Category: Systems

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Education Lessons Nonfiction Policy Reflection Systems

What I Learned in Government.

It’s been nearly four months since I posted something here. Don’t be fooled: The lack of words here did not mean an absence of word salads tossing about in my head.

I recently resigned from my job. (All The Things related to that contributed to my silence here.) My job had two parts: One involved administrative work as the behavioral health medical director for local government; the other involved direct clinical service in a jail. I was in that job for over five years. It took me about two and a half years to figure out what an administrative medical director does. (As the process of becoming a doctor involves frequently feeling incompetent, this discomfort wasn’t new to me.) Now that I’m on the other side of this job, here’s what I’ve learned:

I believe government can do good things. You know that stereotype that government employees are lazy? I did not find that to be true. Every organization has a proportion of staff who do not seem motivated or interested. The proportion, in my experience, does not seem higher in government. If anything, many of my colleagues came to government with eager hopes of improving the community. They came in early, stayed late, and worked on weekends. They convened groups with opposing viewpoints, advocated for different populations in the region, and expressed dissent to people in power. They sought out and willingly worked on complicated problems. They demonstrated the humility that comes with the realization that tax payers are funding their salaries.

I do not enjoy the game of politics. Some people love it! They enjoy the contests of status, flaunting their connections, and attacking perceived enemies in public forums with the brightest of smiles. Sometimes people asked me to speak, not because they cared about the content of my words, but because of my credential as a physician. (“Let’s trot out The Doctor.”) I grumbled about “perception management”; often it seemed that the surface sheen mattered more than the substance underneath. (On the other hand, it is likely that my glittery MD credential is what allowed me to say to superiors that poop will never develop a patina. It is unfair that systems often value specific people more simply because of the letters after their names.)

Government work has made me both more and less patient. It takes time to elicit ideas and information from “stakeholders”, community members, and others. People want to and should be involved if a policy or program will impact their lives. They share perspectives that government never thought to consider. I respect that process. I am less patient with the nonsense people and systems can generate to subvert fair processes. Some people are more prone than others to misuse power. That’s hard to watch in a system like government, which has access to and authority over so much money… and, in our current system, whoever has more money almost always has more power.

I learned a lot about laws and regulations. I came to appreciate the value of regulations, though they tend to address the lowest common denominator. Government spends most of its time aiming low to define the floor instead of inspiring people to elevate the ceiling. (I wrote more about this here.)

Government administrators forget what happens in direct service. Though many people in government once provided “front line” services—as attorneys, social workers, counselors, activists, whatever—many of them seem to forget the challenges of systems that are intended to help people. This includes the thousand little cuts of too much paperwork and the major crises of people dying due to missing or underfunded services. My opinion that all medical directors should routinely provide direct clinical service has only gotten stronger with this experience. Someone has to inform the others at The Table what’s going on outside.

Systems are made of people. Contemporary discourse often focuses on systems, not people… but people make up systems (i.e., individuals create, operate, and maintain systems). As such, single individuals can still have significant impacts on systems. This includes grinding things to a halt… or breathing life into new programs. (This is where political gamesmanship can be useful.) The hierarchical organizational chart can lead people who are “lower” to think that their efforts don’t matter, but that’s simply untrue. Systems can change because people can change… whether that’s because people actually change their ideas and behavior or people in certain positions leave.

I am deeply grateful for the opportunity to work in government. I never thought I would work as a civil servant (and, in fact, there was a time when I said I’d never work for government… which is why I’ve stopped making five-year plans). If for nothing else, now that I’ve been on the inside, I can use that experience and knowledge on the outside.

The outside suits me better. So it’s time to go back.

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Policy Reflection Systems

Belonging in Psychiatry.

I recently finished reading The Art of Community: Seven Principles for Belonging by Charles Vogl. He starts the book with this definition of “community”:

a group of individuals who share a mutual concern for one another’s welfare.

He continues:

[A community] is distinct from a group whose members may share ideas, interests, proximity, or any number of things but lack concern for one another.

He argues that communities (as he defines it) have “shared values”, “membership identity”, “moral proscriptions”, and “insider understanding”.

The American Psychiatric Association (APA) held its annual meeting this past week in San Francisco. I did not attend.

I have never been a member of the APA. There was a time when I took some oppositional pride in this, though I was aware of how this attitude is problematic: I cannot help change an organization if I do not join it.

Why do I resist the APA, even though it is the organization that represents the work I do?

This excellent post over at Slate Star Codex captures many of my reasons: All of the pharmaceuticals! The overt and covert intersections with politics (which can lead to overmedicalization of life and underrecognition of psychiatry as an agent of social control)! And while I know that there are members of APA who care about people, families, and communities that experience severe psychiatric symptoms (e.g., schizophrenia, bipolar I disorder, co-occurring mental health and substance use disorders), I’ve never gotten the impression that these are priority populations for the APA.

If we use Vogl’s definition, the APA, to me, doesn’t feel like “a group of individuals who share a mutual concern for one another’s welfare”.

Maybe professional organizations aren’t intended to be spaces where people have mutual concern for the welfare of others.

In the past I wondered if my lack of affinity for APA had to do with how different my clinical practice is compared to other psychiatrists. There are other psychiatrists who work with people living on the streets and do housecalls for people who live at or near the poverty line… but we are few and far between. I live in the largest county in Washington State. There are hundreds of psychiatarists here. Yet I know of only two other psychiatrists who share my work experiences!

Consider emergency physicians. They all work in generally the same setting and thus have similar clinical practices. I don’t know the membership of their professional organization (American College of Emergency Physicians), though it at least seems that their specialty organization is more cohesive and united. Because their clinical practice is more uniform, perhaps it is easier to have mutual concern for the welfare of their fellow physicians.

Meanwhile, how much does my work have in common with the private practice psychiatrist who provides psychoanalysis? I’m just trying to get the guy who lives outside due to relentless paranoia to look at me long enough so I can say hello in a manner that won’t scare him off.

A few years ago a local psychiatric association contacted me. They anticipated an upcoming vacancy in a committee involved in government relations.

During the phone call, I learned that most of the members were psychiatrists in private practice. The leadership expressed a desire for the association to get more involved in government affairs (e.g., local and state legislation). Because of my role in local government, they highlighted the value I could contribute to the association.

“You’ll have a lot of influence,” they said several times.

They also commented that they were trying to increase the diversity in their organization. In addition to the “influence” I could bring, I could also bring my non-white, non-male self.

By the end of the phone call, I said that I wanted time to think about it. What I actually thought about was the responsibilities I had to myself versus those I would have to the organization. I cannot help change an organization if I do not join it. Could I bring issues related to underserved communities to the association? Would the membership find these issues compelling? Would they have interest in legislation that did not focus on their own patient populations?

A few weeks later, I told them that I wouldn’t join. This decision stemmed chiefly from the substance of the work. However, it was also a reaction to their recruitment methods: They thought I would respond favorably to an appeal to my vanity. “You’ll have so much influence!!!” Perhaps the corollary to that was that my influence would help get stuff done, but the emphasis was on the vast amounts of influence I could wield over the group. That didn’t interest me.

And while I did appreciate the blunt commentary about how my participation would help increase the diversity of the association, it made me tired just thinking about it. Increasing diversity doesn’t just mean increasing the amount of color in a photograph. There’s a lot of work in introducing and maintaining various perspectives in a group. I didn’t want to be the only person responsible for that simply because of my non-white, non-male status.

The association certainly had concern for its own welfare. I wasn’t convinced that the association members had concern for mine.

To be clear, this doesn’t mean I’m great.

At least once a week I wonder if I would be more effective in my medical director role if I were involved in more associations and groups. What if I could bring the “forces” of the local medical society and psychiatric association to my job? What if I could use my status as a medical director in government to influence the priorities of these organizations? Would my “success” in each sphere be greater?

What responsibilities am I shirking? I believe one function of government is to convene people so we can figure out how to collaborate with each other. How many opportunities am I missing to improve the community because I am not participating in these other organizations? If I really care that much about underserved populations, don’t I have some responsibility to persuade these organizations to support initiatives that will serve the the underserved? Isn’t there more strength in numbers?

What would it be like if I shared and coordinated ideas, plans, and concerns with these big organizations with large audiences instead of here on my blog?

This has been true from the very beginning: I am a reluctant psychiatrist. I was never supposed to become a psychiatrist.

But, for reasons known and unknown, people experiencing psychotic symptoms feel comfortable talking to me.

So, here I am, working as a psychiatrist.

And, perhaps because of my affinity for complex problems, this is also why I am more comfortable working at the boundaries of fields. Yes, it is possible that the APA will create and disseminate the cure schizophrenia.

I doubt it.

I don’t think a pharmaceutical product will cure schizophrenia. But, at the intersection of nutrition science and psychiatry we can maximize the likelihood that pregnant women will have access to foods that will decrease the risk of their babies developing schizophrenia. At the intersection of legal systems and psychiatry we can reduce (if not eradicate) the use of solitary confinement so that jails and prisons do not worsen psychiatric symptoms. At the intersection of education and psychiatry we can teach kids and their parents skills to better cope with the adversity that life throws at all of us.

I will continue to struggle with joining APA and other organizations. But I already know that I’m not alone. Those of us—and not just psychiatrists—who care about the welfare of people with severe psychiatric symptoms are already part of a community. Sometimes we’re just harder to find.

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Medicine Systems

Balloons.

I worked with someone (not a physician, but that doesn’t really matter here) whose title was “assistant director”. He and I quickly recognized that we worked well together: His head brimmed with big visions and ideas, whereas my head brimmed with plans as to how to make those ideas manifest in the actual world.

“He’s like a bunch of balloons,” I quipped to a colleague. “He’s got a ton of ideas—shiny, bright balloons—but he needs someone to hold all the ribbons to keep them from floating away.”

“Do you think medical school trains us to become managers or leaders?” my colleague asked. Someone several rungs up on the organizational chart had convened a supervisor training; one of the major points of discussion surrounded the differences between “managers” and “leaders”. One suggested generated a lot of wondrous “ooooh”ing: Managers ensure that the ship is running properly; leaders ensure that the ship is going the right direction.

“Managers,” I responded. “Particularly once you get to internship.” Interns are learning on the job how to diagnose and treat medical problems in actual human beings with all the complicating factors of life: Pregnancy, poverty, rare diseases, under- or over-involved family members, a health care system that can prioritize profits over patients.

“Really? I think medicine teaches us to become leaders. By the time we are attendings, we have to hold the entire context of a specific person in mind while ensuring that junior staff learn skills—the technical stuff in addition to the bedside manner stuff—that do not result in harm to patients.”

“Yeah, I agree with that,” I said after a pause. Only upon further reflection I was able to articulate that physicians are often “stuck” as managers because we are often too busy doing clinical work to exert influence and demonstrate leadership on the systems in which we work.

Sometimes it is the system that gets in the way of us doing all the things we want and should do.

Though I am more likely to be the person holding the balloons than the actual balloons, Big Thoughts still trickle through my mind:

  • What if the public mental health and substance use disorder systems worked from the assumption that people will get better and no longer need services? What if we built a system where people didn’t get stuck in it?
  • What if the ratio of “case management” to “treatment” was flipped in the public mental health and substance use disorder systems? What if people received effective treatment sooner? Would people then need as much “case management”?[1. To be clear, case management is important. The public systems are complicated and confusing. Case managers can help people navigate their way through and hopefully out.]
  • What if various skills—emotion regulation, distress tolerance, effective communication, relating to others, self-reflection—were automatically included in prenatal care and continued post-partum?
  • What if various skills—emotion regulation, distress tolerance, effective communication, relating to others, self-reflection—were included in school curricula for every grade?
  • What if designated leaders and managers of clinics, hospitals, and other health care entities included more clinicians (of all stripes) and people who receive services there? What if it were routine for health care entities and regulators—particularly Medicaid and Medicare—to solicit and implement ideas from clinicians and people who receive services?

I agree that systems—whether formal or not—need both managers and leaders. I also agree that the most effective managers and leaders do not rely upon their hierarchical positions to promote change and improvement; they instead cultivate and nurture interdependent relationships throughout the system. After all, in health care, our primary goal is (or at least should be) to help others.

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Consult-Liaison Education Medicine Reading Reflection Systems

The Challenge of Going Off Psychiatric Drugs for Psychiatry.

Here are my initial reactions to the New Yorker’s The Challenge of Going Off Psychiatric Drugs:

Which populations are most likely to receive large numbers of psychiatric medications?

The woman described in the article comes from a family of money and privilege. These individuals (and families) have both the time and money to seek out psychiatrists who practice “precision psychopharmacology”. These psychiatrists then order complicated medication regimens that ostensibly address and “correct” neuroreceptors. As a consequence, people end up taking multiple medications.

There are also individuals who do not have money or privilege, but are subjected to psychiatric services due to the concerns of the public. They may be behaving in ways that endanger their own lives or the lives of others. As a consequence, they receive medications—sometimes willingly, sometimes through coercion—that aim to reduce certain behaviors. If one medication doesn’t reduce the behavior, then more are added.

What these two populations have in common are (a) the lack of clarity around diagnosis, which often stems from (b) missing information about the person and the context in which s/he lives.

I completely agree with Dr. Frances’s comment from the article:

[There is a] “cruel paradox: there’s a large population on the severe end of the spectrum who really need the medicine” and either don’t have access to treatment or avoid it because it is stigmatized in their community. At the same time, many others are “being overprescribed and then stay on the medications for years.”

The meanings of diagnosis and treatment, particularly medications.

Some people feel relief upon learning that their symptoms belong to a diagnosis, that what they have is “real”. Others don’t want the “label” of a psychiatric diagnosis; they are not damaged human beings.

For various reasons (e.g., the current primacy of biological psychiatry, insurance reimbursement, psychiatry’s seeming inferiority complex within medicine), treatment in psychiatry is often focused on medications. This is not ideal. Medications are a biological solution, though our understanding of the biology of the brain and mind remains limited.

In the meantime, doctors recommend that people take pills. Some people view pills as a necessary intervention to keep them healthy and well. Some people view pills as a shameful reminder that there is something wrong with them that will never improve. The more pills someone has to take, the more potent the reminder that they are beyond hope or repair. Some people view pills as an external validator of their pain and suffering: “Someone else believes and understands my pain and these pills remind them and me that my pain is real.”

The pills may not be treating what psychiatrists think they are treating.

The problems with psychiatric diagnosis.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) focuses only on the “what”, not the “why”.

It doesn’t matter why someone has a depressed mood, takes no pleasure in work or play, can’t sleep, won’t eat, and feels hopeless. The underlying reason could be the cardiologist’s realization that he should have pursued his dream of becoming an architect… or it could be the threat of eviction after losing one’s job.

This affects the way psychiatrists gather a history from people seeking care. Instead of learning the context behind one’s symptoms, psychiatrists now focus on whether certain symptoms are present or absent. What matters more is that she feels paranoid, not that the paranoia started when she learned that her father was molesting her sister.

To be clear, there are some instances in which the underlying “why” doesn’t matter. If someone is terrified of flying on a plane, there are treatments (e.g., exposure therapy) that can help people tolerate plane rides without getting into the reasons why this fear appeared in the first place.

In other instances, though, the “why” is often relevant. Since our understanding of the biology of the brain and mind are limited, we don’t know if the biological properties of Medication A are more useful in military veterans who have fought in combat or if those of Medication B are more useful in women who experience major depression after the birth of a baby. Even if evidence suggests that medications aren’t the best treatment for either population, it is often the easiest intervention to deliver. This is due to the context and underlying “whys” of the health care system.

All of the other psychiatrists.

It’s true that there is scant evidence about how to taper and stop medications. It is a shame that psychiatry, as a field, has nothing to say about deprescribing. The scientific literature has plenty to say about adding medications, but nothing that extols the virtues of taking them away. There are risks to stopping medications, yes, but why are psychiatrists unimpressed with the risks of starting them? In this way we have failed not only the people who receive care from us, but we also fail the people who step in to help in our absence: Other physicians, nurses, family members, friends.

When I consider the psychiatrists I have worked with with, many of them have helped people come off of medications. They work with their patients and go through the trial-and-error process together. While they may not work in ivory towers of acclaim, they are still doing the work of helping people make informed choices about their care so they can lead healthy and meaningful lives. These are the quiet anecdotes that will never make it into the New Yorker.

Psychiatry as an agent of social control.

This is not the first time I’ve written about psychiatry as an agent of social control.

What does it mean that “antidepressants are taken by one in five white American women”? Is this a reflection of white American women? Or a reflection of the society and systems that want to contain white American women?

What does it mean that African- and Latinx-Americans are more likely to receive diagnoses of psychotic disorders? Is this a reflection of these populations of color? Or a reflection of the society and systems that want to contain these populations?

Perhaps there needs to be a “Challenge of Going Off Psychiatric Drugs” for the field of psychiatry. To be clear, there is definitely a role for medications in the treatment of psychiatric disorders, though: first, do no harm. When The Royal We have more humility about what we do and do not know, and exercise more care in current pharmacological tools, then perhaps getting on or going off of psychiatric drugs won’t be a “challenge”.

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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.