Category: Observations

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Lessons Nonfiction NYC Observations Reflection

Living in New York, or Assertiveness Training.

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

  1. may not realize you are there
  2. may not realize that you have something useful or helpful to offer
  3. 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.

Categories
Medicine Observations Reflection

On the Word “Prescriber”.

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:

  1. use interpersonal skills so that people feel comfortable talking to me about personal things
  2. help people design mini-experiments to determine if their beliefs about themselves are helpful or accurate
  3. prompt people to consider different sides of an issue to help them commit to decisions about their health
  4. encourage people to pause and reflect on their own thoughts, emotions, and behaviors
  5. teach people skills about how to manage the expectations they have of themselves and others
  6. 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:

  1. 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.]
  2. 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.]
  3. 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.

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Education Funding Homelessness Medicine Observations Policy Reading Systems

Thoughts on Stuff.

Recent things I have read that I have found interesting, curious, or vexing:

The Social Security Administration maintains a “compassionate allowances” list, which is a list of “medical conditions [that] are so serious that their conditions obviously meet disability standards”.[1. You can learn more about how diseases make it on to the “compassionate allowances” list here.] Cancers, genetic conditions, and diseases still known by eponyms make the list. (Medical types: This is your list of zebras, not horses.)

“Can you receive SSI (Supplemental Security Income)[2. The Social Security Administration mails a check of about $721 once a month to individuals who receive SSI. To receive SSI, you must have “limited income and resources” AND you must be disabled, blind, or age 65 and older. I got lost while digging through all the subsections, so I don’t know what the “limited” income is. “The limit for countable resources is $2,000 for an individual and $3,000 for a couple.”] while living in a public shelter for the homeless?” the Social Security Administration asks.

Answer: “Yes. You can receive up to the maximum SSI benefit payable in your State while living in a public shelter for up to 6 months out of any 9 month period.” (Emphasis mine.)

While it is true that most people are in the shelter system for less than three months, is it possible that some people who receive SSI will need more help over a longer period of time to get out of the system?

If someone must stay in a shelter, that usually means that he can’t pay rent. Most employers prefer to hire employees who have actual home addresses. No job means no income. No income means difficulties finding affordable housing. And it is mighty difficult to pay for housing and food with only $721 a month.

Psychiatry has little to offer in the realm of prevention.[3. Some would also argue that psychiatry has little to offer in the realm of treatment. In moments of frustration, I agree.] We have no medications to prevent schizophrenia, though omega-3 fatty acids might reduce the likelihood that a youth already showing some signs of psychosis will develop “full blown” psychosis. (Researchers are putting efforts into preventing psychosis, which is exciting.) Most people don’t go to therapy prior to experiencing uncomfortable and distressing emotions.

The WHO has a paper about social determinants of mental health that cover the entire lifespan. Frequent themes in the paper include providing education for women; attending to the mental health of mothers before, during, and after pregnancy; reducing poverty; and providing support to people in school and in work. The prevention of and reductions in psychiatric symptoms were not due to medical interventions.

Incorporating mental health into daily living helps people stay well and develop the resiliency to deal with crap. It’s not a separate thing. We know that people who have had adverse childhood experiences are more likely to have psychiatric and medical problems as adults. Exercise, spending time with friends and family, maintaining stable relationships, eating nutritious foods, learning about stuff, finding value in work and hobbies, avoiding conflict and trauma—all of these activities are useful in preventing major psychiatric conditions.

How many of us in psychiatry focus on these social determinants in our daily work? How have we let ourselves become “prescribers”? Can we change that so that we “prescribe” education and activity more often, and only prescribe medications in the most severe circumstances?[4. This is easier said than done, given that we cannot control the behavior of other people or systems. I also detest the word “prescriber”. That’ll be another post.]

Someone pointed me to this article with the polarizing title: Bad Managers Talk, Good Managers Write. The author argues:

When managers write, you create work product — white papers, product requirement documents, FAQs, presentations — that lasts and is accessible to everyone in the organization. From marketing to sales to QA to engineering, everyone has a document off which they can work and consult.

The upshot is that the manager also takes public responsibility for what happens when the rest of the team executes on the point of view taken by the documents. That ratchets up accountability through the organization.

This is also the benefit of keeping a blog. You create a body of work that people can read, refer to, and learn from. More importantly, regardless of your work (whether it is your formal profession or what you do “on the side”), it gives you the opportunity to reflect on things that matter to you, clarify your thinking, express your ideas, and connect with interesting people, including yourself.

Categories
Homelessness Observations Reflection

Continuity of Care.

The first time I saw him he was walking around the shelter with another man. His hands were buried in the pockets of his hoodie and his gaze was fixed on the ground. He looked shorter than his actual height because he was slouching.

He and the man walked laps around the shelter while they talked. His expression was hard: Eyebrows furrowed, jaw tight, lips curled into a slight frown. He moved across the tiled floor like a sleek fish gliding through the water.

“Hi,” I said, introducing myself. “Do you mind if we talk for a few minutes?”

His companion kept walking as he coasted to a halt. His stony expression softened; his eyebrows raised and wrinkles appeared at the outer corners of his eyes as he smiled.

“Sure. Thank you.”

He and I walked laps around the shelter for the next few days. His father beat his mother, his brother, and him. At the age of 11 he found his mother’s body after she committed suicide. His father disappeared for days at a time. When he returned, his speech was slurred, clothes were dirty, and exhalations were thick with malt liquor. He stopped attending school. He ran away from home. He slept in alleys and underneath bridges. The police picked him up on a variety of charges: Theft. Drug possession. Criminal trespass.

The second time I saw him he lying on a mat in the shelter. The stiff blanket was not long enough to cover his entire body; his feet with their long toenails poked out.

He pulled the blanket off of his face and replied, “Heroin. Couple days ago.” Pulling up a sleeve, he showed me the collection of tiny bruises on his arm. He closed his eyes. Beads of sweat collected on the pale skin of his forehead.

“I’ll be done kicking dope tomorrow.” He pulled the blanket back over his head.

The third time I saw him he was sitting on the floor in the shelter, his arms hugging his knees.

“I don’t make many promises. I promised her that I won’t kill myself. I keep the promises I make, so I didn’t do it. I really wanted to.”

He accepted the invitation and got up. He and I walked laps around the shelter. He had yet to talk with her, though he planned to see her tomorrow. The last time he used heroin was over six months ago, but he was also in jail for four of those months.

“You didn’t use anything in jail?”

He shook his head.

After a pause, he said, “You know, I’ve seen you downtown. You were with a guy, so I didn’t want to bug you.”

“Is that where you’re staying these days?”

“Yeah.”

“Outside?”

“Yeah.”

The fourth time I saw him he was standing on the sidewalk outside of a methadone clinic. The hood of his sweatshirt was pulled over his head and baggy jeans covered his long legs. His hands were buried in the pockets of his sweatshirt. The other man made a joke; he chuckled and wrinkles appeared at the outer corners of his eyes as he smiled.

I crossed the street. He was with a guy and I didn’t want to bug him.

The fifth time I saw him he had already passed me. Without realizing that I was reviving an old habit, I wrapped the long white coat closed as I looked over my shoulder.

“Smith!” the officer barked. “Stay where you are. Turn around.”

He stopped, turned, and looked up. We saw each other.

“Go back to your cellblock, Smith.”

He moved across the concrete floor like a sleek fish gliding through the water. Before he passed me, he nodded in recognition. I nodded back.

We both kept walking. I sighed.

Categories
Education Medicine Observations Policy Seattle Systems

A Primer on Psychiatric Boarding.

The Washington State Supreme Court recently stated that “psychiatric boarding” is unconstitutional.[1. You can read the court’s opinion here. It’s a fairly easy read.] I agree with and support the court’s decision. “Boarding” is a terrible practice.

To be clear, though, the consequences of this decision may be undesirable.

Some background: In the state of Washington, the only people who can hospitalize individuals against their will for psychiatric reasons are “designated mental health professionals” (DMHPs). Police officers can bring people to emergency rooms against their wills and physicians and other professionals can evaluate people who show distress. A DMHP, as an agent of the state, makes the ultimate decision whether to detain someone against his will.

Let’s be clear about this: Being hospitalized against your will is stressful, upsetting, and frightening. The state is taking away the rights and freedoms from an individual. Civil liberties? Gone. It is a big deal. No one enjoys the process.

In order for a DMHP to hospitalize someone against his will, a person first must show evidence of a “mental disorder”.[2. A finer point about “showing evidence of a mental disorder” is that there should be some proof that hospitalization is an effective treatment for the mental disorder in question. This is why some people go to jail and not to the hospital. This path can lead us into the weeds.] Having a mental disorder alone, however, is not reason enough to hospitalize someone against his will. At least one of the following three criteria must also apply:

  • He is a danger to himself. (Consider a man with major depression who was found nearly unconscious; a noose made of bedsheets was around his neck.)
  • He is a danger to others. (Consider the woman who is walking across the highway multiple times because she believes that God wants her to proselytize to the drivers.)
  • He shows “grave disability”, or is unable to meet his basic needs. (Consider the man who has not eaten any food in nearly two weeks because he believes that all food is actually composed of his internal organs.)[3. If you think that none of these scenarios ever really happen, I encourage you to go volunteer at your local emergency room.]

Thus, at least two people–the person who wanted the individual to go to the hospital and the DMHP–were concerned enough about the individual to believe that he needed to be in the hospital to get care.[4. For now, let us put aside arguments that psychiatric hospitalization is never helpful or indicated. Some people believe that psychiatric hospitalization is a veiled form of incarceration.]

That “to get care” part is the crucial point when we talk about “boarding”.

People who are involuntarily detained in Washington are only allowed to be hospitalized in certain facilities (or certain beds). Facilities submit an application to the state to become a “certified” place where they can treat people who are hospitalized against their wills.[5. Indeed, there are psychiatric hospitals in Washington State that are not certified to treat people who are hospitalized against their wills.] These places can be entire buildings (called “evaluation and treatment facilities”, or “E&Ts”, here). They can also be specific beds within a hospital, usually on psychiatric wards.

There has been concern if “inpatient psychiatric capacity is sufficient to meet [a] potential increased demand” for involuntary hospitalizations. All certified beds are frequently occupied. Most people who are referred for involuntary hospitalization are not in psychiatric hospitals; they are in hospital emergency rooms.

There are medical centers (and, by extension, hospital emergency rooms) in Washington State that do not have any psychiatric providers on staff.

Thus, DMHPs have been hospitalizing people against their wills, but no certified treatment beds are available. These detained individuals therefore are admitted to hospital emergency rooms or random hospital wards while they wait for certified beds to open up.

If the hospital does not have psychiatric providers on staff, that means these detained individuals don’t receive any psychiatric care. People could wait hours, days, or even weeks before they are transferred to a certified facility to receive formal psychiatric services.

In the meantime, these individuals are often physically restrained to their beds. There might not be enough hospital staff to fulfill the state’s mandate that they remain in the hospital against their wills.

Sometimes these individuals receive doses of sedating medication for multiple days in a row. (Imagine you work in an emergency department. Someone who is detained in your emergency department will not stop screaming obscenities at other patients. He also tries to spit at everyone. He has also tries to punch the nurses whenever they walk by.)

This isn’t treatment. (Remember, the state ordered that this person be hospitalized against his will to get care.)

Thus, you can now see why the state supreme court decreed that it is not okay to “board” psychiatric patients. People who are detained against their will, by the state’s definition, need treatment. “Boarding” isn’t treatment.

This is why I agree with and support the court’s decision.

However, now that you know that there aren’t enough certified psychiatric beds in the state, you can guess what undesirable consequences might come from this decision.

The detained individual in the emergency room who yells and tries to punch all the nurses? Now he might end up in jail on charges of assault. Jail is not a therapeutic environment. Some jails do not offer any psychiatric services. Incarceration, like boarding, is not treatment.

Detained individuals might instead be released into the community if no certified beds are available at that time. Someone else–another police officer, another family member–might try to re-refer them back to the hospital a few hours after they were released. This results in a cycle in and out of hospitals and other institutions. That isn’t treatment, either.

Hospitals that have certified beds may feel pressure to discharge people more quickly due to the heightened demand. These individuals may not have recovered “enough” and may return to the hospital much sooner than anyone would like.

Another potential consequence is that those individuals who seek hospital services on their own–perhaps in an effort to avoid involuntary hospitalization–may not be able to get into a hospital at all. Those detained against their wills may occupy all of the certified hospital beds.

My understanding is that the state is considering various ways to work with the new law: This includes increasing the number of certified beds, creating different options to divert people from hospitals, and reducing the amount of referrals for involuntary hospitalization.

I don’t understand why some hospitals don’t employ psychiatrists.[6. Psychiatric services are not “revenue generators”, so I suspect this is the reason why some hospitals don’t hire psychiatrists.] If a pregnant woman about to have a baby shows up at an emergency room, hospitals have staff available with the expertise to manage her care.

Why isn’t this the case with psychiatry?