Author: Maria Yang, MD

Categories
Education Observations Reflection

A Review of Inside Out by Pixar.

Like others, I saw the Pixar film Inside Out and I, too, recommend it. Drs. Keltner and Ekman[1. Paul Ekman is the guy who studies the expressions of emotions on faces and their universality.], the psychologists who provided consultation to Pixar about the film, were incisive about the point of the story:

“Inside Out” offers a new approach to sadness. Its central insight: Embrace sadness, let it unfold, engage patiently with a preteen’s emotional struggles. Sadness will clarify what has been lost (childhood) and move the family toward what is to be gained: the foundations of new identities, for children and parents alike.

The film demonstrated in colorful and delightful ways how emotions interact with each other; how memories are created, moved, and stored (the marble imagery was both beautiful and fun); and how emotions, thoughts, and behaviors can interact with each other. Parents may wish to bring tissue; all the adults around me (and me, too) audibly cried at least once during the movie.

If you haven’t seen the film yet, please note that the rest of this post has spoilers in it. You have been warned.

Some other observations of the film:

Like others, I didn’t like how Sadness was portrayed in the film. I do not protest that she was the color blue; I do wish she wasn’t portrayed as lumpy, lazy, and lethargic. (At several points in the film, Joy literally drags Sadness around.) While sadness can make us feel listless and inert, sadness often motivates us to take action. Sadness is ultimately redeemed in the film: The family becomes and feel more connected because of the introspection and action Sadness fosters. However, I don’t think Sadness should have been thrown under the bus in the first place.

It is also noteworthy that Sadness is portrayed as female. One wonders if Sadness would have been portrayed as lumpy, lazy, and lethargic if the character were male. Is this social commentary on the perceived “moodiness” of women?[2. Just to be clear, I do not equate “moodiness” to “depression”. Others sometimes do.]

Of course, sometimes a cigar is just a cigar.

The “leader” of the emotions in the mother’s head is Sadness (looking sharp in a business suit, no less!). This choice may have been a foreshadowing device: The mother demonstrates skillful parenting in the film, which hints at the organizing power of sadness. This again suggests that sadness has value and helps us connect with others in meaningful ways, as parents or not.

The film uses the model that thoughts occur as a consequence of emotions. Emotions come “first”. Champions of cognitive therapy[3. Related: Cognitive behavioral therapy may be losing its effectiveness over time. One complaint many people have had about CBT is that the process can feel invalidating: “So… you’re just saying that I think the ‘wrong’ things. If I only thought the ‘right’ things, then I wouldn’t feel this way. So you’re saying it’s all my fault. Thanks a lot, jerk.”] would disagree with this: They would argue that thoughts always precede emotions, even when we have no idea why we feel the way we do.

This is one of many hypotheses about our internal experiences. Other models concur with the film’s assertions that emotions have primacy; our behaviors and thoughts can be consequences of what we feel. I believe that they are ultimately all related and each can have primacy, depending on the circumstances.[4. This isn’t entirely related to the primacy of thoughts, but someone, who I now can’t remember, said something pithy like, “Who are you between your thoughts?”]

There are delightful visual puns in the movie. One that I thought could use elaboration was the “train of thought”. The train in the film didn’t serve much purpose other than as a literal means of transportation for the emotions. Pursuing more meaning in the train may have derailed the film, so I understand why the train of thought was left as a train. It, however, might have been an opportunity to explicitly describe the interactions between thoughts, emotions, and behaviors.

I do recommend the film to adults and children alike. It offers a refreshing counterpoint to the messages we usually get from society about sadness (e.g., feeling sad means that there’s something wrong with you; you should try to avoid feeling sad as much as possible; etc.). When we embrace those emotions we often want to avoid, we learn more about ourselves, what steps we can take next, and the value of our internal lives. Pixar does an excellent job of teaching us these lessons in a fun and colorful way.

Categories
Lessons Observations Reflection

Truths from Glacier National Park.

This is St. Mary Lake from Glacier National Park in Montana:

WGI

My time in the great outdoors reminded me of these truths that I often forget:

The world is much bigger than any of us. Those mountains have existed for much longer than we have and will continue to do so long after we are gone. While it is true that even mountains will one day disintegrate (… and glaciers will melt and inland seas will evaporate…), they will persist much longer than any of us.

What a way to put our problems and worries into perspective!

When we die (a detail we all neglect to remember), none of this stuff will matter. We shouldn’t get too attached to what we do or what the outcomes are. Those mountains, glaciers, lakes, and forests were doing their thing long before we were born… and they will continue to do so after we die. We are lucky to be here to experience all this stuff, but, in the grand scheme of the universe, we are mere blips in time.

Life is ephemeral, so appreciate The Moments while you can. We’re those people who are out on the trails before 7am. The morning light only shines for a few minutes, so you must appreciate the soft glow it casts across the sky, mountains, and valleys when it happens. You also know that you can’t stay on top of the mountain and look at the spectacular vista forever. And you realize—maybe with some sadness—that the camera cannot capture the colors, textures, width, and energy of the scene.

So you appreciate it for what it is… and then you let go of it because you must. There’s a lesson in there about gratitude and grace.

People take care of things. People who venture into the great outdoors are all there for the same reason: We want to see the grandeur and beauty of nature. And these people come from all over: They have different hair, eye, and skin colors.[1. To be clear, though, the vast majority of people we saw while hiking were white people. This is not a new observation. While no one at Glacier asked me if I can speak English, people at other national parks have. White People Love Hiking. Minorities Don’t. Here’s Why.] They speak in different accents, languages, and dialects. They dress in different styles and carry different accoutrements. They nonetheless make eye contact and greet you. They warn you about potentially dangerous wildlife up ahead. They take care of things for you: They don’t pick the wildflowers so you can see them. They pick up their trash so you don’t have to. They stay on the trail to prevent further erosion of the earth.

People can do ugly and violent things. People can also do beautiful and kind things, and not just in national parks.

The world is a beautiful place. Much of the world’s beauty arises from imperfection. Mountains are jagged, lakes are non-uniform shades of blue, glaciers have irregular borders and rough surfaces, trees are bent and twisted in strange ways, boulders are shattered into coarse rocks, and clouds have different textures as they stretch across the sky.

Nature is non-uniform, random, and imperfect—and therein lies its grandeur. Is it the same with us? In society we want “perfection”, whatever that is, but the very nature that we find so beautiful and breathtaking is all imperfect.

May you soon have the opportunity to remember those truths that you know you forget.

Categories
Consult-Liaison Medicine Observations

Chart Notes.

While reviewing old chart notes, I frowned as I learned how distressed the patient had been while he was in the emergency department. Without realizing it I murmured a line from a physician’s note:

Rambling historian, only clear complaint is hunger.

A colleague, who is often hungry, overheard me and responded, “That would be my mental status exam.”

A different chart provided this information:

Patient started getting agitated and threw a bagel at staff.

I couldn’t help but snort with amusement[1. All of us who must write clinical notes often dilute details because they’re often not relevant to clinical care, though these details often add context to what happened. Like the writer of this note, I often include factual details without intending to be funny. Sometimes we laugh because we otherwise would feel overwhelmed with sadness, anger, or helplessness.], though then wondered:

  • Was it a whole bagel?
  • Was it an old, stale, and hard bagel?
  • Did the bagel have cream cheese on it?
  • Was it thrown like a frisbee or like a baseball?
  • Did the bagel actually hit anyone?
  • What happened that led the patient to throw the bagel?
  • Did the patient elect to throw the bagel instead of an open carton of milk? or a single serving of jelly?

Yet another chart included this terse note from a medicine resident in the early hours of the morning:

Interval exam changes. Agitated overnight. Double middle finger to providers. Haldol 5mg IV ordered and given.[2. For those of you who are interested, Haldol 5mg IV equals Haldol 10mg PO (by mouth), which is a standard dose for someone with a diagnosis of schizophrenia. The thing about Haldol 5mg IV is that sometimes doctors order this with the intention of inducing calm in a patient so he doesn’t punch staff, destroy property, hurt himself… but, sometimes, the patient instead becomes sedated and is in a deep sleep for many hours. The goal should be to calm, not snow, the patient.] PRN Ativan.

One would hope that a patient doesn’t receive a sedating antipsychotic medication simply for extending both middle fingers to doctors and nurses!

Categories
Homelessness Nonfiction Observations Seattle

Street Scenes.

The woman walking in front of me on the sidewalk was wearing a short skirt and a sleeveless blouse. After stepping out of the street he readjusted the strap of the large duffel bag on his shoulder and began to drift towards her. Uneven stubble covered his face and his hair stuck out in several directions.

“Hi,” he said, smiling with both his eyes and lips. “How are you?”

She swept past him without turning her head. Unfazed, he then saw me.

“OH, COME ON!” he exclaimed, his voice more delighted than annoyed. He clearly recognized me.

As he continued to grin at me, I offered, “Hi.” I know you, too…

“Hi! How are you?” he greeted, his voice warm and his eyes bright.

“Fine, thank you. How are you?” You were one of my patients, but from where…?

“I’m good, thanks. It’s so nice to see you!” Neither one of us stopped walking, though he slowed down just as I began to cross the street.

I waved good-bye to him. He waved back.

Oh! I last saw you in jail! You thought you were a machine! You told me that everyone could read your thoughts! You shouted at the walls of your cell—

—and how much better you look now![1. The moment someone changes out of a hospital gown or a jail uniform into casual clothes he will immediately look more healthy, independent, and dignified.]

My father was telling me a story as we walked past the corner store. I’m not sure if he saw the man approach me.

“Hey, can you spare some change?”

Turning my head with a small smile and looking at his face, I said, “No.”

“Oh, hey now,” the man said, starting to walk next to me. He then reached out and stroked my arm. “I just want to touch you.”

“DON’T TOUCH ME!” I shouted, still walking. The man stopped. My father, taken aback, looked at the man over his shoulder, though remained silent.

“Go on,” I said lightly to my father, who then did. However, I didn’t hear anything he said. Did that actually just happen?[2. In my years of working with people who are homeless it has been rare for anyone to touch me. This includes people who were actively psychotic or acutely intoxicated. Furthermore, when people have touched me, it was within the bounds of social convention: We shook hands, gave high fives, bumped fists. Hence my alarm after this man touched me.]

The yellow sign on the fence reads: “Illegal activities and loitering not permitted.”

Within the confines of the fence are at least ten tents arranged in a half circle. Some are reinforced with several layers of duct tape. Others are covered with blue tarps.

A small barbecue grill, round and uncovered, is in the center of the circle.

A freeway ramp is on the other side of the fence. Trucks with 18 wheels, cars running on electricity alone, clunkers painted different colors, sleek sedans with round logos, and vans carrying kids, groceries, sporting equipment, and DVDs roll past.

The camps have grown this year.

Categories
Observations Reflection

Some Thoughts on Equus.

I saw the 1977 film Equus this afternoon at the recommendation of some friends. Some of my reactions:

– Had this scenario—a young man believes that horses are gods, which ultimately drives him to stab out the eyes of six horses—occurred in present day he most certainly would have received antipsychotic medication for a presumed psychotic disorder.

(All of the hugging, acting out, night sessions, etc. also would not occur in present day. At least one would hope not.)

– In a monologue near the end of the film the psychiatrist comments:

Passion, you see, can be destroyed by a doctor. It cannot be created.

Indeed! More than one person has shared with me that, while taking psychotropic medication, they don’t feel like “themselves”, their emotions feel muted, they feel “numb”, etc. Certainly medications are not the only agents that can destroy passion: Consider the potential violence in societal expectations, cultural norms, and other social structures.

Only the gods know where passion comes from. People have tried to thwart the gods for as long as we’ve been around.

– In another monologue the psychiatrist notes:

The Normal is the good smile in a child’s eyes. It’s also the dead stare in a million adults. Both sustains and kills… like a god.

Much of the film focuses on the idea of “normal”. Though most people don’t believe horses are gods and experience sexual ecstasy when riding one, everyone has their own penchants that others will find disturbing or peculiar. Most of us have learned to mask these proclivities from public view.

A few times a year people will ask me, in my professional capacity, if I think they are “normal”. While there are a variety of reasons why people ask me that, what often underlies this inquiry is the belief that I can distinguish between “normal” and “not normal”.

Can I just say—I’m sort of joking, but not really—that psychiatrists shouldn’t be the arbiters of “normal”? As a population, psychiatrists are a weird group of people.[1. You will note that I wrote “As a population, psychiatrists are a weird group of people.” To be clear, I didn’t add “as a population” to suggest that I, as an individual, am three standard deviations less weird than the average psychiatrist. I’m weird, too.] Some of the strangest social interactions I’ve experienced have been with psychiatrists… and we all knew that we were all psychiatrists. On more than one occasion I’ve wanted to exclaim, “Why are we so awkward? Can we please just be actual people right now?”

– There’s a lot of violence in the story. I refer not only to the actual stabbing of the horses’ eyes. I refer to the lies about the “truth serum”, the hypnosis and medication administration that seems to occur without consent, the father’s reaction and shame related to his son’s attendance at the “skin flick”, the dreams the main characters have.

Sometimes what we think is kindness is actually violence.

– There’s a bit of dialogue before the climax of the film that goes like this:

Martin: Where are you now, Alan?

Alan: Cabbages, with the moon on them.

I’m pretty sure that Alan’s response is meant to add a rustic, romantic touch to the scene. What do I do? I laugh out loud.

– I don’t recommend the film, though I’d like to see a theatrical production. The monologues of the psychiatrist are noteworthy, though I couldn’t understand much of them until about halfway through the movie.