Category: Observations

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Homelessness Nonfiction Observations Seattle

Simple Pleasures.

People hung hammocks between trees and suspended their disbelief in novels. Cyclists rolled past, talking to each other over their shoulders. Parents pushed sleeping babies in strollers while sipping iced coffees and slushies. Couples held hands and shielded their eyes from the afternoon sun. It tossed silver glitter onto the blue water of the bay.

Not a cloud was in the sky: Mt. Rainier loomed white and massive to the south. The Olympic Mountains, also capped with snow, rose in the west, its jagged ridges carving a grey-blue line on the horizon. Trees full of green leaves covered the islands in the distance.

The man was wearing baggy pants and dirty work boots. Over this was an oversized and puffy winter parka, tattered at the edges and the hood pulled over his head. A duffel bag that was half his size hung from his left shoulder; as he walked he listed to the right to maintain his balance. People gave him wide berth as they walked past him. He held his head low.

He dropped his bag on the boardwalk and sat down. Sitting against a post, his back to the brilliant sun and shimmering water, he zipped open the duffel. From it he pulled a brown paper sack. He used one hand to rustle through the contents within.

He pulled out a small item wrapped in white. With expectation on his face he opened the package. Leaning back, he took a bite from the chocolate-covered ice cream bar. A small smile crossed his lips.

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Consult-Liaison Education Medicine Observations Policy Systems

Buprenorphine and Other Controlled Substances.

I recently completed the buprenorphine waiver training. Buprenorphine, itself a partial opiate, is a medication that can be prescribed to patients who have opiate use disorders (e.g., taking Oxycontins or injecting heroin to get high). A physician must complete an eight-hour training and take an exam to become eligible to prescribe this medication. The physician must then apply for a specific “X license” through the DEA to prescribe it.

In some ways treatment of substance use disorders is the most evidence-based practice in psychiatry. When talking about opiate use disorders, for example, we can talk about specific mu-opioid receptors and their roles in pain and intoxication. We can discuss how drugs—both illicit and licit—work on these receptors and why certain medications can reduce or eliminate illegal drug use. This logic satisfies the analytical mind.

Since completing this training I have wondered: Why must one undergo a specific training and obtain a separate DEA license to prescribe buprenorphine?

With my current licenses I could prescribe all forms of pharmaceutical morphine (e.g., Oxycontin and Dilaudid), which can lead to severe physical and psychological dependence. Which could then result in the intervention of buprenorphine.

As a psychiatrist I would likely arouse the suspicions of the DEA if I prescribed opiate medications. That’s outside the scope of a psychiatrist’s practice.

However, it is not outside of the scope of a psychiatrist’s practice to prescribe benzodiazepines (e.g., Valium and Xanax), which are Schedule IV drugs (“a low potential for abuse relative to substances in Schedule III”).[1. You can learn more about controlled drug “schedules” on the DEA website.] I can also prescribe Schedule II drugs (“high potential for abuse which may lead to severe psychological or physical dependence”), such as Adderall and Ritalin. Physicians are not required to go through any special training or obtain separate licenses to prescribe those medications. Once I got my DEA license, I was free to prescribe these without anyone looking at me askance.

And, get this: buprenorphine is a schedule III drug!

The training offered the Harrison Narcotics Tax Act of 1914 as one reason behind the training requirement: This law suggests physicians can prescribe opiates as part of “normal” treatment, but not for treatment for addiction. Addiction was not considered a disease in 1914. Thus, if addiction is not a disease, no intervention is indicated.

That explanation, however, doesn’t make sense. There is growing consensus that substance use disorders are diseases. Nothing, other than my good judgment, prevents me from cranking out prescriptions for stimulants and benzodiazepines. Use of either medication can lead to addiction. What makes opiates so special?

The consequences of the buprenorphine training are not slight: The eight-hour training alone likely deters some physicians from pursuing it. The extra licensure is also an obstacle, as well as the consequences of using the license: No one wants regular, but unannounced, DEA audits (which, just to be clear, doesn’t happen with when one prescribes benzodiazepines or stimulants). No one is eager to maintain the documentation that is required when one prescribes buprenorphine.

It just makes me wonder what the actual story is….

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Nonfiction Observations Reflection

Grief.

Shortly after my mother died, a coworker asked me about grief: “What does it feel like?”

I remember looking at her and feeling confused. What does it feel like…?

Words like “terrible”, “awful”, “really sad”, and “numb” didn’t seem quite right. Elements of all those adjectives were true, but none of them captured the fine texture of grief.

“It feels like… a really bad breakup,” I finally said. As the words came out of my mouth I realized that wasn’t quite right. It was also an inane comparison.

“Huh,” she answered.

Nine months later, I found words to describe my grief: It feels like my heart is falling.

During moments of stillness, those spaces between exhalations and inhalations, I feel my heart physically dropping. It is an endless fall; there is no bottom.

I remain surprised with how close to the surface the grief lives. I don’t cry when I talk about my mother’s death. Yet, when people ask me about her, I feel my face scrunching up the way faces do when people are about to cry. The sensations in my face remind me of that week she was in the hospital, when I smiled during the day and wept at night, asking God and the Universe questions that nobody could answer.

Though the tears do not come, my face suggests they will. And I know that the person listening to me sees it. It’s like when you blush: You feel your cheeks flash with heat and hope that the other person won’t make fun of you for it.

Emotions always shift, though: Sometimes, in my mind’s eye, I set an imaginary table and place a pot of steaming tea and two cups on it. I invite Grief to sit down and have tea with me. Grief never declines. I ask Grief how it is doing. Grief never says anything in response, but we sit in silence and enjoy our tea together. When Grief is ready, it leaves.

And then I notice that my heart is no longer falling.

Almost 11 months have passed since my mother died. Since I found words for my grief, my heart doesn’t feel like it is dropping as often. Maybe the time I needed has elapsed; maybe the sensation of my heart falling doesn’t overwhelm me as much as it used to.

Maybe by showing Grief some kindness and acceptance with imaginary tea it has also shown kindness to me.

Categories
Medicine Observations Policy Reflection Systems

On “Mental Illness”.

I’ve been invited to speak to a group of attorneys who work at the interface of psychiatry and the law. The topic of my talk? “Psychiatry 101.”

A psychiatrist who gave this talk to a similar group a few years ago advised me: “You should assume that lawyers are laymen. It’s surprising how little they know, given the work that they do.”

This teaching opportunity to teach has given me pause: What is mental illness?

Most of my work has been with people with few resources (no home, no job, etc.) or with people who are experiencing symptoms that cause significant distress (they won’t eat because they think all food is composed of their internal organs; they often try to kill themselves due to hearing voices telling them to do so; etc.). Most people would agree that these individuals have “mental illnesses”, whether “caused” by their circumstances (imagine people trying to set you on fire or rape you because you are sleeping outside) or by apparent biological events (imagine a freshman in college with an unremarkable history who, over the course of months, begins to believe that the government inserted a chip into his brain).

I have also worked in settings where:

  • a wealthy man’s wife felt overwhelmed with anxiety about which of their three homes they should remodel first
  • a aerospace engineer with no symptoms wanted to try an antidepressant because his girlfriend started taking one and she now seemed to have greater clarity of mind; “maybe that will happen to me, too”
  • a college student felt depressed because his parents wanted him to pursue a professional degree, but he didn’t want to do that

Do those individuals have mental illnesses? Does psychological suffering equate to mental illness? Even if they are able to get on with the necessary details and difficulties of life?[1. Do not misunderstand: People with means can and do have mental illnesses. Take the software developer who was certain that public surfaces were contaminated with exotic diseases; he couldn’t get himself to go to work or spend time with friends due to fears that he would get sick and die. Or the accountant who, if she doesn’t sleep enough, would believe that she is the mother of God; she went to hospitals insisting that she was in labor with Jesus when, in fact, she was not pregnant.]

My mind then spins to recent events, such as the Germanwings place crash. Many people have argued that, because the co-pilot killed people, he was mentally ill. He apparently had a diagnosis of depression, but I agree with Dr. Anne Skomorowsky that a diagnosis of depression alone does not explain why he committed mass murder.

But if he was mentally ill, what diagnosis would best describe his condition? What do we call it when people kill other people? Is that behavior alone sufficient to say that someone is mentally ill? If so, what do we make of:

  • soldiers killing other people during war
  • gang members who, without provocation, shoot police officers or other gang members
  • suicide bombers
  • parents who kill their newborn infants because the babies aren’t the parents’ desired sex

Does a person’s intentions affect the definition of “mental illness”? (How good are we at reading the minds of others? We often assume intention when observing behavior. And those assumptions can be way off.) Does the situational context also affect what a “mental illness” is? (When in Rome, do you do as the Romans do? What if you don’t know what Romans do?)

People have surmised that people who kill other people may have conditions such as antisocial or narcissistic personality disorder. However, these designations are still problematic: Not everyone with those personality disorders kill people.

Perhaps this is why I prefer to work with people who demonstrate behaviors that undoubtedly impair their function.[2. It is easier for me to work with people who demonstrate clear evidence of “impairment in function”. Part of this is due to the greater ease and clarity in diagnosis: If someone’s symptoms are within the spectrum of normal human experience, then diagnosis is unnecessary. Part of this is also due to treatment: Some interventions in psychiatry—specifically medications—are not benign. Furthermore, it is unclear how some—many?—psychotropic medications work. We first must do no harm.] I am reluctant to describe most people as “mentally ill” because some behaviors that people find bizarre have helped the person cope with their circumstances. The people who always wear masks or scream on the street? Those behaviors may have somehow protected them in the past—even if it means that the general public derides them for being “weird”. It seems unfair to say someone is “ill” when what they have done before in the past has given them some degree of protection. (To be clear, I don’t necessarily apply this formulation to people who have committed murder. For example, I can’t think of how flying a plane into a mountain could ever be an adaptive coping skill.)

Words matter. I’m not sure that I have more clarity yet about what I should teach, though it is clear that I should focus on how I phrase the information I present.

Categories
Nonfiction Observations

Undercover.

My husband was in the aisle seat, I was in the middle seat, and The Man was in the window seat.

The Man had one white earbud in his ear; the other one was dangling in his lap. His right thumb swiped through several screens of his smartphone in less than a second. He heaved a sigh.

“This is f*cking lame,” he muttered.

The plane was supposed to take off 15 minutes ago. At that time the captain had announced that the plane had technical difficulties, but he anticipated that we would be up in the air soon.

The minute hand continued to sweep its arc across the clock face; soon we were 55 minutes behind schedule. The Man spoke into the microphone of his white earbuds:

“Hey, it’s me… yeah, we haven’t taken off yet… yeah, we were supposed to take off like an hour ago…. This f*cking airline sucks… Whatevs….”

The captain picked up the intercom phone. The Man mumbled something and then pulled the earbud out of his ear.

“I’m sorry, folks,” the captain said. “I thought that we could get this situation under control, but we can’t. The plane’s indicators are telling us that the nose isn’t in neutral position, even though other instruments and external measurements say that it is. I can’t risk flying this plane like this. Safety comes first, so we’re going to switch planes. I’m sorry, folks. The flight crew will tell you where to go shortly.”

Quiet murmuring moved through the cabin.

“F***********CK!!!” The Man screamed.

Then he punched the wall of the plane.

Silence filled the aircraft. I could hear The Man breathing.

I forced myself not to turn my head. My husband also kept looking straight ahead.

“I’m sorry that you have to start working,” my husband said, though his lips did not move and no sound came from this mouth. It was a telepathic message. I sighed in response.

I looked over my shoulder. The people seated behind me were staring at The Man with alarm. A flight attendant about five rows away shot a dark look at The Man, but did not move closer.

Don’t reinforce bad behavior, I reminded myself, wondering if I should say something. I didn’t have enough information at this point to know what to do next. Do I ignore him? Do I pretend that nothing happened? But what if he escalates his behavior because no one is acknowledging his distress? But what if he punches me if I ask him what just happened?

I glanced at him. The Man was chewing on his fingernail. His leg was bobbing up and down. The single earbud was back in his ear.

Okay. Go.

“It’s really frustrating, huh,” I said while grabbing the personal belonging stowed under the seat in front of me. If he tried to hit me, at least I could throw my bag at him.

“Yeah! This sucks!” he exclaimed. The woman in front of him turned her head a few inches to look at him. She swiveled her head back around. “I fly back and forth across the country every week and it’s been a sh*tty week and I just want to get some sleep tonight because I have an 8am meeting tomorrow and I usually fly a better airline and this is just f*cking ridiculous.”

“We all just want to get to where we want to go….” I kept my bag on my lap.

His leg stopped bobbing and he pulled the earbud out of his ear.

“Yeah. I mean, I guess this f*cking plane problem doesn’t happen a lot, but why this plane? At the rate we’re going we won’t get into Seattle until 1am.”

My husband’s posture relaxed as The Man shared his duties as the Vice President of Something Important at The Company Where Important People Work. His Important Boss was expecting A Very Important Report. No one seemed to understand how difficult this Important Report was; it was hard for him to get the Important Report done given all of his other Important Duties.

The Man slumped back into his chair and sighed.

“… but, I guess the most important thing is that we get there safely, right?” he said. He flashed a warm smile at me. I smiled back at him. My husband demonstrated an extraordinary fascination with the contents of his bag.

“So, hey, what do you do for work?” The Man asked.

I paused.

“Oh, I do stuff for the county.”

His phone chirped. The Man looked down and his thumbs began to tap out a message as he mumbled, “Oh, that’s cool.”