Categories
Informal-curriculum

Free Cheese and Extinction Bursts.

While at the grocery store, you hear a toddler beginning to protest. You see him straining to reach a colorful box of cookies. His grunts become piercing squeals as he looks at his father. Both of them know what he wants. Both also know that a tantrum is forthcoming if the child doesn’t get what he wants.

When is the best time to give the toddler a treat to avoid a tantrum?


You may already be familiar with “classical conditioning”. This is what people are talking about when they talk about Pavlov’s dogs. Dogs cannot help but drool when they smell food.

Pavlov rang bells when he presented dogs with food, so dogs soon learned that a ringing bell meant food was coming.

Pavlov then only rang bells without food. The dogs drooled anyway. To the dogs, the sound of the ringing bell was a signal that food was coming. Food was the original stimulus, but the bell took over that role. Drooling was the response.

“Operant conditioning” is a different form of behavior conditioning. It focuses on consequences, not on pairing involuntary responses with arbitrary stimuli.

In operant conditioning, the word “reinforcement” refers to increasing the likelihood that a behavior will happen. The “positive” in “positive reinforcement” refers to adding something to increase the chances a behavior will happen. It does not refer to something “nice” or “pleasant”.

The “negative” in “negative reinforcement” means taking something away to make it more likely a behavior will happen. Some examples will be useful here.

Say I meet one of Pavlov’s dogs and I want him to sit. One strategy I can try is to give the dog a small cube of cheese every single time he sits down. Because I know dogs love cheese, I am intentionally using cheese (stimulus) to increase the likelihood that the dog will sit down (behavior). The dog, in turn, learns that this person will offer FREE CHEESE just for sitting down! This delightful consequence shapes the dog’s behavior. The delivery of cheese to the dog is the addition of a stimulus, so this example is “positive” reinforcement.

“Negative” reinforcement is usually not as effective (or as fun) as “positive” reinforcement, but we can still use it to make it more likely this dog will sit. When the dog is doing anything but sitting, I yell at the dog. When the dog happens to sit down, I stop yelling. The moment it stands back up, I resume yelling. If the dog values quiet, then it will learn to sit down (behavior) to shut me up. The withdrawal of my yelling is the removal of a stimulus, so this is “negative” reinforcement. The goal is to get the dog to sit down.

So let’s return to the example above of the toddler who is on the verge of screaming in the grocery store. If the father wants to increase the likelihood that the child will be serene, when is the best time to give the little one a treat?


Sometimes positive reinforcers stop happening. Let’s revisit the dog who was the lucky recipient of cheese for sitting.

Maybe I run out of cheese, or I’m bored with giving the dog cheese for sitting down. The dog keeps sitting down around me because it is expecting the consequence of free cheese. However, I’m not giving the dog any cheese. What do we expect the dog to do?

This is a bit of a silly example, but chances are good that the dog will try harder to sit more to receive FREE CHEESE. Maybe the dog will sit closer to me. Maybe the dog will even sit ON me. It’s almost as if the dog is saying, “Hey, I’m sitting here! You’re supposed to give me cheese when I sit. Why aren’t you giving me cheese? Can’t you see that I’m sitting?”

This surge in behavior to receive the positive reinforcer is called “extinction”. After heroic efforts at sitting, the dog will eventually learn that no FREE CHEESE is coming. The dog will give up on sitting around me. The cheese (stimulus) has gone away, so the sitting (behavior) also goes away.


If the father wants to the toddler to stay quiet and serene, the best time to give the child his preferred cookies is when the kid is peaceful and chill. The child will likely experience the cookies as a reward and will learn that he gets cookies when he is NOT yelling or screaming.

If the father tends to give the child cookies when the toddler is about to have a tantrum, then the child learns that the best way to get cookies is to yell and scream.

If the father happens to read this blog post and realizes that he is reinforcing an undesired behavior, he may soon see “extinction” behavior from the child. The child may have a meltdown of epic proportions, the likes of which no one has seen, before learning that these tantrums won’t give him the consequences that he wants (cookies).


I’ve been writing about dogs and cheese and children and cookies, but this is actually about American politics and the results from the recent midterm elections. We should expect surges in behavior from the federal administration. Maybe these surges in behavior represent extinction behavior; maybe they represent retribution. (They could be both.)

If the model of operant conditioning is accurate here, then we can expect the behaviors to be more intense and frequent than what we witnessed before. This might mean even more outlandish comments about body parts, more cruel commentary about different groups of people, and more heinous actions that will harm US residents and others around the globe. The behaviors in extinction bursts always end, but they will be hard to tolerate while they persist. We must not give in, and we must not reinforce any bad behavior.

Categories
Nonfiction NYC Observations

Creation and Destruction.

During a recent visit to New York City I went to the Society of Illustrators. Despite living in the city for three years, I had never heard of this museum. The newest exhibit featured botanical art. Who doesn’t like to look at drawings of plants?

It’s a small museum on the eastern side of Central Park, surrounded by stately apartment buildings and schools. On the third floor is a bar and a handsome patio. Between the two on brick walls hang illustrations of plants. 

The drawings are astounding! These dramatic tulips, created from chalk and charcoal, look like a photograph. I felt certain I could reach out and pick up these gleaming red onions, even though they are simply watercolors on paper. 

I kept returning to the only two illustrations that featured decay. This persimmon leaf (scroll down) radiates warmth and life despite the signs of infection. 

My favorite from the collection is this autumn leaf, made entirely from just colored pencils. What?! How can colored pencils create such texture and vibrancy? I was pleased to learn that the artist, Crystal Shin, is from Seattle. No wonder the deteriorating leaf looked familiar; they regularly litter sidewalks and trails in October. Even now, I can’t believe that’s just a drawing.

Illustration of a decaying Pyrus calleryana leaf, which is mostly red and brown, with some green spots, along with black blemishes of decay.

After I moved on from this leaf, I stopped in front this drawing of wild blackberries, another common sight here in Seattle during the late summer. I heard an excited voice approach me: It was the artist, Catherine Park! She couldn’t believe that her piece was in the exhibition. “I’m so happy to see people looking at it,” she said, beaming. She was gracious enough to answer my question about how long it took her to create this. 

“Six months,” she answered with what sounded like mild disappointment. 

“Six months!” I exclaimed. That was far beyond my expectations.

Catherine then explained the process behind her work (which entirely aligns with what she said about the piece here). Her enthusiasm for light, detail, and the lifecycle of the blackberry made me smile. 

That chance encounter with a professional botanical artist was a potent reminder that creation takes time. Destruction is fast. Creating beauty—even the beauty in decay—takes time, planning, and energy. What a way to honor the fullness and blessings of life. The act of creating is time well spent.


“Do you know who Duncan Sheik is?” my spouse asked me. 

“Yes, of course,” I answered. It was unfair of me to expect him to remember my tastes in music before he and I met. 

“He died.”

“What?!”

So he must’ve had a sense that Duncan Sheik meant something to me.

His was the first concert I ever attended, somewhere in Los Angeles when I was in college. (I remember Paula Cole, who hopefully found her cowboy at some point, opened for him.) It’s true, I did like “Barely Breathing”, though I soon recognized that this pop song was an anomaly in his work. (His album, Humming, is what kept me a fan.) I ultimately bought five of his albums, which means Duncan Sheik was part of my life soundtrack for 12 years: College, medical school, and psychiatry residency. 

The New York Times obituary for him is syrupy. Sure, maybe he was “soft-spoken and cerebral”, but “heart-rending melodies” and lyrics “[brimming] with existential angst”? Really?

I will concede that the obituary writer’s comment resonated with me:

[Barely Breathing], along with so much of his work from the ’90s, really strikes a chord with my Gen X soul; it’s a reminder of that moment when we twentysomethings really did think that authenticity would rule the world…

To my ear, his layering of orchestral string instruments with guitars, electronic beats, and his voice naturally led him to composing music for Broadway. I haven’t seen any of them, but now hope to. 

I remember it was with great reluctance that I threw away the shirt I got from his concert. It had difficult colors: The shirt was brown with cyan text and featured his unsmiling face. After years of wear, the seams were unravelling and there were holes in the armpits.

Destruction is fast. I hope Duncan felt that his time creating music was time well spent. 

Categories
Homelessness Policy Public health psychiatry Seattle

Housing as the Most Effective Treatment.

(I know it’s been a minute since my last post. The announcement from HHS about “HHS, ONDCP, and HUD Launch First-Ever ‘Treatment First’ Toolkit to Combat Homelessness and Addiction” reminded me that I submitted the op-ed below at the end of June. The newspaper chose not to publish it, so I’m sharing it here. I’ll review the toolkit above next, though I have a feeling that I may reiterate what I’ve already written below.)


The Trump administration believes that mental illnesses and substance use disorders are the root causes of homelessness. Thus, HHS Secretary Kennedy recently announced funding for the Safety Through Recovery, Engagement, and Evidence-based Treatment and Support (STREETS) program. Because of the “unprecedented burden and impact of addiction and mental illness among the homeless population”, he asserted that this funding “aligns with President Trump’s Executive Order on Ending Crime and Disorder on America’s Streets”.

STREETS may help people with mental illnesses and substance use disorders, but it will not end homelessness. People need safe places to call home to recover.

The vast majority of people with mental illnesses and substance use disorders are not homeless. In Washington State, over 2.2 million adults have had any mental illness and over 1.4 million people over the age of 12 have had a substance use disorder in the past year. Compare these numbers with the 163,000 Washingtonians who are homeless. If we (incorrectly) assume that every person became homeless because of a mental illness or substance use disorder, that means over three million Washingtonians will lose their housing. This is wrong. Someone in a Mercer Island mansion drinks bottles of wine between meetings, just as someone in an Auburn apartment takes medication for schizophrenia before going to work. 

I work as a psychiatrist in Seattle with people who are currently and formerly homeless. Psychiatric conditions that are common in the general population, like anxiety and depression, are also common among those who are homeless. For many of them, housing is the most effective treatment. Having reliable access to one’s own bathroom and bed reduces stress. A lock on the door assures safety and security. 

Practically everyone who is homeless now has had a place to call their own in the past. Because of rising rents, reduced incomes, and the onset of health problems, nearly half of people becoming homeless for the first time are over the age of 50. With older age often comes increased physical and cognitive vulnerability. Anxiety and depression often follow. The loss of health and housing can tip people into major mental illnesses and substance misuse. 

In a minority of people, severe mental illnesses and substance use disorders are the primary drivers of their homelessness.  Because of their symptoms, they sometimes are unwilling or unable to work with traditional health care systems. Finding these individuals is often the hardest part of my job. I cannot build relationships and then offer treatment if I cannot find my patients. When someone has a stable and safe place to live, it is far more likely we will connect. Only then can people participate in care.

For those who are unable or unwilling to engage in outpatient treatment, civil commitment is the last option. Laws for involuntary hospitalization already exist. Every day, someone is hospitalized against his will. In many instances, this is lifesaving. However, recovery quickly unravels if people have nowhere to go when they are discharged from the hospital. It is hard to attend appointments, take medication consistently, and build a life you want to live when you don’t know where you will sleep.

To be fair, STREETS funding will help the health and wellbeing of some people, including individuals who are homeless. Prevention and early intervention work. Some people at risk of becoming homeless because of mental illnesses and substance use disorders will remain housed. However, psychotherapy and medications are often no match for the stress and chaos that comes with homelessness. Housing is health care.

RFK Jr. has shared his own history with drug use and depression. As far as we know, he never experienced homelessness. Having a stable place to call home was foundational to his recovery. He knew where he could go after attending 12-step meetings; he had a safe place indoors to read books by Carl Jung. Housing alone does not treat mental illnesses and substance use disorders. But treatment alone also doesn’t solve homelessness. People need both. 

Categories
Education Reflection

Seen Around the Internet.

Three recent items for your consideration:

Psychiatry in the Public Square. As if in response to my post asking for post suggestions, this essay appeared. The author, Adrian Preda, argues:

Psychiatry and mental illness remain inadequately represented in public discourse, and when they do appear, the representations are often partial, distorted, and repetitive.

He offers “four principles of engagement”:

Visibility. “Psychiatry needs to be present where the public already is—not only in newspapers and medical journals, but on podcasts, YouTube, social media, and the other platforms that increasingly function as people’s primary sources of health information.”

Correction. “When mental illness or psychiatric treatment is portrayed inaccurately—as they regularly are—psychiatry should react quickly, clearly, and constructively.”

Education. “Beyond correcting myths, psychiatry should proactively use media to provide practical, accessible information.”

Collaboration. “Psychiatry cannot improve its public presence by speaking alone.”

I am trying! (It is also true that I am ambivalent.)

Thanks to those of you who responded to my request for suggestions. I may not have the largest audience, but it seems that I have a devoted one. Thanks the gifts of your ongoing attention.

Drowning Doesn’t Look Like Drowning. Please be generous and share this. Here’s a 1:20 video that covers the same information, but it induces way more anxiety than the article.

“I Feel Good”: The Many Flaws of the Wellness Movement. Arthur Caplan is a giant within bioethics. This article is a book review, but he throws in plenty of grouchy editorial comments. His opinions about the wellness industry are clear.

He rightly points out:

… proponents of wellness have one thing in common—it is up to you to do something. Social determinants and economic conditions that drive health just don’t get much attention.

And even when it is up to you to do something, the wellness industry tends to gloss over the unsexy basics: Sleep enough. Eat just enough. Get outside and exercise every day. Cultivate and maintain relationships. These activities don’t sound as alluring as putting a stone egg in your vagina. (Look who’s grouchy now?)

Caplan closes his essay with sound and exhausting counsel: “Being well means taking steps to change your behavior and demanding the EPA go back to its mission of protecting you from pollution and environmental hazards.”

Categories
Uncategorized

Wanted: Your Suggestions.

Dear reader, what topics would you like me to write about?

Some of you have given me the gift of your attention for months, if not years. (Thank you!) I’m never sure what draws people back here to read my writing.

Now that I am clearly a “middle career” psychiatrist, I feel a duty to share what I know. This moment in time feels unstable. My professional niche seems atypical. It feels important to contribute what (little) I know in case it can help someone, somewhere. (Sharing what I know here also helps me improve my writing skills.)

So, I welcome your feedback and suggestions. What would you like to read here? What questions do you have? How can I be useful within this context?

Comments are open, so feel free to share your ideas there. You can also send me an e-mail at maria at mariayang dot org. If you’re reading this through the e-mail newsletter, you can reply to the e-mail.

Thank you!