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In this way, critics argued, psychiatry was being mischaracterized by Yager’s views. It wasn’t that psychiatrists were bludgeoning chronically ill patients because they couldn’t acknowledge their own shortcomings, or couldn’t respect an anorexic person’s wishes, or didn’t have the empathetic imagination required to tak... |
Naomi’s parents, Evelyn and Hal, first heard about palliative care in a hospital conference room, where different members of the medical team told them what they did and what was going to happen to their daughter. At first, Evelyn was just confused. She told Naomi that if something had a chance of working, then it was ... |
The thing was, there were things Naomi hadn’t tried. Her parents wondered if meditation or yoga might bring her some peace, but Naomi always said that none of that stuff worked for her. She didn’t like to journal. She didn’t believe in acupuncture. For a while, she took oral ketamine, which can have a rapid antidepress... |
“But that’s never really been the case,” Evelyn said. “She’s never been able to pull herself out.” |
Benjamin, one of Naomi’s brothers, mostly felt bad for his parents: two elderly people who were left alone to absorb Naomi’s chaos when they were supposed to be living out their golden years. But he also wondered if his parents had enabled their daughter with all the emotional and financial cushioning that, in the end,... |
In Colorado, a court-appointed guardian can have a patient forcibly tube-fed — but only through a special court order and only until the patient is medically stable and no longer at imminent risk of dying. And while guardians can order short-term measures, they can never compel a ward into long-term psychiatric treatme... |
After starting palliative care in 2019, Naomi quit her job as patient coordinator at a hospital. She went on Medicare and Medicaid for disability and moved back into her parents’ small house in the Denver suburbs. Naomi knew that her parents didn’t accept the palliative approach. How could they? “They hold out hope,” s... |
Naomi’s room at her parents’ house was tiny. It had three of Evelyn’s quilts hanging on the walls, patchworks of black and white and red, and a TV by the doorway. There were piles of stuffed animals on the floor. There was no bed. Naomi preferred to sleep in a brown recliner, elevated, to keep the stomach acid down aft... |
Sometimes Naomi sat in the recliner and read through her electronic medical notes. Because she was on palliative care, Naomi’s doctors were prompted to indicate, after appointments, whether they expected her to live longer than six months. Sometimes they did, and sometimes they didn’t. |
From there, she spent a year cycling in and out of the hospital, not eating for long enough that she might come close to dying and then agreeing to go to the hospital for emergency intravenous nutrition — but then, often, discharging herself after just a few days. Sometimes, during those admissions, Treem said, he was ... |
Then came the winter of 2022, which was a very bad winter. Within a six-week stretch, Naomi was hospitalized four times for suicide attempts. Then there were more. Sometimes someone would call her an ambulance. Other times, she would get scared and call one herself. The episodes involved different things: weed killer, ... |
The attempts were never planned in advance, and later, Naomi could never quite reconstruct her thinking. In February, she ended up in the intensive-care unit on a ventilator. That winter, the bipolar disorder seemed to eclipse the anorexia. “I’m at the end stage with the bipolar,” Naomi told me. “Like, I’m at the end. ... |
Part of the problem was that the eating disorder had turned on her. At some point, Naomi had lost the ability to purge. She would try and try, but the vomit would not come. Her doctors explained that this happened sometimes with chronic patients. Unable to purge, a kind of mental pressure built up inside her. Her moods... |
Her parents weren’t sure what to make of the suicide attempts. “They’ve been feeble,” Hal told me. “In other words, she hasn’t thrown herself off a thousand-foot cliff, jumped out of an airplane without a parachute.” Then again, he said, “they’re serious attempts.” Some caused damage. Some didn’t work but theoretically... |
Yager agreed that, at times, it seemed as though Naomi was trying to “play Russian roulette” with her life. “There are some patients who are fatalistic and throw it up to God,” he told me. |
“That’s the grayness,” Treem said. “How do we know when Naomi has made a rational decision about being in line with her values versus when she is reacting to a torment in herself?” |
At home, Naomi talked about “a decline in cognitive functioning.” She spoke of being “flat” and “cloudy.” She did not think that she was irrational, but as the terrible winter turned to spring, she had started to feel a little blurry. |
What she really couldn’t stand was how pointless it all felt. If there were at least a point to her suffering, then maybe she could bear it. But Naomi did not believe in salvation through struggle. She did not believe that her misery would lead her to some other, better place — or even to an enlightened understanding o... |
In February 2022, Yager co-published a new paper titled “Terminal Anorexia Nervosa.” The article, whose lead author was Jennifer Gaudiani, an internal-medicine physician who founded an outpatient eating-disorders clinic in Denver, proposed that psychiatry recognize a new clinical disorder, terminal anorexia, which woul... |
The paper offered several criteria for determining terminality: that a patient have a diagnosis of severe and enduring anorexia nervosa; that she be at least 30 years old; that she have previously attempted “high-quality” eating-disorder care; that she have consistent decision-making capacity and be prepared to die; an... |
The paper presented three case studies: all deceased patients of Gaudiani’s. One was a 36-year-old woman named Jessica, whose eating disorder began in her junior year of high school, when she tried to lose weight for a vacation. Jessica had anorexia and obsessive-compulsive disorder, and she abused laxatives, sometimes... |
Yager and Gaudiani acknowledged that there were no explicit physiological markers of terminality in anorexia, no set point at which a patient could not possibly recover. For them, this fact did not preclude the possibility of a “terminal” diagnosis. |
But for many readers, the paper had a warped logic. In its formulation, it was the patient’s perspective of her illness, rather than the illness itself, that mattered. A mentally ill person was terminal, in large part, if she said she was. |
Some of Yager’s colleagues moved quickly to denounce the paper. Several journals published counterarticles: “Terminal Anorexia Is a Dangerous Justification for Aid in Dying,” “Terminal Anorexia Nervosa Is a Dangerous Term.” Everything that made Yager’s model of palliative care alarming was in that paper — but made wors... |
Most of the criticism focused on the case-study patients who were approved for assisted death. Everyone wanted to know how this could have possibly happened because, as of yet, there were no professional standards governing when, if ever, an anorexic person should qualify for assisted dying. And American psychiatrists ... |
In states with legal “medical aid in dying,” a person had to be terminally ill and within six months of a natural death to qualify. But these patients’ doctors had gone ahead — gone rogue — and proceeded anyway, after first inventing a medical term, “terminal anorexia,” to cover their backs. Critics wondered what the f... |
Philip Mehler, the founder and medical director of ACUTE, the hospital unit where Naomi was admitted for medical stabilization in 2018, was one of the detractors, though he told me that he has “a lot of respect for Joel Yager,” who is “a very thoughtful guy.” For several years, Mehler has watched the debate about palli... |
Other critics worried that the terminal diagnosis would exert a kind of downward pressure, that once labeled terminal, a patient would feel a certain obligation to become the thing she was described as being. Guarda, the Johns Hopkins professor, said she fears a future in which “patients actually become invested in acq... |
Yager had little patience for the frenzy. He was particularly bothered by criticism that “terminal anorexia” was too hazy a definition and too unmathematical to be operationalized. That was literally every diagnosis in psychiatry. “Anorexia nervosa” was once a contested term, too — there were long arguments about how i... |
In somatic medicine too, a patient’s decisions and beliefs could affect whether his condition was considered terminal. When a patient in renal failure decided to stop using dialysis machines, for instance, it was his choice that rendered him “dying” and “terminal.” |
What’s more, in somatic medicine, a patient didn’t need to have a good reason for stopping care. She didn’t even have to try getting better in the first place. A cancer patient could decline chemotherapy that would very likely save her life. Because she didn’t think the benefit was worth the pain. Because she wanted to... |
Yager was also frustrated by critiques that referred to larger problems with the mental-health-care system. Colleagues kept telling him that eating-disorder care wasn’t good enough or accessible enough to allow for a terminal diagnosis — but what were they proposing in the meantime? That patients be made to suffer beca... |
Jennifer Gaudiani, Yager’s co-author, told me that she has asked her critics directly: What would you have done differently with those patients? “And it can’t be, ‘I would change the eating-disorder system to be more inclusive and accessible.’ Nope. We’ve got a patient in front of you, right now.” Should she be abandon... |
“It doesn’t make sense,” Yager agreed. “They’re ‘incompetent’ unless they want treatment?” His critics, he said, had no data at all to back up their claim of universal incapacity among anorexic people. Existing studies showed the opposite. Yager thought his critics were suffering from “positive outcome bias”; they reme... |
By late 2023, though, amid all the furor, even Gaudiani was walking back parts of the paper. Her own criteria for terminality, she told me, were “too inclusive” — and the phrase “terminal anorexia” was so controversial that it had, itself, become “harmful.” (Gaudiani still believes that some patients with eating disord... |
Already, Yager could feel some of the paper’s ideas burrowing their way into psychiatry. At the 2022 annual meeting of the American Psychiatric Association, there was a session on palliative psychiatry for severe and persistent mental illness. At the 2023 Royal College of Psychiatrists Conference in London and the Aust... |
In July, a professional gathering on palliative psychiatry was held in Toronto. Sarah Levitt, a psychiatrist at Toronto’s University Health Network and one of the organizers, told me that the process of framing “palliative psychiatry” might pose a broader challenge to the profession. “There is maybe some interest in br... |
“I just feel like there’s so many things going on. And all I can think about right now is the fact that, since I was last here, I’ve lost six pounds.” |
In September, four years after starting palliative treatment, Naomi was seated in a small hospital meeting room, across from Treem and a chaplain named Beth Patterson. The room was unadorned, apart from a single framed photograph of the Colorado mountains in winter. Treem and Patterson looked at Naomi, who looked down ... |
She did feel depressed, though. The drugs for her bipolar disorder couldn’t seem to lift her up, though they did flatten out the periods of mania. For several months, she hadn’t been able to shower, because she couldn’t stand to undress in the bathroom, which had mirrors in it. She was angry too. (“Bipolar rage,” she s... |
At the appointment, Naomi mostly wanted to talk about her parents: how there was something the matter with her dad’s heart, how her mother was growing frailer. Naomi had started doing more around the house to help them. She cleaned and took care of the yard. She cooked them dinner — sometimes complicated recipes, from ... |
“This is a bit of a precipice,” Treem said. “I don’t know which way it moves.” He wondered aloud whether the needs of Naomi’s parents could compete, in some useful way, with her eating disorder. Could Naomi’s transition from sick patient to caregiver be elevating for her? Could it be the resolution of her story — or ma... |
“We have been looking for a long time for meaning in your suffering, right?” he said. “Your suffering exists. It’s not going to change. It’s a part of this disease, and the disease doesn’t change. So the agony of suffering, the pain, is permanent. And living with that, without meaning or purpose to it, is demoralizing,... |
“We have talked a lot about the crisis of dying,” Treem continued. “We haven’t really talked about the crisis of survival. How that might be really painful, and really difficult. Maybe even more so.” |
“Yes,” Naomi said softly. |
“Yes,” the chaplain agreed, leaning in. “Yet here you are.” |
On some days, Naomi thought about assisted dying and whether she might qualify for it one day. It would be better to die that way than the other ways she had tried. An assisted death, at least, would be clean and painless. It would mean that someone had given her permission. |
Naomi had read Yager’s paper about terminal anorexia. She liked parts of it but thought it was incomplete. The paper proposed all these criteria for terminality, but it didn’t include suffering. The assisted-dying law in Colorado didn’t mention it, either. “That’s completely ridiculous,” she told me. Naomi knew that sh... |
“Let’s presume you don’t die,” Treem said toward the end of the hourlong appointment. He asked Naomi if she could imagine looking back, 10 years from now, and being able to say, “That was a good life.” |
Naomi looked so startled by the question that everyone laughed a little. But, no. She couldn’t imagine that. “I can’t,” she said. “I can’t imagine continuing on.” |
National security employees with ties to Asia say U.S. counterintelligence officers wrongly regard them as potential spies and ban them from jobs. |
When Thomas Wong set foot in the United States Embassy in Beijing this summer for a new diplomatic posting, it was vindication after years of battling the State Department over a perceived intelligence threat — himself. |
Diplomatic Security officers had informed him when he joined the foreign service more than a decade ago that they were banning him from working in China. In a letter, he said, they wrongly cited the vague potential for undue “foreign preference” and suggested he could be vulnerable to “foreign influence.” |
Mr. Wong had become a U.S. diplomat thinking that China was where he could have the greatest impact. He had grown up in a Chinese-speaking household and studied in the country. And as a graduate of West Point who had done an Army tour in the Balkans, he thought he had experience that could prove valuable in navigating ... |
As he looked into the ban, he discovered that other diplomats — including many Asian American ones — faced similar restrictions. Security officers never gave the exact reasons, and they made the decisions in secret based on information gathered during the initial security clearance process. Thousands of diplomats have ... |
Similar issues range across U.S. government agencies involved in foreign policy and national security. In the growing espionage shadow war between the United States and China, some American federal employees with ties to Asia, even distant ones, say they are being unfairly scrutinized by U.S. counterintelligence and se... |
The paranoia weakens the United States, they say, by preventing qualified employees from serving in diplomatic missions, intelligence units and other critical posts where their fluent language skills or cultural background would be useful. |
This story is based on interviews with more than two dozen current and former officials from multiple national security agencies and a review of dozens of Defense Department documents on security clearance cases. |
The concerns, most loudly voiced by Asian American diplomats, are urgent enough that U.S. lawmakers passed bipartisan legislation in December to try constraining some practices at the State Department. The military spending bill of Dec. 14 includes language pushed by Representative Ted Lieu, Democrat of California, int... |
“We should be asking ourselves how to deal with the risk, not cutting off the people who have the best skills from serving altogether,” Mr. Wong said. “That’s a self-inflicted wound.” |
The State Department eventually reversed the ban on Mr. Wong after he and others raised the issue internally. Similarly, the State Department has lifted 1,400 assignment restrictions during the Biden administration, and Secretary of State Antony J. Blinken this year announced an end to the practice. |
But there are still bars for officials to clear. Today, some 625 State Department employees remain under the ban, according to department data released to The New York Times. The agency did not initially explain why, then said in a statement two days after this story was posted online that those cases were ones in whic... |
In addition, counterintelligence officers can recommend bans after investigating employees with job offers to countries, most prominently China, judged to pose special intelligence threats. |
At the F.B.I., two counterintelligence officers said separately that they were persecuted by colleagues because of their China background, according to interviews and documents examined by The Times and reported here for the first time. |
Similar fears of Chinese espionage in American institutions led to the creation of the Justice Department’s China Initiative during the Trump administration, when the F.B.I. investigated many ethnic Chinese scientists inside and outside the U.S. government whom federal agents suspected of illegally aiding China. In som... |
The processes inside the national security agencies have existed since before the China Initiative and occur in the secretive world of vetting for security clearances and assignments. Because these inquiries are not public criminal investigations, they have gotten less public attention. |
Critics of the bans say an American with family members in China is no more susceptible to becoming a Chinese intelligence asset than anyone else. And they say the U.S. government has failed to catch up to a population that has undergone vast demographic shifts in recent decades. One in four children in America has at ... |
Government employees have little control over those family circumstances. Some U.S. officials argue, however, that security clearance denials or job restrictions are still justified because of the Chinese government’s record of putting pressure on some foreign citizens by detaining or harassing family members in China. |
Legislation in 2021 cited State Department data showing the agency had placed the most restrictions for posts in China, followed by Russia, Taiwan and Israel. Some Russian American diplomats have been affected. |
The State Department said in a statement that it does not practice discrimination based on race, ethnicity or national origin, and that Mr. Blinken is determined to build a diverse workforce. It also said its counterintelligence processes are based on guidelines from the Office of the Director of National Intelligence,... |
Senior Asian American officials do work throughout U.S. agencies, including on Asia policy. Vice President Kamala Harris’s mother is from India, and Katherine Tai, whose parents are from Taiwan, is the U.S. trade representative, a cabinet post. |
But Representative Andy Kim, Democrat of New Jersey and a former State Department diplomat, said Asian American employees from across the government have approached him with concerns about the “constant specter hanging over them.” |
Mr. Kim, who is Korean American, got a State Department letter a dozen years ago saying he was barred from working on issues involving the Korean Peninsula. |
“It was one of the most disrespectful, humiliating experiences of my career,” he said. |
Counterintelligence Hunt |
Many federal government agencies have their own internal security unit that conducts investigations into employees, often without notifying the employee or giving any insight into their process. In the F.B.I., the unit conducts polygraph tests and can recommend that the department withhold or revoke an employee’s secur... |
At the State Department, security officers would use information gleaned during regular background checks for security clearance to determine whether or not to take the extraordinary step of putting an assignment restriction into the file of a diplomat. |
For many U.S. officials, obtaining the initial top-secret security clearance is an intrusive process, but is needed for their jobs. Applicants list their ties in foreign countries and subject themselves to a microscopic review of their personal relationships, former employers, financial history and lifestyle. Security ... |
The bar that certain federal employees and contractors have to clear appears to have risen as concerns have grown about China’s espionage capabilities. Public documents posted online by the Defense Department show how in the vetting of security clearances for individual federal contractors, the assessments of China’s s... |
Applicants with ties to China face a “very heavy burden” of persuasion that they are not potential intelligence threats, the decisions often say. |
In one 2020 decision, a 24-year-old engineer for a defense contractor who immigrated to the United States from China in middle school was described by an administrative judge as a “loyal American citizen” who lived a “typically American lifestyle.” But his ties to family members in China, while “perfectly normal,” also... |
In another case from 2022, a man who was born in the United States and worked for a defense contractor was denied a clearance because of his wife’s Chinese relatives. The judge acknowledged that “coercion is rare,” but added that “it does occur, and there is little that China would not do to further its goals.” |
Mark Zaid, a lawyer who has represented hundreds of government employees fighting agencies on security clearance decisions, said “there’s no doubt that Asians bear the brunt of that scrutiny more so than many others.” |
Susan Gough, a Defense Department spokeswoman, said that security clearance determination is a “risk-based decision,” and that the department aims to verify each employee “is worthy of the special trust granted to them on behalf of our nation.” |
Several public cases have revealed counterintelligence overreach within federal departments. In November 2022, Sherry Chen, a China-born American hydrologist who worked on flood forecasting, won a $1.8 million settlement from the Commerce Department after officials there accused her of unlawfully downloading sensitive ... |
“They have a mindset that you are a spy, and all they want to do is prove their theory,” Ms. Chen said in an interview. |
In 2021, a Senate committee released a report about the Commerce Department’s security unit that revealed Ms. Chen was one of many Chinese American employees who had been unlawfully investigated. |
The report concluded that the unit had functioned as a “rogue, unaccountable police force,” and that it had broadly targeted offices with “comparably high proportions of Asian American employees.” |
‘The Stigma Around China’ |
Even government officers who work on China counterintelligence are sometimes perceived as potential threats by security officials. They say those parts of their background that give them a familiarity with China unfairly mark them in the eyes of officials as possible spies. |
Chris Wang became a counterintelligence analyst in the F.B.I.’s Los Angeles field office after graduating from the University of California at Davis. Although he got a top-secret security clearance, he was handed a letter on his first day in 2011 stating he was being placed in a special internal surveillance program kn... |
“Your foreign contacts and foreign travel create a heightened risk of foreign exploitation,” it said. |
Mr. Wang had trained under Chinese martial arts teachers in California and had done a half-year of undergraduate study in Shanghai. |
His supervisors assigned him to counterintelligence on China. Then he lost access to the most sensitive information after failing a polygraph test; he said he was nervous because he feared being wrongly accused of having nefarious China ties. |
While he passed a subsequent polygraph test and security interview to become an agent, Mr. Wang quit in 2020, after officials told him they would do an administrative inquiry into him, he said. |
“Because of the stigma around China, Chinese Americans are more likely to be put in a box even if their associations are innocent in nature,” Mr. Wang said. |
Another former F.B.I. officer who worked in counterintelligence, Jason Lee, said he was suing the agency for discrimination and for using national security as a cover for abusive behavior. At one point, he said, a polygraph test interrogator noted that Mr. Lee’s father also worked in a sensitive government job and wron... |
The F.B.I. declined to comment on specific cases but said it conducts polygraph tests fairly. It also said that “diversity is a core value” and that it fosters an environment where employees “are respected, are encouraged to be who they are, and are afforded every opportunity to thrive.” |
Diplomacy Denied |
At the State Department, a group representing Asian American employees has worked to push the agency to overhaul assignment restrictions. That has led to laws since 2016 aimed at forcing changes. |
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