Category: Reflection

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Nonfiction Observations Reflection

Grief.

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

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

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

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

“Huh,” she answered.

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

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

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

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

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

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

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

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

Categories
Medicine Observations Policy Reflection Systems

On “Mental Illness”.

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

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

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

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

I have also worked in settings where:

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

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

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

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

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

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

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

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

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

Categories
Education Lessons Medicine Nonfiction Reflection

We Want to See Them Better.

When he and I first met he told me that he had a doctoral degree in psychology, was the CEO of the jail, and could speak 13 languages. To demonstrate, he said, “Hong tong ching chong lai tai!” He then punched the door to his cell and shouted, “GET THE F-CK OUT OF HERE, B-TCH!”

I did.

The next week, he answered my questions about the pencil drawings on his walls.

“My name is John Doe,” he said, the words spilling out of his mouth. “You all think my name is Peter Pan, but it’s not. It’s John Doe. See my name up there?” He pointed at the “John Doe” he had written in two-foot high letters on his cell wall. “That’s my name. My people call me John Doe. I am the leader of all the people. I am the leader of all the Asians. I am half-Asian.”

Nothing about him looked Asian.

More weekly visits occurred.

“I can speak 13 languages,” he said again. “Tingee tongee tai tai—;”

“You’re making fun of me,” I interrupted.

“I’m not,” he said, smiling. I’d never seen him smile before.

“No, I’m pretty sure you are.”

“I’m not. Aichee aichee—”

I walked away.

“Hey! I’m a doctor! I own the jail! I CONTROL ALL OF THIS!” he shouted at me.

I kept walking.

One week I was trying to speak to a man in a nearby cell. John Doe was shouting: “The police are pigs! They don’t know anything! I hired all of them! I own them!” His vitriol bounced off of the concrete surfaces of the cell block; I couldn’t hear anything but his reverberating voice.

“Excuse me,” I said to the man. John Doe was still shouting when I arrived at his cell door. He fell silent.

“Could you please not yell for ten minutes so I can talk to another guy here?”

He nodded.

“Thank you,” I said, returning to the man.

Two minutes later, John Doe started yelling again. I sighed.

“That John Doe—he really pushes my buttons. I don’t know what it is about him—people have said and done much worse things, but there’s something about him….” I said in exasperation to my colleagues. “I mean, I know he’s ill, but…!”

He declined to take medications. He followed his own prescriptions of daily showers, three meals with extra fruit if he could get it, and daily bodyweight exercises. He rarely slept.

Another week the same situation occurred again: I wanted to talk to another man in the same cell block as John Doe, who was shouting.

John Doe stopped yelling when he saw me approach his cell.

“Could you please not shout for ten or fifteen minutes so I can talk to another man here?” I asked, resisting the urge to shout at him.

He nodded. I didn’t say “thank you” this time.

I completed my interview with the other man. John Doe remained silent the entire time. I was surprised.

“Thank you for not yelling. I appreciate it,” I said to John Doe on my way out. He nodded.

As I walked out of the cell block, I heard him shouting again.

More weekly visits occurred. John Doe still declined to take medications. He stopped speaking to me in faux-Asian languages, though would occasionally speak in gibberish that I did not understand. He stopped shouting whenever he noticed that I had entered the cell block.

“You’re not a real doctor,” he said one day. “You must be a nurse.”

“What makes you think that?”

“You’re a woman. Women aren’t doctors. Maybe you’re a clinic assistant. A really smart clinic assistant. But you’re not a doctor. Women can’t be doctors. I’m the president of all the doctors and hospitals. I own all the hospitals and jails—”

“Okay. Is there anything I can help you with today?”

A few weeks later, John Doe was no longer in jail. A judge declared that he wasn’t competent to stand trial due to his psychiatric symptoms. He went to the state hospital to receive treatment.

More weeks passed. He eventually returned to jail once his competency was restored, but he didn’t return to psychiatric housing. My colleagues who evaluated him upon his return, however, shared news about John Doe with enthusiasm.

“He’s taking meds now and he’s better. He’s polite. He answers questions. He doesn’t talk in fake languages. He doesn’t shout. I mean, he’s not warm or friendly and he doesn’t talk much, but he can hold a conversation. He’s definitely better.”

“What?” I exclaimed. “Are you serious?”

I wanted to see him. I wanted to see him better.

Despite that, I never did: He would not have found my visit therapeutic or helpful. The only person who would have felt better after that visit was me.

One of the greatest rewards in health care is helping and seeing people get better. This is particularly true when people have severe illnesses. We want to see them better. It gives us hope that other people who have comparable symptoms—symptoms that scare us, worry us, sadden us—will get better, too.

“How will [action x] change your management?” That’s a question we often talk about. If that lab study won’t change what you do, don’t order the lab. If the patient’s answer to your question won’t change how you proceed, don’t ask the question.

John Doe was no longer my patient. He was better. I didn’t need to see him to believe it.

Categories
Observations Reflection

Jewelry in Jail.

When I started working in the jail, officers and health staff alike told me, “You will get more comments about your jewelry here than anywhere else in your life.”

I don’t wear much jewelry, but inmates—who are people, so let’s call them people—do notice and comment:

  • “Those are nice earrings.”
  • “Wow—what a pretty bracelet!”
  • “So you got a man, huh?”
  • “Hey, that’s a nice bracelet. What’s it made of? Is it real? Where’dya get it from?”

It is obvious in some conversations that the people in jail are assessing the value of my jewelry. In rare instances they might use their questions or comments to frighten or intimidate. (“I once stole a bracelet off of a woman that looked just like yours….”)

In most cases, people in jail blurt out compliments about jewelry. They’re just reacting.

Jail is a rough place: The one I work in is a concrete block. Many walls are coated with institutional blue, grey, or yellow paint. The floors and ceilings feature that speckled grey hue associated with pavements and cement trucks.

Everyone in jail wears a uniform: Inmates wear red uniforms. Officers wear black uniforms. Health staff wear long white coats.

Many things in jail are uniform: Meals are served at the same times every day. Meals are contained in uniform brown paper sacks. The food inside the paper sacks is often the same day after day. Inmates often stay in the same cells with the same cellmates and the same officers. There are few things for the officers and inmates to do as everyone waits for the time to pass.

The only shiny things people see are things associated with hostility: The glint of the steel handcuffs and waist chains. The dull finish of the chrome-plated shower stalls that offer just enough—but not complete—privacy. The glare of the fluorescent lights overhead. They’re not things of beauty.

When you’re in a place where everything is dull and uniform, sometimes you can’t help but notice different and pretty things. That bracelet, that ring, that necklace: Those are small items of beauty in a place where few things are beautiful… or are allowed to be beautiful.

Categories
Observations Policy Reflection Systems

How People Agree to Torture Others.

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?