Category: Observations

Commute Through the Jail.

To get in, out, and through the jail one must go through a series of locked doors. The doors are both taller and wider than standard doors; they are also thicker and made out of metal. Next to each door on the wall is a small silver panel, perhaps the size of two playing cards, that has a small silver button and a flat speaker. Several cameras are bolted to the ceiling near the doors.

“Central control” monitors all the doors through the cameras and speakers. Pushing the button on the silver panel alerts central control that someone wants to pass through. After central control looks you over on the camera, they unlock the door. When the bolt disengages, a loud and jarring “CLICK” bounces off the cinderblock walls and concrete floor. You may then pull or push the door open.

People can wait several minutes before central control unlocks the door. We’re all accustomed to adding five to ten minutes to our commute through the jail.

When I first started working there, I was advised to be patient:

“The officers will yell at you if you push the button too much.”
“The officers learn who is patient and who is not, and if they know you’re not patient, they might make you wait longer.”

If you wish to call an elevator, you push the button as you would with any other elevator. However, you’re not actually calling the elevator; you’re asking central control to bring it to your floor. As with any other door, there is a silver panel with a speaker and button nearby.

“What floor?” a voice usually asks through the speaker.

You answer into the speaker and, when the elevator arrives, the button to your floor is often lighted. If central control didn’t ask you what floor you wanted before you boarded the elevator, there is also a speaker, paired with a camera, inside the elevator. The floor buttons are “placebo buttons“; nothing happens when you push them.[1. Everyone shares the elevators: Officers, inmates, ancillary staff, visitors. That is why the elevator buttons are “placebo” buttons.]

If central control recognizes an officer in the elevator, sometimes central control becomes mischievous: The entire button panel will light up simultaneously and the elevator looks like it will stop on every floor. After everyone has chortled, all the lighted buttons will darken except for the button for the floor the officer wants.

During my first few weeks in the jail, I often was unsure where I was going, particularly when I was trying to exit the building. (There are no “exit” signs and all the doors and corridors look the same.) Upon stepping out of the elevator, I would look confused and lost.

“Over here,” a voice would call through a panel ten feet in front of me.

“Thank you,” I would say as I tread through the empty corridor. If I didn’t know where to go next, the same voice would call through a farther speaker, “Down here. Go through this door, then turn right.”

These were creepy reminders: People are watching you.

Now that I know how to get in and out of jail with confidence (which helps boost one’s sense of competence in general), central control rarely talks to me through the speakers.

A few weeks ago, central control was extraordinarily attentive. Every door unlocked as I approached it. I didn’t need to push any buttons. I preemptively spoke into the speaker at the elevator to request the floor I wanted. The elevator doors slid open a few seconds later and the button for the floor I wanted was already lit.

It felt like victory: I did not have to wait. I did not have to stop walking. Doors literally unlocked for me.

For a moment, it almost felt like God was watching, that God was opening doors, that God was showing me The Path.

Except it wasn’t God. It was an officer in central control who, for whatever reason, decided that it was worth his or her time to make my trip go smoothly.

Observations Policy Reflection Systems

How People Agree to Torture Others.

Post author By Maria Yang, MD
Post date December 12, 2014

Atul Gawande posted a series of tweets, based on findings in the Senate CIA Torture Report, about the significant role physicians and psychologists played in torture. He comments, “But the worst for me is to see the details of how doctors, psychologists, and others sworn to aid human beings made the torture possible.”

Agreed. Upon reading how these professionals used their knowledge to torture their fellow human beings I felt disappointed, sad, and sick.

“How could those people sleep at night?” I exclaimed.

But I know how “those people” were able to sleep at night, perhaps even with pride that they were doing good work.

Three studies—all controversial, though still illustrative—provide hints as to how people who engage in “bad behavior” believe that their actions are noble.

One is the Stanford prison experiment.

Briefly, college students were divided into two groups: One assumed the role of “guards” and the other became “prisoners”. Though everyone knew that this was an experiment, the behavior of the “guards” became more cruel and sadistic over time. For example, they forced the “prisoners” to be naked; they also refused to empty the buckets that “prisoners” used as toilets. As Wikipedia comments, this experiment demonstrated the “impressionability and obedience of people when provided with a legitimizing ideology and social and institutional support”.

Another is the Milgram experiment.

In this experiment, an “experimenter” instructed subjects (called “teachers”) to push a button that reportedly delivered electric shocks to a “learner” if the “learner” did not answer a question correctly. The “teachers” could not see the “learner”, but could hear the “learner”. The intensity of the electric shocks increased each time the “learner” answered the questions incorrectly. In fact, no one was receiving any electric shocks, but the “learner” would scream and start hitting a wall as the intensity of the electric shocks increased.

Most of the “teachers” continued to deliver shocks even though they heard the distress of the “learner”. Wikipedia quotes Milgram’s conclusion: “The extreme willingness of adults to go to almost any lengths on the command of an authority constitutes the chief finding of the study and the fact most urgently demanding explanation.”

The third is the Rosenhan experiment.

Here, volunteers were instructed to try to get admitted into psychiatric hospitals by reporting that they were hearing vague auditory hallucinations. Once the volunteers were actually admitted to the hospitals, they were supposed to “act normally” and to state that they were now feeling fine and were not hearing voices.

All of the volunteers got admitted and all received psychiatric diagnoses (often schizophrenia). None of the patients were released until they agreed with the psychiatrists’ assessments and plans: that they had a mental illness and should take antipsychotic medication.

All three experiments suggest the power of context in influencing human behavior. Most of the “guards”, “learners”, and staff at the psychiatric hospitals did what they thought they were “supposed” to do. From an outsider’s perspective their behaviors were “wrong”. To the subjects, though, they were doing the “right” thing because that is what they were “supposed” to do.

I don’t know any of the physicians or psychologists who participated in the government-sanctioned (!) torture, though I suspect that most, if not all, of them believed that they were doing “the right thing”. That they were using their knowledge and power for good, and not for evil.

Many of us—myself included—would like to believe that we would never do something like help torture people, that we would never be one of “those people”. We want to believe that we would have the mental fortitude to exercise independent thought, stick to our values and morals, and speak up against injustice.

But with experiments and events like these, how can any of us be so sure that we wouldn’t bend to authority and get sucked into groupthink?

NYC Observations Reading Reflection

Three Comments about Race.

I’m currently reading Nelson Mandela’s autobiography Long Walk to Freedom. Learning about his experiences with apartheid in South Africa provide both hope and discouragement about current race relations[1. The juxtaposition of reading Mandela’s book with the protests about Ferguson and Eric Garner is… interesting.] in the United States. While there has been some progress in the past fifty years, it seems like it’s not happening fast enough. Why do Nelson Mandela’s experiences and words still apply to the world today?[2. Though I am just over halfway through it, I would recommend Mandela’s autobiography. He tells his story with clarity, humor, and dignity. Do note that it over 650 pages long.]

While in New York I visited the New York Historical Society, which had an exhibit entitled Chinese American: Exclusion/Inclusion. The banner fluttering in front of the museum for this exhibit features the “certificate of identity” of a Chinese actress. I, of course, have no idea what she was thinking when the authorities took her photo, though I see fierceness and indignation in her face.

There I learned that the Geary Act of 1892, which served as an extension of the Chinese Exclusion Act of 1882, introduced the first form of photo ID in the United States. (Which makes me wonder if the Chinese in America were the first to create fake IDs.)

Again, there has been progress in the past century, but that there exists a museum exhibit on the exclusion/inclusion of Chinese Americans tells me that, as a population, we continue to wobble across that slash. And I think it is meaningful that “exclusion” comes first.[3. Iris Chang wrote an engaging book about The Chinese in America that discusses these exclusion acts. I will note that Chang’s writing brims with anger and hostility at points throughout the book. I nonetheless still recommend it. A more modern perspective on Chinese exclusion/inclusion is Gene Yang’s lovely graphic novel American Born Chinese.]

One of my patients in the jail, a man who is not Caucasian, has significant psychiatric symptoms. Some days he tolerates our conversation better than others. He recently became overwhelmed with rage and, in the midst of some colorful epithets, shouted, “I’m gonna rape you! No! You know what? I’m gonna get a whole bunch of WHITE GUYS to rape you!”

I immediately ended the conversation (for what I hope are obvious reasons). His commentary, though, fascinated me:

The emphasis of his threat was focused on race, not on the number of men. When you look him or me, you can instantly discern that neither one of us is white. He judged that the threat of a white man raping me was more demeaning and insulting than a man of any other race raping me.

It is also noteworthy, though perhaps not surprising, that he has directed this specific threat only to me. He has told my male colleagues that he will either beat or kill them. Neither threat, of course, is desirable.

Lessons Nonfiction NYC Observations Reflection

Living in New York, or Assertiveness Training.

Post author By Maria Yang, MD
Post date November 22, 2014

Over three years have passed since I moved out of New York—or returned to Seattle, however you want to look at it. I have had the good fortune to visit New York every year since my departure, though I was unable to last year due to my mother’s illness.

Whenever people ask me about my time in New York, I usually say something like, “I’m so thankful that I had the chance to live there, but I ultimately found it too overstimulating.” Sometimes I comment how I found myself laughing when I realized the number of people who seemed to take everything, including themselves, so seriously. I didn’t laugh because I found their behaviors funny; I often didn’t know how else to react.

When I was an intern in Seattle, one of the fellows told me about the year he spent in Boston earning an Master’s degree in public health. “Living on the East Coast is like going through assertiveness training,” he quipped.

Indeed, I found my three years in New York to be a course in assertiveness training. This training did not occur because “people are rude in New York”. To be clear, there are rude people in New York, but not more so than anywhere else.

People learn to assert themselves in New York City because of the constant crush of people and what seems like scarce resources. (“Resources” isn’t limited only to money; I refer also to time, attention, and space.) If you don’t assert yourself, people overlook you. And I’m not even talking about people overlooking you for promotions, relationships, or praise. I’m talking about crowds overlooking you while you try to get on a subway car[1. Here are photos of men taking up too much space on the train. Many of the photos feature the New York City subway.], taxi drivers overlooking you as they race down the avenues, or the guys at the pizza counter overlooking you when you’re trying to order a slice.

You learn to change the way you walk, the way you hold yourself, the way your form occupies space. You learn to arrange your body and face to announce, “I am here.” You don’t send that message because you want to be the center of attention; you just want to get stuff done.[2. Because you learn how to adjust your body and face to make your presence known and felt, you also learn how to turn all that off. Sometimes you want to disappear into the crowd; you just want to watch what is happening around you without having to take part.]

You learn to speak up. Speaking up doesn’t mean speaking more; you learn how to get enough attention for enough time to say what you need to say. You learn that if you don’t speak up, people

may not realize you are there
may not realize that you have something useful or helpful to offer
may develop wrong opinions about you, what you think, or what you’re about

You learn to speak up and make your presence known because you witness someone else speak up and advocate for you. You pay that forward and notice that, for whatever reason, that karmic system works.

You also learn to assert yourself because sometimes you get attention you don’t want. There are all the irritating men who catcall you[3. I am an N of 1, but men in New York catcalled me way more than men in any other city I have lived in. That video resonated with me.], the taxis that trail you as you walk on the sidewalk, and the disgruntled people you happened to interact with at the wrong time. You learn to ignore the unwanted attention without showing discomfort or fear on your face. You arrange your body and face to announce, “I am here, but not for you.”

You learn that people respond to you—favorably!—when you assert yourself. You learn that when you speak up and deliver your message in an envelope of good manners, people often change their behavior. You learn who respects you. You also learn that one of the best ways to show respect to others is to tell them what you’re thinking and feeling. You learn that they can handle it. You also learn that you can handle it, too.

I remain grateful to New York for teaching me how to sharpen my assertiveness skills. I’ll be visiting the great city soon and trust that I will have no choice but to review the coursework.

Medicine Observations Reflection

On the Word “Prescriber”.

Post author By Maria Yang, MD
Post date October 5, 2014

Please don’t call call me a “prescriber”. Yes, I know it’s easier to say “prescriber” than “psychiatric nurse practitioner, physician assistant, or psychiatrist”.[1. I don’t know if ARNPs, PAs, and physicians are called “prescribers” in other areas of medicine. Do people call their cardiologists or pediatricians “prescribers”?] The word “prescriber”, however, puts severe limits on what I can do and how I can help.

You may believe that, because I have a license to prescribe medications, that’s all I choose to do. In fact, you may believe that’s all I know how to do.

Psychiatrists can do a lot more than that.

As a psychiatrist, I can:

use interpersonal skills so that people feel comfortable talking to me about personal things
help people design mini-experiments to determine if their beliefs about themselves are helpful or accurate
prompt people to consider different sides of an issue to help them commit to decisions about their health
encourage people to pause and reflect on their own thoughts, emotions, and behaviors
teach people skills about how to manage the expectations they have of themselves and others
educate people on how to help themselves so that they eventually won’t have to see me or another psychiatrist in the future[2. This list in technical terms would translate to:
1. engage and build rapport with a wide variety of people
2. gently challenge cognitive distortions
3. enhance ambivalence, as in motivational interviewing
4. encourage self-reflection to facilitate mindfulness and create more opportunities for positive reinforcement
5. teach skills related to interpersonal effectiveness and the dialectic of acceptance and change
6. help people exit the mental health system
]

While it is true that I might use those skills to encourage some people to take medications, I can also use those skills to:

help people to reduce the number and amount of psychiatric medications they are taking[3. Some people end up taking multiple medications for unclear reasons. This often occurs when physicians do not have a clear diagnosis; they are instead chasing symptoms. One irritating example is the prescription of antipsychotic medications for insomnia… for someone who is not psychotic. Yes, antipsychotic medications are sedating. They can also cause high blood pressure, weight gain, diabetes, and involuntary movements. I’m not confident that all doctors regularly share this information with patients.]
coach people to first try interventions other than medications[4. Remember, when we prescribe medications, we are recommending to people that they put chemicals into their bodies. In psychiatry, we often can’t offer solid explanations as to how these chemicals work. To be clear, I am not anti-medication; I use the word “chemicals” to highlight what we’re asking people to do when we write prescriptions.]
provide education about the interactions between mind and body, whether related to medications or medical conditions

If my skill set is limited to prescribing medications alone, those automated psychiatrist machines will replace me in short order.

Psychiatrists should continue to strive to be the artisans of the clinical interview. As with the other specialties in medicine, the goals in psychiatry should focus on improving quality of life and reducing suffering. Sometimes that involves medications; sometimes it doesn’t.

The word “prescriber” overlooks those goals entirely.