Category: Education

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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.

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Education Homelessness Observations Reflection Systems

Do People Choose to be Homeless?

One of the things we talked about during dinner was whether people choose to be homeless.

“Yeah, it seems like some people want to be homeless,” he said.

“No… I don’t think so,” his friend replied.

They looked at me.

I cannot speak for all people who have ever been homeless. However, I have several years of experience working with people who were homeless and refused housing again and again[1. When working within a housing first model, the goal is to give people housing without any expectations that people will participate in mental health or substance abuse treatment. The goal is really just to get them inside.], as well as people who left their housing and returned to the streets.[2. In my experience, people who leave housing usually return to street homelessness. Most do not return to the shelter system.]

Thus, I believe that people who are homeless do not want to be homeless. They usually have concerns about the housing offered to them.

Here are some reasons people have shared with me when I have asked them why they don’t want housing:

I can’t move in anywhere. I have to stay outside. The aliens say that if I move in anywhere, they will exterminate me. I’ve already been exterminated three times. I don’t want to get exterminated again.

I don’t want to live inside. It never feels safe. Bad things happened to me when I’ve been inside. It’s too hard to get away.

But I don’t need your housing. One day my boss will hire me again–I was really good at my job–and when I start working again I can pay for my own apartment. (This man, for years, sat on the sidewalk across the street from the building where he said he previously worked.)

There’s too many rules: Curfew at 10pm? No guests? What if I want to bring a lady friend over? Nope. Don’t want to deal with all that.

I know that place. There’re too many people using dope. I know what’s gonna happen if I am around that crowd. I’m trying to stay away from all that.

That place? Isn’t that where all the crazy people live? No, thank you–I don’t want crazy neighbors.

If I could move in without giving my name or social security number, then, yes, I’ll move in. But people keep asking me for personal information and I don’t know what the government will do with that.

So, the reasons people give generally fall into three categories:

  1. People want freedom and don’t appreciate the constraints of rules.
  2. People are concerned about their safety within the building. These reasons may or may not have any basis in reality.
  3. People may feel some guilt or shame related to the housing (whether they deserve it, what it would mean if they moved in, etc.).

It’s hard for those of us who have a stable place to live[3. One consequence of working with people who are homeless is that you never stop giving thanks that you have a place to live. You don’t have to worry about where you’re going to sleep that night. You don’t have to worry that someone might try to rob you or set you on fire. You don’t have to worry about the police picking you up simply because you have nowhere else to go. These are the things we all take for granted.] to understand why some people seem to “choose” to live outside. Sometimes people point to Maslow’s hierarchy of needs and ask, “But isn’t housing a physiological need? People need water, food, and shelter. Why would someone ignore this basic need?”

Yes, shelter is a basic need. However, people who live outside can and do meet their basic needs, including shelter. They sleep in abandoned buildings, underneath bridges, in tents, in covered doorways, in wooded groves, in bus shelters, etc. These are not ideal places to live, but they’re sufficient.

No one wants to be homeless. What they want is psychological safety. For those individuals who decline housing, sometimes the need for psychological safety will override what seems like the “logical” choice of accepting housing.

People continue to astound me with their resilience. When people resist housing for years, though, it makes me wonder what happened to them that resulted in this resilience.

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Consult-Liaison Education Medicine Observations Policy Systems

Buprenorphine and Other Controlled Substances.

I recently completed the buprenorphine waiver training. Buprenorphine, itself a partial opiate, is a medication that can be prescribed to patients who have opiate use disorders (e.g., taking Oxycontins or injecting heroin to get high). A physician must complete an eight-hour training and take an exam to become eligible to prescribe this medication. The physician must then apply for a specific “X license” through the DEA to prescribe it.

In some ways treatment of substance use disorders is the most evidence-based practice in psychiatry. When talking about opiate use disorders, for example, we can talk about specific mu-opioid receptors and their roles in pain and intoxication. We can discuss how drugs—both illicit and licit—work on these receptors and why certain medications can reduce or eliminate illegal drug use. This logic satisfies the analytical mind.

Since completing this training I have wondered: Why must one undergo a specific training and obtain a separate DEA license to prescribe buprenorphine?

With my current licenses I could prescribe all forms of pharmaceutical morphine (e.g., Oxycontin and Dilaudid), which can lead to severe physical and psychological dependence. Which could then result in the intervention of buprenorphine.

As a psychiatrist I would likely arouse the suspicions of the DEA if I prescribed opiate medications. That’s outside the scope of a psychiatrist’s practice.

However, it is not outside of the scope of a psychiatrist’s practice to prescribe benzodiazepines (e.g., Valium and Xanax), which are Schedule IV drugs (“a low potential for abuse relative to substances in Schedule III”).[1. You can learn more about controlled drug “schedules” on the DEA website.] I can also prescribe Schedule II drugs (“high potential for abuse which may lead to severe psychological or physical dependence”), such as Adderall and Ritalin. Physicians are not required to go through any special training or obtain separate licenses to prescribe those medications. Once I got my DEA license, I was free to prescribe these without anyone looking at me askance.

And, get this: buprenorphine is a schedule III drug!

The training offered the Harrison Narcotics Tax Act of 1914 as one reason behind the training requirement: This law suggests physicians can prescribe opiates as part of “normal” treatment, but not for treatment for addiction. Addiction was not considered a disease in 1914. Thus, if addiction is not a disease, no intervention is indicated.

That explanation, however, doesn’t make sense. There is growing consensus that substance use disorders are diseases. Nothing, other than my good judgment, prevents me from cranking out prescriptions for stimulants and benzodiazepines. Use of either medication can lead to addiction. What makes opiates so special?

The consequences of the buprenorphine training are not slight: The eight-hour training alone likely deters some physicians from pursuing it. The extra licensure is also an obstacle, as well as the consequences of using the license: No one wants regular, but unannounced, DEA audits (which, just to be clear, doesn’t happen with when one prescribes benzodiazepines or stimulants). No one is eager to maintain the documentation that is required when one prescribes buprenorphine.

It just makes me wonder what the actual story is….

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Education Lessons Medicine Nonfiction Reflection

We Want to See Them Better.

When he and I first met he told me that he had a doctoral degree in psychology, was the CEO of the jail, and could speak 13 languages. To demonstrate, he said, “Hong tong ching chong lai tai!” He then punched the door to his cell and shouted, “GET THE F-CK OUT OF HERE, B-TCH!”

I did.

The next week, he answered my questions about the pencil drawings on his walls.

“My name is John Doe,” he said, the words spilling out of his mouth. “You all think my name is Peter Pan, but it’s not. It’s John Doe. See my name up there?” He pointed at the “John Doe” he had written in two-foot high letters on his cell wall. “That’s my name. My people call me John Doe. I am the leader of all the people. I am the leader of all the Asians. I am half-Asian.”

Nothing about him looked Asian.

More weekly visits occurred.

“I can speak 13 languages,” he said again. “Tingee tongee tai tai—;”

“You’re making fun of me,” I interrupted.

“I’m not,” he said, smiling. I’d never seen him smile before.

“No, I’m pretty sure you are.”

“I’m not. Aichee aichee—”

I walked away.

“Hey! I’m a doctor! I own the jail! I CONTROL ALL OF THIS!” he shouted at me.

I kept walking.

One week I was trying to speak to a man in a nearby cell. John Doe was shouting: “The police are pigs! They don’t know anything! I hired all of them! I own them!” His vitriol bounced off of the concrete surfaces of the cell block; I couldn’t hear anything but his reverberating voice.

“Excuse me,” I said to the man. John Doe was still shouting when I arrived at his cell door. He fell silent.

“Could you please not yell for ten minutes so I can talk to another guy here?”

He nodded.

“Thank you,” I said, returning to the man.

Two minutes later, John Doe started yelling again. I sighed.

“That John Doe—he really pushes my buttons. I don’t know what it is about him—people have said and done much worse things, but there’s something about him….” I said in exasperation to my colleagues. “I mean, I know he’s ill, but…!”

He declined to take medications. He followed his own prescriptions of daily showers, three meals with extra fruit if he could get it, and daily bodyweight exercises. He rarely slept.

Another week the same situation occurred again: I wanted to talk to another man in the same cell block as John Doe, who was shouting.

John Doe stopped yelling when he saw me approach his cell.

“Could you please not shout for ten or fifteen minutes so I can talk to another man here?” I asked, resisting the urge to shout at him.

He nodded. I didn’t say “thank you” this time.

I completed my interview with the other man. John Doe remained silent the entire time. I was surprised.

“Thank you for not yelling. I appreciate it,” I said to John Doe on my way out. He nodded.

As I walked out of the cell block, I heard him shouting again.

More weekly visits occurred. John Doe still declined to take medications. He stopped speaking to me in faux-Asian languages, though would occasionally speak in gibberish that I did not understand. He stopped shouting whenever he noticed that I had entered the cell block.

“You’re not a real doctor,” he said one day. “You must be a nurse.”

“What makes you think that?”

“You’re a woman. Women aren’t doctors. Maybe you’re a clinic assistant. A really smart clinic assistant. But you’re not a doctor. Women can’t be doctors. I’m the president of all the doctors and hospitals. I own all the hospitals and jails—”

“Okay. Is there anything I can help you with today?”

A few weeks later, John Doe was no longer in jail. A judge declared that he wasn’t competent to stand trial due to his psychiatric symptoms. He went to the state hospital to receive treatment.

More weeks passed. He eventually returned to jail once his competency was restored, but he didn’t return to psychiatric housing. My colleagues who evaluated him upon his return, however, shared news about John Doe with enthusiasm.

“He’s taking meds now and he’s better. He’s polite. He answers questions. He doesn’t talk in fake languages. He doesn’t shout. I mean, he’s not warm or friendly and he doesn’t talk much, but he can hold a conversation. He’s definitely better.”

“What?” I exclaimed. “Are you serious?”

I wanted to see him. I wanted to see him better.

Despite that, I never did: He would not have found my visit therapeutic or helpful. The only person who would have felt better after that visit was me.

One of the greatest rewards in health care is helping and seeing people get better. This is particularly true when people have severe illnesses. We want to see them better. It gives us hope that other people who have comparable symptoms—symptoms that scare us, worry us, sadden us—will get better, too.

“How will [action x] change your management?” That’s a question we often talk about. If that lab study won’t change what you do, don’t order the lab. If the patient’s answer to your question won’t change how you proceed, don’t ask the question.

John Doe was no longer my patient. He was better. I didn’t need to see him to believe it.

Categories
Education Funding Homelessness Observations Policy Systems

Asylums are not the Answer.

The New York Times recently featured an op-ed from a psychiatrist, Dr. Montross, who argues for the return of the asylum.

I understand her frustrations: I have worked with homeless individuals in both New York and Seattle who, if they were in psychiatric institutions, would not have had to worry as much about their safety, getting food, or sleeping at night. Many of the patients I now see in jail should undoubtedly be in a psychiatric institution (though not necessarily for a long period of time).

However, I disagree with her assertion that we should return to the era of the asylum.

President Kennedy signed the Community Mental Health Act into law in 1963. The goal of this legislation was to move people out of long-term psychiatric institutions, such as state hospitals, and help them integrate into the community by enrolling them in outpatient services. This is what “deinstitutionalization” refers to.

The Community Mental Health Act, however, only provided funds for the construction of the community mental health centers. The law made no provisions to fund the services that would occur in these buildings.

What we see now—the “transinstitutionalization” of people with severe psychiatric conditions into homelessness and jails—is a consequence of this lack of funding and support for patient care services.

Think of it this way: A city wants to improve its public transportation system. The city passes a law that provides funds to buy a lot of buses. However, the law provides no money to hire and retain bus drivers. There is also no money to hire and retain mechanics for bus maintenance.

The people of the city are frustrated: “Our public transportation system sucks! The city should build a subway system!”

The bus system never got a fair chance.

We also moved away from asylum care for good reasons: Conditions in psychiatric institutions were often terrible. It was not uncommon for state psychiatric hospitals to have insufficient staff for the number of patients in the institution. In Alabama in 1970, one psychiatric institution had one physician for every 350 patients, one nurse for every 250 patients and one psychiatrist for every 1,700 patients.

Dr. Montross herself notes (emphases mine):

But as a result, my patients with chronic psychotic illnesses cycle between emergency hospitalizations and inadequate outpatient care. They are treated by community mental health centers whose overburdened psychiatrists may see even the sickest patients for only 20 minutes every three months.[2. Unfortunately, 20-minute appointments every three months for the sickest patients is also a common occurrence here in Washington.]

If that is the quality and quantity of care “the sickest patients” in outpatient settings receive, then of course “many patients struggle with homelessness” and “many are incarcerated.”

Dr. Montross calls for “modern” asylums, though it is unclear to me what incentives government has at this time to build and support institutions that “would be nothing like the one in ‘One Flew Over the Cuckoo’s Nest'”. Asylums from years past did not receive sufficient funding to provide adequate care. Current outpatient centers often do not receive enough funding to provide adequate care. (How much longer must we wait before this changes?)

To be clear, I do believe there is a role for asylums in patient care. There is a small segment of the population with severe symptoms who would benefit from care in an institution. I’m talking about people who keep trying to jump off of buildings because they believe they can fly. Or people who cannot stop smashing their heads against the wall because they are trying to dislodge the computer chip they believe is in their heads. Or the people who eat their own feces and literally cannot use words to explain why.[1. As I have noted before: If you do not believe that these scenarios actually happen, I encourage you to volunteer at your local emergency department.] These individuals can and do recover; they are not necessarily destined to spend the rest of their lives in an asylum.

We also now have interventions such as assertive community treatment, assisted outpatient treatment[3. Assisted outpatient treatment is controversial, though preliminary data support its use. You can read an admittedly biased summary about it here.], and supportive housing/housing first. There is evidence that these intensive outpatient services keep people in the community and out of psychiatric institutions. What would happen if government and communities supported these interventions?

Modern psychiatric services—in an asylum or elsewhere—will not be modern at all if there are not enough staff to provide care for patients. It also will not be modern if the staff do not receive ongoing training and supervision for the care they provide. It cannot be modern if administrators do not understand the work and are unwilling to provide financial, technical, and emotional support to the front-line staff.

We must get away from the idea that where people receive services is more important than the quality of those services.