Category: Observations

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Nonfiction NYC Observations

Creation and Destruction.

During a recent visit to New York City I went to the Society of Illustrators. Despite living in the city for three years, I had never heard of this museum. The newest exhibit featured botanical art. Who doesn’t like to look at drawings of plants?

It’s a small museum on the eastern side of Central Park, surrounded by stately apartment buildings and schools. On the third floor is a bar and a handsome patio. Between the two on brick walls hang illustrations of plants. 

The drawings are astounding! These dramatic tulips, created from chalk and charcoal, look like a photograph. I felt certain I could reach out and pick up these gleaming red onions, even though they are simply watercolors on paper. 

I kept returning to the only two illustrations that featured decay. This persimmon leaf (scroll down) radiates warmth and life despite the signs of infection. 

My favorite from the collection is this autumn leaf, made entirely from just colored pencils. What?! How can colored pencils create such texture and vibrancy? I was pleased to learn that the artist, Crystal Shin, is from Seattle. No wonder the deteriorating leaf looked familiar; they regularly litter sidewalks and trails in October. Even now, I can’t believe that’s just a drawing.

Illustration of a decaying Pyrus calleryana leaf, which is mostly red and brown, with some green spots, along with black blemishes of decay.

After I moved on from this leaf, I stopped in front this drawing of wild blackberries, another common sight here in Seattle during the late summer. I heard an excited voice approach me: It was the artist, Catherine Park! She couldn’t believe that her piece was in the exhibition. “I’m so happy to see people looking at it,” she said, beaming. She was gracious enough to answer my question about how long it took her to create this. 

“Six months,” she answered with what sounded like mild disappointment. 

“Six months!” I exclaimed. That was far beyond my expectations.

Catherine then explained the process behind her work (which entirely aligns with what she said about the piece here). Her enthusiasm for light, detail, and the lifecycle of the blackberry made me smile. 

That chance encounter with a professional botanical artist was a potent reminder that creation takes time. Destruction is fast. Creating beauty—even the beauty in decay—takes time, planning, and energy. What a way to honor the fullness and blessings of life. The act of creating is time well spent.

“Do you know who Duncan Sheik is?” my spouse asked me. 

“Yes, of course,” I answered. It was unfair of me to expect him to remember my tastes in music before he and I met. 

“He died.”

“What?!”

So he must’ve had a sense that Duncan Sheik meant something to me.

His was the first concert I ever attended, somewhere in Los Angeles when I was in college. (I remember Paula Cole, who hopefully found her cowboy at some point, opened for him.) It’s true, I did like “Barely Breathing”, though I soon recognized that this pop song was an anomaly in his work. (His album, Humming, is what kept me a fan.) I ultimately bought five of his albums, which means Duncan Sheik was part of my life soundtrack for 12 years: College, medical school, and psychiatry residency. 

The New York Times obituary for him is syrupy. Sure, maybe he was “soft-spoken and cerebral”, but “heart-rending melodies” and lyrics “[brimming] with existential angst”? Really?

I will concede that the obituary writer’s comment resonated with me:

[Barely Breathing], along with so much of his work from the ’90s, really strikes a chord with my Gen X soul; it’s a reminder of that moment when we twentysomethings really did think that authenticity would rule the world…

To my ear, his layering of orchestral string instruments with guitars, electronic beats, and his voice naturally led him to composing music for Broadway. I haven’t seen any of them, but now hope to. 

I remember it was with great reluctance that I threw away the shirt I got from his concert. It had difficult colors: The shirt was brown with cyan text and featured his unsmiling face. After years of wear, the seams were unravelling and there were holes in the armpits.

Destruction is fast. I hope Duncan felt that his time creating music was time well spent. 

Categories
Homelessness Observations Public health psychiatry Systems

Psychiatry in Context.

A few reactions on topics related to psychiatry from the past week:

An example of a transitional object in baseball. The catcher for the Seattle Mariners, Cal Raleigh, did not play a few games due to injury concerns. Early in the game against the Atlanta Braves, the camera operator lingered on him in the dugout:

Cal Raleigh leaning against the dugout railing while holding a baseball (transitional object) in his right hand. A water bottle is directly in front of his face on the railing.

Notice that he’s not dressed to play. An unmarked bottle keeps him company. In his right hand is a baseball.

The Wikipedia page about transitional objects is pretty good (though psychobabbly). The best explanatory example of transitional objects is Linus and his security blanket:

Transitional objects give us comfort and a sense of security. Maybe the baseball gave Cal comfort and security during his mandatory time off. (Some players can hold six or seven baseballs in one hand. That’s probably more about showing off!)

The MAHA Action Plan to Curb Psychiatric Overprescribing. Per the HHS press release:

HHS Secretary Robert F. Kennedy, Jr. laid out a new action plan to promote appropriate psychiatric prescribing and drive deprescribing when clinically indicated.

Does “inappropriate” psychiatric prescribing happen? Yes. Does deprescribing, whether clinically indicated or not, already happen? Yes.

Back in 2015, while mulling over the value of psychiatrists, I commented:

When people think about medication management, they often think only of adding medications or exchanging one for another. Medication management also includes helping people come off of medications.

Many psychiatrists practice “deprescribing”. In 2019 I wrote about the ongoing difficulties in treating psychosis. There I commented on my own deprescribing experiences:

One of my early jobs was working in a geriatric adult home. My work there taught me that people with psychotic disorders can and do get better. The burdens of antipsychotic medications—paying for medications, the actual act of swallowing the pills every day, the side effects, some mild, some intense—add up. I was fortunate to work with some people to successfully reduce the doses of their antipsychotic medications and, in some cases, stop them completely! (There [was] also at least one instance when tapering medications was absolutely the wrong thing to do; that person ended up in the hospital. I felt terrible.)

Psychiatry is an easy target. Psychiatric medications, especially antidepressants, are common prescriptions. Many factors contribute to this: Health care appointments are short. (There’s not enough time for deep conversations.) It’s hard to access non-medication treatments. (Most rural areas do not have experts in evidence-based therapies.) Emotion literacy is not where we all want it to be.

For several decades psychiatry has focused on biological causes of psychological symptoms. The natural corollary is medications fix biological problems. As I noted in 2019, “Medications are a biological solution, though our understanding of the biology of the brain and mind remains limited.”

To be clear, I am not anti-medication. Psychiatric medications can not only save lives, but also improve quality of life. However, medications are not the only tool psychiatrists have to help people. Most of us do prescribe appropriately. (Some people are vexed when we decline to write prescriptions.) Many of us do deprescribe when clinically indicated. (Some people express anxiety when they want to stay on their medications.)

Ongoing hypocrisy related to “ending crime and disorder on America’s streets”. The primary community psychiatry journal published this (free) article: The Executive Order on “Crime and Disorder”: An Affront to Policy, Law, and Ethics.

I agree with the authors. I previously shared my reactions to the executive order here.

It’s fresh that the federal administration cannot recognize the crime and disorder they bring to America’s streets:

… among many other federal actions that reduce stability and increase anxiety. Choose your issue.

Categories
Nonfiction Observations

Trump and Bundy.

When I read what Donald Trump said, it immediately made me think of comments by Ted Bundy.

From today’s New York Times:

“Ownership is very important,” Mr. Trump said as he discussed, with a real estate mogul’s eye, the landmass of Greenland….

When asked why he needed to possess the territory, he said: “Because that’s what I feel is psychologically needed for success. I think that ownership gives you a thing that you can’t do, whether you’re talking about a lease or a treaty. Ownership gives you things and elements that you can’t get from just signing a document.”

From the Wikipedia page about Ted Bundy:

Possession proved to be an important motive for rape and murder as well. Sexual assault, [Bundy] said, fulfilled his need to “totally possess” his victims. At first, Bundy killed his victims “as a matter of expediency … to eliminate the possibility of [being] caught”; but later, murder became part of the “adventure”. “The ultimate possession was, in fact, the taking of the life”, he said. “And then … the physical possession of the remains.”

And further elaboration:

“[Bundy] said that after a while, murder is not just a crime of lust or violence”, [FBI Special Agent] Hagmaier related. “It becomes possession. They are part of you … [the victim] becomes a part of you, and you [two] are forever one … and the grounds where you kill them or leave them become sacred to you, and you will always be drawn back to them.”

When one covets this much, it is no longer possible to recognize the humanity of others.

Categories
Consult-Liaison Observations

Regime Change and Labels.

Not everyone buys into the idea that people have “personalities”. Sure, you may think that your friend acts in predictable ways. But you’ve also seen your friend change their behavior in different settings. In front of their parents they become someone else.

Heck, let’s not talk about your friend. Let’s talk about you. Do you adjust your behavior when you’re at work? (Have you ever peeled off your socks at the workplace and left them bunched on the floor?) Do you use different words when you’re with your parents versus when you’re with your friends? (If you text your parents, look at the emojis you use with them versus the emojis you use with your friends. Are they the same set?)

Maybe not so consistent and predictable, huh.

But for those who do believe in the concept of a personality—”a set of distinctive traits and characteristics“—then the idea of a “personality disorder” seems reasonable. It makes sense that people with personality disorders would have a set of “abnormal” traits and characteristics.

Over the past year(s) and maybe in response to the yesterday’s news, some have wondered if people in positions of power have personality disorders. Their rhetoric, policy decisions, and implementation of regime change via kidnapping—their emotional and behavioral characteristics—all seem abnormal. Our frowns do not turn upside down. They deepen with ongoing and worsening misbehavior.

It is imprudent to diagnose public figures with physical or psychological conditions. I don’t know these people; I will never be in a position to assess them. As an academic exercise, though, let’s look at what it means to have a “personality disorder”. This is how the most recent version of the Diagnostic and Statistical Manual defines a general personality disorder:

A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:

  1. Cognition (i.e., ways of perceiving and interpreting self, other people, and events).
  2. Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response).
  3. Interpersonal functioning.
  4. Impulse control.

B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.

C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.

E. The enduring pattern is not better explained as a manifestation or consequence of another mental disorder.

F. The enduring pattern is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., head trauma).

It is hard to argue that the elected leader of a nation has “impairment in social, occupational, or other important areas of functioning”. To achieve that level of power one must be able to navigate (nay, dominate!) social relationships and occupational duties. Maybe the methods they use seem “abnormal”, but “abnormal” and “impaired” don’t mean the same thing.

Consider the history of the United States. It includes ugly events—both distant and recent—of dehumanization, oppression, and exclusion. Aren’t these “expectations of the individual’s culture”? Are we witnessing any actual deviation from these expectations?

It’s true: We don’t know if these Very Important People experience “clinically significant distress”, even as they induce that in others. Maybe they have other medical, mental, or substance use disorders. We just don’t know.

“Personality disorders” are actual clinical conditions. They are not slurs. It’s okay to dislike the totality of someone’s emotional and behavioral characteristics. That doesn’t automatically mean, though, that they have a personality disorder. We can have low approval of someone with high status. They might simply be “a stupid, annoying, or detestable person“.

Categories
Observations Public health psychiatry Seattle

How Atmospheric Rivers Affect People in Jail.

An atmospheric river is a river in the sky.

I don’t remember these from my youth, though they seem to happen most years now on the West Coast.

An atmospheric river that reaches Seattle is often called a “pineapple express” because the long band of moisture in the atmosphere originates around Hawaii. When the pineapple express arrives, the temperatures here become unseasonably warm (mid to high 50s°F / 12 to 15°C) as the rain falls.

The thing about rain in Seattle is that it usually isn’t rain. It’s more like a mist, a quiet visitor that stops by maybe for an hour or two, then slips away. Within the hour the drizzle returns again, just to make sure you didn’t forget about it. This is why most people here don’t use umbrellas. Raincoats are enough; umbrellas are a burden.

In contrast, the rain of atmospheric rivers demands your attention. The droplets are heavy and full. The water falls in sheets. It’s the mob of young people dressed up like Santa who sing Christmas carols off-key on a crowded light rail platform.

A particularly long river in the sky recently passed above Washington State. Grey clouds rushed overhead, churning past each other like currents of a river, dark water soaring through the heavens. Mud slid, highways collapsed, and lakes formed.

Walking around in it was like walking through a warm blizzard: My face stung from all the water droplets slapping against my cheeks. I had to squint to keep the water out. One afternoon, despite only walking for about 30 minutes, the hems of my pants were soon dragging on the ground. The rain had penetrated every thread and the weight of the water stretched everything down.

There is a small city in South King County that operates its own jail. It has only around 100 beds. (Compare this to the main county jail, which operates two adult facilities with around 1500 beds.)

This small city jail is near one of the rivers whose levee failed. Even as of this writing, the major roads on three sides of the jail are closed, one of which is a state highway. At the height of flooding, the state ordered people to evacuate.

What do jails do when the state orders people to evacuate because of a flood?

Reputable word on the street is that this jail took two actions:

Some people were released from jail. I don’t know what system jail officials used to determine who should be released. Presumably there was some consideration about the severity of the alleged crime. Releasing people from jail, though, results in the former inmates themselves holding the hot potatoes: If people have been ordered to evacuate and roads are closed, how do they return to their homes? (What if they don’t have homes?) People leave jail with only the belongings they came in with (and sometimes not even that), so if they didn’t come in with rain gear, oh well.

Other people were sent to a jail on the other side of the Cascade Mountains. This means inmates piled into secured vans or buses and travelled about 150 miles to Central Washington. Again, I don’t know what system jail officials used to determine who to relocate. Jails are meant to serve the local community and people can be released from jail unexpectedly. Will these people get a ride back to this small city? Will they have to figure out their own way back? With the exit of the atmospheric river, a polar vortex has taken its place. There is snow on the pass.

May our federal government stop manufacturing artificial disasters through inhumane policies. Natural disasters are distressing enough.