Author: Maria Yang, MD

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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.

Categories
Reflection

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.

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Consult-Liaison COVID-19 Homelessness Nonfiction Reflection

How One Psychiatrist is Coping with the Pandemic.

Context: I work as the medical director for an agency that provides shelter, permanent supportive housing, and crisis and behavioral health services. I also do clinical work there as a psychiatrist, where I see people in shelter, housing, and in clinic.[1. A few of the people I see agree to use telehealth, but those who have phones tend to prefer telephone over video.]

Like many other essential workers, my colleagues and I have worked long hours, spent even more hours worrying and planning, and have had to figure out how to manage ourselves in the midst of uncertainty. Though we have been fortunate to be able to move many people out of congregate settings into motel and hotel rooms,[2. Here are some anecdotes about what happens when people move from a congregate setting into their own room with a private bathroom, a bed, and a door that locks: 911 calls go down. People who previously did not routinely take showers start showering daily. Some people use less drugs; some people stop using drugs and alcohol completely. People start planning and taking steps towards goals, such as school, employment, financial planning, relationships.…] we still have some people staying in congregate settings, which is undesirable during a pandemic. Many of the people who stay in shelter and housing have significant and chronic medical problems, which makes us nervous that they will have worse outcomes if they contract Covid-19. I express gratitude every day—though maybe not out loud—for the very few cases that have occurred within the agency. With over 500 people in shelter (though, again, many have moved into motel and hotel rooms) and over 1000 people in permanent supportive housing, plus hundreds who have different living circumstances but are enrolled in our clinics, we thus far have had fewer than 50 positive cases of Covid-19.

The strain on staff is significant. People will have different memories of this pandemic: Some people (reportedly; I don’t personally know anyone who falls into this group) have expressed some relief during this time, as they have the time and resources to do things like learn new languages, travel to cute cabins in remote places, and other things that seem like fiction to me. Others have had to learn how to navigate congregate settings and provide care to people with significant health conditions in the absence of national guidelines and plans.[3. Do I sound resentful? I think the underlying emotion is disappointment.]

I don’t think people who are trained as psychiatrists are necessarily more skilled at coping during a pandemic, as none of us in the US[4. Recall that there have been epidemics in the recent past. I found Mental health and psychosocial support in ebola virus disease outbreaks and Protecting Mental Health During Epidemics helpful… and don’t get the sense that the CDC or other federal agencies have reviewed these articles and/or are interested in providing this sort of support to any of us. Am I still sounding resentful?] have ever lived through one. Here’s what I’ve been doing (or at least trying to do) to manage myself:

Get up early to do stuff to take care of me. (Because I wasn’t born a doctor and, God willing, I will be able to retire before I die.) I aim to get out of bed at 5am. This tends to be the quietest time of day and few, if any, people want or need my attention. The long summer days in Seattle make getting up that early easier, but, let’s be real: Sometimes the spirit is willing, but the flesh is weak.

Exercise. Sometimes this means what most people mean by the word “exercise”, like push-ups, squats, etc. Sometimes this means “movement”, which can be a one-person dance party. The face covering mandate has interfered with my willingness to run. I do want to run, but I haven’t been able to get over the hump of running while wearing a mask. (I live in a neighborhood where there are at least some people around, even at 5am. I am committed to wearing a mask when I am out and about.)

Invest time on hobbies. During those early morning hours I study Chinese to improve my literacy. Though I haven’t posted much here, I am trying to write daily (I continue to use 750 Words, which helps me with quantity, even if the quality is terrible).

Eat cookies. Sometimes I eat only a few; sometimes I end up eating over half the box. This is not the greatest coping mechanism, though it is something I have done because my frustration tolerance is sometimes low and impulse control is hard.

Walk during meetings. I’m that person who often joins a video call by telephone. This is related to technological deficits, as well as willfulness: If the meeting doesn’t require video presence, then I will take the less stimulating option of audio only. I occasionally quip that I’m like tuna: If I stop moving, I will die. If I’m able to walk during a meeting, that not only helps me dispel anxious energy, but also reduces the likelihood that I will get distracted by e-mail or other tasks during the meeting. This also helps me feel like I’m taking advantage of the summer weather while we still have it.

Talk to myself. Out loud. And often in an effort to meet and greet whatever emotion I’m feeling. (Hang in there with me.) Earlier this week I exclaimed much louder than I intended, “I feel so anxious!!!” and then proceeded with this conversation:

Hello, Anxiety! What brings you here today? Are you enjoying this summer weather? What are you worried about? What are you trying to tell me today? What can I do to help you feel better?

This is a concrete way to acknowledge whatever it is I am feeling because avoiding emotions is generally impossible and ineffective: It’ll come out some other way (e.g., eating half a box of cookies).

Observe the sky. The sky is bigger than me. The pandemic is bigger than me. The sky changes. The pandemic will change. I want to witness the sky. I want to witness the pandemic. To stop and look at the sky—the clouds, the moon, the sun, the colors—allows me to pause and claim time that sometimes never feels like mine.

Try to make other people laugh. During this time of differing degrees of isolation, sharing laughter with someone is a treasure. Sometimes the humor is admittedly dark, though I much prefer that people get it out of their systems with trusted confidants, rather than on others (like patients).

Sleep. Sometimes sleep doesn’t feel restful—I am sorry to confess that, sometimes, my dreams center on Covid-19—and occasionally I wake up from sleep thinking about all the things I should do related to the pandemic. Having a fixed “get out of bed” time helps with regulating sleep.

Thank people. There is no way any of us could manage this ridiculous time by ourselves. There are so many people to thank: The janitors who clean and sanitize spaces to keep us all healthy. The grocer who is there so you can buy food. The doctors and nurses who provide Covid-19 testing and counseling. The sanitation staff who continue to empty out the garbage and recycling bins. The plumbers who fix emergency sewage leaks. The person on the street who acknowledges you and makes an effort to stay at least six feet away. The bus drivers who continue to transport essential workers around the city. The first responders, including police, who are kind to the seemingly increasing number of people who are sleeping outside. God/the Universe/whatever Deity that I still have a job, a stable place to live, and, thus far, good health.

Do you have other suggestions?

Categories
Systems

Revisiting Racism in Psychiatry.

While much of the current conversation has focused on racism within the criminal-legal system, institutional racism also exists elsewhere, including psychiatry.

I’ve written a few posts about this topic in the past:

Here’s one from 2017 that discusses “drapetomania“.

In 2018 I wrote about the use of race in advertisements for antipsychotic medication.

I also wrote about the intersections of race, jail, and psychiatry in 2017.

More to follow….

Categories
Observations Seattle Systems

About the CHAZ….

You’ve heard about Seattle’s Capitol Hill Autonomous Zone (CHAZ), right? With free press from President Trump, people both in the US and abroad now know about the “Seattle takeover” and his imperative to “Take back your city NOW”.

Well, dear reader, if you believe that I am reliable narrator, let me share with you my observations of the CHAZ.

First of all, this is how the CHAZ website describes the Capitol Hill Autonomous Zone:

The Capitol Hill Autonomous Zone née “Free Capitol” is a 6 block section around the East Precinct in Seattle, WA. Abandoned by police and left to burn, this area was instead siezed [sic] by anarchists, BLM supporters and other protestors who have since transformed it into a unverisal [sic] community based on mutual aid. Fundamentally, CHAZ is an occupation of Capitol Hill, not an official declaration of independence.

Here’s some context about the Capitol Hill neighborhood where the CHAZ is located: In addition to being the gay mecca of the Pacific Northwest, Capitol Hill is the hip neighborhood of Seattle.[1. Some would comment that Capitol Hill is the hipster, not hip, neighborhood of Seattle.] Bars old and new cater to the spectrum of genders. There’s wood-fired bagel cafe; a bike shop where, after spending time in the physio lab, one can order a Matcha Chicken Avocado Bowl; and a music venue called whose full name includes “Crystal Ball Reading Room”. Two blocks south from the CHAZ is a dealership shared by Ferrari and Maserati. A local cafe offers apricot jam doughnuts for $3.85 each. Rent for a one-bedroom apartment near the CHAZ is around $2000 a month.

Now, onto my observations:

According to the City of Seattle, about 65% of the city population is white and nearly 7% are Black. The vast majority of people (much more than 65%) I saw in the CHAZ were white. Perhaps this was due to the clumps of white tourists who wanted to witness the CHAZ themselves. Maybe white allies had taken upon themselves to “do the work” and use the CHAZ to advocate for Black Lives Matter (BLM) causes and demands. (Of note, I cannot find any comments from the Seattle-King County chapter of BLM about the CHAZ.) Despite the ongoing pandemic, a notable fraction of these white individuals were not wearing face coverings.

While there is a beautiful mural of “Black Lives Matter” physically on Pine Street and references to Black individuals of Seattle and beyond who have been killed by police, the overall vibe of the CHAZ seems more focused on opposing authority. The graffiti on and around the now abandoned police station, the “conversation cafe” stations, and the new community gardens seemed to chiefly cater to white audiences and suggest an anti-establishment philosophy. Black Lives Matter and “a universal community based on mutual aid” are not the same thing, and this is highlighted in the deliberate demands of the Seattle-King County chapter of Black Lives Matter. To be fair, there is overlap between the demands of CHAZ and BLM, though what people do often reveals actual intentions compared to what people say.

In addition to philosophical contrasts, there were physical contrasts within the CHAZ. A man was hugging his adult poodle like a baby, while a crowd of people were nearly running after a man who was yelling at someone about a stolen phone. A white man with what appeared to be a taxidermy weasel draped around his shoulders got into a profane shouting match with a Black man (one of the very few I saw) seated on a bench, a push cart stuffed with belongings next to him.[2. I promise you, dear reader, that there was indeed a man who had draped what appeared to be a taxidermy weasel around his neck. Maybe it was a plush weasel, but the effect was the same.] A (white) man was shoveling wood chips into a new community garden marked with a hand-written sign that read “This garden is for Black and Indigenous folks and their plant allies”. All the doors to the public bathroom were closed and the phrase “shoplift your future back” was scrawled in spray paint on its foundation.

Meanwhile, Seattle Parks and Recreation collected trash from the CHAZ and hauled it away. An employee, wearing a face covering, emerged from a Seattle Public Utilities truck with a clipboard and headed towards the park.

Here are my questions:

Is the Capitol Hill Autonomous Zone a distraction from Black Lives Matter? If yes, what are the consequences of that distraction at local, state, and federal levels, now that President Trump has condemned this “occupation of Capitol Hill”? What are the consequences to BLM if it is conflated with the CHAZ?

Could an Autonomous Zone exist anywhere else in Seattle? Does it matter that this part of Capitol Hill is young, trendy, and expensive? Could the Autonomous Zone exist in a Seattle neighborhood with more Black lives, such as the Central District or Rainier Valley? Even if the Autonomous Zone could exist in another neighborhood, would it exist? Would protestors want that? Would the neighborhood support that?

Has the local chapter of BLM made a statement about CHAZ? If yes, why is it difficult to find? If no, what worries or hopes does BLM have about doing so? The Seattle-King County BLM chapter has demonstrated great thoughtfulness about its activities in the midst of this pandemic, including specific rules about their protest. Their silent march drew around 60,000 protestors despite the rain. I look forward to learning more about and supporting their perspectives.

Will the CHAZ protestors vote? Some argue that the only way to change the system is to join it. Others insist that change can only come from the outside, as there are too many conflicting interests from within. Voting applies in either scenario.

Will the CHAZ protestors follow the lead of BLM? Sometimes the urge to “do something” is overwhelming, when the most productive and helpful action is to wait and follow. Before people congratulate themselves on the actions they are taking, it is prudent to ensure that these actions are in the service of the goal that will both change and improve the system.

How will the CHAZ end? Will the protestors leave of their own accord? Will they stay until forced to leave? Will there be non-violent negotiations, or will we witness more violence? How much effort will Seattle Police put into returning to their precinct building? What is the Mayor’s strategy about this, now that she is the target of antagonizing messages from both Seattle residents and the President of the United States?

When will the CHAZ end? With unemployment rates high in Seattle, as in the rest of the nation, some people may choose to remain in the CHAZ because the economy continues its slump. There is a Presidential election in November and if the President continues to give his attention to the CHAZ, that may reinforce their desire to remain. If Seattle sees a spike in coronavirus cases, will the city recruit Public Health to help assess the safety of the encampments and gatherings and then ask people to leave?

If you live in the Seattle-King County area and are able, please donate money to the Seattle-King County chapter of Black Lives Matter. Whether you live in Seattle or elsewhere, please also participate in the US Census and make sure you vote in the upcoming elections. Please continue to ask questions, engage your mind, and exercise critical thinking. Change will take all of us.