Category: Lessons

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Education Homelessness Lessons Medicine NYC Policy

Involuntary Commitment (I).

It’s winter in New York City. The temperature is hovering around 32 degrees Fahrenheit. Large, slushy snowflakes are falling from the pewter sky.

You are already familiar with this woman; you had met her the previous Spring. No one is sure of her age, but she looks over 65 years old. She had said that she had immigrated to the US when she was in her 20s because she had a scholarship to a prestigious university. Something interrupted her schooling. She ultimately stopped attending classes and hitchhiked here. She’s been homeless on the streets of New York ever since.

She has never shared her date of birth for fear that the government would use that information against her. It’s not clear if her stated name is really her name. She’s a familiar figure in the neighborhood; people regularly give her styrofoam bowls steaming with hot soup, sandwiches wrapped in white butcher paper, shiny cans of soda, and cups of coffee. Some people have been giving her food for the past ten years. Upon receipt she murmurs, “Thank you,” and nods her head on her slender neck.

She never makes eye contact. The irises of her eyes have grey halos and her gaze is usually over your right shoulder. You’ve tried to learn more about her past, what led to her homelessness, and her interest in housing, but she usually ends the conversation and walks away. One time before bidding you good-bye she did comment, “The government secrets are safe with me.”

People in New York walk past her everyday while she sleeps and never realize it: She buries herself underneath black garbage bags stuffed with paper. What looks like a mountain of trash on the curb or underneath scaffolding is actually her private fort.

“The paper keeps me warm,” she has said. To prove her point while the autumn winds sent the dying leaves swirling through the air, she rolled up a sleeve of her parka to reveal wads of newspaper crumpled in her clothing. At times she donned a hat made out of a paper bag and stuffed it with newspaper to warm her head.

It is not yet 10am on this snowy morning and the weather forecasters predict that the storm will worsen as the day goes on. The snow is already sticking to the sidewalk. Over six inches are predicted to fall in the next few hours.

Today, the woman’s camp is underneath the short awning of the back door of a clothing boutique. Underneath her is a flattened cardboard box, the corners already beginning to darken and soften from the snow. On top of her are only four or five garbage bags, fewer than what usually covers her. Upon hearing you, she sits up and her face, as expected, does not show any expression.

Her parka is unbuttoned and underneath is a thin white shirt with a tattered collar. The skin of her neck is mottled and red.

“There’s a snowstorm coming through, it’s supposed to be pretty bad. Would you be willing to stay in a shelter until it’s done?” you ask.

“No, I’ll be fine.”

“It looks like you’re cold; you don’t have as many bags as you usually do and your skin is turning red. We don’t want you to be outside when it is this cold out,” you try again.

“I’m fine.”

“We worry that if you stay out here, you might get frostbite.”

“I’m fine.”

“Where have you gone in the past when there were big snowstorms?”

“I’m fine.”

Meanwhile, snow is beginning to collect on her coat, her bags, and in her hair. She makes no motion to move.

Does this woman have a mental illness? Does she need to be sent to the hospital for psychiatric evaluation? If she doesn’t want to go to the hospital, should she be forced to go to the hospital against her will?

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Consult-Liaison Education Informal-curriculum Lessons Medicine Observations

Personality Disorders to Difficult Interactions (I).

I successfully delivered my talk on personality disorders recently. The second half of the talk strayed from personality disorders to a discussion about how to manage difficult interactions with people. The two topics are peripherally related, as you will recall that individuals with personality disorders often have difficulties with interpersonal relationships.

To be clear, though, just because you have a difficult interaction with someone doesn’t mean that that person has a personality disorder. There are plenty of people without personality disorders who behave in unbecoming ways.

Think about the last time you had a rough day. It is within the realm of possibility that, during that slice of time, you behaved in ways that suggest you have a personality disorder. It may not happen often, but it happens to all of us at some point.

Most of us rely on “gut feelings” to identify when we’re having difficult interactions with people. There are behavioral cues, though, that can serve as “red flags” to alert you that an interaction isn’t going well:

1. There are frequent interruptions. The other person keeps interrupting you… and you keep interrupting the other person.

2. There is a lot of repeating. You keep saying the same thing over and over again… and the other person keeps saying the same thing over and over again.

3. Many words are spoken, but nothing is really said. The literature describes this as “disengagement”. You’re just saying things to end the conversation. (e.g., “There’s nothing else I can do. Sorry. There’s nothing else I can do. Sorry.”)

Though emotional cues are valuable, sometimes it is easier to recognize these behavioral cues. We may not realize how we’re feeling until it reaches an uncomfortable intensity.

Once you recognize that you are in the midst of a difficult interaction, what can you do?

A useful first step is to stop talking.

The reason why it is important to stop talking is because when you stop talking, you can then self-reflect. I know that sounds “woo woo”. Hang in there with me.

Acknowledge the emotions you are experiencing. If you do not recognize and acknowledge what you are feeling, those emotions will likely manifest themselves in behaviors that you may not like.

If I refuse to acknowledge that I feel angry with someone, I might speak in a tone of voice that sounds sarcastic and condescending, give an icy glare, or say something biting and rude. Acknowledging what I am feeling gives me the opportunity to adjust my behavior accordingly. It gives me choices as to how I want to proceed.

To be clear, people aren’t stupid, so the other person probably knows that I feel angry. Acknowledging my anger, though, can cue me to take a deep breath, relax my face, or do something else to prevent the situation from getting worse. If I’m not paying attention to how I feel, I won’t do any of those things.

The other important aspect about acknowledging your emotions is that it grants you permission to feel what you feel. People sometimes have this idea that you must like all of your patients (or clients or customers or…). However, you won’t like all of your patients. That’s okay. That’s not the expectation. The expectation is that you show respect and provide the best care you can to them. That doesn’t mean that you have to like them.

You feel how you feel. There may be days when you feel anger towards people you like. And that’s okay. You will be much more effective if you acknowledge how you feel to yourself because you will be giving yourself choices. Those choices can give you significant influence over the rest of the interaction.

This is one important reason why you stop talking. More reasons to follow.

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Consult-Liaison Education Lessons Medicine

Personality Disorders (IV): Refocus.

The education steering committee (a formal title they don’t actually have) called me on Friday to offer specific suggestions for my presentation on personality disorders. It is always a blessing when members of your audience tell you what they want to learn. Don’t let that information go to waste.

The committee opined that the personality disorders staff encounter most often include:

  1. borderline personality disorder
  2. antisocial personality disorder
  3. dependent personality disorder

(The first two did not surprise me, but the third did.)

They also commented that staff often do not view personality disorders as psychiatric conditions; they merely comment that “they’re just personality disorders”. Even worse, when some staff hear that someone has a personality disorder, they automatically think, “Oh, so that person is an @$$hole.”

(There’s that heuristic again of reducing conditions down to a single word. To be clear, “@$$hole” is not a clinical entity.)

Upon listening to the committee’s suggestions, it appears that they would like the audience to learn the following three things[1. When giving talks or presentations, “start with the end in mind”: What are the main points you want the audience to take away? Realize that you can’t cover anything. What ideas can you plant that will make people want to learn more?]:

The etiology of personality disorders. Though personality disorders may be egosyntonic, the vast majority of people do not actively choose to experience the thoughts, emotions, and behaviors they have. There is a fair amount of research on borderline and antisocial personality disorders[2. Individuals with antisocial personality disorders are often a captive audience… because they are incarcerated. More commentary on that later.], which indicate that genetics and childhood experiences influence the development of these conditions.

One of the tragic childhood experiences that seems to foster development of both borderline and antisocial personality disorders is chronic sexual abuse. It is not difficult to imagine how someone who was sexually abused as a child may have problems regulating his own thoughts, behaviors, and emotions as an adult.

Empathy training. Learning the etiology of personality disorders will hopefully lend itself to “empathy training”. It’s not easy to “put yourself in someone else’s shoes”, though, at some point, we have all felt like our emotions were out of control, had thoughts that disturbed us, and did things that we don’t like. All of those things have negatively affected our relationships with other people. (Remember that individuals with personality disorders are often unable to adopt more flexible ways of coping with stress, not because they don’t want to, but because they just can’t in that particular moment. That doesn’t mean that they can’t learn new coping skills in the future.) Reminding people of their own experiences with unpleasant past experiences (i.e. when they were pissed off and did things they now regret) and how it affected their relationships will hopefully help them change their perspective and increase their patience and empathy.

Brief, effective interventions when working with individuals with personality disorders. Oh, how we all want the quick fix.

One of the main points I will address I already touched upon in a previous post. To be effective with other people, particularly when their emotions (regardless of what those emotions are) are running high, you must have some awareness of what your own emotions are. (Psychodynamic types call this “countertransference”.) People naturally tend to blame others for how they are feeling and, yes, it is true that our emotions are affected by what other people do. However, your resulting thoughts and behaviors from your emotions can have a significant impact on what happens next.

Acknowledging that you are feeling an emotion and then recognizing what that emotion is are vital first steps to managing difficult situations with skill. (Acknowledging and recognizing the emotions of the other person are vital next steps. Behavioral types call this “validation”.)

I cannot control how the audience will use the information I present, but I fear that any suggestions I offer will be applied as an algorithm. Flowcharts and recipes can be useful, but flexibility and creativity are important tools when working in situations that are not logical (and, really, emotions and the thoughts and behaviors we have in response to emotions are often illogical). Learning how to really pay attention in the moment seems like a “touchy feely” concept instead of a technical skill. It’s also a skill that is often difficult to execute.

Time to do more reading and think about delivery. More to follow.

Categories
Education Homelessness Lessons Medicine Observations

When I Grow Up…

When I grow up, I want to be a drunk.

I want to wake up feeling restless and uncomfortable. It’ll be neat to drag myself out of bed to open that first bottle of wine. I’ll drink all of it within an hour. Then I’ll go to the liquor store. The guy behind the counter will know that, everyday, I will buy a pint of vodka from him. He will look at me with stony eyes, which will make me feel even more restless and uncomfortable. What he doesn’t know is that I will also get two more bottles of wine and a case of beer from the grocery store before I return home. As an adult, I want my sole coping skill to consist of getting drunk.

When I grow up, I want to get fired from all of my jobs because I am frequently drunk. I can’t wait for my boss to call me into his office because my coworkers smell alcohol on my breath. It’ll be fun to make an a$$ of myself while working because I just can’t stop myself from drinking that bottle of wine in the morning.

When I grow up, I want strangers to see me doubled over a tree planter with vomit on my shirt. I look forward to police officers shouting at me to get the f-ck up and move along. I am eager to see the disdain and disgust of the firemen and paramedics when they realize that the 911 call was, yet again, for me. I can’t wait to hear the doctors and nurses in the emergency rooms say things like, “Oh, not him again. I’m so tired of seeing him. He’s taking up a bed that could be used for someone who is really having an emergency.”

When I grow up, I want to ruin all of my relationships because I am a drunk. I look forward to destroying property and scaring my girlfriends. I can’t wait for my wife to request a restraining order against me because I’ve threatened to kill her one too many times. It’ll be great when my parents and siblings never invite me over to their houses because they think my behavior is out of control. I can’t wait to achieve that level of isolation and notoriety.

When I grow up, I want to spend a lot of time in jail. I look forward to receiving charges of public intoxication, disorderly conduct, assault, and battery. I can’t wait to collect warrants because I was too drunk to show up for my court dates. It’ll be fun to bounce in and out of jail and frequently apologize to of all of my probation officers. It’ll be neat to lose my housing because I couldn’t pay my rent while I was in jail. Homelessness will be a delight!

When I grow up, I want people to judge me because of my alcohol problem. I look forward to people hating me because they believe that I choose to drink alcohol to the point that I can’t function. It’ll be exciting to realize that people believe I am useless and a waste of a human being.

When I grow up, I want to hate myself because I am a drunk. It’ll be fun to feel constant shame and complete lack of control over myself or anything else. I can’t wait to experience unending self-loathing and disappointment. And how thrilled I will feel when I realize that the only thing that makes me feel better in the moment is drinking more alcohol.

Categories
Fiction Lessons Observations

Stoicism.

“I HEAR THEM! THEY ARE CALLING ME A CHEAP PROSTITUTE!”

Her shouting is like a gas: It completely fills the space, regardless of the size of the container. The sound originates deep in her abdomen and bellows from her mouth before reverberating throughout the room.

“THESE DISGUSTING MEN,” she shouts, “KEEP CALLING ME A WHORE! I AM NOT A WHORE!”

Her wrinkled hands flecked with liver spots loosely hold a fashion magazine open. Long strands of her gray hair are falling into her dark eyes.

“I HATE ALL OF THEM! THEY ARE SO DISGUSTING!”

Spittle flies from her chapped lips as she roars. Her eyes are focused on the empty chair directly across from her.

“IF THEY KEEP CALLING ME A DIRTY WHORE, I WILL SLIT THEIR THROATS! ALL OF THEM!”

A receptionist, a doctor, a nurse, and a dietician all stand around her in the waiting room. The shouting woman is waiting for her appointment. The staff are waiting either for her to calm down or for the last cue to escort her out.

Silence fills the room like a gas. The woman’s lips are stretched into an uncomfortable grimace.

Seated directly to her right is an older man. He still has not looked around the sheet of newsprint he is holding. He has not shifted position. The newspaper does not rustle.

Seated to her left is another man who is holding a small cell phone in his right hand. His right thumb periodically pushes a button on the phone and his eyes remain fixed on the small screen.

Two men and one woman are seated across the room. The woman continues to dip her crochet hook into the yarn; the hook has not stopped since the shouting began. One man has his arms crossed; his chin is tucked in and his eyes look closed. The other man rests his elbows on his knees, his fingertips lightly touching, and his eyes stare at the floor. If he has flinched, no one has noticed.

“STOP CALLING ME THAT!”

This story isn’t about her. It’s about the other people in the waiting room.

What happened in their lives that gave them the stoicism to completely ignore her?

They didn’t get up. They didn’t change seats. They didn’t stare with curiosity or fear. They didn’t look at each other with knowing eyes.

None of them had met her before, but they were already familiar with her behavior.

What happened to all of them?

Did their parents only scream at them? Was a shouting parent more comforting than silence, as that meant that at least a parent was present? Did they learn to tune out the shouting when they were incarcerated? Were they beaten as adolescents, such that shouting like this was a benign alternative? Did strangers only shout at them, making this situation nothing out of the ordinary?

How did they learn to cope like this? Who or what trained them to react like this, to react with nothing at all?