Category: Nonfiction

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Nonfiction Observations Seattle

Bridges, Frustration, and Coping.

The longest floating bridge in the world is in Seattle. It is 7,710 feet (2,350 meters) long and spans beautiful Lake Washington. Locals call it the “520 bridge” and, in its current incarnation, only cars may use the bridge.

Yesterday, the Washington State Department of Transportation hosted the grand opening of the new 520 bridge. On the bridge were several food trucks, booths with information related to the engineering and construction of the bridge, and equipment and heavy machinery used in its creation.

To get to the event from Seattle, people had to take shuttle buses that originated at the University of Washington campus. The buses drove about three miles on the old bridge and delivered the crowds to the start of the new bridge.

Tens of thousands of people took the opportunity to walk across the bridge and enjoy the surrounding views that, prior to then, one could only enjoy by car.

In the early afternoon hundreds of people got in line to get back to Seattle. A young man wearing an orange vest carried a sign that read “End of the Line Here”. He folded the line back and forth to compress hundreds of people into a narrow area while we awaited the shuttle buses.

Behind us were two women who appeared to be in their 60s. One wore a visor that pushed her short white hair out of her face. The other had a greying bob.

“This is ridiculous!” Visor exclaimed. “This isn’t organized at all! We’ve been waiting in line for over 30 minutes and I don’t see any buses coming!”

“I know!” Grey Bob agreed. “We haven’t moved at all. This is terrible. This is ruining the entire event!”

Thin white clouds were streaked across the bright blue sky. A refreshing breeze swept around us. Mt. Rainier stood in the distance, a lenticular cloud atop its peak like a floating hat.

“OH MY GOD we’re actually moving!” Grey Bob squealed as the line shuffled forward. “We might actually get off this bridge!”

“I’m not going to be that optimistic,” Visor replied. “I’m going to wait until we actually get to UW before I say that.”

Shimmering white light danced on the dark blue ripples of Lake Washington. As the clouds dissolved under the sunlight the snow-capped peaks of the Cascade Mountains revealed themselves. A media helicopter, less than 100 feet above us, drifted past.

“HELP US!” Visor screamed at the helicopter.

When we could no longer hear the helicopter, Grey Bob sighed, “It’s been over 45 minutes. This is unacceptable.”

“If I have to wait in line any longer, I’m going to jump over the side of the bridge and kill myself,” Visor squawked.

Grey Bob laughed before commenting, “The barriers aren’t that high. Someone could really jump over. It wouldn’t be that hard.”

“Oh yeah, you’re right,” Visor said, her voice non-plussed. “That’s not good.”

At around 55 minutes the line was no longer still. We walked in quick strides towards five buses. Two of them faced West to go to UW. Three of them faced East.

“All the buses are gonna go to Seattle,” the event planner shouted at us. “Get on any bus on the other side of the barrier. All the buses will go West.”

I smiled as I watched my father scramble over the barrier—while not a spring chicken, he is still spry—and my husband and I made a point of scurrying away from Grey Bob and Visor. The three of us got on a bus facing East.

Nearly 100 of us packed into the bus. My father sat to my right. A woman in her 50s wearing a bicycle jersey sat to my left. My husband gave up his seat in an act of chivalry for her. He stood near the rear exit of the bus.

The bus headed East towards the fancy-pants neighborhoods of Medina and Hunts Point. Once the bus was off the bridge, it passed an exit. Then another.

“WHAT?” Bicycle Jersey exclaimed. She leaned forward and barked at her friend, an older woman with glasses reading a newspaper, “Why is the bus driver not turning around? Doesn’t the driver know that we’re supposed to go to SEATTLE?”

Someone pulled the wire to signal the bus to stop. People snickered.

The bus slowed to a halt at an intersection with several other shuttle buses. It did not move for nearly 15 minutes.

“This is so disorganized,” Bicycle Jersey said. “This is not worth it. This has ruined the entire day for me.” Her right thumb scrolled through an article by Nick Kristof: “When Whites Just Don’t Get It”.

The bus then crept north towards Kirkland.

“WHAT?!” Bicycle Jersey shouted. “Why are we going to Kirkland? We’ve been on this bus for over half an hour! We should’ve gotten on a bus that was going the other way. They’re already back home.”

“I never take the bus,” a woman standing over my dad said to no one in particular. “I’m never doing this ever again. Unless it’s a shuttle bus at a really nice wedding. And I mean a REALLY nice wedding.”

A young man with facial stubble near my husband hugged a pole. “We’re almost out of water. We’re going to die on this bus.”

“It’s like we’re hostages on this bus,” Bicycle Jersey spat.

The bus stopped at the Kirkland Park and Ride, but not at the curb.

“He better not make us get off this bus,” Bicycle Jersey said.

One man got off the bus.

“Did we come all the way here just for that one guy?” Bicycle Jersey continued. “What about the rest of us?”

The bus rolled back down the hill and stopped at an intersection.

“WHY WON’T THE DRIVER GET BACK ON 520?” Bicycle Jersey shouted. “TURN RIGHT HERE.”

“We’ve been on this bus for almost an hour,” Facial Stubble announced.

When the light turned green, the bus turned right and we were back on 520.

“We’ve been on this bus for almost an hour,” Facial Stubble announced again.

The bus rolled past the line of people waiting for buses. It was nearly a mile long now.

“DON’T GET ON A BUS HEADING EAST,” Bicycle Jersey shouted at them. None of the windows of the bus were open. The bus was going over 40 miles an hour.

“We’ve been on this bus for an hour now,” Facial Stubble said. “This is the worst mistake of my life.”

Some people have to wait over an hour every day just to get food and water.

I’m going to guess that you ate breakfast this morning. I’m also going to guess that you’re going home. Because you didn’t have to work today.

You’re not showing any overt signs of dehydration. Shut up. You’re not going to die.

The only person holding you hostage right now is you. Your bitterness isn’t going to make us get back to Seattle faster.

If you are joking about suicide because you’ve been waiting in line outside on a beautiful day for 45 minutes, how do you deal with actual stress?

Maybe you sustained a brain injury in your frontal lobe and that’s why you have low frustration tolerance.

Maybe your prefrontal cortex hasn’t fully developed yet. That process isn’t complete until your mid-20s, at which point you’ll hopefully have better impulse control.

Maybe no one ever taught you emotion regulation and distress tolerance skills. So maybe this is a skills deficit.

Maybe you’re having a rough time in life right now. Maybe a relationship you value is ending. Maybe someone you care about is sick and dying. Maybe, under different circumstances, you’d exercise more patience.

Maybe you’re a victim of specific operant conditioning: Maybe you’ve learned that people only pay attention to you and value what you say when you’re expressing snark or distress. And that people will only take you seriously the louder you talk.

My dad shrugged.

“We just had bad luck today.”

Categories
Nonfiction Reflection

Entitlement.

“Do you have any questions for me?” I asked. It’s how I usually close clinical interviews. It’s also a way to acknowledge how one-sided the interviews are.

“Will you go out on a date with me?” he replied. We were looking at each other through the window of his cell. His face was serious.

“No. Don’t ask me that again.” I want to be clear. There’s no ambiguity in that answer. “Do you have any other questions for me?” Even though I said no, I will still talk to you in my professional capacity.

He said nothing, but now he was frowning.

“Are you angry?”

“Yes, I’m mad. You said no when I asked you out on a date.” His cheeks were now red. He roared, “I HAVE SEXUAL NEEDS, TOO!”

“Good-bye, sir.” He was still shouting racial and misogynistic epithets at me as I left the area.

It’s not his request for a date that was noteworthy. That, unfortunately, has occurred before. It doesn’t happen often.

This is usually how these conversations occur:

SCENARIO 1: “Do you have any questions for me?”

“Will you have sex with me?”

“No. Don’t ask me that again.”

“Okay.”

And the subject never comes up again.

SCENARIO 2: “Do you have any questions for me?”

“Will you give me a blow job?”

“No.” (walking away)

“I’M SORRY, I’M SORRY, I WAS JUST KIDDING….”

These men usually apologize again the next time I see them.

SCENARIO 3: “Do you have any questions for me?”

“When I get out, I’ll take you to that burger place, I’ll buy you a burger and small fries, you can choose Pepsi or Coke—”

“Thank you, but no. That won’t happen.”

“But you can choose your own soda—”

If it comes up again, the requests are benign and may not make a lot of sense.

What made this man’s reaction noteworthy was his rage.

Nobody likes rejection. We all feel that visceral crushing sensation when we want something and we can’t have it. That crushing sensation is particularly harsh when we can’t have what we want due to arbitrary reasons. Like when a woman declines a date with a man.

This man and I had an interaction in a jail through the door of his cell. It was civil. To me it was a clinical interview. To him it may have been a nice and encouraging conversation. Something about the interaction made him feel comfortable enough to ask me for a date.

(Never mind the cues that indicated that such a request was inappropriate: He was in a jail cell. He knew that I worked as a physician there.)

The men in jail who have asked for dates or sex, though, recognized that they were not entitled to either. Sure, they could ask whatever they wanted. But, they also had the understanding that I could respond however I wished.

This man, though, was furious that I declined his request for a date. His reaction suggested that he could not believe that I had the gall to say no to him. How dare you say no when you were the one who asked me if I had any other questions? You started this. If my role as a physician was to help him, he had ideas as to how I could do that. Boundaries had blurred for him. He disliked that they had not blurred for me.

And, to be clear, this sort of behavior is not a function or manifestation of psychiatric illness. Some people with severe psychiatric conditions have extraordinary manners. Some people without any psychiatric conditions have vulgar manners.

If we look at the entire population of heterosexual men who are talking with a female psychiatrist:

  • Some (most?) men will never think to ask for a date or sex when asked, “Do you have any questions for me?”
  • Some men will think to ask that question, but won’t actually ask it.
  • Some (few?) men will actually ask the question (whether earnest or not), though will not react as this man did.

And, as unpleasant as this interaction was, he did use his words to express his displeasure with me. Would he have shared his thoughts with me had I not asked him if he was angry? There are all the ways this interaction did not play out:

  • He could have spit on the window (and if the window wasn’t present, his saliva would have landed on my face).
  • He could have hit or punched the window.
  • He could have reached through the open slot in his cell door and grabbed me.
  • He could have thrown something—wet or dry—at me through the open slot.

What would have happened if this interaction had occurred outside of the jail?[1. As I write often here, context matters. Some behaviors occur in jail because of the jail. When you are deprived of your freedom and must spend time in an uncomfortable place with limited to no privacy and nothing to do, you may find yourself behaving in uncharacteristic ways because you are angry or bored… or just because you can.]

He might have walked away.

He might have grabbed me to demonstrate his power and elevate his status.

He might have hit or punched me to express his rage.

He might have grabbed me and taken what he wanted.

Categories
Education Nonfiction Policy Reflection Systems

A Review of the National Council for Behavioral Health Conference.

Those of you who follow me on Twitter already know that I spent much of last week in Las Vegas. I attended the National Council for Behavioral Health Conference, “featuring the best in leadership, organizational development, and excellence in mental health and addictions practice.” Here are my reflections about the experience:

It was large. I have never attended a conference with 5000 other people. I already find Las Vegas overstimulating. Not being able to get away from thousands of people for hours on end was draining for me.

There were many sessions I wanted to attend, but could not. This, of course, was a function of the size of the conference. Humans, thus far, can only physically be in one place and mentally elsewhere. During this conference I often wished I could physically be in two places at once.

The sessions that most inspired me often had little to do with formal behavioral health. Nora Volkow, the director for the National Institute of Drug Abuse, gave a talk about the neurobiology of addictive behaviors. Did I learn anything new? No, only because I had learned this while in medical training. Did she present the information in an engaging and compelling way? Yes.

Charles Blow, an opinion writer for the New York Times, authored a memoir about his youth and past sexual abuse. During his talk he read from his book and shared his reflections about his experience. Did I learn anything new? Nothing obvious that would affect either my clinical practice or policy considerations. He won me over with his personal perspective, grace, and vulnerability.

Susan Cain spoke about introversion and leadership. Did I learn anything new? No, because I had already read her book. Was it nonetheless worthwhile to hear her speak in person? For me, yes.

The conference featured a large session called “Uncomfortable Conversations”. The intention was for Big Names in the field to discuss controversial topics. These included involuntary commitment, confidentiality laws that are specific to substance use disorder treatment that can interfere with clinical care, and the concept of cultural competency. Each pair, however, had less than ten minutes to discuss their issue. The moderator also seemed to speak more than each member of the pair. The session could have been thoughtful, though ended up feeling underdeveloped and unfocused.

Where were my psychiatrist colleagues? I understand that this is my own issue—after all, this was not a physician conference. The National Council, however, is supposed to be the leadership conference for community behavioral health. Are psychiatrists involved in leadership in community behavioral health? If not, why not? [1. As I have noted elsewhere: “Physicians, as a population, don’t advocate for ourselves as much as we should because we’re “too busy taking care of patients”. This is true. However, our busy-ness creates a vacuum where non-physicians step in and make decisions for us. We then express resentment that we have to follow the edicts of people who have never done the work. If we did a better job of regulating and advocating for ourselves, we might not be in this position.” Advocacy in this case is leadership.]

Only two “small” sessions I attended featured physician presentations. One involved the introduction of trauma-informed care into primary care settings. The other discussed a concrete integration of mental health, substance use, and primary care services. In both cases the physicians were family practice physicians. Which, to be clear, is fantastic. We must work across systems to provide good care for individuals and populations. I nonetheless felt both puzzled and disappointed with the lack of psychiatrist representation. [2. To be fair, Nora Volkow and several of the panelists for the “Uncomfortable Conversations” are trained as psychiatrists.]

There was a “medical track” meant for medical professionals. Few of those sessions discussed systems issues or leadership. I had planned to attend one that discussed guidelines for benzodiazepine use, though there was no room by the time I arrived. (One of my colleagues, a psychiatrist, later told me that many attendees were not doctors.)

The conference will be in Seattle next year. My colleagues and I are already discussing what we can present.

A lot of people want to do good. I often comment, “Life is terrible… and life is wonderful.” That people have done good work to help others and want to share what they learned in the process is remarkable. That people continue to strive to provide useful services to people who are suffering is humbling. That people are creating new programs to help solve problems, often rooted in inequality, a variety of disparities, and the randomness of existence, is inspiring.

When we have our heads down in our own work, we often forget that we are part of a system. Though I have critical opinions about the conference, I am grateful that I could attend. May we all seek inspiration and always learn from others.

Categories
Nonfiction Reflection

My Conflicted Relationship with Fried Chicken.

They are clear memories from my youth: After riding our bikes along the beach on warm summer mornings, my parents frequently picked up a bucket of Kentucky Fried Chicken. After we settled into our seats at the kitchen table, I always got the drumsticks and biscuits. My parents both preferred dark meat. My mom would take the cole slaw. My dad enjoyed the mashed potatoes and gravy. Chilled watermelon or papaya completed the meal.

A pot of tea was now on that same kitchen table. The wedding band was loose on my mom’s finger.

“You know why I got cancer?” she asked me in Chinese. Before I could say anything, she replied in English, “I ate too much Kentucky Fried Chicken.”

“No,” I blurted out.

“There’s too much grease in it,” she continued.

“No,” I repeated, now both amused and disturbed that she was attributing her lung cancer to Kentucky Fried Chicken.

“If I didn’t eat so much Kentucky Fried Chicken, I probably wouldn’t have gotten cancer.”

“NO.”

I repeated what the oncologist had told us: It was probably genetics. She was a relatively young, non-smoking, Asian female. Something about all that put her at higher risk of developing non-small cell lung cancer. The Kentucky Fried Chicken had nothing to do with it.

She looked away and sighed. Even though I had a medical degree, I was still her daughter and my statement was a child’s opinion.

“I’m not hungry, but I should eat something,” I said, wiping the snot from my nose with my arm. Less than an hour had passed since I had learned that my mom had died.

When we got home, we pulled the paper containers from the plastic bag and put them on the kitchen table. Tears were trailing down my cheeks and my chest still hurt, but I started laughing as I bit into the fried chicken from Ezell’s.

“I get a senior citizen’s discount,” my dad said, smiling. He put the red tray down between us and opened the red and white box.

“I’m glad,” I replied, smiling back at him. He reflexively gave me the drumstick and the biscuit. I handed him the mashed potatoes and gravy.

“Mmm,” he said between bites. “Kentucky Fried Chicken is good.”

“Mm hm,” I mumbled in agreement while chewing. I’m going to enjoy this fried chicken and cancer can go f-ck off.

Categories
Lessons Nonfiction Reflection

Racial Slurs and Hurt Feelings.

You could feel the air rushing out of her lungs and into your face if she was screaming at you.

“STOP CALLING ME A WHORE! I AM NOT A WHORE, YOU DIRTY N-GGER!”

No one, in fact, was calling her a whore.

“DON’T LIE TO ME, MOTHERF-CKER! I HEAR ALL OF YOU CALLING ME A WHORE! I HEARD IT, JUST NOW!”

Her best defense was a loud offense that included liberal use of racial and homophobic slurs. We winced and asked her to stop when the colorful epithets flew from her mouth. She glared at us, her face red and fists clenched.

Despite seeing her multiple times over the course of two years, she, up to that point, had never made any comments about my race. (I look obviously Asian.) Then, one day, with an audience of a dozen people:

“YOU CAN F-CKING GO TO HELL, DR. YANG, YOU F-CKING CHINK!”

As she stormed out of the building, I grinned and put my arms up in the air in victory.

It’s about time!

Some people immediately expressed their concerns (“I’m sorry she said that”; “Are you okay?”), the distress apparent on their faces.

“It’s okay,” I replied. “I consider it a badge of honor.”

“Yeah, but that still must hurt.”

I shrugged. I felt amused, not hurt. I didn’t need them to take care of me.

They, of course, had good intentions. There was just so much they didn’t know:

That one time when my parents and I were biking along a dry river bed. I was eight years old. Two young men, both white, began trailing us. They began to shout things at us that I didn’t understand. They didn’t seem friendly.

“Stay between your mom and me,” my dad instructed in Chinese.

“Don’t say anything back to them,” my mom added.

For the next half hour, they continued to follow us. They continued to shout things at us. They often laughed.

They followed us to the parking lot and continued to shout things at us as my parents loaded the bikes into the van. As my dad drove away, they threw something at the car.

That one time I was pleading again with my mother to leave the Girl Scout troop. I was nine years old.

“I don’t want to go anymore!” I said in English.

“No, you have to go. It’s a good activity and you learn how to get along with others,” she replied in Chinese.

“But I don’t fit in. I just don’t fit in!” in English.

“Of course you fit in. You go to school with the other girls, you know all of them, they’re all good kids—” in Chinese.

“That doesn’t matter. I don’t look like them, I don’t act like them, we don’t do the same things. I don’t like it. I don’t fit in!” in English.

Silence.

“You don’t fit in,” my mother said in her thickly accented English. There were at least ten girls in the troop. I was the only person of color. Her face was no longer stern.

“Okay,” she said. It’s a word that is used in both English and Chinese.

That one time when my parents and I were walking through a parking garage. It was a hot day and a convertible with its top down approached us. The group of white guys in the car shouted “KONNICHIWA!!!” at us; we could hear them laughing as they roared past.

“WE’RE NOT JAPANESE!” I shouted back. I was ten years old. My parents shushed me.

That one time when I used my fingers to briefly transform the Asian monolids of my eyes into something that resembled double eyelids.

That one time became multiple times over the course of several months. One day, I didn’t have to manipulate my eyelids anymore: My double eyelids remained stable. My eyelids sort of (but only sort of) looked like the eyelids of the girls in Teen Magazine.

I was twelve years old.

We all have ways in which we don’t fit in, in which we’re different. We all have also learned how to take care of ourselves when others antagonize us for being different. We wouldn’t be who we are today—for better or for worse—if we didn’t have those unpleasant experiences.

No, it didn’t hurt when she said the slur. Other things have hurt much more.