People say time freezes when you immigrate. My parents were rural farmers in Vietnam before becoming refugees of the war. They settled down with thousands of others like them in Little Saigon, a neighbourhood in San Jose, California. Being oceans away from Vietnam, our ethnic enclave wasn’t exposed to the social progression that occurred there over the years. And because my parents didn’t speak English, they were removed from American society, too. The result was that my parents’ values were decades more conservative than most, frozen in time.

When I came out to my mother at age 20, she didn’t look up from washing the dishes. The trickling water from the faucet paralleled the confession spilling from my mouth. Finally, when she did look up, she said only two things: “I accept this. Don’t tell the family.” She went back to washing the dishes, and we didn’t speak about it again for years.

Of course, I stayed silent. On the one hand, it was painful to keep it to myself after finally finding the strength to be honest. On the other, it was a relief. Hiding was an instinct engraved over a lifetime and it meant putting off the burden of having to come out again. I knew my cousins wouldn’t care. My aunts and uncles would gossip, but it would only be awkward, not unbearable. For my grandparents, though, it would be damning.

After my grandfather passed and my grandmother had been diagnosed with Alzheimer’s and vascular dementia, I revisited the topic of coming out with my mother. “Not yet,” she said. But as time went on, my grandmother lost her memories, her ability to form sentences and to even recognize me. I wondered, what was my mother waiting for?

My grandmother waxed and waned. Most days were quiet. On other days, she talked excitedly and endlessly. She would always tell me I had beautiful hands, a reminder that, unlike she and my mother, I had never had to work in the fields or factories. One day, she told my future as if from a storybook: the girl I’d meet, my mother’s engagement ring, the way my children would look, the house we’d live in. My mother beamed nearby. My eyes filled with tears as time seemed to slow, the moment magnified. I finally saw what my mother was waiting for. She wanted me to receive this moment, this expression of love. She must have believed it was owed to me. Suddenly, my absolute desire for acceptance felt childish and idealistic. There was never going to be a perfect reality where I could both express myself freely and receive this moment while caring for my family in their time of need. Though I couldn’t choose who I was, I could choose what was important to me, like respecting my grandmother in the last lucid moments of her life.

As I went on to medical school, I began to see parallels to my story in my patients. I was sitting in a psychiatrist’s outpatient office as a third-year medical student when I encountered a veteran with schizophrenia, who spoke in poetry. Rhyme, rhythm, cadence: his speech was replete with musical tones. He told endless flowing stories about his time in the war, his life at home, the things he saw that weren’t there, and what he could feel, even in the air. He spoke with the puzzling metaphor of Ocean Vuong, the jarring character of Faulkner, the nightmare realism of Kafka. It was as if he had chewed up these great writers and spat them back out — not as men, but as ink, to scrawl prose that ignited the air.

So, when my attending suggested that this patient take medication to “improve his speech,” I was stunned. When the patient left the room, I turned on her with “how could you”s and “why can’t he”s. She stayed calm, explaining how his speech wasn’t just unique, but it meant he couldn’t work, make friends, or feel like a normal person. She’d heard what I hadn’t. He was sad and isolated.

For me, expressing myself freely was something I’d spent a lifetime fighting for. I was afraid that to strip him of his speech, his idiosyncratic way of being, was akin to stripping him of his “self.” If someone lost their house, their job, their legs, would they still be them? A sadder, thicker-skinned version, but undoubtedly them. Or, if someone lost their memories, much like in the dementia we so often encounter first in our families before we ever see it in patients. How do you know who someone is, if not by what they say, how they make you feel, and their characteristic sounds and sways? But I also grappled with the fact that on medication, this man might uncover a new sense of self. Perhaps what I took away was that hard choices make loss inevitable, and no matter what you lose, you are always, in each elapsing second, a new and continuously renewing version of you.

Herein I saw the unique burden of psychiatry and nosology, to draw the line between normal and abnormal when operating on the “fuzziness” of human behaviour.1 Making this distinction affects not only the self, but entire communities and societies. Decades ago, when psychiatrists agreed that homosexuality belonged in the Diagnostic and Statistical Manual of Mental Disorders (DSM), I would have been considered sick by scientific terms. Surely, it was a condition that could cause “significant distress” to anyone living during that time. In a few decades, will this man’s speech remain pathological? If by then, universal income has abated the need to work, how will “function” be redefined? Or is there an enduring fundamental truth regarding pathology, a sort of moral universalism? What we can be sure of is that our understanding of disorder will change as society does. It must. Decades ago, it was also psychiatrists who led the effort to reform the DSM and erode the bigotry of previous generations, and decades from now, it will be psychiatrists once again. This reflects the unique dual nature of psychiatry, to draw the boundary between the normal and abnormal and to redraw it again and again, never frozen in time.

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