Category: Observations

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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.”

Categories
Nonfiction Observations

Acts of Aggression.

The curls of his hair fell past his neck and a green knapsack hung from his shoulders. He plodded up the sidewalk and began to drift towards the curb.

His arm shot out and his fist slammed into the window of the vegetable truck. He paused, then punched the window again. The window did not break.

Nobody was seated in the vehicle. The vegetables and fruits painted on the side of the truck continued to smile. The man pushed the button at the stoplight and waited for his turn to cross the street.

Three men, each in a dark business suit, were walking north. Because they were shoulder to shoulder they occupied the entire width of the sidewalk. One held a cup of steaming coffee; another adjusted the trench coat slung over his arm; the third tucked his new cell phone into his pocket.

A man wearing a reflective vest, carrying a broom, and pulling a rolling trash can was walking south. Upon seeing the three men he began to move away from the center of the sidewalk and towards the building.

The three men approached, their paths straight lines. The man in the vest stopped and pressed himself and his supplies against the building. He looked down. The three men brushed past and looked only straight ahead.

The red dot of the laser pointer appeared on the sidewalk. It wobbled in the shadows, uncertain of where to go. Finding a target, it lurched up and landed on the white jeans of a woman waiting for the traffic light to change.

The red dot quivered as it rested on the woman’s butt, as if it were trying to stifle its own laughter. It clung to her as she crossed the street.

Categories
Nonfiction Observations Reading

King Solomon’s Ring.

I often smiled to myself while reading King Solomon’s Ring by Konrad Lorenz. In this delightful book he shares stories of animal intelligence and character that humans often disregard. It reminded me of the botanical garden at UCLA.

The botanical garden at UCLA is not large, but it had tall trees with thick trunks and rugged bark, ferns with luxurious leaves that stretched along the edge of a small stream, and bright hibiscus flowers that beckoned butterflies and hummingbirds. Footpaths wound through the garden to quiet corners and pockets of shade. The garden offered respite from urban university life.

During my last year of college at UCLA, I helped with research projects in a behavioral ecology lab. One project I worked on involved scrub jays. They are related to crows, which means that they are intelligent birds.

Near the entrance to the botanical garden were two small chessboard-sized platforms, each on a post. This is where I did experiments with the scrub jays.

Prior to working with the birds, I prepared peanuts. Some peanuts I did not open; I merely painted them in one of four different colors. Other peanuts I opened, but took only one or two nuts out before gluing the shells back together. For some peanuts I removed all the nuts before gluing the shells back together. I also painted these manipulated peanuts.

Scrub jays can distinguish different colors. A bird will shake a peanut in its beak to discern how much food is inside.

I don’t remember the exact experiments, but this was the general procedure: I would place two peanuts, each a different color, on a platform. Scrub jays, their legs marked with rings, would appear one at a time to select a nut. Part of the task was to see if scrub jays could learn what specific colors meant (e.g., “red peanuts never have nuts in them; green peanuts are always full of nuts”). Another part of the task was to see how quickly scrub jays learned to adapt to changing circumstances (e.g., “something is different—now the green peanuts are empty and the red peanuts have some nuts in them”). I spent about 15 to 20 minutes several times a week putting pairs of peanuts on the platforms. The scrub jays would land on the edge of the platform, look at the peanuts, pick up and test the peanuts, and then fly away to a nearby tree with a peanut. I scribbled down my observations and readings from my stopwatch.

I did this for several weeks, maybe a month. It was fun. (Scrub jays usually learned within two to three trials what different colors meant and could retain this information over time.)

Once my time at the lab was over, I still took walks in the garden. Scrub jays saw me enter the garden and followed me, often for over ten minutes. They flew from branch to branch, sometimes trailing behind me, sometimes flying ahead of me on the path.

This occurred for months after I had stopped leaving peanuts for them.

I took walks in the garden before I joined the behavioral ecology lab. Scrub jays never followed me around then. I can only assume that the scrub jays learned to recognize me and hoped that I would leave peanuts for them.

My experiences with the scrub jays pales in comparison to Lorenz’s work, but it felt both magical and eerie to see scrub jays following me around—always in silence and never too close—as I took walks in the garden. I can only wish that everyone will have such an experience at least once in their lives.

Categories
Education Funding Homelessness Observations Policy Systems

Asylums are not the Answer.

The New York Times recently featured an op-ed from a psychiatrist, Dr. Montross, who argues for the return of the asylum.

I understand her frustrations: I have worked with homeless individuals in both New York and Seattle who, if they were in psychiatric institutions, would not have had to worry as much about their safety, getting food, or sleeping at night. Many of the patients I now see in jail should undoubtedly be in a psychiatric institution (though not necessarily for a long period of time).

However, I disagree with her assertion that we should return to the era of the asylum.

President Kennedy signed the Community Mental Health Act into law in 1963. The goal of this legislation was to move people out of long-term psychiatric institutions, such as state hospitals, and help them integrate into the community by enrolling them in outpatient services. This is what “deinstitutionalization” refers to.

The Community Mental Health Act, however, only provided funds for the construction of the community mental health centers. The law made no provisions to fund the services that would occur in these buildings.

What we see now—the “transinstitutionalization” of people with severe psychiatric conditions into homelessness and jails—is a consequence of this lack of funding and support for patient care services.

Think of it this way: A city wants to improve its public transportation system. The city passes a law that provides funds to buy a lot of buses. However, the law provides no money to hire and retain bus drivers. There is also no money to hire and retain mechanics for bus maintenance.

The people of the city are frustrated: “Our public transportation system sucks! The city should build a subway system!”

The bus system never got a fair chance.

We also moved away from asylum care for good reasons: Conditions in psychiatric institutions were often terrible. It was not uncommon for state psychiatric hospitals to have insufficient staff for the number of patients in the institution. In Alabama in 1970, one psychiatric institution had one physician for every 350 patients, one nurse for every 250 patients and one psychiatrist for every 1,700 patients.

Dr. Montross herself notes (emphases mine):

But as a result, my patients with chronic psychotic illnesses cycle between emergency hospitalizations and inadequate outpatient care. They are treated by community mental health centers whose overburdened psychiatrists may see even the sickest patients for only 20 minutes every three months.[2. Unfortunately, 20-minute appointments every three months for the sickest patients is also a common occurrence here in Washington.]

If that is the quality and quantity of care “the sickest patients” in outpatient settings receive, then of course “many patients struggle with homelessness” and “many are incarcerated.”

Dr. Montross calls for “modern” asylums, though it is unclear to me what incentives government has at this time to build and support institutions that “would be nothing like the one in ‘One Flew Over the Cuckoo’s Nest'”. Asylums from years past did not receive sufficient funding to provide adequate care. Current outpatient centers often do not receive enough funding to provide adequate care. (How much longer must we wait before this changes?)

To be clear, I do believe there is a role for asylums in patient care. There is a small segment of the population with severe symptoms who would benefit from care in an institution. I’m talking about people who keep trying to jump off of buildings because they believe they can fly. Or people who cannot stop smashing their heads against the wall because they are trying to dislodge the computer chip they believe is in their heads. Or the people who eat their own feces and literally cannot use words to explain why.[1. As I have noted before: If you do not believe that these scenarios actually happen, I encourage you to volunteer at your local emergency department.] These individuals can and do recover; they are not necessarily destined to spend the rest of their lives in an asylum.

We also now have interventions such as assertive community treatment, assisted outpatient treatment[3. Assisted outpatient treatment is controversial, though preliminary data support its use. You can read an admittedly biased summary about it here.], and supportive housing/housing first. There is evidence that these intensive outpatient services keep people in the community and out of psychiatric institutions. What would happen if government and communities supported these interventions?

Modern psychiatric services—in an asylum or elsewhere—will not be modern at all if there are not enough staff to provide care for patients. It also will not be modern if the staff do not receive ongoing training and supervision for the care they provide. It cannot be modern if administrators do not understand the work and are unwilling to provide financial, technical, and emotional support to the front-line staff.

We must get away from the idea that where people receive services is more important than the quality of those services.