Category: Lessons

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Consult-Liaison Lessons Nonfiction

Approach, Don’t Avoid.

I don’t think the crisis center had been open for even one week. There were dozens of staff and fewer than five patients. Most of the staff were young, eager, and brand new to social services. Only the nurses and I had experience working in higher acuity settings.

One late afternoon, an elderly woman using a walker got a hold of a pair of scissors. One arthritic hand wielded the scissors while the other gripped the walker. Her feet were heavy; she plodded across the floor, chanting, “Kill, kill.” The walker swiveled because her torso wobbled with each step.

Our colleagues fled; doors to staff-only areas clattered shut. A nurse and I looked at each other when we realized we were the only people left in the room with this patient. We both sighed. I used my chin to signal that I would follow him.

Later, I asked to meet with all the staff working that shift. Why did you all leave the scene?

“Because she had scissors and was talking about killing people,” they said. “She had a weapon.” We were fearful that she was going to kill us, dummy!

Because this was my first job as a medical director, I thought I always had to “direct”. I didn’t realize that I could keep asking questions:

  • How do you know that she wanted to kill other people?
  • What else might have happened if everyone left her alone with a pair of scissors?
  • What realistic damage could she have done with the scissors?
  • What unspoken message did we send to each other when we all left?
  • What unspoken message did we send to her?
  • Are there things we could have said to get more information from her?
  • What steps could we have taken to separate her from the scissors?

You can’t always believe what you think.

(To be fair, people who don’t know what to do often run away. Avoidance is a common strategy to cope with fear and anxiety.)

The nurse approached the elderly woman from one side. He took three steps for every one step she took.

“Hi. Can you put the scissors into the basket of your walker, please?” he asked.

“Kill, kill,” she continued to chant, holding the scissors in the air. She continued to plod forward.

“Hi. Put the scissors here, please,” I echoed, pointing at the basket.

Her forward movement stopped. The scissors remained in her raised hand. We stood in stillness together.

Mumbling, she dropped the scissors into the basket. I plucked them out. After thanking her, we asked her to please sit down. “And please don’t do that again. It scares people.”

“Please don’t leave when things like that happen,” I said, directing the team. “When there’s a situation, approach. People might need you to do something. Your presence alone can help de-escalate situations. And someone will send you away if it gets too crowded. But don’t immediately leave.”

For the remainder of my time there, staff never disappeared again during a crisis.

(inspired by claims that RFK, Jr., left the scene of Oval Office medical emergency)

Categories
Lessons Reflection

Your Six-Foot Radius.

I don’t think I was that mouthy during my medical training.

Some East Asian women are shy, deferential, and taciturn. It’s no wonder some people were surprised when critical comments came out of the mouth that is attached to my face.

Advocacy comes in different flavors. My initial attempts were salty.

While I didn’t occupy the lowest rung on the neurology service (that honor went to the medical students), I was but an intern. Furthermore, I wasn’t even an neurology intern. I was training to become a psychiatrist.

The attending neurologist, who looked like those doctors exalted in enormous oil paintings that adorn the hallways of hospitals, had too many letters after his name. He also riffed on too many subjects unrelated to neurology during our morning rounds.

Rounds in academic medical centers serve two main purposes: To organize care for patients, and to educate trainees. The team, under the guidance of the attending physician, executes the plan of care for each patient following rounds.

One autumn morning we stood in a circle outside of a patient’s room. Rounds were just starting. Patients—and a whole lotta work—awaited us.

“It’s the season for soup,” the attending neurologist opened, smiling. “Chief Resident, what is your favorite kind of soup?”

I couldn’t restrain myself.

”Can we not talk about soup? There are patients waiting and work we need to do,” I snapped. My fellow intern, a future emergency physician and more accepting of reality than me, didn’t stifle his laughter in time.

Both the chief resident and frowning attending physician shot me a look. “I know you’re focused on getting work done, Dr. Yang,” the chief resident chided, “but there is time to talk about other things.”

My cheeks burned. But no one spoke more of soup. We started talking about the patient waiting in the room. 



Three years later, I myself became a chief resident. Junior residents shared with me that one of the attending psychiatrists, another decorated physician considered a national expert in his field, wasn’t meeting with them for supervision. This was one of his responsibilities. Esteemed professors were supposed to spend time with us trainees so we could learn from them. He wasn’t doing his job.

Chief residents have some responsibility to advocate for junior residents. Annoyed, I asked to meet with him. This flavor of advocacy was spicy.

He didn’t ask for an agenda ahead of time and I didn’t think to provide one. After sharing with him what residents told me, I said, “It is your responsibility to meet with residents for supervision. Why isn’t this happening?”



Well, you can imagine how that went. He became shouty, waved his arms, and wondered how I, a mere resident, had the audacity to talk to him that way.

My cheeks burned again. However, he didn’t deny the allegation.

My program director was dismayed—maybe embarrassed on my behalf?—when I told her what happened. “You didn’t need to tell him yourself!” she exclaimed. “You could have told me and I could have spoken with him.”

The junior residents told me later that he had reached out to schedule regular supervision with them all. 



With additional experience (read: missteps and errors), my advocacy is now more mellow. I’ve learned to ask more questions, orient people ahead of time, and be more mindful of power and status. When all else fails, be direct.

The word “advocacy” often conjures political images: chanting slogans at rallies or calling elected officials.

But those aren’t the only ways to advocate for ideas you value. Effective advocacy can happen within our six-foot radius. It’s asking questions or making statements. Sometimes, it only takes a short conversation to start shifting long-held assumptions:

“Quite frankly, I wish the president would give us a purge [of homeless people]. Because we do need to purge these people.”

“I wonder what the parents and friends of homeless people would think of that plan. What hopes and dreams do you think they had as kids? Surely they didn’t aspire to be homeless.”

“Every time I find one of these lunatics, I take away their visas.”

“When you say ‘lunatic’, what does that mean? What is the process for applying for a visa, anyway? It’s following the law, right?”

“The probability of a trans person being violent appears to be vastly higher than non-trans.”

“I don’t think that’s true, but let’s look at the data together. Where can we look to learn accurate information?

Advocacy can look like curiosity. At its sweetest, advocacy illuminates the humanity of others. Such reminders can take just a few seconds.

To be clear, this doesn’t mean talking to anyone and everyone who enters your six-foot radius. A small minority of people are not curious and not interested in dialogue. They seek targets for their frustration and anger. If you’ve tried to make a connection in good faith, but the effort is not reciprocated, stop. Sometimes, quitting is the best option.

In times—these times—when problems feel too big for us to understand or solve, when we feel like nothing we do makes a difference, speaking up still matters. Your statements (or silence!) affects other people.

Advocacy doesn’t have to involve bullhorns or giant signs. Do not obey in advance. Have faith in what you can accomplish within your six-foot radius.

Categories
Lessons

On Mental Endurance.

Although “mental endurance” is more wordy than “grit”, I prefer the extra syllables. “Grit” sounds difficult and uncomfortable: Jaws clenched, the jagged surfaces of molars grinding together, or granules of sand scratching the surface of your eyeball.

“Grit” also suggests firmness and unyielding. It doesn’t matter what the conditions are: I will not change my strategy or tactics. I will not bend, even if I might break.

“Mental endurance” offers more flexibility. There is room to breathe. Maybe you can keep more enamel on your teeth.

When Things Are Hard, how can we unclench our jaws? When we run psychological marathons we did not sign up for, how can we keep moving without falling down from exhaustion or heartache? How can we practice and manifest mental endurance?

Build and commit to routines. If the word “ritual” is more pleasing to your ear, build and commit to rituals. This includes the essentials of eating, sleeping, and other healthful activities. (Without a basic foundation, any type of endurance is hard to achieve.) Creating and sticking to routines brings comfort when most things seem out of control. Rituals help us feel like we have agency over something. To start, the less profound the ritual, the better:

  • Make the bed every morning.
  • Always say “thank you” to the bus driver, even if they don’t make eye contact with you and look like they’re grinding the enamel off of their teeth.
  • After you put your kids in the car and shut their door, make a point of taking three full breaths before you get in to drive.

No one has to know what your routines are or the reasons behind them. Maybe you run because you actually want to run away from your problems. Maybe you watch the same video on YouTube before bed because it increases the chances that you will fall asleep. Maybe you behold the cereal in your bowl and say thanks to all the nameless people who transformed and transported the cereal to you.

What matters is that you created a ritual. You’re choosing to do it. Within is freedom and power.

Pace yourself. Or, it’s okay to take a break. When Things Are Hard, we often want to get through All Of It as soon as possible. Who wants to feel psychologically uncomfortable?

However, the logical conclusion of this approach doesn’t make sense: Life is hard. If we want to get through the Hard Stuff as fast as possible, that means we should try to get through life as fast as possible. This is impossible. (Puberty over in 24 hours! bone fracture healing in five minutes! grief resolved in two seconds!)

Yes, there are often external pressures: The boss wants us to do something. The kids have a need that only you can fulfill. There isn’t enough money to deal with The Thing the way you’d like to deal with The Thing.

It’s okay to take a break. If you were able to think your way out of this problem, you would have already thought of the solution. Spending 30 minutes thinking about something else is nothing when you spend hours dwelling on The Thing. Your mind will welcome the break, too, because it needs it. (Epiphanies seem to arrive when we give our mind a break: showering, doing our laundry, etc.)

Talk with people you trust. Many burdens are not meant to be carried alone. If someone is able and willing to help lift the burden from your mind, or at least shift it so you can adjust your psychological grip, not only are you blessed, but you are also letting someone help you. Sometimes our grip is so tight on The Thing because we insist on bearing it ourselves. (What would it mean if we let someone help us? Does it mean that we’re weak? unreliable? a failure?) Olympians and chess grandmasters all have coaches and esteemed colleagues. Amateur chefs share their dishes with tasters and amateur writers share their words on blogs. While it may be true that no one in your social circle has been through what you’re going through, that doesn’t mean that they are useless. Support, attention, and care from others has value. It’s okay to unclench.

Remember that everything changes. Things may not change as fast as we want them to, but everything changes. What feels intolerable now will one day be a memory. We ourselves change because of The Thing; our values will shift and we will make different choices. With heartbreak, we might ultimately discover more love flowing through our lives. Instead of the friction associated with grit, there can be a softening, a light, gentle expansion of our hearts. There is room to breathe. Our bigger hearts will buoy us forward for whatever changes await us next.

Categories
Education Lessons Public health psychiatry

Watch for the Political Abuse of Psychiatry.

The Lancet recently reported that women in Iran who disobey religious law by refusing to wear a hijab are being diagnosed with antisocial personality disorder. These women subsequently “undergo psychotherapy treatment” and must provide “mental health recovery certificates”.

The article also refers to this piece, Iran sentences unveiled women to jail, washing dead bodies in a cemetery and undergoing therapy, that reports a

ruling by a third criminal court in Tehran defining not wearing the veil as “a contagious mental illness that causes sexual promiscuity.” The defendant was sentenced to two months in prison and ordered to pay for six months of psychological treatment.”

(It’s unclear what “psychotherapy / psychological treatment” means. This is likely intentional.)

Do women in Iran who refuse to wear a head covering truly have antisocial personality disorder?

Here are the primary DSM-5 criteria, which are similar to the criteria in ICD-10:

A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following:

  1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.
  2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
  3. Impulsivity or failure to plan ahead.
  4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
  5. Reckless disregard for safety of self or others.
  6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
  7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

The key here is disregard for and violation of the rights of others. I am unfamiliar with Iranian religious law, though it is hard to understand how a woman who is not wearing a head covering is disregarding and violating the rights of others. Is the argument that the hair of women impinges on the rights of men? What freedoms are taken from men when they see women’s hair? What freedoms are returned to them when women’s heads are covered?

However, it’s also not hard to see how one can twist the criteria for women to receive a diagnosis of antisocial personality disorder:

Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest. Women are required to wear a hijab by law. Women who don’t cover their heads are breaking social norms and the law.

Impulsivity or failure to plan ahead. Wearing a hijab requires planning. Only someone who is impulsive or short-sighted would forget to wear a hijab when going out.

Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations. A responsible woman would consistently wear hijab.

Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another. Women who refuse to wear a hijab are unapologetic about their behavior. They clearly don’t care about the disrespect they are showing to religious law.

That’s four criteria when only three are required. Though it’s still unclear whose rights are being violated, the twisting of criteria is easy to do to distract from the intentional distortion of context.

The Lancet article correctly notes that the “diagnosis” of women who refuse to wear hijabs and their subsequent “treatment” is political abuse of psychiatry. One of the authors, Robert van Voren, has written other articles on this topic, including Political Abuse of Psychiatry—An [sic] Historical Overview, where he teaches us that the Soviet Union was a major culprit:

Socialist ideology is focused on the establishment of the ideal society, where all are equal and all will be happy, and thus, those who are against must be mad. … The political abuse of psychiatry in the Soviet Union originated from the concept that persons who opposed the Soviet regime were mentally ill because there was no other logical explanation why one would oppose the best sociopolitical system in the world.

In a separate article, Ending political abuse of psychiatry: where we are at and what needs to be done, van Voren argues that regimes abuse psychiatry because “in most cases it is a combination of expedience and ideology.” He goes on to note:

Sending people to a psychiatric institution is particularly practical because hospitalisation has no end and thus, if need be, people can be locked away forever, or as long as they continue to have views that are considered politically or socially dangerous, or remain inconvenient to the authorities. … At the same time, declaring a person mentally ill provides a perfect opportunity not to have to respond to their political or religious convictions, as they are the product of an ill mind and do not have to be taken seriously.

He argues that the way to combat political abuse of psychiatry is similar to combating misinformation:

stimulating communication and access, providing training in issues of medical ethics and human rights, and translating key documents and manuals into local languages may make it impossible for the public to remain uninformed.

Why am I writing about abuses of psychiatry in Iran? With increasing overt conflict between and within nations, psychiatrists and other mental health professionals should know the history (some of it recent!) of the political abuse of psychiatry. None of us are immune to persuasion and coercion. Though I hope that governments and other authorities will never ask us to use our skills to harm people, hope is not a strategy. People in power can exhibit antisocial behaviors, too. Democracy may decrease the likelihood that psychiatrists will succumb to political pressure, though psychiatrists are still people. Most people avoid conflict, respond to incentives, and do not want their status to drop. Psychiatrists are not morally invincible.

The public also needs to know this history. (I recognize I am but a tiny fish in the ocean that is the internet. I appreciate that anyone is willing to give the gift of attention to my writing here.) If psychiatrists and other mental health professionals start “treating” people whose only symptom is having an opinion that diverges from the government’s perspective and propaganda, we need the public to call this out.

Hospitals have better food, softer linens, and more space than jail, but both places can restrict your movements and prevent you from leaving. Psychotherapy can be harmful and punishing. The stigma of mental illness and treatment, while decreased over the past few years due to the pandemic, persists and can be used to reject and dismiss people.

Civil disobedience doesn’t disregard and violate the rights of others.

Categories
Lessons Nonfiction

Thanks, Speedy Old Man.

When I lived in New York, my then boyfriend and I ran races with the New York Road Runners. Boyfriend was a much faster runner than me, but, given the literal thousands of other runners in each race, there were always people faster than him… including an elderly man.

One of the people who consistently finished ahead of Boyfriend was a man who was 30 years older than him! We’ll call this person Speedy Old Man. Sometimes Boyfriend was quick enough to finish seconds behind Speedy (Old Man), so we eventually learned what he looked like. (To be fair, this wasn’t hard: The wrinkles in Speedy’s skin and his thinning white hair exposed his geriatric status.) Speedy became both a target and an inspiration: Could Boyfriend outrun Speedy this time? (No.) Or next time? (No.)

We automatically started checking Speedy’s race times after looking up our own. Speedy ran a lot of races! He was nearly always the fastest person in his age group! (Can you believe that he had competitors???) What a marvel: Speedy was prolific, persistent, and a paragon of successful aging.

In addition to leaving us in the dust, he left us feeling inspired.

Boyfriend became Husband, and then we moved out of New York. Despite living on opposite coasts, we still thought of Speedy whenever the New York City Marathon made the news or when the YouTube algorithm introduced us to elderly athletes.

We recently watched elite international runners race the rainy New York City 5th Avenue Mile. (The winner of the men’s race finished the mile in less than 3 minutes and 48 seconds!) This made us wonder about Speedy: Was he still running? (Was he still alive?)

The New York Road Runners race archive revealed that his last race was in early 2020. He was in his mid-80s! His age group ranged from 80 to 99 years old; he placed 3rd at a pace of about 12 minutes per mile! Incredible.

But what happened? There have been races since early 2020, but many other things had happened since then. Was he still running? (Was he still alive?)

After some sleuthing, I found his e-mail address and, pushing my reluctance aside, pressed send after writing this note:

My name is Maria Yang and I live in Seattle, Washington. I am writing to thank you for inspiring my husband and me.

We’ve never met, but my husband and I have “known” you since 2008 or so. At that time, he and I lived in New York City and routinely ran in NYRR races. My then boyfriend and now husband was consistently impressed / playfully irked that you consistently beat him in NYRR races, given the 30+ years of difference in age. 

Since then, both in New York and since moving to Seattle, we have periodically thought of you. We enjoyed the idea that you were still running and inspiring people of all ages with your running and speed.

Today we watched the NYC Fifth Avenue Mile race on YouTube, which made us think of you again. We looked up your results on the NYRR results page (sorry that this is creepy behavior; we also found your e-mail address here) and were amazed with your results from your races in 2019 and 2020. We hope that we ourselves will still be running and racing when we are in our 80s. 

We hope that you and yours remain healthy and well. Thank you for offering a valuable perspective on successful aging and for the inspiration you offer to runners of all ages and abilities. Your influence is transcontinental! 

No automated e-mail bounced back to tell me that the address no longer existed. I released any expectations of a response–I just wanted to thank him.

I squeaked when I saw Speedy’s name in my mailbox. Two days had passed and he had sent a response!

Maria: Thank you for your email. Although I can no longer run, I do aerobics and strength training as much as I can. I believe that this has really helped me in my life. My last race was a 5K [in early] 2020. Although I was in the last corral and finished behind almost everyone else, I really enjoyed doing it. Speedy Old Man

He wasn’t running, but he was still alive! And was willing to respond to a stranger on the internet!

I immediately forwarded this to Husband and, when we saw each other later that day, we beamed. What a gift.

One of the later reactions I had to Speedy’s e-mail was sadness and anger. I don’t know why he can no longer run, but it seems likely that the pandemic was a contributor. Maybe he got infected with Covid in 2020. Maybe he became ill with something else and couldn’t access medical care because of the pandemic. Maybe, like one of my beloved family members, he became deconditioned and his mobility drastically declined.

The pandemic has taken so much from so many people.

I learned this lesson upon the death of my mother, though the pandemic reinforced it: If you want to thank someone, don’t hesitate. Thank them as soon as you can. Tell them what they mean to you, what they did that you appreciate, how they have made your life better. Time is short. If you wait, you may never again have the chance to offer the gift of your attention and thanks.

Thanks, Speedy Old Man.