Author: Maria Yang, MD

Categories
Nonfiction Observations Reflection

Grief.

Shortly after my mother died, a coworker asked me about grief: “What does it feel like?”

I remember looking at her and feeling confused. What does it feel like…?

Words like “terrible”, “awful”, “really sad”, and “numb” didn’t seem quite right. Elements of all those adjectives were true, but none of them captured the fine texture of grief.

“It feels like… a really bad breakup,” I finally said. As the words came out of my mouth I realized that wasn’t quite right. It was also an inane comparison.

“Huh,” she answered.

Nine months later, I found words to describe my grief: It feels like my heart is falling.

During moments of stillness, those spaces between exhalations and inhalations, I feel my heart physically dropping. It is an endless fall; there is no bottom.

I remain surprised with how close to the surface the grief lives. I don’t cry when I talk about my mother’s death. Yet, when people ask me about her, I feel my face scrunching up the way faces do when people are about to cry. The sensations in my face remind me of that week she was in the hospital, when I smiled during the day and wept at night, asking God and the Universe questions that nobody could answer.

Though the tears do not come, my face suggests they will. And I know that the person listening to me sees it. It’s like when you blush: You feel your cheeks flash with heat and hope that the other person won’t make fun of you for it.

Emotions always shift, though: Sometimes, in my mind’s eye, I set an imaginary table and place a pot of steaming tea and two cups on it. I invite Grief to sit down and have tea with me. Grief never declines. I ask Grief how it is doing. Grief never says anything in response, but we sit in silence and enjoy our tea together. When Grief is ready, it leaves.

And then I notice that my heart is no longer falling.

Almost 11 months have passed since my mother died. Since I found words for my grief, my heart doesn’t feel like it is dropping as often. Maybe the time I needed has elapsed; maybe the sensation of my heart falling doesn’t overwhelm me as much as it used to.

Maybe by showing Grief some kindness and acceptance with imaginary tea it has also shown kindness to me.

Categories
Medicine Observations Policy Reflection Systems

On “Mental Illness”.

I’ve been invited to speak to a group of attorneys who work at the interface of psychiatry and the law. The topic of my talk? “Psychiatry 101.”

A psychiatrist who gave this talk to a similar group a few years ago advised me: “You should assume that lawyers are laymen. It’s surprising how little they know, given the work that they do.”

This teaching opportunity to teach has given me pause: What is mental illness?

Most of my work has been with people with few resources (no home, no job, etc.) or with people who are experiencing symptoms that cause significant distress (they won’t eat because they think all food is composed of their internal organs; they often try to kill themselves due to hearing voices telling them to do so; etc.). Most people would agree that these individuals have “mental illnesses”, whether “caused” by their circumstances (imagine people trying to set you on fire or rape you because you are sleeping outside) or by apparent biological events (imagine a freshman in college with an unremarkable history who, over the course of months, begins to believe that the government inserted a chip into his brain).

I have also worked in settings where:

  • a wealthy man’s wife felt overwhelmed with anxiety about which of their three homes they should remodel first
  • a aerospace engineer with no symptoms wanted to try an antidepressant because his girlfriend started taking one and she now seemed to have greater clarity of mind; “maybe that will happen to me, too”
  • a college student felt depressed because his parents wanted him to pursue a professional degree, but he didn’t want to do that

Do those individuals have mental illnesses? Does psychological suffering equate to mental illness? Even if they are able to get on with the necessary details and difficulties of life?[1. Do not misunderstand: People with means can and do have mental illnesses. Take the software developer who was certain that public surfaces were contaminated with exotic diseases; he couldn’t get himself to go to work or spend time with friends due to fears that he would get sick and die. Or the accountant who, if she doesn’t sleep enough, would believe that she is the mother of God; she went to hospitals insisting that she was in labor with Jesus when, in fact, she was not pregnant.]

My mind then spins to recent events, such as the Germanwings place crash. Many people have argued that, because the co-pilot killed people, he was mentally ill. He apparently had a diagnosis of depression, but I agree with Dr. Anne Skomorowsky that a diagnosis of depression alone does not explain why he committed mass murder.

But if he was mentally ill, what diagnosis would best describe his condition? What do we call it when people kill other people? Is that behavior alone sufficient to say that someone is mentally ill? If so, what do we make of:

  • soldiers killing other people during war
  • gang members who, without provocation, shoot police officers or other gang members
  • suicide bombers
  • parents who kill their newborn infants because the babies aren’t the parents’ desired sex

Does a person’s intentions affect the definition of “mental illness”? (How good are we at reading the minds of others? We often assume intention when observing behavior. And those assumptions can be way off.) Does the situational context also affect what a “mental illness” is? (When in Rome, do you do as the Romans do? What if you don’t know what Romans do?)

People have surmised that people who kill other people may have conditions such as antisocial or narcissistic personality disorder. However, these designations are still problematic: Not everyone with those personality disorders kill people.

Perhaps this is why I prefer to work with people who demonstrate behaviors that undoubtedly impair their function.[2. It is easier for me to work with people who demonstrate clear evidence of “impairment in function”. Part of this is due to the greater ease and clarity in diagnosis: If someone’s symptoms are within the spectrum of normal human experience, then diagnosis is unnecessary. Part of this is also due to treatment: Some interventions in psychiatry—specifically medications—are not benign. Furthermore, it is unclear how some—many?—psychotropic medications work. We first must do no harm.] I am reluctant to describe most people as “mentally ill” because some behaviors that people find bizarre have helped the person cope with their circumstances. The people who always wear masks or scream on the street? Those behaviors may have somehow protected them in the past—even if it means that the general public derides them for being “weird”. It seems unfair to say someone is “ill” when what they have done before in the past has given them some degree of protection. (To be clear, I don’t necessarily apply this formulation to people who have committed murder. For example, I can’t think of how flying a plane into a mountain could ever be an adaptive coping skill.)

Words matter. I’m not sure that I have more clarity yet about what I should teach, though it is clear that I should focus on how I phrase the information I present.

Categories
Nonfiction

What Goes Around Comes Around.

As my father and I stepped out of the crosswalk onto the curb, I looked up and saw John Doe. I didn’t realize who he was until we had already passed each other.

A baseball cap was on John’s head and a colorful satchel was slung across his torso. He had rolled up the cuffs of his jeans with care and his unbuttoned jacket revealed the bright sweater he wore underneath. He was looking down at the street.

My dad continued to talk to me; he didn’t hear me exhale with relief when John kept walking.

John had asked me to step closer to the door of his cell so he didn’t have to speak as loud.

“I didn’t break her windows, I didn’t set any fires, I didn’t kill her dog, I never said anything scary to her,” John said, his eyes fixed on mine. He smiled at me through the cell window. “You believe me, right?”

The police report stated that several witnesses had seen John smash her windows, set a small fire after he broke down her door, and attack her dog.

I said nothing.

“It doesn’t matter what she said,” he continued. “She lied. What goes around comes around.”

I followed my dad up the small set of stairs that led to the glass doors of the restaurant. When I glanced up, I saw John’s reflection in the glass: He was standing near the base of the stairs, his eyes fixed on me.

My dad looked over his shoulder at me as he approached one of the glass doors. “The food here is supposed to be good.”

“Uh huh,” I replied, my eyes still looking at the reflection in the glass. I placed a hand on my father’s back and gave him a gentle push. Go faster, go faster. John lingered for a few moments before he turned back to the sidewalk.

My dad opened a door and smiled at me. I smiled back. He didn’t hear me exhale with relief when John walked away.

Categories
Nonfiction Observations

Undercover.

My husband was in the aisle seat, I was in the middle seat, and The Man was in the window seat.

The Man had one white earbud in his ear; the other one was dangling in his lap. His right thumb swiped through several screens of his smartphone in less than a second. He heaved a sigh.

“This is f*cking lame,” he muttered.

The plane was supposed to take off 15 minutes ago. At that time the captain had announced that the plane had technical difficulties, but he anticipated that we would be up in the air soon.

The minute hand continued to sweep its arc across the clock face; soon we were 55 minutes behind schedule. The Man spoke into the microphone of his white earbuds:

“Hey, it’s me… yeah, we haven’t taken off yet… yeah, we were supposed to take off like an hour ago…. This f*cking airline sucks… Whatevs….”

The captain picked up the intercom phone. The Man mumbled something and then pulled the earbud out of his ear.

“I’m sorry, folks,” the captain said. “I thought that we could get this situation under control, but we can’t. The plane’s indicators are telling us that the nose isn’t in neutral position, even though other instruments and external measurements say that it is. I can’t risk flying this plane like this. Safety comes first, so we’re going to switch planes. I’m sorry, folks. The flight crew will tell you where to go shortly.”

Quiet murmuring moved through the cabin.

“F***********CK!!!” The Man screamed.

Then he punched the wall of the plane.

Silence filled the aircraft. I could hear The Man breathing.

I forced myself not to turn my head. My husband also kept looking straight ahead.

“I’m sorry that you have to start working,” my husband said, though his lips did not move and no sound came from this mouth. It was a telepathic message. I sighed in response.

I looked over my shoulder. The people seated behind me were staring at The Man with alarm. A flight attendant about five rows away shot a dark look at The Man, but did not move closer.

Don’t reinforce bad behavior, I reminded myself, wondering if I should say something. I didn’t have enough information at this point to know what to do next. Do I ignore him? Do I pretend that nothing happened? But what if he escalates his behavior because no one is acknowledging his distress? But what if he punches me if I ask him what just happened?

I glanced at him. The Man was chewing on his fingernail. His leg was bobbing up and down. The single earbud was back in his ear.

Okay. Go.

“It’s really frustrating, huh,” I said while grabbing the personal belonging stowed under the seat in front of me. If he tried to hit me, at least I could throw my bag at him.

“Yeah! This sucks!” he exclaimed. The woman in front of him turned her head a few inches to look at him. She swiveled her head back around. “I fly back and forth across the country every week and it’s been a sh*tty week and I just want to get some sleep tonight because I have an 8am meeting tomorrow and I usually fly a better airline and this is just f*cking ridiculous.”

“We all just want to get to where we want to go….” I kept my bag on my lap.

His leg stopped bobbing and he pulled the earbud out of his ear.

“Yeah. I mean, I guess this f*cking plane problem doesn’t happen a lot, but why this plane? At the rate we’re going we won’t get into Seattle until 1am.”

My husband’s posture relaxed as The Man shared his duties as the Vice President of Something Important at The Company Where Important People Work. His Important Boss was expecting A Very Important Report. No one seemed to understand how difficult this Important Report was; it was hard for him to get the Important Report done given all of his other Important Duties.

The Man slumped back into his chair and sighed.

“… but, I guess the most important thing is that we get there safely, right?” he said. He flashed a warm smile at me. I smiled back at him. My husband demonstrated an extraordinary fascination with the contents of his bag.

“So, hey, what do you do for work?” The Man asked.

I paused.

“Oh, I do stuff for the county.”

His phone chirped. The Man looked down and his thumbs began to tap out a message as he mumbled, “Oh, that’s cool.”

Categories
Homelessness Nonfiction

Shame.

I was sitting in a seat that faced sideways. Scenes of the city flashed past as the train sped to the airport. I looked down and adjusted my bag so it wouldn’t slip off my lap.

When I looked up, he was seated across from me. He had a small smirk on his face.

“Hey,” he said. His eyes glanced at my bag, then returned to my face.

“Hey.” I knew his name, but did not say it.

“Where are you going?”

“To the airport.”

“For work?”

“Yeah.” It was mostly true.

“I’m going to the airport, too. Trying to get back home.”

The blue sleeping bag was sliding off his lap. He grabbed it as it unfurled onto his dirty white sneakers. His tee shirt was too large for his slender frame: When he leaned forward to stuff the sleeping bag back onto his lap, the neckline drooped. He ran a hand through his hair to push the long locks out of his face. The blue-purple bags underneath his eyes suggested he did not rest in the sleeping bag the previous night. Though red wisps surrounded his blue irises, he didn’t look intoxicated.

He was coming off of heroin when he first became my patient. Cranky and bellicose, he snarled, “Leave me the f-ck alone—you’re asking too many f-cking questions.” After eating a few meals, taking a shower, and getting some sleep at the crisis center, he spoke: His father, whether drunk or sober, beat him; his mother tried to kill herself three times in their home before he was ten years old. His uncle introduced him to marijuana when he was 11; he dropped out of school at age 16. He worked in construction when could get work; he sold drugs when he couldn’t. He eventually got his GED at age 19; he worked in welding, landscaping, and carpentry. He saved enough to buy a motor home when he was 25; his mother succeeded in killing herself in his motor home shortly thereafter. He fled the state and into the arms of drugs for comfort. He slept under bridges and dug through trashcans for food. He and I met about six months later.

“Can I use your phone?” he asked.

“I’ll help you when we get to the airport.”

He looked disappointed. Turning to a man sitting nearby who was using his thumbs to send a text message, he said, “Hey man. Can I use your phone? It’ll be a short call.”

“Oh, no, it’s not personal, I don’t let anyone use my phone, sorry, it’s not personal, it’s just my personal policy—”

“It’s okay. I get it.”

He looked up at the ceiling and sighed. It had been a few days since he had shaved.

The second and third time he came through the crisis center he asked the nurses if I could be his doctor.

“YO DOC!” he shouted at me the last time he was there.

I shot him a stern look and murmured, “Shh!”

He turned the baseball cap so it sat askew on his head. He winked at me. “I’m feeling better. It’s gonna be all right. I’m gonna try to pick up work in construction and save up money so I can go home. The city’s too big here. I can’t be using dope if I wanna buy a plane ticket.”

The doors of the train slid open. No one who entered captured his interest. Leaning forward over his sleeping bag, he said, “The sun’s coming out. You know what happened since I—”

“Have your tickets ready,” the fare police barked. Two of them had stepped into the car moments before the train doors closed.

His shoulders slumped. He looked down.

The fare police scanned my ticket without a word, then asked to see his ticket.

He dug around both pockets of his pants. His sleeping bag slid to the floor. He fished out a ticket stub and handed it to the fare police.

“This isn’t a current ticket.”

He looked down.

“Do you have another ticket? A current ticket?”

“No, sir—”

“You can’t ride the train for free. Everyone who rides the train needs to buy a ticket.”

“Sir, I’m sorry—”

“It doesn’t matter that you’re sorry. Hey, I think I’ve seen you before. We’ve had this conversation before, haven’t we?”

He said nothing. He began to stuff his sleeping bag back onto his lap.

“Do you have money to pay for a ticket?”

“No, sir—”

“—I’ll cover his fare,” I blurted.

He looked at me.

“Thank you, miss, that’s very nice of you,” the fare officer said. Turning to him, he said, “You’re lucky that this lady here is willing to pay your fare.” Without asking me for any money, the fare police then walked on.

He and I sat in silence for the rest of the train ride to the airport. I glanced at him a few times; he was looking out the window. It looked like he was gritting his teeth.

When the train arrived at the airport, he cradled the sleeping bag underneath his arm and squeezed through the mass of people to get out of the train first. He walked with haste to the descending escalator; he was stepping off of it as I was stepping on.

As he walked towards the terminal, he looked up and scanned the crowd. He saw me looking at him. He held my gaze, then turned away before disappearing into the airport.