Category: Education

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Education Lessons Medicine Reflection

Talking About Suicide.

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.

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Education Informal-curriculum Lessons Medicine Observations Reflection Systems

Thoughts on the Movie “Get Out”.

Have you seen the movie Get Out? If you haven’t, what follows might spoil part of the movie for you. You might want to watch it before reading this.

If you have seen Get Out, this post ponders the role of psychiatry in the movie. (Full disclosure: I enjoyed and recommend the movie.)

We learn early on in the movie that Rose’s mother is a psychiatrist. Chris, Rose’s boyfriend, asks something like, “She’s a psychologist?”

The response Chris receives is something like, “No, she’s a psychiatrist.”

While I can’t know for sure, I believe that the writer of the film, Jordan Peele[1. If you are not familiar with Jordan Peele, please go watch some clips of Key and Peele.], wanted to highlight the difference between the two. Psychiatrists are physicians. And some physicians, under the guise of expertise, have promoted racist ideas.

Dr. Samuel Cartwright was a physician who practiced in Alabama, Mississippi, and Louisiana in the years leading up to the American Civil War. He defended slavery and wrote pieces that argued that blacks were inferior to whites.

One of his articles, “Diseases and Peculiarities of the Negro Race“, describes “drapetomania, or the disease causing Negroes to run away”. Because he describes drapetomania “is as much a disease of the mind as any other species of mental alienation”, it is clear that this is a psychiatric condition, such as kleptomania (compulsive stealing), pyromania (compulsive fire-setting), and dipsomania (the old name for alcohol use disorders).

In this article Dr. Cartwright asserts that God has ordained blacks as “submissive knee-bender[s]” and are “intended to occupy… the position of submission”. To support that blacks were destined to be “submissive knee-benders”, he states that “in the anatomical conformation of his knees, we see [it] written in the physical structure of his knees, being more flexed or bent, than any other kind of a man.”

To prevent the development of drapetomania, he states:

if his master or overseer be kind and gracious in his hearing towards him, without condescension, and at the same time ministers to his physical wants, and protects him from abuses, the negro is spell-bound, and cannot run away.

In Get Out, Chris (plus Georgiana, Walter, and Andrew) becomes obviously “spell-bound” through the hypnotic powers of the porcelain cup and silver spoon. One could argue that Rose is demonstrating faith in this practice as she was initially “kind and gracious”, “without condescension”, “ministers to his physical wants”, and “protects him from abuses” (remember the police officer who pulled them over?).

Dr. Cartwright comments that, in the course of drapetomania, slaves become “sulky and dissatisfied” before they run away. He advises that “the cause of this sulkiness and dissatisfaction should be inquired into and removed, or they are apt to run away or fall into the negro consumption.” However, if slaves were “sulky and dissatisfied without cause,” he states that the treatment was “in favor of whipping them out of it, as a preventive measure against absconding, or other bad conduct. It was called whipping the devil out of them.”[2. Wikipedia also comments that another treatment for drapetomania included “removal of both big toes”, which makes running difficult.]

Chris becomes understandably “sulky and dissatisfied” with his time at the Armitage home and seeks to flee. Though he wasn’t whipped to treat his drapetomania, it’s not a hard stretch to argue that the plan to remove most of his brain (“coagula”) is essentially whipping the devil out of him so that only his body remains.

Dr. Cartwright apparently published these ideas in the New Orleans Medical and Surgical Journal (as well as De Bow’s Review, a magazine of “agricultural, commercial, and industrial progress and resource” in the American South). This publication came from his work as the chairman Louisiana State Medical Convention committee. One of their tasks was to “examine the diseases peculiar to the Black slaves of the antebellum South”.[3. From a Lancet article called “Drapetomania“.] This was a professional medical opinion!

To be clear, not all physicians agreed with Dr. Cartwright’s opinion. Dr. Hunt, a physician who practiced in Buffalo, New York—that is, North of the Mason-Dixon line—lampooned Dr. Cartwright’s concept of drapetomania. He rightly wondered why drapetomania seemed to only exist in the South. He made wry remarks that drapetomania seems to affect the neurons of slaves so that they only flee in a northerly direction. He also pointed out that drapetomania resembled the condition of schoolchildren who ran away from school to play.

In essence, Dr. Hunt shouted, “Context matters!”

Dr. Cartwright sincerely believed that drapetomania was an inherent quality of black people.[4. Dr. Cartwright also described “dysaethesia aethiopica“, or “hebetude or mind and obtuse sensibility of body” that only occurred in blacks in the South.] As he was a fish in the sea of Southern slaveowning culture, he either could or would not believe that social and political context affects the definitions of psychiatric conditions. (He also could not believe that his ideas were wrong.) Maybe Jordan Peele was thinking about Dr. Cartwright and drapetomania when he created the characters in Get Out. Maybe he wasn’t; maybe he was pointing out the consequences and longevity of racism.

Psychiatry has been and can easily become an agent of social control. The moment we begin to think that we’re too good or too smart or too sophisticated to become agents of social control, we and the people under our care are doomed.

It is paramount that we remember this always in the current political climate. May we have the wisdom and courage of Dr. Hunt.

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Consult-Liaison Education Medicine Nonfiction Reflection Systems

Reflections While Writing About Psychiatry

I know I haven’t posted in a while. Someone presented me with the opportunity to write a section on psychiatry for medical students. This is wonderful (an opportunity to influence future physicians!!!) and terrible (GAAAAH there’s so much in psychiatry!!!). Between thinking about psychiatry at multiple levels at work and thinking about the foundations of psychiatry while writing the section, I’ve felt cognitively impaired when thinking about what I should write here.

But the thinking never stops… and here are some reflections I’ve had over the past two months while writing:

The differences between what physicians and patients want. Many medical students choose medicine because of the opportunity to help people in a very real way: In helping people improve their health, physicians help people experience a better quality of life. This is rewarding for both patient and physician. Right?

As physicians go through training, they learn the heartbreaking lesson, often repeatedly, that it’s not that simple.

Sometimes people want physicians to help them in ways that physicians can’t or won’t. Some people want medicine that will make the cancer go away and never come back. Other people want pain medicine or sedatives for short-term relief, though the long-term consequences are problematic and potentially devastating.

Other times, people reject the best help that physicians offer. Some people will not take insulin, even though it will prevent prevent worse outcomes from diabetes. Other people don’t want to see any physicians, even though medical interventions for their conditions are simple and effective.

Many medical students assume that patients will only be grateful for and accepting of the help physicians offer. That assumption is wrong.

But this is part of the “art” of medicine, right? How do physicians and other medical professionals help people when we don’t have an intervention that “works”? How do we help people who don’t want the help that we know “works”?[1. There are, of course, strategies we learn as psychiatrists to address how to help people who don’t want the help physicians offer. The problem is that the issue then gets cast as a “psychiatric problem”, when it, in fact, is a “human relations problem”. Psychiatrists often feel frustrated when some physicians either want us to have the doctor-patient relationship in their stead or, worse, when some physicians assume that a Disagreeing Patient is a Mentally Ill Patient.]

The psychiatric conditions that psychiatrists don’t encounter. I’ve worked in a variety of settings—in clinics, hospitals, a crisis center, a jail, homeless shelters, housing, and on the street—and, despite all that exposure, I have never met with someone with a diagnosis of somatic symptom disorder or factitious disorder. While both conditions are rare, my colleagues in primary care and emergency departments see people with these conditions more frequently. Those same people don’t want to see a psychiatrist.

When we think about systems that take care of patients, sometimes we need to remember that the patient isn’t always the actual patient. Sometimes the best way psychiatrists can help these patients is to help the physicians who actually see them. If we wipe our hands and say, “Well, they won’t see me, so that’s not my problem,” what are we doing? If there are barriers in the system that prevent us from helping our colleagues, how can we work together to remove them to increase the likelihood we can help them?[2. This is an argument for “integrated care”, which refers to the integration of physical and behavioral health services. Unfortunately, how these services are paid for often creates barriers… which is exactly why we need more physicians involved in advocacy and leadership.]

Conversations on what is “wrong” instead of the experience of being ill. While in training, physicians learn how to diagnose and treat conditions based on what is “wrong”. We learn the characteristics of the condition, its underlying causes, and the treatments that often correct it. However, we don’t spend a lot of time learning just how much the condition afflicts people.

To be fair, there is so much to learn in medical school and beyond. Furthermore, physicians, as a population, like to solve problems. This temperament was likely present in all of us even before we went to medical school. If talking and listening won’t actually fix the problem, but doing Something actually will, why don’t we just do the Something and get on with it?

Because of this focus on Fixing the Problem, some people assume we are uncaring. That assumption is often wrong, too.

There are also other forces at work: Physicians often don’t have as much time with patients as they would like to listen, provide education, and offer encouragement. Those are Receptive skills and, while complementary to, are often not as glamorous (or billable) as Problem-Solving skills. All of us—in health care or otherwise—often forget that healing occurs with both Receptive and Problem-Solving skills.

I’m grateful for many reasons to have this opportunity to write for medical students. A major reason is the chance to explicitly go back to the basics. Examining the foundation reminds me why I chose to go into psychiatry in the first place, highlights (again) just how much I don’t know, and challenges me to consider what is actually important in my clinical work. And let me tell you, knowing the doses of various medications is not actually important. That’s stuff you can look up. As Dr. Edward Trudeau said, what is actually important is “to comfort always”.[3. The full aphorism attributed to Dr. Trudeau is “To cure sometimes, to relieve often, to comfort always.”]

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Education Medicine Nonfiction Observations Systems

A Day in Jail.

Three of us are waiting for the elevator. A few moments earlier I had walked into the jail for the day, so I have not yet donned a white coat. The other two are wearing their standard uniforms: The inmate is in red and the officer is in black.

“I have to take my seizure medicine while I’m here, you remember, right?” the inmate says, clutching a clear bag holding several pill bottles, a pair of jeans, and a dark jacket.

“Yes,” the officer says, her voice warm and firm at the same time. “You told the nurse, right?”

“I always do, ma’am.” A shy smile crosses his face. She smiles back at him as the elevator doors open. She motions for him to enter first.

The hem of the white coat hits the back of my calves as I climb the stairs. My habits from my intern year remain: I still fold papers in half lengthwise and the first stack will go into the left pocket. I never button my coat.

When I reach the top of the staircase, one of the standing inmates glances at me, then returns his gaze to the inmate seated in front of him. The standing inmate looks like he’s in his 20s. The seated inmate might be in his late 30s. Twenty-something guides the electric razor along the contour of Thirty-something’s head; clumps of light brown hair tumble onto the black cape and the concrete floor.

There are two barbers on duty. They volunteered their services; they will probably get extra food as compensation. The men in the chairs bow their heads, their eyes open, their bodies still. No one says anything.

Everyone gets the same haircut.

The floor officer is worried about an inmate: “He didn’t eat breakfast this morning and wouldn’t come out to take a shower.” While I scribble this information down on my paper folded lengthwise, I hear the deck officer raise his voice.

“What are you looking at?” the deck officer barks at two inmates. They are trustees, which means that they have demonstrated good behavior while in jail and are allowed to participate in chores. In exchange for doing tasks such as preparing meals and cleaning floors (which also gets them out of their units), they can receive more food .

A trustee mumbles something in response.

“I asked you, what are you looking at?” the deck officer barks again.

“Nothing, sir.”

“Okay. If I see you looking at ‘nothing’ again, I’m sending you back. Do you understand me?”

“Yes, sir.”

“Get back to work.”

The floor officer and I ask the deck officer what happened.

“They saw you,” he says, pointing at me, “and started grinning, elbowing each other, all that stuff.”

While wrapping my coat tighter around me, I glance at the two trustees. One of them happens to look at me at the same time; he turns away and takes a sudden interest in the mop in his hands.

“Thank you, Officer.”

“Just looking out for the doctor.”

It’s been a few years since I’ve talked to God.

Perhaps I meet God more frequently, but s/he chooses not to reveal that to me. More often I talk to angels or the Anti-Christ.

“Psychiatry is sorcery,” God tells me. “If you only had more faith, you would see the error in your ways. Turn towards faith and away from your analytical ways of thinking.”

God is charged with criminal trespass. God is a young man. His bail amount isn’t that high. Is there no one in God’s life who could post his bail so he could get out?

“One of the best things about being God,” he tells me, “is that I can see the true intentions of people. I know their thoughts.”

He pauses and looks at me.

“Although you practice witchcraft, I can tell that you’ve got a good heart. I will pray for you that you will have more faith, that you will believe in me.”

I will pray for you, too.

When I’m finished talking with God, the floor officer comes by and gives God a second lunch.

“Thank you! I bless you!” he calls out.

The brown paper sack contains one sandwich (two slices of wheat bread, one slice of bologna), one mayonnaise packet, one slice of American cheese wrapped in plastic, a small baggie of baby carrot sticks, and one apple the size of a tennis ball.

“He’s still growing,” the floor officer murmurs.

The day has ended. I’ve already stuffed my white coat into a laundry bag, but I’m still making my way through all the doors to physically get out of jail. When I exit the elevators near where inmates are booked into jail, I see an officer wincing and grasping his leg. One medic is kneeling by him; the other is on the phone.

I pass by a bank of holding cells. Two women knock on the wall and beckon me towards them. The one with tattoos all over her young face and anxiety in her eyes asks, “Can you tell them to let us out? We’ve been waiting a long time.”

“An officer looks hurt,” I say, raising my voice. We’re talking through a thick pane of plexiglass. “The medics are here. It might be a while before they will get to you.”

“Oh,” she says. They take a step back and their shoulders slump. “I hope they’re okay. Thanks.”

Most people look either relieved or thrilled when they leave jail. They throw their shoulders back as they cross the threshold from the jail lobby into the fresh air. How much more comfortable they appear in their own clothes! The red uniforms incarcerated them just as much as the concrete block. Sometimes they give each other high fives; their voices are light and bright as they tell each other to take it easy.

A few will look up and around, confused and forlorn. They squint at the numbers at the bus stop. After taking a few steps heading south, they pause, turn around, and head north. They finally decide to cross the street to get away from the jail. It seems like the best idea.

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Consult-Liaison Education Medicine Observations Policy Reflection

Why I Agree with the Goldwater Rule.

The New York Times and NPR recently published articles related to the Goldwater Rule. In short, a magazine sent a survey to over 12,000 psychiatrists in the US with the single question of whether they thought Presidential nominee Mr. Barry Goldwater was fit to serve as President. Few psychiatrists responded. Of those that did, more than half—still over 1,000—said that he was not. Mr. Goldwater ended up losing the Presidential race, but he sued the magazine over this… and he won. Thus, the American Psychiatric Association has advised that psychiatrists should not diagnose public figures with psychiatric conditions. Some psychiatrists have felt otherwise for the current Presidential election.

There is a hypothetical concept in psychiatry called the “identified patient“. It is most often applied in family systems. For example, consider a family that consists of a mother, a father, a son, and a daughter. The parents bring the daughter to a psychiatrist and say that she has worrisome symptoms. Maybe they say that she is always angry, doesn’t get along with anyone in the family, and does everything to stay out of the house. The parents and the son argue that there must be something wrong with her.

As the psychiatrist works with the family, the psychiatrist learns that the parents have the most conflict. The daughter may have developed ways to cope with this stress in ways that the parents don’t like. Because the parents have the most authority in this system and do not recognize how their conflicts are affecting everyone else, they assume that the daughter is the problem. To oversimplify it, the daughter becomes the scapegoat. The daughter is the identified patient.

Presidential nominees don’t become nominees through sheer will. There is a system in place—putting aside for now whether we think the system is effective or useful—where the American public has some influence in who becomes the ultimate nominee. Candidates are eliminated through this process.

Does the Presidential nominee actually have psychopathology? Could a nominee rather reflect the public that supports him or her? Could it be more accurate to describe the nominee for a specific party as the “identified patient”?

Erving Goffman presents an argument in his book The Presentation of Self in Everyday Life that has similarities with the monologue in Shakespeare’s As You Like It:

All the world’s a stage,
And all the men and women merely players;
They have their exits and their entrances,
And one man in his time plays many parts

Goffman and Shakespeare are both commenting on the presence and importance of performance in our daily lives. Goffman argues in his text that context matters[1. I agree that context matters. See here, here, and here.]. We all do things within our power to alter ourselves and the contexts to present ourselves in certain ways.

Some mental health professionals have argued that we can diagnose public figures with psychiatric conditions because of “unfiltered” sources like social media. While it may be true that some people are more “real” (or perhaps just more “disinhibited”) on social media than others, that does not mean that people are revealing their “true selves”. Do you think that people are always eating colorful vegetables in pleasing arrangements? or that people are always saying hateful things, even while waiting to buy groceries, attending a church service, or folding laundry? or that their cats are always cute and adorable, that hairballs and rank breath have never exited their mouths?

Lastly, the primary purpose of diagnosis is to guide treatment. There is no point in considering diagnoses for someone if you’re not going to do anything to help that person.

People have commented that psychiatric diagnoses often become perjorative labels. Unfortunately, there are those who work in psychiatry who will use psychiatric diagnoses as shorthand to describe behavior they don’t like. Instead of saying, “I feel angry when I see her; I don’t like her,” they will instead say, “She’s such a borderline.” That’s unfair and often cruel. If you’re not going to do anything to help improve her symptoms of borderline personality disorder, then why describe her that way? (We’ll also put aside that such a sentence construction reduces her to a diagnosis, rather than giving her the dignity of being a person.) If we are serious about addressing stigma or sanism, then we should only use diagnosis when we intend to help someone with that diagnosis.

I agree with the Goldwater Rule, though not because of the exhortations of the American Psychiatric Association.[2. I’m not a member of the APA. The reasons why I am not a member are beyond the scope of this post.] Diagnosis should have a specific purpose. We often do not have enough information about public figures across different contexts to give confident diagnoses. Presidential nominees are often appealing to various audiences, which can both affect and shape their behaviors. Most importantly, giving a diagnosis to a public figure without any intention of helping that person doesn’t help anyone, especially those who would ultimately benefit from psychiatric services.