Category: Observations

Categories
Observations Reflection Systems

Race.

No one was sitting near us at the fast food chain, but my dad lowered his voice anyway.

“You were three or four years old,” he said. “We were watching an NBA game on TV. You asked, ‘Where are the white people who play?’ Even little kids notice these things.”

“How did you answer my question?”

“I didn’t.”

About 5% of inmates in the jail are in psychiatric housing at any given time. My current post assignment is with males who demonstrate acute symptoms, which comprises about 2% of the entire jail population. A small team works with this 2%.

To be clear, not all people with psychiatric conditions are put in psychiatric housing. Sometimes people start there and, as their condition improves, they move on to general population housing. Some people with psychiatric conditions never come to psychiatric housing. How one behaves, not one’s diagnosis, determines where one is housed.

I don’t know if the racial mix of my patients is proportional to the racial mix of all the people in jail. It’s rare that the patients I care for are comprised of only one race. I have yet to ask, “Where are all the white people?” However, I’ve certainly asked that before in another correctional setting.

I’ve often framed the processes of clinical work as a game. Maybe this is a product of clinical training: When working in hospital services, you’ve “won the game” if you were able to discharge all of your patients. You make informal wagers as to the duration of rounding: “Oh, our attending is Dr. So-and-So, so we’ll finish in less than an hour, tops,” or “Dr. Blah-Blah is on service now. You think three hours? Four? Five?!”

It’s probably just one way of coping.

While on various outreach teams, the objective of the game was to keep all of my patients out of the hospital. When working in a clinic in a medical center, it was to get all my patients well enough so that I could send them back to primary care. Now, the game is to get them out of the most acute unit and prevent them from returning. (The object of the game really should be how to keep people out of jail. That requires coordinated efforts across space and time, particularly for people with complex psychiatric conditions.)

Sometimes my patients are young black males. Sometimes they talk about problems they’ve had with officers or other inmates in the jail.

“I don’t want you to come right back to this unit if we send you out.” That’s how I usually start it. “If someone else gives you a hard time or starts being a jerk to you, what are you going to do to help you stay there and not get sent back here?”

People are often doing much better by the time we’re able to have this conversation. They usually provide reasonable answers.

Even though no one else is sitting near us, I then lower my voice.

“You’re a young black man. Some people here—not everyone, but some of them—react to you in certain ways just because of the color of your skin. That’s not fair, but, sometimes, that’s what happens. You know this much better than I do.”

I remain struck with how their faces soften. Jail is a hard place to be and people adopt hard expressions on their faces. When this coversation happens, these young black men invariably smile, but not from joy.

“So if something happens, you have to figure out how to respond so that you’re not the one who comes back here. Does that make sense?”

Sometimes they thank me for talking about race; sometimes they tell me that they already know what they need to do; sometimes they simply assert, “Don’t worry, I won’t come back here.”

Why do I lower my voice when I talk about this? Would I bring this up if I were a white female? a white male? Does the fact that I look obviously Asian work in my favor? Do I need to bring up something that they already know? Am I just being rude? Do good intentions matter when people find the intentions condescending?

Am I actually helping them when I frame things this way? Or am I only making myself feel better?

It’s a small sample size and completely anecdotal: After we have this conversation, they don’t return to the unit.

Maybe they were never going to come back, anyway.

Categories
Lessons Nonfiction Observations Reflection

On Knowing Yourself.

I know of only two people who, upon starting medical school, knew that they wanted to become psychiatrists. (How did they know what they wanted to do eight years before they did it???) They both achieved their professional goals: One created a community clinic for people with severe psychiatric illnesses. The other became an addiction psychiatrist and now oversees an entire substance use disorder program for a health care organization.

I was not one of those people. As a youth, I aimed for family medicine, a generalist that would help people of all ages. While studying microbiology in college, I aimed for infectious diseases: The ingenuity of single-cell organisms! The science behind antibiotics and antiretroviral medications! The elegance of diagnosis and treatment! (My fascination with microbiology persists.) In medical school, I learned that infectious disease is a subspecialty of internal medicine and, WOW, there are a lot of subspecialities within internal medicine! Oncology (cancer) and nephrology (kidneys) captured my attention for a while—more incredible physiology that occurs on a cellular level!—and, then, seemingly out of nowhere, appeared psychiatry.

We’re biased when we look back at how things unfolded: We can’t change the past, so we tell ourselves that it all worked out the way it was supposed to. So, yes, of course I was supposed to go into psychiatry all along.

It became clear during my psychiatric training that I prefer to work with people who are experiencing severe psychiatric symptoms, particularly psychosis (e.g., people who hear voices saying terrible things about them, people who believe that someone has exchanged their internal organs for someone else’s). I also like the intersection and interplay of physical and mental conditions: Sometimes people who have significant medical illness develop striking psychiatric symptoms, which resolve along with their medical illnesses. Sometimes people with significant psychiatric illnesses develop significant medical problems, and successful treatment of both conditions requires teamwork. Complex problems are fascinating. Witnessing people recover from complicated conditions is rewarding. I’m lucky that I have had the opportunities to do this work.

I’ve also recognized that I am not consistently warm and empathic to people who are experiencing mild psychiatric symptoms. Two previous patients come to mind:

  • “I’m so stressed out,” she said while wringing her hands. She began to pick at the tassel of her Coach bag. “I don’t know which to remodel first: The beach house? the pied-a-terre? or the kitchen in our home? It’s all I think about and I’m starting to lose sleep over this.”
  • “My girlfriend started taking Prozac a few months ago, and it seemed to really help her. She has a lot more creativity. I’m thinking it might help me with that, too. In my line of work, creativity is important and if Prozac will help me with that, I won’t feel as much pressure on the job.”

For the woman with the three properties, we worked through that with minimal use of medications. I’m not proud to say that, for the man who desired creativity, I stared at him blankly when he was done speaking.

It’s important to know yourself. As I understand it, it usually takes at least a lifetime to learn about yourself. Even then, most people never know themselves completely by the time they die.

Learning about yourself helps you recognize how you could do things better or differently. We all have our weaknesses. They exist, even if we wish they didn’t. Everyone else sees them, even though we don’t.

There are many ways to get glimpses of our blind spots. If we’re willing to linger a bit when we catch these glimpses, we have the opportunity to make ourselves more awesome.

However, it’s hard to linger because these glimpses often occur when we’re angry or annoyed. Maybe you make an executive decision for something to happen and a lot of people don’t like it. Maybe you learn that not as many people liked or supported you when you thought they did. Maybe you wish that an institution or a group of people would write or say nice things about you, but they don’t.

How it burns!

These are all opportunities to get to know yourself a little better:

  • What emotion am I experiencing?
  • What happened that led me to feel this way?
  • What do I think the truth is?
  • Is it possible that what I think is true isn’t actually true?
  • What questions could I ask to learn more?
  • What do I think might happen if I start to ask questions?
  • What would it mean to show ignorance?
  • What would it mean if I were wrong?

Wherever you go, you bring yourself with you. Even if you do not yet have any interest in learning about youself, that doesn’t stop other people from learning about you. It is much more humiliating when everyone else knows you much better than you know yourself.

Categories
Nonfiction Observations

Pity.

Few people are walking the streets at 5am. Some are rolling old suitcases or holding overstuffed bags as they wander away from the shelter. Their eyes are often downcast. Sometimes they shout obscenities at no one and everyone; no one responds.

People who drive the produce trucks haul crates of fruits and vegetables into cafes. There’s a heap of oranges in the middle of the sidewalk. The driver will pick up all the oranges when he gets back.

The fragrance of organic, fair trade coffee mingles with aromas of pastries made with genetically modified flour, eggs from caged chickens, and sugar from saccharine grasses sprayed with pesticide.

The guys waiting to start their construction work are loitering by the loading dock. A man in a yellow reflective vest inhales and the end of his cigarette glows orange. His hair is the same color as the plume wafting from his lips.

She’s not wearing any shoes and the soles of her feet are nearly black. Her heather grey sweatshirt is covered with stains and there is a tear in the left shoulder. She’s not wearing a bra. Her torn jeans stop above her ankles and the button is missing from the fly. There are tangles in her light brown hair.

She walks on her toes towards the man in the reflective vest, then turns away. She shrugs her slender shoulders, the sweater falling further down her arm. She walks back towards him, this time on her heels, while making waves out of her arms. After stopping, she tilts her head from side to side, then stands on one leg.

He watches her. His eyes show interest, his face shows boredom.

He pulls the cigarette from his lips.

“You want this?” he asks, holding the cigarette out.

She nods. She stands on her other leg.

“Take it,” he responds. The breeze pushes wisps of nicotine smoke towards her.

He doesn’t move. After gazing at the cigarette for a few moments, she hops forward and plucks it from his fingers. In one smooth motion, she takes a drag from the cigarette and then flicks the ashes away.

She walks away, quickly, quietly, her left arm extended. He watches her until she disappears around the corner.

Categories
Education Medicine Nonfiction Observations Systems

A Day in Jail.

Three of us are waiting for the elevator. A few moments earlier I had walked into the jail for the day, so I have not yet donned a white coat. The other two are wearing their standard uniforms: The inmate is in red and the officer is in black.

“I have to take my seizure medicine while I’m here, you remember, right?” the inmate says, clutching a clear bag holding several pill bottles, a pair of jeans, and a dark jacket.

“Yes,” the officer says, her voice warm and firm at the same time. “You told the nurse, right?”

“I always do, ma’am.” A shy smile crosses his face. She smiles back at him as the elevator doors open. She motions for him to enter first.

The hem of the white coat hits the back of my calves as I climb the stairs. My habits from my intern year remain: I still fold papers in half lengthwise and the first stack will go into the left pocket. I never button my coat.

When I reach the top of the staircase, one of the standing inmates glances at me, then returns his gaze to the inmate seated in front of him. The standing inmate looks like he’s in his 20s. The seated inmate might be in his late 30s. Twenty-something guides the electric razor along the contour of Thirty-something’s head; clumps of light brown hair tumble onto the black cape and the concrete floor.

There are two barbers on duty. They volunteered their services; they will probably get extra food as compensation. The men in the chairs bow their heads, their eyes open, their bodies still. No one says anything.

Everyone gets the same haircut.

The floor officer is worried about an inmate: “He didn’t eat breakfast this morning and wouldn’t come out to take a shower.” While I scribble this information down on my paper folded lengthwise, I hear the deck officer raise his voice.

“What are you looking at?” the deck officer barks at two inmates. They are trustees, which means that they have demonstrated good behavior while in jail and are allowed to participate in chores. In exchange for doing tasks such as preparing meals and cleaning floors (which also gets them out of their units), they can receive more food .

A trustee mumbles something in response.

“I asked you, what are you looking at?” the deck officer barks again.

“Nothing, sir.”

“Okay. If I see you looking at ‘nothing’ again, I’m sending you back. Do you understand me?”

“Yes, sir.”

“Get back to work.”

The floor officer and I ask the deck officer what happened.

“They saw you,” he says, pointing at me, “and started grinning, elbowing each other, all that stuff.”

While wrapping my coat tighter around me, I glance at the two trustees. One of them happens to look at me at the same time; he turns away and takes a sudden interest in the mop in his hands.

“Thank you, Officer.”

“Just looking out for the doctor.”

It’s been a few years since I’ve talked to God.

Perhaps I meet God more frequently, but s/he chooses not to reveal that to me. More often I talk to angels or the Anti-Christ.

“Psychiatry is sorcery,” God tells me. “If you only had more faith, you would see the error in your ways. Turn towards faith and away from your analytical ways of thinking.”

God is charged with criminal trespass. God is a young man. His bail amount isn’t that high. Is there no one in God’s life who could post his bail so he could get out?

“One of the best things about being God,” he tells me, “is that I can see the true intentions of people. I know their thoughts.”

He pauses and looks at me.

“Although you practice witchcraft, I can tell that you’ve got a good heart. I will pray for you that you will have more faith, that you will believe in me.”

I will pray for you, too.

When I’m finished talking with God, the floor officer comes by and gives God a second lunch.

“Thank you! I bless you!” he calls out.

The brown paper sack contains one sandwich (two slices of wheat bread, one slice of bologna), one mayonnaise packet, one slice of American cheese wrapped in plastic, a small baggie of baby carrot sticks, and one apple the size of a tennis ball.

“He’s still growing,” the floor officer murmurs.

The day has ended. I’ve already stuffed my white coat into a laundry bag, but I’m still making my way through all the doors to physically get out of jail. When I exit the elevators near where inmates are booked into jail, I see an officer wincing and grasping his leg. One medic is kneeling by him; the other is on the phone.

I pass by a bank of holding cells. Two women knock on the wall and beckon me towards them. The one with tattoos all over her young face and anxiety in her eyes asks, “Can you tell them to let us out? We’ve been waiting a long time.”

“An officer looks hurt,” I say, raising my voice. We’re talking through a thick pane of plexiglass. “The medics are here. It might be a while before they will get to you.”

“Oh,” she says. They take a step back and their shoulders slump. “I hope they’re okay. Thanks.”

Most people look either relieved or thrilled when they leave jail. They throw their shoulders back as they cross the threshold from the jail lobby into the fresh air. How much more comfortable they appear in their own clothes! The red uniforms incarcerated them just as much as the concrete block. Sometimes they give each other high fives; their voices are light and bright as they tell each other to take it easy.

A few will look up and around, confused and forlorn. They squint at the numbers at the bus stop. After taking a few steps heading south, they pause, turn around, and head north. They finally decide to cross the street to get away from the jail. It seems like the best idea.

Categories
Consult-Liaison Education Medicine Observations Policy Reflection

Why I Agree with the Goldwater Rule.

The New York Times and NPR recently published articles related to the Goldwater Rule. In short, a magazine sent a survey to over 12,000 psychiatrists in the US with the single question of whether they thought Presidential nominee Mr. Barry Goldwater was fit to serve as President. Few psychiatrists responded. Of those that did, more than half—still over 1,000—said that he was not. Mr. Goldwater ended up losing the Presidential race, but he sued the magazine over this… and he won. Thus, the American Psychiatric Association has advised that psychiatrists should not diagnose public figures with psychiatric conditions. Some psychiatrists have felt otherwise for the current Presidential election.

There is a hypothetical concept in psychiatry called the “identified patient“. It is most often applied in family systems. For example, consider a family that consists of a mother, a father, a son, and a daughter. The parents bring the daughter to a psychiatrist and say that she has worrisome symptoms. Maybe they say that she is always angry, doesn’t get along with anyone in the family, and does everything to stay out of the house. The parents and the son argue that there must be something wrong with her.

As the psychiatrist works with the family, the psychiatrist learns that the parents have the most conflict. The daughter may have developed ways to cope with this stress in ways that the parents don’t like. Because the parents have the most authority in this system and do not recognize how their conflicts are affecting everyone else, they assume that the daughter is the problem. To oversimplify it, the daughter becomes the scapegoat. The daughter is the identified patient.

Presidential nominees don’t become nominees through sheer will. There is a system in place—putting aside for now whether we think the system is effective or useful—where the American public has some influence in who becomes the ultimate nominee. Candidates are eliminated through this process.

Does the Presidential nominee actually have psychopathology? Could a nominee rather reflect the public that supports him or her? Could it be more accurate to describe the nominee for a specific party as the “identified patient”?

Erving Goffman presents an argument in his book The Presentation of Self in Everyday Life that has similarities with the monologue in Shakespeare’s As You Like It:

All the world’s a stage,
And all the men and women merely players;
They have their exits and their entrances,
And one man in his time plays many parts

Goffman and Shakespeare are both commenting on the presence and importance of performance in our daily lives. Goffman argues in his text that context matters[1. I agree that context matters. See here, here, and here.]. We all do things within our power to alter ourselves and the contexts to present ourselves in certain ways.

Some mental health professionals have argued that we can diagnose public figures with psychiatric conditions because of “unfiltered” sources like social media. While it may be true that some people are more “real” (or perhaps just more “disinhibited”) on social media than others, that does not mean that people are revealing their “true selves”. Do you think that people are always eating colorful vegetables in pleasing arrangements? or that people are always saying hateful things, even while waiting to buy groceries, attending a church service, or folding laundry? or that their cats are always cute and adorable, that hairballs and rank breath have never exited their mouths?

Lastly, the primary purpose of diagnosis is to guide treatment. There is no point in considering diagnoses for someone if you’re not going to do anything to help that person.

People have commented that psychiatric diagnoses often become perjorative labels. Unfortunately, there are those who work in psychiatry who will use psychiatric diagnoses as shorthand to describe behavior they don’t like. Instead of saying, “I feel angry when I see her; I don’t like her,” they will instead say, “She’s such a borderline.” That’s unfair and often cruel. If you’re not going to do anything to help improve her symptoms of borderline personality disorder, then why describe her that way? (We’ll also put aside that such a sentence construction reduces her to a diagnosis, rather than giving her the dignity of being a person.) If we are serious about addressing stigma or sanism, then we should only use diagnosis when we intend to help someone with that diagnosis.

I agree with the Goldwater Rule, though not because of the exhortations of the American Psychiatric Association.[2. I’m not a member of the APA. The reasons why I am not a member are beyond the scope of this post.] Diagnosis should have a specific purpose. We often do not have enough information about public figures across different contexts to give confident diagnoses. Presidential nominees are often appealing to various audiences, which can both affect and shape their behaviors. Most importantly, giving a diagnosis to a public figure without any intention of helping that person doesn’t help anyone, especially those who would ultimately benefit from psychiatric services.