Category: Lessons

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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.

Categories
Lessons Medicine Nonfiction

Treatment Options.

Reading this essay, A Major Problem With Compulsory Mental Health Care Is the Medication, made me think of the following anecdote. I’ll say more about compulsory mental health care (also called involuntary psychiatric treatment) and involuntary medications in a separate post.

Long time readers (from 2004—close to 20 years ago! thanks for spending decades with me!) will recall a physician I dubbed the Special Attending. (In this post from 2019 I identify him by his first name, Matthew.) I am certain that I wrote about the following anecdote at the time it happened; I was upset and distressed. The Special Attending was not a desirable flavor of “special” at this point. Frankly, I believed he was unnecessarily cruel and unfeeling.

I was an intern on the general medicine service. The patient was an elderly, frail woman with multiple medical conditions. She looked and sounded ill; the numbers from her blood and imaging studies confirmed her health was deteriorating.

The senior resident, the other intern, and the medical students all expressed concern about her viability. She looked miserable; she told us with her weak voice that she felt exhausted and uncomfortable. Why are we still poking and prodding her? we wondered. What are we doing?

“We should put her on comfort care,” someone offered. This quickly became the team consensus. We all knew the adage: Cure sometimes, relieve often, comfort always. With confidence that bloomed from the shallow earth of inexperience, we believed that none of our interventions would cure her. The pathway to relief, from our distressed perspective, was only through comfort care.

We—probably me, since this was my patient—proposed this plan with certainty to the Special Attending.

“No,” he replied. It wasn’t that he uttered only one syllable and nothing more. He was frowning. Though I had only worked with him for a few days, it was clear that he was radiating disappointment and disapproval.

Maybe it was me; maybe it was someone else with more courage who finally sliced into the uneasy silence by asking, “Why?”

Because we haven’t tried everything yet, he tersely answered, making no eye contact with any of us. There are still things we could do.

After rounds, we grumbled as a team. “Why is he making us do this?” we whined. “We’re the ones who have to tell her about next steps and do all the things. She’s not going to want this. She’s already suffering so much.”

See, the thing is, we couldn’t tolerate her suffering. We couldn’t bear to witness the deterioration of her body. We didn’t want to try another thing that would fail and prolong our mutual suffering. And what better way to help us escape than by limiting options and withdrawing?

So what does this anecdote have to do with involuntary psychiatric treatment?

My own view is that involuntary psychiatric treatment (inclusive of detention and medications) is a bad outcome. It means that multiple systems failed. The Big We either did not intervene earlier or care to intervene sooner. The Big We didn’t create or maintain enough options to avert this undesired result.

(To be clear: I have provided involuntary psychiatric treatment. It’s not an option I ever want to choose. I never feel great about it.)

We must create as many options as possible for people to receive care and treatment. We must tell people about these options and eliminate barriers so people can access them with ease. When you’re already feeling terrible, the last thing you want to do is climb uphill to knock on doors that won’t open.

It’s hard to witness suffering, but dealing with our discomfort is a problem for us to solve. For those who are suffering, they should not have to solve our discomfort, too.

In retrospect, I wish the Special Attending had explicitly talked with the team about our distress from witnessing the woman’s suffering. It doesn’t have to be a “processing” conversation or “touchy feely”. It could have been something like, “It’s hard to witness someone who is really sick. Our job, though, is to think of and share all treatment ideas with patients. They trust us to help them, so we must try. We can’t give up and look away, though, just because it’s hard for us. We are talking about this woman’s life.”

In the end, we talked with the woman about another treatment plan. She agreed to it. It didn’t help. And that’s when the Special Attending said, “Now we can talk with her about comfort care.”

Categories
Blogosphere Lessons Nonfiction Reading Reflection

Time Millionaires, etc.

A cartoon illustration of a father and son aging together, from birth to the grave.
Artwork by Pascal Campion

Since my last post, I have recovered from illness, though spasms of coughing still occasionally overtake me. Other circumstances have changed, too, that have highlighted to me the importance of spending time with people we love. American culture often focuses on becoming financial millionaires when becoming time millionaires is vastly more important.

Here are some things I read while recuperating that may be of interest to you:

What My Father’s Martial Arts Classes Taught Me about Fighting Racism. “Self-defence means to protect yourself, to protect others around you, and to protect your opponent from committing a crime.”

The Politics of Paying Real Rent Duwamish. This is of greatest interest to people who live in the Seattle-King County area. After reading this article I stopped paying Real Rent. The tagline is accurate: “Why a simple act belies a complicated history.”

“A 1996 Super Mario 64 manga suggests that 1-Up Mushrooms grow from the bodies of dead Marios, perpetuating the cycle of life and death.” The image is what drew me in.

What It Felt Like to Almost Die. “My near-death experience taught me not to fear those final moments.” I hope that this is true for us all.

Generation Connie. I am a bit older than the cohort of Asian American women who were named Connie (and my father said that my parents never considered the name Connie for me), though I definitely remember seeing Connie Chung with Dan Rather when I was growing up. Fun photos in the article.

A Killing on the F Train. Of all the writing I’ve read about Jordan Neely, the man experiencing homelessness and psychiatric symptoms in NYC who died when another subway passenger restrained him (via chokehold), this piece by John McWhorter resonates the most with me. His perspective is kind, nuanced, and empathic. Highly recommended.

Categories
Education Lessons Nonfiction Policy Reflection Systems

What I Learned in Government.

It’s been nearly four months since I posted something here. Don’t be fooled: The lack of words here did not mean an absence of word salads tossing about in my head.

I recently resigned from my job. (All The Things related to that contributed to my silence here.) My job had two parts: One involved administrative work as the behavioral health medical director for local government; the other involved direct clinical service in a jail. I was in that job for over five years. It took me about two and a half years to figure out what an administrative medical director does. (As the process of becoming a doctor involves frequently feeling incompetent, this discomfort wasn’t new to me.) Now that I’m on the other side of this job, here’s what I’ve learned:

I believe government can do good things. You know that stereotype that government employees are lazy? I did not find that to be true. Every organization has a proportion of staff who do not seem motivated or interested. The proportion, in my experience, does not seem higher in government. If anything, many of my colleagues came to government with eager hopes of improving the community. They came in early, stayed late, and worked on weekends. They convened groups with opposing viewpoints, advocated for different populations in the region, and expressed dissent to people in power. They sought out and willingly worked on complicated problems. They demonstrated the humility that comes with the realization that tax payers are funding their salaries.

I do not enjoy the game of politics. Some people love it! They enjoy the contests of status, flaunting their connections, and attacking perceived enemies in public forums with the brightest of smiles. Sometimes people asked me to speak, not because they cared about the content of my words, but because of my credential as a physician. (“Let’s trot out The Doctor.”) I grumbled about “perception management”; often it seemed that the surface sheen mattered more than the substance underneath. (On the other hand, it is likely that my glittery MD credential is what allowed me to say to superiors that poop will never develop a patina. It is unfair that systems often value specific people more simply because of the letters after their names.)

Government work has made me both more and less patient. It takes time to elicit ideas and information from “stakeholders”, community members, and others. People want to and should be involved if a policy or program will impact their lives. They share perspectives that government never thought to consider. I respect that process. I am less patient with the nonsense people and systems can generate to subvert fair processes. Some people are more prone than others to misuse power. That’s hard to watch in a system like government, which has access to and authority over so much money… and, in our current system, whoever has more money almost always has more power.

I learned a lot about laws and regulations. I came to appreciate the value of regulations, though they tend to address the lowest common denominator. Government spends most of its time aiming low to define the floor instead of inspiring people to elevate the ceiling. (I wrote more about this here.)

Government administrators forget what happens in direct service. Though many people in government once provided “front line” services—as attorneys, social workers, counselors, activists, whatever—many of them seem to forget the challenges of systems that are intended to help people. This includes the thousand little cuts of too much paperwork and the major crises of people dying due to missing or underfunded services. My opinion that all medical directors should routinely provide direct clinical service has only gotten stronger with this experience. Someone has to inform the others at The Table what’s going on outside.

Systems are made of people. Contemporary discourse often focuses on systems, not people… but people make up systems (i.e., individuals create, operate, and maintain systems). As such, single individuals can still have significant impacts on systems. This includes grinding things to a halt… or breathing life into new programs. (This is where political gamesmanship can be useful.) The hierarchical organizational chart can lead people who are “lower” to think that their efforts don’t matter, but that’s simply untrue. Systems can change because people can change… whether that’s because people actually change their ideas and behavior or people in certain positions leave.

I am deeply grateful for the opportunity to work in government. I never thought I would work as a civil servant (and, in fact, there was a time when I said I’d never work for government… which is why I’ve stopped making five-year plans). If for nothing else, now that I’ve been on the inside, I can use that experience and knowledge on the outside.

The outside suits me better. So it’s time to go back.