COVID-19 Medicine Nonfiction Public health psychiatry Reading

Things That Made Me Smarter This Week.

Some media recommendations for your consideration:

Three Years Into Covid, We Still Don’t Know How to Talk About It. This article is one of the few that resonated (more) with my experience of the Covid-19 pandemic. Despite my professional training and expertise as a psychiatrist, I still can’t find the “right” words to describe what happened to me, the people around me, and the world. Without adequate words to create a coherent narrative of my experience, I still don’t fully understand what happened. (I hope that I will not give up trying.)

Freedom House Ambulance: The FIRST Responders. Did you know that the first modern ambulance service in the United States was developed in a Black neighborhood in Pittsburgh? The Freedom House Ambulance served as a model for the rest of the world.

This Book Changed My Relationship to Pain (title of the podcast, not my comment). Dr. Zoffness explains the bio-psycho-social nature of pain in an engaging way with plain language. (I am one of the many people she describes in the podcast who developed chronic pain during the pandemic; I have known since its arrival, both as a professional and as a human being, that there is significant a psychological component.) Pain is not all in your head AND the state of our minds affects how we experience pain.

Mathematician Explains Infinity in 5 Levels of Difficulty. I have always found math interesting. What I particularly enjoyed in this video is the skill Dr. Riehl shows in teaching the concept of infinity to different audiences. This is something I aspire to (and have mused about doing something like this for myself for psychiatry, à la the “Feynman Technique“). I also appreciated the similarities between the explanations she provided at level one and level five.

Salve Lucrum: The Existential Threat of Greed in US Health Care. When I read things like this, I see yet another pathway that someone can unwillingly tread upon that will result in homelessness. (Some people think they are immune to homelessness; that’s just not true.) “… unchecked greed concentrates wealth, wealth concentrates political power, and political power blocks constraints on greed”, and “[g]reed harms the cultures of compassion and professionalism that are bedrock to healing care.”

Education Homelessness Policy Public health psychiatry Systems

What I Talked About: Complexities.

Many thanks to those of you who left comments or sent me a note in response to my call for suggestions for a presentation about homelessness and mental illness.

I gave the presentation earlier this week and ended up presenting (a) homelessness data specific to Seattle-King County, (b) general data in in published research about rates of different psychiatric conditions in people experiencing homelessness (there’s actually not a lot of data about this; my understanding is that there is a national study underway right now to assess people experiencing homelessness through structured psychiatric interviews), and (c) the topic of “Involuntarily Removing Mentally Ill People from Streets“. I asked the group—students within various health professions schools—for their thoughts about New York City’s plan.

Many of the students were unfamiliar with involuntary detention for psychiatric reasons, along with the process for how that happens (the laws in Washington State differ from those in most other states in the nation; namely, physicians and other mental health professionals in Washington State cannot detain people directly; we must call a third party, called Designated Crisis Responders, and refer someone for detention). The initial group consensus favored civil liberties; they spoke of loss of dignity, the psychological and physical trauma that can result from involuntary detention, and the importance of autonomy.

When the scenario was adjusted so that the person who was experiencing homelessness and major psychiatric symptoms was someone that the students knew and loved, they quickly changed their arguments to support involuntary detention. When we love someone, we are more comfortable taking away their rights.

Like many complex issues, “right” answers escape us as more facets of the problem are illuminated. Involuntary detention itself is a complicated issue and, because most people are not experiencing homelessness, the majority of people who are detained are people who have an indoor place they call home.

Some research indicates that around 76% of people experiencing homelessness also have a psychiatric disorder, though the association is complex and likely goes in both directions: Some people have a psychiatric condition that contributes to poverty and then homelessness (e.g., losing a job); others become homeless and then develop a psychiatric condition due to the challenges of not knowing where you will sleep at night.

I continue to learn the complexities of working at the intersections of poverty and mental health. I am grateful that more people are interested in this work, too. I hope that things don’t have to get worse before we can offer better help and care to these individuals, who are ultimately our neighbors.

Consult-Liaison Education

On the Emotion of Anger.

I have no idea if the vicissitudes of life at this moment are more challenging than times past. Perhaps the intensity and quality of suffering in humanity remains unchanged, but now, due to technology and the increased breadth of our situational awareness, we are simply more aware of the degree and scale of human suffering. Our ancestors had no way of knowing as much as we do now.

(Humans, though, have suffered individual and local tragedies for as long as we have existed. Sometimes—often?—these individual tragedies induce greater suffering than we can ever imagine. Consider the parent whose spouse and child have both died. Surely deaths from disease and war affect this person, too, but how do those compare to the indescribable grief and heartbreak from the loss of kin? I don’t know. Someone out there does know. For them, I wish them peace, even if this wish is functionally just a spindly raft in a deep sea of sorrow.)

The range of human emotions is vast. In American culture, certain emotions are more acceptable than others. (This is likely true across all cultures.) And perhaps I should be more precise here: American culture tolerates the expression of certain emotions more than others. For example, American culture is intolerant of men weeping for any reason. We have been conditioned to consider that men who are crying—even for the most valid of reasons—are weak, incompetent, and incapable.

These social norms influence the individual and shape our behavior. If society cannot tolerate my tears, then I will do what I can to avoid crying. This can involve psychological acrobatics to avoid feeling the emotion that induces crying.

The problem is that emotions serve a function. Emotions give us information about the people we are around, the situations we are in, and what matters to us. They help us choose and express our behaviors, even if some of these choices don’t happen entirely consciously.

There’s a concept called “secondary emotions”, which are emotions we feel (and then express) as a result of other emotions. Some examples will help clarify this. (The emotion of anger—and we see so much anger these days—is what prompted this post, so I will use anger in these examples.)

American culture often discourages women from expressing anger. Women who express anger are often called “bitches”, even if their anger is justified. The (antiquated?) phrase “resting bitch face” illustrates this: That woman isn’t really an angry “bitch”, that’s just her face. If a woman feels and expresses the primary emotion of anger, she may then quickly feel and express the secondary emotion of guilt: “I shouldn’t feel anger; it makes me seem like I’m not a nice person. But I want to be a nice person. But maybe I’m not a nice person because nice people don’t get angry like this. So maybe I’m a terrible person. Oh no.” Society is more accepting of a woman’s deferential behavior that may follow. (Those familiar with CBT will recognize black-and-white thinking happening here.)

Similarly, American culture discourages men from expressing sadness. Our culture instead tolerates men expressing anger. Thus, men may actually feel a primary emotion of sadness, but the secondary emotion is anger. Maybe they express anger to counteract their perceived “weakness” for feeling sadness. Maybe they express anger because they know, whether consciously or not, that they are less likely to get want (including respect) if they express sadness.

Anger is also an activating emotion. Recall that emotions can and do drive behavior. When feeling sad, people are generally more likely to withdraw and isolate. Some people who feel sad will reach out to others for support, but sadness usually pulls people inward. When feeling angry, people are generally more likely to do something and take initiative. Feeling angry makes people feel more powerful.

Consider someone stomping down a hallway and throwing open a door while exiting. This behavior may seem like a withdrawal from people, but they busted out the door. Such a behavior requires initiative and energy, and often benefits from an audience. We turn our heads when we see someone storm out of a building while muttering profanity; we don’t when someone slips out the back door in tears.

There is little utility in denying our emotions. You feel what you feel. Sometimes, though, we resist feeling the primary, foundational emotion, maybe one that is too tender for us to acknowledge. It forces questions to the surface that we may not want to answer: What does it mean if I am unwilling or unable to feel sad? What would I discover if I sat with my anger and felt its sharp, jagged edges? What would I learn about myself if I explored this contempt? What things would I have to change about myself if I understood that there is something soft and vulnerable under this rage?