Category: Systems

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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?

Categories
Nonfiction Observations Seattle Systems

What Seattle Got From Amazon.

Yesterday’s New York Times had an article with the title “Amazon’s HQ2 Will Benefit From New York City. But What Does New York Get?” I don’t know what New York (and Crystal City) will get, but here are my observations (as someone who lived in Seattle from 2004 to 2008, and then from 2011 to now) as to what Seattle got:

Lots of young people. Some of these people look like they’re 12 years old, but that’s because I’m now officially old. And some of these young people, fresh out of college, make six-figure salaries. Sometimes it shows. Sometimes it doesn’t.

Lots of blue badges. Amazon employees wear blue badges. You can tell your proximity from the Amazon campus (which is a campus; it occupies an entire neighborhood) by the density of blue badges hanging from lanyards, dangling off of belts, and swinging off of coats.

Food trucks. The young people apparently like food trucks. Caravans of food trucks rumble towards South Lake Union, the site of the Amazon campus. The rotating food trucks sell Thai bowls, Italian sandwiches, barbecue wings, Turkish kebabs, Hawaiian poke bowls, and other international cuisines from their portable kitchens.

Hip restaurants that sell overpriced food. Here’s an anecdote that I share with some bitterness: One such restaurant has the following item on its dessert menu:

Warm chocolate chunk cookie with whole milk. $8.

Long-time readers know that I am fond of cookies, particularly the chocolate chip variety. Upon seeing this item, my eyes lit up, but the light drained from my eyes when I saw the price.

“No cookie and milk is worth $8,” I said. “Even my favorite cookie (the Levain Chocolate Chip Walnut Cookie) is just $4.”

“But what if it is the best chocolate cookie you will ever eat?” my husband countered.

“I doubt it. This is a restaurant, not a bakery.”

“Let me buy it for you.”

I relented and ordered the warm chocolate chunk cookie with whole milk, my taste buds eager and my mind skeptical.

What actually arrived? Two cookies, each about four inches in diameter, and a glass holding about six ounces of milk. The cookies were barely warm, the chocolate was not chunky, and the overall texture of the cookies was dry. The milk was wholly unremarkable. The dessert was rich only in the flavor of disappointment.

These restaurants can charge $8 for cookies and milk because they know that the young people who work at Amazon have no qualms spending such a ridiculous sum on a treat that is sweet only in memory.

Traffic. The tens of thousands of people who moved to the Seattle metropolitan area have to get around somehow. When I was a resident, I saw few taxis downtown or on Capitol Hill. Taxis of all colors now zip around the city, along with ride sharing vehicles. There are a lot more fancy cars—Teslas, Porsches, and the like—crawling up the hills. The buses, streetcars, and trains are packed with well-heeled young people.

High rents and expensive homes. The city of Seattle is in King County. The average rent in King County is $1,731, which doesn’t seem impressive compared to rents in other major metropolitan areas. The rent in King County, though, has increased 155% in the past twenty years. Furthermore, Seattle, by far, is the most expensive and developed city in the region and pulls the average up, as other areas in the county are sparsely populated and considered rural.

Income inequality. I don’t know if Amazon was/is the cause of the homelessness crisis in this region (remember, correlation does not mean causation). As young people with gobs on money have moved in, more people with little money have moved out onto the streets. Certainly the higher rents have pushed many people out of the city: Some people work in Seattle and live in neighboring counties, as that is the only way they can afford their rent or mortgage. Landlords in Seattle know that they can charge nearly $3000 for a one-bedroom apartment because someone from Amazon can afford to pay that. (Just like restaurants can charge $8 for cookies and milk.)

Anti-Amazon and anti-Jeff Bezos graffiti. It is not uncommon to see graffiti painted on sidewalks and buildings that denounce Amazon and Jeff Bezos. Some of it is frankly disturbing (e.g., death threats), though it illustrates the strong feelings people have about Amazon.

Spherical buildings. They took all the trees / And put ’em in a tree museum / And they charged the people / A dollar and a half to seem ’em

Amazon has done well for itself, though it seems that many people in Seattle have an uneasy relationship with Amazon. They like what Amazon has to offer, but don’t like how the wealth of the company has affected the city. Perhaps the leadership of New York and Crystal City will forge closer working relationships with Amazon from the outset to prevent the congestion, big income disparities, and resentment[1. The resentment that people have for Amazon also comes from its own employees. For a while I worked in a clinic where some of my patients were Amazon employees. They often spoke of the pressures working at Amazon, whether they worked in programming, marketing, supply chain, or warehousing. There’s likely selection bias at play, but their work nonetheless induced anxiety and affected their abilities to cope.] that occurred in Seattle.

Categories
Lessons Nonfiction Reflection Systems

Phone Calls.

I don’t miss making the phone calls in the middle of the night.

“Hi, this is Dr. Yang calling from the Psychiatric Emergency Service. May I speak to Mr. or Mrs. Doe?”

“Yeah, this is Mr. Doe,” he’d reply, his voice thick and slow with sleep.

“I’m sorry to call so late. Your son is here at the hospital.” Take a breath and slow down for the next part. “He’s alive and doing okay at this moment”—I quickly learned that it is important to say these words at the start of the call—“but I hope to get some information from you about him.”

I have marveled at the grace people have extended to me during these conversations. Sometimes family members have grown accustomed to these 2am calls and their voices sound not only physically sleepy, but also psychologically exhausted. Sometimes family members have never received this phone call, but their voices remain calm with only the occasional quaver while they talk.

These days, it’s “Dr. Yang calling from the jail”. Though I’m not making these phone calls in the middle of the night, it is questionable that these are better phone calls.

It is a blessing when family members are still involved, when there’s someone I can call. The person in question is usually a male in his 20s. He often has reached desirable milestones: Maybe he just graduated from high school or is in college. His primary health issue is the mental health condition—often bipolar disorder or schizophrenia—and he’s otherwise healthy. He is often able to tell me about a family member who loves him, even if what he tells me doesn’t make a lot of sense in the moment.

For so many others under my care, there’s no one to call:

  • “They died.”
  • “I don’t want anything to do with them.”
  • “I don’t know where they are.”

Sometimes the person in question is much older. In some ways, these phone calls are more tragic:

  • “I’m in my 70s now and I’m the process of moving my wife into a memory care facility….”
  • “My husband has already died and I worry who will take care of my son when I go. He still needs a lot of help.
  • “Thank you for calling, Doctor, but it doesn’t seem like anything will change. I’ve been doing this for almost thirty years now.”

I marvel at the grace people have extended to me during these conversations, too. For some of these family members, they’ve had dozens of these conversations with many other doctors, nurses, counselors, and social workers. They know what questions I will ask; their answers are succinct because others have interrupted them in the past; they have lists of information already prepared to send.

Almost without fail, after I thank these family members for their help and then comment on the difficulty of the situation, they cry. Sometimes the sobs that escape their throats surprise them.

“I’m sorry,” they mumble. I can hear them wipe the tears from their faces with haste.

I’m sorry that we can’t do better for your son. I’m sorry that the science hasn’t advanced enough that we can prevent this from ever happening to your son ever again. I’m sorry that your son is in jail when he should be in a hospital. I’m sorry that your hopes and dreams for your son haven’t come true. I’m sorry that few people know the depth of the worry you have for your son. I’m sorry that these systems fail you and your son. I’m sorry that your love for your son isn’t enough to save him from these systems.

“Please, don’t apologize,” I say instead.

I wonder why.

Categories
Medicine Observations Systems

Representation Matters.

This post comes directly from a Twitter conversation I was in a few days ago:

Screen Shot 2018-04-22 at 1.28.25 PM

… though this topic has actually been on my mind for nearly a year due to some events that have occurred at work.

Many medications that were originally developed for the treatment of schizophrenia, called antipsychotic medications, are now used for other conditions, such as major depression and bipolar disorder. (The reasons for this are beyond the scope of this post. However, I will comment that this is why the “serotonin theory” of depression should really be called the “serotonin hypothesis“.) Several antipsychotic medications come not only in pill form, but are also available in long-acting injectable forms. Instead of swallowing pills everyday, some people receive an injection of medication once every few weeks or once a month. These medications are injected into shoulder or butt muscle.

Some people prefer to receive injections because that means that they don’t to remember to take pills everyday. Many people who accept long-acting injectable medications do well. No one would guess that they have had experiences hearing voices or believing fixed, false ideas. Some of these individuals report that these medications have saved their lives.

Some people, in varying degrees, are coerced into receiving injections (e.g., payee allowances—money—are handed over only after the individual receives the injectable medication; courts “encourage” individuals to receive injectable medication). Long-acting injectable medications are never used in emergencies, regardless of who is defining the word “emergency”.

Most people prefer not to get shots of medication, even if they know they are in their best interests. Many adults look away and wince when they receive vaccines, even though they know that the benefits far outweigh the risks. Most vaccines, though, are available only in injection form, so people don’t have a choice as to how else they can receive the vaccine.

So, with that, let’s look at the advertisements for long-acting injectable antipsychotic medications and any intersections they have with race. The target population is admittedly small: Only around 1% of the population has a diagnosis of schizophrenia at any given time. (However, if you’re part of that 1%, this stuff matters a lot.)

Here’s the landing page for one long-acting injectable antipsychotic medication:

InvegaSust

We see what look to be white people with sporting equipment. I’ve drawn in a pink arrow to show the link that leads to the page about the use of this medication for the treatment of SCHIZOPHRENIA. If you click on that link, it brings you here:

InvegaSchizophrenia

Anything different about the people in the photo?

There are journal articles that span decades that show that schizophrenia is overdiagnosed in black people. One wonders: Do the ads come from the overdiagnosis? Or does the overdiagnosis come from the ads?

To be fair, if you scroll through the photos in that image, the other photos are of white people, including women. However, the scrolling does not automatically occur. The photo of the three men of color is what you see when you click on “schizophrenia” from the main page.

So what happens if you click on “schizoaffective disorder” from the page for schizophrenia? (Curious that there isn’t a link to schizoaffective disorder on the main page.) This shows up:

InvegaSchizoaffective

Only women for a psychotic disorder that also features mood symptoms, huh? (Side note: There’s ongoing debate within psychiatry whether schizoaffective disorder is even a valid condition. Meaning, psychiatric researchers are still arguing about whether this condition even exists. This is a topic for another post.)

“Oh, Maria,” you might be thinking. “You’re reading too much into this. It’s just one ad for one medication.”

Okay, let’s look at another long-acting injectable antipsychotic medication. How about this landing page?

AbilifyMaintena

Note the comment in the bottom right-hand corner: “Model portrayals.” Meaning, the company chose these specific images for these specific diagnoses.

The “schizophrenia” link takes you to a page that has scrollable photos: Two women with less melanin and a man with more melanin. The “bipolar” link has two scrollable photos: One light-skinned woman and a darker-skinned man. Maybe there’s something there; maybe there’s not.

Here’s another one for essentially the same medication, but with a different manufacturer:

Aristada

Okay, so this photo assortment seems to strike a more even racial balance. I won’t nitpick further on this one.

Let’s go to the longest-acting injectable antipsychotic medication on the market right now, an injection that is administered once every three months:

Trinza

Oh goodness.

If you click through the “Go to videos” link, there are three video vignettes. Two of the individuals are black. Again, one wonders: Do the ads come from the clinical diagnosis? Or does the overdiagnosis come from the ads?

The other long-acting injectable antipsychotic medications are now available as generic formulations, so their websites are full of text. My efforts to find past advertisements, commercials, and press kits for them yielded no images. I find that interesting, too.

To be clear, these ads comprise a small sample and are for a specific form of medication. I don’t know what advertisements look like for all other psychiatric medications. Maybe I am reading too much into these websites. However, when (1) local, regional, and national data indicate that people of color, particularly African Americans, are more likely to receive a diagnosis of schizophrenia, (2) medications used to treat schizophrenia often have significant side effects of sedation and lethargy, and (3) these medications are available in long-acting forms, it makes me wonder.

Categories
Education Medicine Nonfiction Reflection Systems

I Have No Plan.

We learn about SOAP notes early in medical school:

S = Subjective, or what the person reports to you

O = Objective, or the data you gather from the person (vital signs, physical exam, lab studies, etc.)[1. We’ll put aside for now the discussion of the problems with labelling these sections “Subjective” and “Objective”.]

A = Assessment (a diagnosis and formulation based on the Subjective and Objective data)[2. We’ll also put aside for now the potential problems that arise at the intersection of billing and diagnosis.]

P = Plan (the next steps or recommendations that occur as a result of the Assessment)

Most medical notes, regardless of specialty, setting, or length, follow this SOAP format.

While recently typing up some notes, I blurted to my colleague, “What I really want to write under the ‘Plan’ section of my note is, ‘I have no plan’. Can I do that?”

Sometimes the Plan is direct and clear:

S: Mr. Doe reports that he hasn’t heard voices in three days. He finds it easier to read books. He denies side effects from medicine.

O: He isn’t talking to someone who isn’t there. He’s not demonstrating tremors. He’s showing more emotional expression in his face.

A: A psychotic disorder that could be due to This, That, or The Other Things.

P: No changes in medication. Continue to encourage activities he enjoys. Cheerlead his ongoing efforts to monitor his own progress. Follow up in a few weeks.

Sometimes I have a Plan, but it’s not a Plan I write down because the next steps or recommendations are beyond our control:

S: Ms. Doe reports that she uses methamphetamine to help her stay awake at night. She fears that if she falls asleep, men will hit or rape her. She still hears voices. They have gotten more intense since she left her foster family a year ago, as a member of the foster family was molesting her.

O: She’s distracted, looks exhausted, and, since she doesn’t have a safe place to stay, has little interest in reducing or stopping her use of methamphetamine.

A: Methamphetamine use disorder. Some flavor of a trauma- or stressor-related disorder. Maybe an anxiety disorder? Maybe a psychotic disorder that could be due to This, That, or The Other Things?

P: (1) Ensure that people have safe places to live. (2) Stop human beings from sexually assaulting other human beings. (3) Instill proper ethics and morals into all of humanity.

Then, there are times when the Plan doesn’t include concrete steps that will guarantee forward movement:

S: Mr. Doe was reluctant to talk to me. He only shared that his words are potent and, if he misspeaks, my face will melt off. He said that he doesn’t want to hurt me or anyone else with his power. My efforts to inform him that my face will remain intact were unsuccessful.

O: He’s eating, he’s sleeping, he avoids other people, and this is the most he’s spoken to anyone.

A: Probably a psychotic disorder due to This, That, or The Other Things?

P: ???

Since I have to write something, the Plan in these situations usually looks like this:

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P: Continue to build rapport as tolerated. Gather more history. Will try to talk to him again in X amount of time.

The most difficult notes to write are those when I know I have no plan. This is distinctly different from not knowing what the Plan should be. (This is a function of time and experience, of knowing what I don’t know.) These situations usually involve a combination of the last two situations I described:

S: Ms. Doe said that there is a dead baby inside of her. Records state that she has reported this for the past four years, though there is no evidence that she has been or is pregnant. She was the victim of a significant assault five years ago; she sustained head trauma from this event, which many believe is the cause of her erroneous belief. She visits emergency departments multiple times a week due to her belief that there is a dead baby inside of her. She has assaulted both of her parents multiple times, so they have filed “no contact” orders against her. Because she now has no place to live and her anxiety about a dead baby inside of her persists, her behaviors sometimes result in law enforcement encounters, which land her in jail. She has avoided psychiatric services because she insists that her belief is true.

O: When she does talk, she speaks with dread and grief about a dead baby inside of her. Other times, she screams, demanding that people leave her alone. When she menstruates, she smears the blood all over herself while crying, mourning the loss of what she believes is her dead baby.

A: A psychotic disorder probably due to the head injury, but maybe due to Other Things?

P: … [I have no plan. I just don’t.]

The best Plans are those constructed with the person in question. Unfortunately, Ms. Doe usually doesn’t have a plan, either. So, I write down the little I can actually do:

P: Work with team to build rapport as tolerated. Find out what else she cares about. Work with other systems to create a plan to help reduce her distress without causing more trauma.

… and hope that patience and persistence will reward us in the future. Because sometimes hope seems to be the only thing we can do.