her. The older woman sitting next to me shot a glance at me, then sighed.

The young woman grabbed the young man’s hand and pulled him down the aisle. The two or three people ahead of them had no place to sit, so they halted and turned around. The young woman was thus about six feet away from me; she couldn’t get any closer.

As the bus lurched into motion, she leaned around the two or three people and raised her voice over the rumble of the engine: “Hey, Doc! I’m doing better these days! I haven’t been to the crisis center in like a month!”

“That’s good,” I replied. Maybe this will be the end of the conversation.

“I still take the Seroquel and Depakote now,” she continued. “Those meds really help. I take them every day.”

There was no street for me to cross. Okay, I guess this is really happening.

“But the meds are expensive! I want to keep taking them, but they cost a lot. Do you know where I can get meds for cheap?” Her eyes were eager.

The older woman sitting next to me heaved another sigh and closed her eyes.

Okay, if we’re going to do this, let’s really do this, then. I took a deep breath.

“Target has a four dollar list and those medications might be on that list. So, best case scenario, each medication will only cost $4 a month. Costco also has medications for cheap, sometimes medications that aren’t on the Target list. You don’t need a membership to use the pharmacy there.”

“For real? I can get medications at Costco without being a member?”

“Yeah. It’s a good deal.” Maybe someone else on the bus can use this information, too.

“Okay, cool. Target and Costco. Thanks, Doc!” She turned to the young man and began planning where they would get food for dinner.

As I stepped off the bus a few stops later, she called, “Bye, Doc! Thanks again!” I smiled and waved.

“Hi!” I said to the man with the gravel in his voice. you look familiar but how do I know you jail yes you were my patient in jail and what is your name what is your name wow you look so different but of course you do because you’re wearing regular clothes and you’re smiling and you’re outside on this beautiful day

I extended my right hand. We bumped fists.

“I’m doin’ real good, Doc. I take my meds every day and I live here.” He pointed to the handsome brick building down the street. “I ain’t picked up in a while and I’m takin’ care of myself. Things are good, Doc.”

“I’m glad to hear that.” I smiled.

“How you doin’?” he asked again, the gravel rattling in this throat.

“I’m well, thank you.”

“Well, you have a blessed day and you take care of yo’self!” He laughed and pointed at me while he walked away.

The white walking man appeared on the traffic light. I crossed the street. I was still smiling.

Blogosphere Random

Four Items.

Post author By Maria Yang, MD
Post date May 7, 2017

Four items, the first of which is self-promotion:

A medical student interviewed me on UC Irvine’s independent, underground radio station. Kyle runs the radio program Monkeywrench, which “features music from across the punk spectrum and interviews with activists, artists, musicians, and organizers working to create a better world in Orange County and beyond.” He asked thoughtful questions about my past work with underserved populations and my current job in the jail. You can listen to the interview here.[1. The internet has connected me with interesting, thoughtful, and intelligent people who hold a variety of perspectives. Start a blog; you’ll be pleasantly surprised with who you meet and what you learn.] Then wish Kyle good luck as he starts his fourth year of medical school!

The remaining three are articles I recently read that are related to psychiatry:

The Nightmarish Online World of ‘Gang-Stalking’ (hat tip: Brock)

Gang-stalking victims describe “complex systems” financed by the US government, employing “civilian volunteers, government agents, contractors, and often dangerous ex-convict felons” to harass people. Gang-stalking functions as a nexus for further conspiracy.
John Hinckley Left the Mental Hospital Seven Months Ago

On June 21, 1982, a jury found Hinckley not guilty by reason of insanity for shooting and attempting to kill President Ronald Reagan in a display of romantic devotion to the actress Jodie Foster, who was then 19. Now, after 34 years in residence at St. Elizabeths Hospital, a public psychiatric facility in Washington, D.C., John Hinckley is home.
Deadly Decision: Malheur County murder suspect feigned insanity for 20 years to avoid prison (hat tip: Scott)

Available records establish that Montwheeler ran a medical con for 20 years, insisting to a string of state psychiatrists and psychologists that he was mentally ill. He did so to evade state prison, where he would be sent if he was convicted of kidnapping his first wife and son in Baker City in 1996. Because he was found to be guilty but insane, he was treated as a patient instead of a convict.