Consult-Liaison COVID-19 Education

Triangle of Thoughts, Behaviors, and Emotions.

diagram showing that thoughts, behaviors, and emotions are all interlinked

(T) = thought
(E) = emotion
(B) = behavior

All are interrelated and we can intervene at any point of the triangle to change the other factors.

Starting with THOUGHTS:

(T) “The federal government, in providing no support or interventions for the pandemic, has abandoned the people of this nation.”
(E) Anger, sometimes rage.
(B) Eat six servings of cookies.
Result? Fleeting pleasure (E) from the taste and texture of cookies, leading to thoughts of, “I ate too many cookies; I should have done something different” (T), which can lead to disappointment and guilt (E).

(T) “The federal government, in providing no support or interventions for the pandemic, has abandoned the people of this nation.”
(E) Anger, sometimes rage.
(B) Write a blog post about it.
Result? Satisfaction (E) from accomplishing a task that helps me feel more calm (E) and may help other people try something different so they can feel less anger (T).

(T) “The federal government, in providing no support or interventions for the pandemic, has abandoned the people of this nation.”
(E) Anger, sometimes rage.
(B) Go out for a walk.
Result? Sense of calm (E) due to changing my enviroment and recognizing that I am doing something to improve my health (T).

Sometimes we don’t recognize our emotions, which could result in events like this:

(T) “The federal government, in providing no support or interventions for the pandemic, has abandoned the people of this nation.”
(B) Throwing something across the room.

Starting with EMOTIONS:

(E) Grief and anger.
(B) Pull the blankets over your head.
(T) “I don’t want to get out of bed and deal with all the things related to the pandemic.”
Result? Loitering in bed (B) because the world feels overwhelming and I feel helpless (E), which makes me believe that things won’t get better (T).

(E) Grief and anger.
(B) Go out for a walk.
(T) “Look at the leafless trees, how the color of the fog matches the color of the water, how the world seems to reflect our collective mood….”
Result? Recognizing that I at least took a step to take care of my mind and body (T), which helps me feel some measure of serenity and gratitude (E).

(E) Grief and anger.
(T) Think about the how the emotions of grief and anger affect my thoughts and behaviors.
(B) Write a blog post to clarify my thoughts, emotions, and behaviors.
Result? Feeling hope (E) that maybe these words will help other people feel more empowered, less lonely, and less angry (T).

There are some professionals who believe in the “primacy of thought”, meaning that they believe that thoughts precede all emotions and behaviors. I do not hold this view, as (a) our current understanding of thoughts center on the use of language, and sometimes we all struggle to name the emotions we feel and (b) reflexes circumvent thoughts (i.e., we yank our hands away from the flame without thinking about the fire burning our fingers).

Starting with BEHAVIORS:

(B) Clenching my jaw and shoulders.
(E) Anxious. Maybe angry. Maybe sad, particularly since many cultures tolerate and accept anger more than sadness.
(T) “Let’s get up and drink some water. Changing positions will help me relax my jaw and shoulders.”
Result: Momentary release of muscle tension (B) that may help reduce anxiety (E).

(B) Checking e-mail way too many times in an hour to learn updates about people staying in the shelter who may have tested positive for Covid-19.
(T) “Oh, please say that no one tested positive, please don’t let anyone have Covid….”
(E) Anxiety and fear. Probably an attempt to limit prevent guilt, too.
Result: Feeling annoyed (E) with myself for trying to control things that I cannot control (T), then resolving to get up and do something else away from the computer (T) and encouraging myself to adhere to a schedule of checking e-mail (B) so I don’t clench my jaws and shoulders (B) due to anxiety (E)

Thanks for reading this and working through this triangle with me. (This triangle forms the basis of cognitive-behavioral therapy (CBT), in case you wish to learn more.)

Consult-Liaison COVID-19 Homelessness Medicine Nonfiction Seattle Systems

“The Impact of Covid-19 on Homeless Services in Seattle.”

On Friday, I presented Grand Rounds to an agency in New York City. The title of my presentation was “The Impact of Covid-19 on Homeless Services in Seattle, Washington”. The audience was comprised mostly of psychiatrists who also work with people who are currently unhoused or have been homeless in the past.

In some ways, this presentation was easy to create: I simply described the agency I work for and walked the audience through the timeline of events:

While the Seattle-King County region was scrambling due to the first death from Covid-19, the first case of Covid-19 was diagnosed in New York City on March 1.

In other ways, this presentation is the only one I’ve made where I had to take breaks while making it because of anger, grief, and sadness.

The month of March was hectic for us and everyone else: We tossed routine policies out the window and scribbled new ones down. We shattered many of our old habits and hastily introduced new practices. Our collective workload increased significantly as we tried to be as flexible and responsive to the changes that were coming at us. We watched systems grind to a halt because systems can’t change that fast: We had to buy hand sanitizer from local distilleries and we donated N95 masks to hospitals. Systems that had long failed us suddenly had the harsh glow of media light on them: In all of Seattle, there were only five bathrooms with hand-washing sinks that were open 24/7. Congregate shelters, where over 200 people had no choice but to share one giant room and one bathroom, suddenly became unacceptable because the beds were not at least six feet apart.

And, yet, eight months later, not much changed. We haven’t had the opportunity to abandon restrictions; many of these new practices are now status quo because the situation hasn’t gotten better. I was honest with the audience: There was no resolution or hopeful conclusion at the end of my talk. Why was that? How could it be that, eight months later, things hadn’t actually changed much?

The audience said nothing. What is there to say? The lack of ownership and coordination at the federal level is the same now as it was in March/April. New York City has significantly more resources than Seattle, though those resources only go so far while SARS-CoV2 can cross state lines and national boundaries when no barriers are erected and no interventions happen. If people in a boat are not rowing in the same direction—or if people aren’t rowing at all—then the boat and everyone in it wastes a lot of time and energy.

I was surprised by the gifts of validation from the audience. Yes, we all work as psychiatrists and the last time most of us saw someone get intubated was when we were residents. However, we all recall doing consults on people in the ICU who were sick. Ostensibly, we were there to take care of the patient and maybe their family members. We also know, though, that an important (and often unspoken) part of psychiatric consults is to support the treating team.

We all have a sense of how terrible it is for the treating teams. These are the reasons why we desperately try to keep people healthy and out of hospitals. We know that our contributions are small—most people don’t live on the streets, in shelters, or in supportive housing; most people don’t have diagnoses of schizophrenia or severe substance use disorders—but we also know that our people are often maligned when they pass through the doors into traditional health care systems. We all have a sense of how terrible it is for our people. We also know that, due to the stress of living marginalized lives, our people often have more severe health conditions. They already have many risk factors that increase the likelihood of complications and death due to Covid-19. We’re trying to mitigate the stress of everyone involved.

It’s heartbreaking, terrible, and unfair.

To end the talk on a positive note, I mentioned several things I am grateful for:

  • The rainy season has arrived in Seattle and I get to sleep in a dry bed indoors.
  • I have confidence in where I am going to sleep tonight.
  • I have a job and can pay my bills.
  • I know I will eat (again!) today.
  • There now exists technology where I can speak to an audience of colleagues on the other side of the continent!

These both mean a lot and nothing at the same time.

In the meantime, we continue to do what we can while we wait.


Hope for the Future.

It’s been over three months since I posted something here, though it feels right to write a few words here today.

Upon learning that Biden and Harris have won the Presidential election, my first thought was:

Thank God we will have a better Covid-19 response.

For all of us who have the privilege and responsibility to look after the health and well-being of others, the weight of the pandemic over the past few months has felt like it would grind us into dust, regardless of our efforts. I sustained a significant muscle strain in my back over a month ago and someone quipped, “Who doesn’t feel like the world is straining their back?”

Of course, a new administration won’t make the pandemic disappear. People will continue to get sick from Covid-19. Some will die. A federal administration, though, that takes the pandemic seriously will result in thoughtful planning, greater prevention efforts, and coordination that will directly impact those of us who are trying to prevent some of the most vulnerable in our communities from getting sick.

I am also thankful that I get to witness the first Black and Indian Vice President!

The upcoming days, weeks, and months will be noisy. As Trump continues to demonstrate low frustration tolerance and impulse control, his vitriol will become more hostile. He has been rewarded with the gifts of attention and validation for these behaviors for over five years now; these behaviors will amplify before they are extinguished. We can never truly get away from ourselves.

For those of us who have been lucky enough to have good health and safety, may this continue. May more and then all people be able to experience good health and safety as time continues to move forward.