Category: Observations

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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.

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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.

Categories
Observations Reflection Systems

Black Lives are Also Lives.

For the past few weeks I have felt discouraged about ongoing local, national, and global violence. I felt powerless to do anything—including write—to help make things better. I could not find the words to express my sorrow.

So I turned to Buzzfeed.

I came across an article describing the efforts of Asian-Americans who were writing letters in their respective Asian languages to their parents about Black Lives Matter. My father and I hadn’t discussed the deaths of Philando Castile and Alton Sterling. However, the topic of race in America comes up in our conversations every few months.

Several months earlier, while discussing experiences of racism in his life, my father commented, “The Chinese should not be surprised to experience racism. We made the choice to come to America. It was voluntary. Black people didn’t have a choice. They were forced to come here.”

It was a perspective that I hadn’t considered before. And while I understood his point, I wondered what degree of racism any person should experience without feeling “surprise”.

It was only recently that I understood that some people who hear “Black Lives Matter” interpret that to mean “Only Black Lives Matter”. Thus, the rebuttal “All Lives Matter” came into being.

Of course All Lives Matter, I thought. That’s the whole point. Perhaps it would be more precise to say Black Lives Matter, Too.

I asked my dad if Black Lives Matter was receiving as much media attention in Taiwan and China as it was here in the US. I also expressed my surprise about the rebuttal of “All Lives Matter”.

“The Chinese media talk about it in a different way,” he said. “It’s not ‘Black Lives Matter’. It’s ‘Black Lives are Also Lives.’ It’s more clear.”

Indeed! There is no pithy retort to that. The clear implication is that we, as a society, value lives. The death of a Black life should disturb us as much as the death of any other life.

For all of us who are ever considered The Other—and everyone, at some point, is considered The Other—we must support the other Others.[1. We support other Others if their causes are noble and just. Make no mistake: I am not saying that we should support The Others who advocate for genocide, torture, etc.] There was a time in the US when The Majority were fearful of the Chinese, which resulted in the Chinese Exclusion Act. This was the first law that explicitly stated that a specific ethnic group could not immigrate to the United States. Though this law was ultimately overturned in 1943 (not even 100 years ago!), the Chinese are still the only ethic group specifically named for exclusion in the United States Code.

People who were not of Chinese descent disagreed with this law before, during, and after its implementation. They also supported its repeal.[2. I understand that some people opposed the Chinese Exclusion Act solely for commercial reasons. They did not care about equality. I’m not talking about those people.] I am grateful that they spoke up. Had they not, my parents would not have been able to immigrate to the US, contribute to this society, enjoy what America has to offer, and raise a daughter who now writes this blog.

We all speak up in our own ways: Some people participate in protests; others write words for others to read; still others have quiet conversations about it. Advocacy takes many forms. Choose what works best for you.

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Consult-Liaison Informal-curriculum Medicine Observations Reading

Psychiatrists and Demonic Possession.

A colleague sent me a Washington Post article, “As a psychiatrist, I diagnose mental illness. Also, I help spot demonic possession.”

After the author lists his credentials as a psychiatrist, Dr. Gallagher explains why he believes that some people who demonstrate unusual behaviors do not have psychiatric conditions, but are actually possessed by demons.

The sheer number of comments (over 2300 as of this writing) tells me that many people had strong reactions to this piece. (Or perhaps the bulk of comments are vitriolic arguments, name calling, and other unfortunate aspects of communication on the internet.)

It appears that Dr. Gallagher and I share some general principles when it comes to psychiatric diagnosis. For example, he notes:

I technically do not make my own “diagnosis” of possession but inform the clergy that the symptoms in question have no conceivable medical cause.

Indeed, one of the most important services psychiatrists can provide is giving an opinion about whether someone has a psychiatric condition or not. A common saw in medicine is that diagnosis guides treatment. Incorrect diagnosis can lead to incorrect treatment which, at best, will do nothing or, at worst, will harm someone.

Say a man is thrashing around the room, shouting nonsense, and looks confused and angry. The cause of his behavior is low blood sugar. If, however, all the physicians in the room assume that this man has schizophrenia, then instead of giving this man some form of sugar, they may instead give him a variety of tranquilizers.[1. In practice, people with low blood sugars who are behaving this way often receive both tranquilizers and sugar.]

Sometimes people may not recognize that a psychiatric condition is present, which can delay useful treatment. Sometimes people assume that a psychiatric condition is present, when in fact it is a medical condition. Sometimes people assume that a psychiatric condition is present, when in fact it is a variant of human behavior.

As I’ve written many times in the past, though, context matters. Where I believe Dr. Gallagher has taken a misstep is his assured belief that, if these individuals don’t have a psychiatric condition, then they must have demonic possession.

All of his referrals come from clergy who believe in demonic possession. To his credit, Dr. Gallagher does comment

I’ve helped clergy from multiple denominations and faiths to filter episodes of mental illness —– which represent the overwhelming majority of cases —– from, literally, the devil’s work. (emphasis mine)

In medical parlance, then, the chief complaint for his referrals is always “does this person have a psychiatric condition?”. It appears that the answer is often “yes”.

I must comment, though, that I cringed when I read some of his descriptions of people with psychiatric conditions. For example, he describes some of these people as

histrionic or highly suggestible individuals, such as those suffering from dissociative identity syndromes

I will assume that he has no ill will towards “histrionic or highly suggestible individuals”, though no one wants to be described as either. It’s not clear to me if he believes in the construct of “dissociative identity syndromes”. I am skeptical.

He also describes some of these people as

patients with personality disorders who are prone to misinterpret destructive feelings, in what exorcists sometimes call a “pseudo-possession,” via the defense mechanism of an externalizing projection.

Perhaps I underestimate the fund of knowledge the general public has about psychoanalysis. I had to read this sentence twice at a slow pace to understand what he was trying to say. If you believe in psychoanalytic theory, then, yes, that sentence makes sense. If you don’t believe in psychoanalytic theory, then that sentence might make as much sense as demonic possession.

If the answer to the question of “does this person have a psychiatric condition?” is “no”, though, then it appears that the only other option Dr. Gallagher considers is demonic possession:

This was not psychosis; it was what I can only describe as paranormal ability. I concluded that she was possessed.

This is dangerous, whether we’re talking about medicine or any other field. The moment you limit your options, you overlook evidence that supports other ideas and focus only on evidence that supports your theory. This is also called confirmation bias.

The following list may be absurd, but for the sake of illustration, is the only possibility that the “self-styled Satanic high priestess” is possessed by a demon? What if:

  • she is an alien?
  • her previous devotion to the Catholic faith has turned into contempt, so she is using her abilities to combat the faith?
  • she has excellent skills in “reading” other people and senses that Dr. Gallagher may be “histrionic or highly suggestible” to the ideas of demonic possession?

In medicine we often speak of the importance of “having a wide differential diagnosis”. Yes, the man described above who was thrashing around the room, shouting nonsense, and looked confused and angry could have schizophrenia. He could also have low blood sugar. Or he might:

  • have dangerously high blood pressure
  • have an infection in or around his brain
  • not be getting enough oxygen
  • be bleeding in his brain
  • be intoxicated with illicit drugs
  • be experiencing toxic effects from a poison

If we’re only thinking about a few of those things on that list, we might miss everything else. And all the things on that list can lead to the man’s death.

Do I think it is possible that people are possessed by demons?[2. My initial experience with Catholicism was spending hours in debates with my college roommate about transubstantiation. She, raised in the Catholic faith and able to recite Catholic prayers while falling asleep, insisted that the Communion wafer was literally the body of Christ and the wine was literally his blood. I insisted that this was physically impossible. These debates then wandered into other differences in Catholicism compared to other Christian faiths (faith versus good works, etc.—to be clear, I’m a big fan of good works).] Maybe. Is “demonic possession” high on my list of possibilities? No. Do I think that people experience spiritual distress? Yes. Do I think Dr. Gallagher has done an excellent job of promoting his forthcoming book about demonic possession? Absolutely.

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Observations Reflection Systems

Us and Them and Homicide.

If an event doesn’t happen often, it’s difficult to predict when it will happen next. We can only talk about “risk factors”.

For example, no one can predict when an earthquake will occur. We can, however, talk about the risk of an earthquake. We know that the risk of an earthquake is much higher in Seattle than in Houston: Seattle is on a fault line while Houston is not. Because earthquakes are rare, though, we don’t know when Seattle will have an earthquake. We just know that it’s more likely to happen there than in Houston.

Homicide is also a rare event. In 2013, about five out of 100,000 people died from homicide. That means 99,995 out of 100,000 people did not die from homicide that year.[1. A reader told me that these numbers are confusing. More than 100,000 people died in the US in 2013. My point is that the vast majority of people don’t die from homicide. Communication is hard.] Compare that with suicide: In the same year about 13 out of 100,000 people died from suicide. That’s right: In the US, people are over twice as likely to kill themselves than other people.

Because homicide is such a rare event, it is difficult to predict when, where, and how it will occur. We can discuss risk factors (e.g., alcohol and other substance use; access to firearms; gang involvement; exposure to domestic violence and child abuse; previous history of fighting of violence), but none of those risk factors will help us predict when it will happen. There are adults who were beaten as children, drink alcohol now, and own a firearm… but they will never kill anyone.

The data is mixed about the association between mental illness and homicide.[2. Here are three papers that discuss mental illness and suicide:

] Based on numbers alone, though, it is both inaccurate and unfair to state that homicide is due to psychiatric conditions alone:

Compare that to the rate of homicide: 5 out of 100,000 people.

With increasing news reports of people killing others, my colleagues and I have wondered how we can intervene. Many people who have committed homicide have never encountered the mental health system. Even if they did, they may not have endorsed or demonstrated symptoms that would warrant any intervention, including a follow-up visit. We agree that individuals who kill others are disturbed, but they may not have a “mental illness” that is described in our field. (We then wonder: So what is going on with them?)

The book The Spirit Level describes the correlation between greater interpersonal violence in societies with greater inequality. The authors also show evidence of higher prevalences of psychiatric disorders, obesity, and teen pregnancies in societies that are more unequal.

While it is easier to attribute these acts of heartbreaking violence to individuals—They are the problem; this happens because They are “mentally ill”; Their religion dictates that They should kill people; We would never do that—perhaps we should attribute this violence to our society and our communities (or lack thereof).

How would our society function if everyone had food, clothing, and a home? What would happen if everyone had steady employment and income? How would relationships change if everyone in school and at work learned how to recognize their emotions and practiced coping skills? What would happen if people didn’t drink, use drugs, or resort to violence when feeling distressed? What would shift if everyone had the chance to go to school and learn about different people, places, and ideas? How would things be different if people didn’t feel hopeless and helpless? What if people believed their communities could create something better? What if people didn’t believe that the only solution involves destruction?

It is easy to blame Them: They have mental illness; They believe in a religion that is false; there is something wrong with Them.

They and We, however, are part of the same community. Until we realize that we must work together to reduce risk factors and help each other, we cannot expect that these tragic events will stop.