Category: Policy

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Medicine Policy Reading Systems

The Word is Not the Thing, And…

This past week I finished reading McCloud’s Understanding Comics: The Invisible Art.[1. I purchased Understanding Comics to learn a different perspective about storytelling. I am not a routine reader of comics. Regardless, I do recommend this book. It is a thoughtful and fun read, and it’s a comic book.] The second chapter, “The Vocabulary of Comics”, reiterates a major point in Hayakawa’s Language in Thought and Action:

The first of the principles governing symbols is this: The symbol is NOT the thing symbolized; the word is NOT the thing; the map is NOT the territory it stands for.

McCloud uses René Magritte’s “The Treachery of Images” to welcome the reader to “the strange and wonderful world of the icon”:

I’m using the word “icon” to mean any image used to represent a person, place, thing or idea.”

This idea that “the word (or icon) is not the thing” is relevant to a recent opinion piece, “Beware the Word Police“, in the academic journal Psychiatric Services:

Frequent calls for changing diagnostic labels to decrease stigma may result in unintended consequences. Condemning incorrect language by policing word choice oversimplifies the depth of work involved to increase opportunities for people with mental illness. This Open Forum reviews three unintended consequences of using scolding language.

The author of that opinion piece, Patrick Corrigan, lists these three unintended consequences:

  1. the word police’s focus on “just changing terms” misrepresents the depth and persistence of bias and bigotry
  2. word police are a major barrier to the essential goals of stigma change
  3. word police may undermine stigma change at the policy level

I’m One of Those People who avoids using the words “addict”, “schizophrenic”, or “diabetic”. I instead say “individual with a substance use disorder”, “person with a diagnosis of schizophrenia”, or “someone with diabetes”.

While I agree with all the authors above—words and icons aren’t the thing, they only represent the thing; the use of different words does not equate to actual reduction in discriminatory behaviors—I also believe that, as a society, The Royal We have come to agree that certain words have certain meanings.

For example, if I describe a person as a “diabetic”, what comes to mind? Perhaps you think of a family member who has diabetes and has excellent management of her blood sugars. Maybe you think of the person who goes to the emergency department multiple times a month due to high blood sugars and non-healing wounds. Or maybe you’re thinking about the growing number of people who struggle to pay for insulin to treat their diabetes. The range of ideas that come to mind with the word “diabetic” is broad.

But if I say someone is an “addict”, what comes to mind? Maybe you think of a senior vice president of a major business who wears tailored suits, but most people don’t. When I teach and ask audiences—comprised of health care professionals or otherwise—to list what comes to mind when I say “addict”, the list always includes things like

  • dirty
  • mean
  • desperate
  • selfish
  • etc.

(When the audience is comprised of health care professionals, I remind them that, right now, they are likely working with someone with a substance use disorder… and that person won’t disclose how much s/he is suffering because they feel shame about the presumed characteristics of “addicts”.)

It is true that the word “addict” is NOT the person with a substance use disorder. However, we, as a society, have somehow arrived at the agreement that the word “addict” describes someone who is dirty, has no self-control, etc.

Even though a different word doesn’t change the actual thing, the different word can change the idea about the thing. A different word can have a different definition, different associations.

Again, if I describe someone as “schizophrenic”, what characteristics comes to mind?

But what if that person with schizophrenia is your neighbor? works as a barber? works at Microsoft? is raising two kids? just earned her graduate degree? volunteers at the animal shelter? is the owner of that plot in the community garden that is overflowing with flowers and vegetables?

If different words can change the idea about the thing, then different words can help people change their behaviors about the thing.[2. To be clear, insight does not always result in behavior change. Even if the psychoanalysts argue otherwise.] In regards to the “word police” piece above, shifts in ideas and behaviors can drive improvements in health and social policy. This can lead to a reduction in stigma. The Royal We can develop new agreements for these different words. And using different words is sometimes easier than changing definitions for the same word (e.g., consider racial slurs).

Maybe I am falling into the “word police” camp. However, I do agree that behavior change is the ultimate goal, since what we do matters more than what we say. As with many things, the solution is somewhere in-between: Let’s work on word choice to help shift ideas and behaviors, but also remind ourselves that the word is not the thing.

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Policy Reading Systems

About that APA Statement on “Toxic Masculinity”…

Several people asked me about the American Psychological Association’s (APA) statement about “toxic masculinity”. You can find the statement, which is actually a practice guideline, here.

I read the entire guideline. My reactions and opinions follow:

1. The title of the practice guideline is not “Toxic Masculinity”. The title is “APA Guidelines
for Psychological Practice with Boys and Men”. The word “toxic”, let alone the phrase “toxic masculinity”, does not appear anywhere in the document.

2. This APA practice guideline, like other clinical practice guideline, is a “statement[s] that suggest or recommend specific professional behavior, endeavor, or conduct for psychologists”. Psychologists are the intended audience. On page one of the document, it states:

These guidelines serve to (a) improve service delivery among populations, (b) stimulate public policy initiatives, and (c) provide professional guidance based on advances in the field. Accordingly, the present document offers guidelines for psychological practice with boys and men.

3. The introduction to the document includes a section of definitions. Language is how we communicate with each other, but, wow, can words get in the way. I suspect some readers had strong reactions to the definitions (and, perhaps, to the legitimacy of some of the words defined). And if those readers do not agree with the definitions (or question the validity of the words themselves), then the rest of the document will seem like a pile of poo.

My guess is that the phrase “traditional masculinity ideology”, tucked into the “masculine ideology” section, and the accompanying definition made some people clutch their pearls. I myself did not react one way or another to the phrase “traditional masculinity ideology”, which the APA defines as

anti-femininity, achievement, eschewal of the appearance of weakness, and adventure, risk, and violence.

This phrase has apparently been in use since 2007. This definition gets more attention later in the document, which may have caused the strands holding the pearls to rip, thus sending hundreds of pearls clattering to the floor.

So many words. So many opportunities to develop heartburn over words.

4. The practice guideline includes ten specific guidelines. Here they are:

Psychologists…

  1. strive to recognize that masculinities are constructed based on social, cultural, and contextual norms.
  2. strive to recognize that boys and men integrate multiple aspects to their social identities across the lifespan.
  3. understand the impact of power, privilege, and sexism on the development of boys and men and on their relationships with others.
  4. strive to develop a comprehensive understanding of the factors that influence the interpersonal relationships of boys and men.
  5. strive to encourage positive father involvement and healthy family relationships.
  6. strive to support educational efforts that are responsive to the needs of boys and men.
  7. strive to reduce the high rates of problems boys and men face and act out in their lives such as aggression, violence, substance abuse, and suicide.
  8. strive to help boys and men engage in health-related behaviors.
  9. strive to build and promote gender-sensitive psychological services.
  10. understand and strive to change institutional, cultural, and systemic problems that affect boys and men through advocacy, prevention, and education.

Lots of striving happening here.

While I can understand why some people might hurl spittle at their electronic screens at a few of these guidelines, most of them are reasonable and want to improve the well-being of boys and men. Don’t we want boys and men to successfully integrate various aspects of their identities? Who objects to helping men become better fathers? Why would anyone get upset about reducing the problems that boys and men are more likely to encounter in both behaviors and health?

4. I took the most notes for the first three guidelines:

Guideline 1: Psychologists strive to recognize that masculinities are constructed based on social, cultural, and contextual norms.

And this is where the pearls spilled all over the floor.

Recall that the APA’s definition of “traditional masculinity ideology” refers to “anti-femininity, achievement, eschewal of the appearance of weakness, and adventure, risk, and violence”. In this section, APA asserts that this ideology “can be viewed as the dominant… form of masculinity” that “strongly influences what” people in a culture assume is normal.

APA goes on to assert that this “dominant masculinity” has historically excluded men “who were not White, heterosexual, cisgender, able-bodied, and privileged”.

So many words in there that induce emotional reactions, right?

I argue, however, that this definition is fair. Let’s go through a thought experiment together:

In the United States, the image of a cowboy easily comes to mind upon hearing the word “masculine”. Picture a cowboy in your mind’s eye, if you will:

  • What color is his skin? Does he look like this or this?
  • When he is riding off into the sunset, who does he want to make sweet love to? Why was Brokeback Mountain so scandalous?
  • Did you even consider that your cowboy could be a trans man?
  • Does your cowboy wear glasses? hearing aids? a prosthetic limb?
  • And does your cowboy push the saloon doors open with bravado? Or does he brush off all the dust from his face and clothes, ensure that he has proper identification on him, and knock on the wall of the saloon?

APA never states that this definition of “dominant masculinity” is “toxic”. Instead, APA asserts that the “ideal, dominant masculinity is generally unattainable for most men”. As a consequence, men “who depart from this narrow masculine conception by any dimension of diversity… may find themselves negotiating between adopting dominant ideals that exclude them or being stereotyped or marginalized”.

Because it’s too hard to reach that ideal, “men not meeting dominant expectations often create their own communities”.

APA then recommends that psychologists work with individuals in their care to “become aware of how masculinity is defined in the context of their life circumstances”. More importantly, APA advises that “psychologists strive to understand their own assumptions of, and countertransference reactions toward, boys, men, and masculinity”. Because if I think Mr. Doe should be like a cowboy and refrain from crying after the death of his child, Mr. Doe is going to pick up on that, even if he wants to weep. And, thus, I’m a jerk and I’m not helping him.

Guideline 2: Psychologists strive to recognize that boys and men integrate multiple aspects to their social identities across the lifespan.

This guideline delves more into the intersection of things like race, age, sexual orientation, etc. and being a boy or man. And these intersections aren’t limited to these “social justice warrior” flavors: A man who has served in the military has a social identity that many others lack. Military service is its own culture and affects how men interpret and define masculinity.

As such, APA recommends that psychologists “working with boys and men strive to become educated about the history and cultural practices of diverse identities” and

[w]hile attempting to understand, respect, and affirm how masculinity is defined in different cultures, psychologists also try to avoid within-group stereotyping of individuals by helping them to distinguish what they believe to be desirable and undesirable masculine traits and to understand the reasons upon which they base these beliefs”.

This recommendation is easiest to understand through a lens of race or ethnicity (e.g., a black man or a refugee from Somalia), though has other applications.

Guideline 3: Psychologists understand the impact of power, privilege, and sexism on the development of boys and men and on their relationships with others.

More words that have the power to launch spittle across the screen.

My overall read of this guideline suggests that the ostensible privilege that boys and men have can also trap them. If boys and men are trying to fit into a masculine ideal that is unattainable, and that masculine ideal includes behaving in ways that are intended to restrict resources and power from others, that pursuit impairs their abilities to have effective and meaningful relationships with human beings. This leads to suffering for all involved. This ties into Guideline 4:

Psychologists strive to develop a comprehensive understanding of the factors that influence the interpersonal relationships of boys and men.

The recommendation is that psychologists

can discuss with boys and men the messages they have received about withholding affection from other males to help them understand how components of traditional masculinity such as emotional stoicism, homophobia, not showing vulnerability, self-reliance, and competitiveness might deter them from forming close relationships with male peers.

For me, the punchline of the practice guideline is actually tucked in the section that defines “masculine ideology”. The last sentence in that section is:

acknowledging the plurality of and social constructionist perspective of masculinity, the term masculinities is being used with increasing frequency. (emphasis mine)

If there are multiple definitions of “masculinity”, and knowing that those definitions can change over time, even within the same person, then we can use those changing definitions to help improve the psychological and physical health of boys and men.

Do I think the moral fiber of our nation will disintegrate if a boy or man chooses to wear nail polish? No.

Do I want boys and men to stop trying to achieve things? No.

Do I want them to avoid risks and adventure? No. (Do I want them to avoid stupid risks and pursue noble adventures to make great achievements? Yes.)

Do I want boys and men to engage in less violence? Yes, because I want everyone to engage in less violence. I value cooperation over conflict… and that’s the only way we’re going to survive as a species.

Do I think men should feel comfortable crying in public when they feel heartbroken? Given what some (many?) of them have experienced, yes. I want them to know we don’t think less of them when they need help… because we all do.

The “anti-femininity, achievement, eschewal of the appearance of weakness, and adventure, risk, and violence” of “traditional masculine ideology” is not “toxic” or evil. There were assumptions behind that definition and it’s outstanding that we can now challenge those assumptions. It means that we’re growing and learning, and don’t we want people and societies to change for the better as time passes?

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Homelessness Nonfiction Policy Systems

How to Prevent All of This?

Some of the people under my care in the jail right now are quite ill. (This statement is always true, but it seems that the intensity of illness is greater now than usual.) As a result, the perennial question seems more urgent now: Is there any way to prevent All of This?

For some of them, it seems that the answer is No. Some of them sought out psychiatric services, attended appointments regularly, and had good working relationships with their physicians and therapists. They shared their concerns with friends and family members; they sought out help when they started feeling overwhelmed. Despite these relationships and support, they allegedly did things that resulted in significant criminal charges. And now they’re in jail.

For some of them, the answer might be Yes. Maybe if they had more people they trusted in their lives; maybe if they had a better connection with the counselor or doctor they saw that one time; maybe if their friends and family had more time and resources to seek help with and for them.

Then again, for some of them, the answer might be No, but for frustrating and sad reasons. Maybe their friends and family did everything they could to help them, but they didn’t want their aid. Maybe they became so fearful for their safety that they withdrew from everyone and, in isolation, their symptoms became worse. Maybe they believe that they are fine; it is the rest of the world that is confused and ill. Maybe their only experience with psychiatrists was involuntary hospitalization: Who wants anything to do with a system that takes away your rights and forces you to accept medication?

Some of these people are so young. To be clear, it’s troubling whenever someone of any age ends up in jail solely because of psychiatric symptoms. But can you imagine being 18, 19, or 20 years of age and landing in jail in the midst of hearing incessant, taunting voices, believing disturbing things that simply aren’t real, and having no visitors because the few people who are in your life are scared of you?

It’s heartbreaking.

At least these individuals come to clinical attention. And many get better: They form relationships; they talk with my colleagues and me; they learn how to get along with others; they reflect on what has happened and how to avoid similar consequences in the future; some take medication to help reduce their symptoms.

But then I think about all the people who never encounter law enforcement and never enter the criminal justice system, but they also experience significant symptoms. How do we prevent All of This for:

  • the man who doesn’t tell anyone any personal information and stuffs his tattered clothes with plastic bags to stay warm
  • the woman who won’t move indoors because she believes that the aliens will execute her if she does so
  • the woman who won’t leave her house because she believes her neighbors are cannibals
  • the man who sits all day on the sidewalk across the street from his old employer because he believes that he will get his job back

What about them? How do we help those individuals when the system ignores those who cannot or will not play by the rules?

Many mornings I see the same woman standing near a bus stop. The bus stop is covered, but she never stands underneath the awning. She stands behind the bus stop, even when it’s raining.

You can smell her—a mixture of sweat, dirty socks, and yeast—from several feet away. Pedestrians move around her the way water swirls away from large rocks on the riverbed.

Two black garbage bags sit at her feet. They are full. Plastic zip-lock bags poke out of one of them.

She is a young woman of color. She wears a dark hoodie that is too large for her slender frame, but it’s not zipped up all the way. She’s not wearing anything underneath the hoodie, not even a bra. An unwashed skirt smeared with dirt covers her legs. Her mangled sandals reveal that she has not clipped her toenails in many months.

She talks to an unseen audience and everyone can hear what she says. Her voice is rich and though her sentences do not make sense, she speaks with dignity.

The other morning the rain wasn’t the usual mist that falls from Seattle skies. The droplets were full and heavy, a shower of dark water as the sky was filling with grey light.

No one was standing in the bus shelter. Her clothes were already damp.

“Excuse me?” I asked. She had raised an arm to make a point in her discussion.

She fell silent and blinked a few times.

“Do you want to move so you’re under the bus shelter? So you won’t get wet?”

She turned her head and looked away.

“I can help you move your stuff. It’s raining pretty hard right now.”

She dropped her arm and turned her head further.

“What’s your name? My name is Maria.”

She glanced at me, raised her arm back up, and resumed speaking: “All in all, we must to the left….”

I stood there for a moment, waiting for a sign. None came. I walked away.

Categories
Education Homelessness Medicine Nonfiction Policy Systems

People Get Better.

“What?!” he exclaimed. “Are you serious?”

“Yeah,” I replied, puzzled.

“That’s… amazing.”

“Yeah, it is.” I paused, finally realizing that he had never heard me talk about this before. “It actually happens a lot. People get better. People get better all the time.”

When I first met him, he screamed at me, his face red, spittle flying from his lips. He refused to believe I was a physician.

“Women can’t be doctors! They can’t!”

He did believe, though, that televisions could control his thoughts.

“They know what I think! When they start talking, they control what I think and what I say and what I do!”

He drew a swastika that covered the entire wall of his jail cell.

“Yes, I believe in white supremacy! But I’m not part of a group!”

He accepted medications on his own. First, the yelling stopped. Then, the swastika disappeared. Drawings of cute farm animals took its place. Within a few weeks, he greeted me with a smile.

“Hi, Dr. Yang. How are you doing today? I hope you’re well.”

He invited me to sit at the small table next to the kitchenette in his apartment.

“You want anything to drink?”

“No, thank you. How are you doing?”

“I’m okay. What do you know about the Mediterranean diet? I want to try that. I want to lose some of this weight.”

After discussing the merits of vegetables and lean proteins as they related to heart health, he leaned back in his chair. He then blurted, “It’s been six months since I smoked a cigarette.”

He never smiled when he shared his accomplishments. His condition prevented him from doing so. I smiled for him.

He resumed musing about dietary changes. I mused about how far he had come: Just 18 months ago he was living on the streets, often snarling at strangers and the voices that only he heard. He came to the attention of the police when he chased a young mother pushing her baby in a stroller. He threatened to beat them with the metal pipe in his hand. The police thankfully sent him to the hospital for care.

“Thanks for seeing me,” he said as he walked me to the door. The voices hadn’t completed disappeared, but he could ignore them now. “I like steak and potatoes, but I’ll try the leafy vegetables.”

He used both hands to smear his own feces on his arms, chest, and belly. He applied toothpaste to his elbows and his knees. I asked him why.

“because it’s protection it’s protection against all of you I shouldn’t be here I’m fine I’m not sick you don’t understand who I am they all know who I am you would be scared too if you knew who I am people know me from way back—”

He began howling at the door.

Within days of him receiving medications, all of that stopped. His jail cell was clean. He took showers. He never spoke of what happened. Neither did I.

I was taking a walk a few months later when I heard someone call, “Hey, Dr. Yang!”

I turned around and saw a group of men in uniform working. This man, suited up like his colleagues, waved at me and smiled.

I couldn’t help but smile—this is fanstastic!—but felt a twinge of embarrassment. Did he know that he had called me “doctor”? What would his coworkers think?

First do no harm. I waved back.

“Nice to see you, Doc,” he continued. “I’m doing good.”

“I’m glad to hear that. Take care of yourself.”

“I will, Doc. Thanks.”

People get better. The science hasn’t yet generated interventions that guarantee that everyone will get better. Furthermore, some people who could get better can’t access care due to barriers related to finances, policy, and other systemic factors.

Until then, we must share both stories and data (try this, this, and this) that people get better. It is amazing, but it shouldn’t be surprising.

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Funding Homelessness Nonfiction NYC Policy Reflection Seattle Systems

God’s Work versus Meaningful Work versus Value.

Every now and then, when some people learn what kind of work I do, they say, “You’re doing God’s work. Thank you.”

They mean well, so I accept the compliment, though I also tack on, “I also like what I do. It’s meaningful work for me.”

So many of the people I see, whether in my current job or in my past jobs working in other underserved communities, have a lot going on that psychiatry and medicine cannot formally address. One example is housing. It is often an effective intervention for the distress of people who don’t have a place to live, though housing is not something physicians can prescribe. However, there are individuals who are eligible for housing, but do not want to move into housing for reasons that do not make sense to most people. For example, in New York I worked with a man who would spend his days sitting in front of the building where he once worked before he became ill. He talked to himself and burned through multiple packs of cigarettes. He did not recognize how soiled his clothes and skin became with time. At night he disappeared into the subway tunnels and rode the trains. He did not want to move into an apartment until he was able to get his job back, even though he hadn’t worked there in over ten years. With time (nearly two years!) and unrelenting attention, our team was able to persuade him to try living indoors. He eventually accepted the key and moved in.

There are other active conditions that I do not have the skills to treat: Sometimes it’s institutional racism; sometimes it’s multiple generations of poverty. Both prevent people from accessing education, housing, and other resources. Do some of these individuals end up taking psychotropic medications due to the consequences of these systemic conditions? Yes. Do I think they’re always indicated? No.

Most of my jobs have been unconventional: I worked on an Assertive Community Treatment team that often provided intensive psychiatric services in people’s homes. I worked with a homeless outreach team and did most of my clinical work in alleys, under bridges, and in public parks. I worked in a geriatric adult home and saw people either in my office, which was literally the storage room for the recreational therapist’s stuff, or in their apartments if they were uncomfortable seeing me in the storage room. I was recruited to create and lead the programming for a new crisis center whose goal was to divert people from jails and emergency departments.

And now I work in a jail.

As time progresses, it has become clear to me that I have not had the typical career for a psychiatrist. I like that. However, I often also feel out of touch with my colleagues. I believe that they are all trying their best, but they don’t have the time to see how systems end up failing the most vulnerable and ill in our communities. They work in the ivory towers of academia and don’t seem to realize the dearth of resources—financial, administrative, academic—in the community. They work in private practice and don’t seem to realize how ill some people are and how we need their expertise. They work in psychiatric hospitals and seem to believe that some of these individuals will never get better when, in fact, they do.

Because much of my work has been outside of the traditional system, I consider myself fortunate that I have been able to escape the box of simply prescribing medications. Many of the individuals under my care do not want to take medications. Their desire to not take medications, though, doesn’t stop us from working with them. We meet them where they are at and remember that they are, first, people. As we are in the profession of helping people shift their thoughts, emotions, and behaviors, we believe that there will come a time—maybe soon, but maybe not for weeks, months, or years—that something will change. Just getting someone to talk to us becomes the essential task. This is true whether someone is in a jail cell, living in a cardboard box under a bridge, or residing in a studio apartment.

Should systems pay psychiatrists to do this work? Maybe it’s not “cost effective” because of its “low return on investment”. After all, this task of “building rapport” means psychiatrists aren’t working “at the top of their licenses”. If a psychiatrist is able to get people to talk to her and help them shift their behaviors, whether or not that involves medications, does that have value?

Does the psychiatrist’s efforts have value if it helps the “system” save money?

Is there value if it reduces the suffering of these individuals who have had to deal with police officers, jails, and living on the streets due to a psychiatric condition?

Perhaps my idealism blinds me. One of my early mentors in New York City often said, “I want the guy who lives under the Manhattan Bridge to have a psychiatrist who is as good as, if not better than, the psychiatrist who has a private practice on Fifth Avenue.” I couldn’t agree more.