Author: Maria Yang, MD

Categories
Homelessness Policy Public health psychiatry

Homelessness is Not a Crime.

Last week, the current Presidential administration released an executive order with a noble title, “Ending Crime and Disorder on America’s Streets.” Here is the opening paragraph of this problematic memo:

Endemic vagrancy, disorderly behavior, sudden confrontations, and violent attacks have made our cities unsafe. The number of individuals living on the streets in the United States on a single night during the last year of the previous administration — 274,224 — was the highest ever recorded. The overwhelming majority of these individuals are addicted to drugs, have a mental health condition, or both. Nearly two-thirds of homeless individuals report having regularly used hard drugs like methamphetamines, cocaine, or opioids in their lifetimes. An equally large share of homeless individuals reported suffering from mental health conditions. The Federal Government and the States have spent tens of billions of dollars on failed programs that address homelessness but not its root causes, leaving other citizens vulnerable to public safety threats.

There are misconceptions and factual errors throughout this order. (There are errors and twisting of facts in that single paragraph alone.) Dear reader, I’m just one finite person, so I will only address one problem today.

This order conflates homelessness with mental illness, substance misuse, and crime. This is wrong.

The Venn diagram below is an approximation of the reality of the intersections of homelessness, mental illness, substance misuse, and crime:

Green = Homeless; Yellow = Mental Illness, Substance Misuse; Red = Criminal Behavior; Blue = Civil Commitment

Most people are not homeless, which is why the green circle is small. Here in King County (the county Seattle is in), over 97% of people will sleep indoors tonight. Are there people who are homeless with mental illness and/or substance misuse? Of course. Did some of these people have such issues before losing their housing? Yes. Did some of them develop these problems after becoming homeless? Indeed.

Then there are all the people with a place to call home who also have mental illnesses and substance use disorders (yellow circle). In fact, many people with mental illnesses (including schizophrenia and bipolar disorder) and substance use disorders (like alcoholism, which kills more people each year than opioids) are not homeless. Furthermore, they will never be homeless.

Likewise, many people who do criminal things do not have mental illnesses or substance use disorders (red circle). If they are incarcerated, they go home when they are released from jail. Psychiatric “beds” make up only a small fraction of all jail beds. Most people who are incarcerated do not behave in ways that warrant psychiatric intervention while they are there.

The blue dot represents civil commitment, or forcing someone into an institution for psychiatric reasons. The vast majority of people with mental illnesses and/or substance misuse will never be hospitalized, let alone involuntarily committed. Some people end up in jail when they would be better served (i.e., get treatment) in a psychiatric institution.

This seems to be the worldview of the current Presidential administration:

Green = Homeless; Yellow = Mental Illness, Substance Misuse; Red = Criminal Behavior

The language of the executive order suggests that if someone is homeless, then they must have a major mental illness and/or substance use disorder. (Hence the green “homeless” circle is completely surrounded by the yellow “mental illness, substance misuse” circle.) This is wrong. It does not reflect reality.

However, as a result of this cognitive error of conflating homelessness with mental illness and substance misuse, they offer the solution of civil commitment:

Green = Homeless; Yellow = Mental Illness, Substance Misuse; Red = Criminal Behavior; Blue = Civil Commitment

Notice that the blue dot of civil commitment has transformed into a bigger blue circle that surrounds the green circle of homelessness. The memo also argues for “maximally flexible” civil commitment, which is a convenient way to keep people off the streets if homelessness equals mental illness and substance misuse (which, again, it does not).

To be clear, I am not cool with people being homeless. I ended up in public health psychiatry because there are people who are homeless because of debilitating mental illnesses and substance misuse. They get better with treatment. Then they escape homelessness — and all the challenges that come with it.

If you look at that first diagram, though, the overlap between homelessness and mental illness and substance misuse is limited. And a number of people — often people in their late teens and early 20s — don’t have any major mental health or substance use problems when they become homeless. (They are often fleeing unsafe and untenable situations in their homes.) Not knowing where you will sleep tonight is stressful. Trying to appear “normal” and “fine” makes you anxious and depressed. Worrying about unwanted attention and personal safety while outside, unsheltered, when it is dark is exhausting. No one, as a kid, thinks, “When I grow up, I want to be homeless, have a drug or alcohol problem, and need psychiatric services.” That is literally no one’s ambition.

This administration wants you to believe it’s humane — offering treatment to people with mental illness and substance use disorders. But that’s not what it’s about. It’s about hiding people who are so poor they have nowhere to live.

If this were really about providing mental health and substance use disorder support and treatment — you know, actually helping people — then the Presidential administration would not have cut $1 billion (yes, billion with a B) from the Substance Abuse and Mental Health Services Administration. The administration would not have gutted Medicaid, which is the primary funder of mental health and substance use disorder support and treatment to people who are poor, including those who are homeless.

Don’t be fooled. Pay attention.

Categories
Homelessness Policy Public health psychiatry Systems

Loud Music Is Disorder. What About Memecoins?

I read this provocative essay about “disorder” when it was first published in September 2024. I found myself alternating between nodding and frowning. It’s not a short essay, but I do encourage you to read it. (For those who lean left politically, the author is a thoughtful conservative commentator named Charles Fain Lehman, a fellow at the Manhattan Institute.) I considered writing up my reactions at the time, but I deferred. My reactions felt squishy. I didn’t have data to back up my reasons for frowning.

I still don’t have data, but the increasing disorder at the federal level frustrates me.

To summarize: Lehman opens by citing statistics that crime has indeed fallen in the US. Many Americans, though, feel that crime is rising both in their communities and across the nation. He then argues that “disorder” is increasing and offers these as examples of “disorder”:

  • A man blasting loud music from his phone in a subway car;
  • Teenagers spray-painting graffiti on a public park;
  • A large homeless encampment taking over a city block;
  • A man throwing his trash on the ground and walking away;
  • A group of women selling sex on a street corner.

From this, he proposes a definition for “disorder”: domination of public space for private purposes.

He goes on to argue that engaging in disorderly behavior is the rational choice, but most people do not contribute to disorder. Why? He attributes this to

“social control”—the regulation of individual behavior by social institutions through informal and formal means.

Lehman says that the Covid pandemic, in particular, weakened social control (e.g., fewer “eyes on the street” due to increasing remote work; reduction of law enforcement numbers due to the George Floyd murder and defund the police efforts). He adds that “the core to combating disorder is restoring public control of public space.”

To his credit, he doesn’t offer law enforcement as the sole solution. Lehman briefly describes changing the environment with intention (e.g., broadcasting deterrent music, putting pressure on landlords to clean up spaces). But, once informal efforts fail to restore order, then formal systems must intervene. In his view, law enforcement is the primary formal system.

Most of my professional work has been with people experiencing homelessness and mental illness. But I’m not actually cool with people living outside. I feel discouraged and unsettled when I see tents blocking lengths of sidewalks. When I see people slumped on the sidewalk due to fentanyl, my first thought is, “I wish you would stop using drugs.” I am not a fan of disorder.[1]

I like Lehman’s definition of disorder. While not comprehensive, “domination of public space for private purposes” is a reasonable starting point.

What I don’t like is how many of his examples are associated with poverty (homeless encampment; prostitution; loud music on public transit, a space rarely used by wealthy people). Yes, these are visible and common examples of disorder. But what about the disorder associated with people with wealth and power? Just because we don’t see it every day doesn’t mean people with money and influence are paragons of morality. Why no commentary on that?

Is it disorder when the President visits golf resorts that he owns? He profits from his Secret Service detail staying in his hotels. Isn’t that the domination of public funds (our tax dollars!) for his private, profit-building purposes?

Likewise, is it disorder when the President and his wife launch their own memecoins? Isn’t their use of public office to collect millions of dollars a form of disorder?

Is it disorder when the deputy chief of staff in the White House redirects ICE agents to enact his own anti-immigration agenda?

Is it disorder when the federal administration cuts millions of dollars from scientific research funding because language in the grants references race, gender, and sex? Isn’t this the domination of public resources for a private, anti-DEI ideology?

Is it disorder when the federal administration wants to cut billions in Medicaid funding so that people with extraordinary wealth will get tax breaks? How is that not domination of public resources for private purposes?

None of these actions had occurred by September 2024. Regardless, I wonder if Lehman had considered the intersection of power with his definition of disorder. Lehman says early on in his essay that

critics [contend] that disorder is just another word that the powerful use for whatever it is the non-white, poor, and otherwise marginalized do.

This criticism, combined with Lehman’s omission of power, illustrates who does and does not get to define “disorder”.

We are seeing nauseating abuses of power in this Presidential administration. If blasting music on a bus is disorder, but funneling public money into personal projects is not, then we’re not defining disorder. We’re excusing power.

[1] I am a fan in believing that people can change. And they do! People stop drinking and using drugs. They start taking medication, and they learn how to manage their symptoms sooner. Again, just because we don’t see that change every day doesn’t mean it isn’t happening.

Categories
Nonfiction

Why I Never Went Camping.

I have never gone camping.

During my short stint in Girl Scouts[1], my parents never allowed me to go on troop camping trips. During our family vacations to national parks, we always stayed in a motel in an outlying town. Though we loved the outdoors, we always slept indoors.

Now that I’m well into adulthood, I’m Too Old to go camping. Despite the pressures of living on the West Coast (the Best Coast!) and REI’s endless advertising efforts, I’m convinced my camping window has closed.

People wonder why. I usually quip, “My parents didn’t immigrate to the US so their only child would sleep outside!”

Both of my parents were born in China, but moved to Taiwan before their first birthdays. Their parents were able to get out of China before the Communists took over. In Taiwan they lived under a military dictatorship. Everyone was poor.

No one had plumbing in their homes. It was up to the sons to bring buckets of water from the town well back home. Balance was essential when using the outhouses. Meat was a luxury and served only on special occasions.

One of my grandmothers did not have the opportunity to attend any school.[2] She only started to learn how to read Chinese after she got married. Her husband was a teacher.

My mother attended school, but society expected her to be a beautiful and dutiful mother.

The educational opportunities in the United States exceeded the imaginations of both women. My grandmother was illiterate. My mother got an associate’s degree. I became a physician.

Such was the promise of the United States.

Only after my dad moved to Seattle did I learn about one of his favorite songs, Abraham, Martin And John, by Dion. Released in 1968, this song was a tribute to Abraham Lincoln, Martin Luther King, Jr., and John F. Kennedy. Dion mourned, “[They] freed a lot of people but it seems the good they die young.”

The result of the 2016 Presidential election was dispiriting for my father. The man who would become the 45th (and 47th) President was unlike Abraham, Martin, and John.

My parents didn’t immigrate to the United States for this sh!t. What drew them to the United States were the ideals of democracy, justice, and freedom.

Didn’t you love

The things that they stood for

Didn’t they try to

Find some good

For you and me

“They don’t make music like that anymore,” my dad lamented when he introduced me to Dion’s song. The music changed; the nation changed.

We write, rally, and protest to denounce the federal government’s cruel and unjust actions. We recognize the humanity in our friends and neighbors, even as the government fails to do the same. We advocate for people in our various and overlapping communities.

We also write, rally, and protest to honor the people who came before us. Our immigrant parents recognized the value of democracy, justice, and freedom. These were abstract ideas that existed only within the confines of their imaginations. In the United States these worthy ideals promised to manifest in three dimensions. They strived and worked so what seemed possible to them could be real for us.

(Thanks, Dad. I miss you.)

[1] I’m not sure why my mom enrolled me in Girl Scouts. I suspect she had two reasons: (1) Because I didn’t have siblings, she wanted me to have more friends. (2) This seemed like a very American activity. The pressure to assimilate was great. I eventually asked to drop out of Girl Scouts. Disappointed, she asked why. “I don’t fit in,” I said. At the time I could not articulate why I felt uncomfortable: All the other girls were white.

[2] I never got to meet this grandmother, as she died when my dad was only 21 years old. Despite her inability to read, she apparently picked up languages with ease. What she lacked in literacy, she made up for in emotional and social intelligence.

Categories
Consult-Liaison Nonfiction

Learning from Those Who Hear Voices.

When we learn that someone hears voices, we may assume that this person must be “crazy.” Some people who hear voices have a diagnosis of schizophrenia. Others hear voices because of past trauma or profound depression. Despite their symptoms, many of them cultivate peaceful lives. Their ways of coping can teach the rest of us something about cultivating sanity during times of cruelty and injustice.

When people share with me that they hear voices, I aim to ask as soon as possible, “If the voices suddenly disappeared and never came back, would you miss them?”

A small number of people pause before answering, “Yes.” They want to hear the voices of their parents, friends, and other loved ones again. Sometimes they don’t recognize the voices, but the things they say are hilarious.

Most people, though, offer an emphatic “no!” What they hear are constant attacks on their character (“you’re not worthy of love”), frightening instructions (“go punch that woman”), or unwanted chatter (play-by-play commentary of their lives). In desperate bids to shut the voices up, some people resort to stuffing their ears with cotton, screaming back, or drinking alcohol to drown them out. Sometimes they attempt suicide because they can’t tolerate the torment any longer.

However, many people find ways to manage the voices. They learn that increases in stress—hunger, not enough sleep, drug use—make the voices louder and meaner. While grieving the death of a loved one, the voices are noticeably overwhelming. More stability brings more symptom relief.

People who hear voices often have multiple healthful strategies to manage their voices. They’ve tried things and made discoveries. So when I ask, “What do you do now so the voices bother you less?”, they reply:

  • “I put on headphones and listen to music.”
  • “I put on headphones and sing so people think I’m listening to music.”
  • “I call my family or friends.”
  • “I go outside for a long walk and look at trees.”
  • “I go to church and pray to God to make them go away.”
  • “I find people to talk to.”
  • “I go to the library and look at maps.”
  • “I fix bikes with my friends.”

(And, for some people, “Take medicine.”)

While doing these activities, the voices may not go away completely. However, they quiet down enough to be ignored. They are small acts of defiance against despair. Any respite gives them some peace of mind. Furthermore, these activities are self-reinforcing: They improve the quality of their lives in other ways, so they learn to incorporate these activities into their daily routines.

You may not think this post about people hearing voices has anything to offer you. But, if you are seeking more peace of mind right now from things that seem out of your control, we can learn from our friends and neighbors who hear voices.

They, like you, largely do not want to cause problems for themselves or other people. The voices distress them, but they don’t give up in their pursuit for peace and sanity. Instead of waiting for someone else to make the world feel sane, they create their own quiet.

Persisting in the face of adversity reinforces our dignity as people. Maintaining our sanity is a form of resistance. Continuing to do good and refusing to do harm, even just within the limits of the six-foot radius that surrounds each of us, is an act of courage.

Categories
Lessons Reflection

Your Six-Foot Radius.

I don’t think I was that mouthy during my medical training.

Some East Asian women are shy, deferential, and taciturn. It’s no wonder some people were surprised when critical comments came out of the mouth that is attached to my face.

Advocacy comes in different flavors. My initial attempts were salty.

While I didn’t occupy the lowest rung on the neurology service (that honor went to the medical students), I was but an intern. Furthermore, I wasn’t even an neurology intern. I was training to become a psychiatrist.

The attending neurologist, who looked like those doctors exalted in enormous oil paintings that adorn the hallways of hospitals, had too many letters after his name. He also riffed on too many subjects unrelated to neurology during our morning rounds.

Rounds in academic medical centers serve two main purposes: To organize care for patients, and to educate trainees. The team, under the guidance of the attending physician, executes the plan of care for each patient following rounds.

One autumn morning we stood in a circle outside of a patient’s room. Rounds were just starting. Patients—and a whole lotta work—awaited us.

“It’s the season for soup,” the attending neurologist opened, smiling. “Chief Resident, what is your favorite kind of soup?”

I couldn’t restrain myself.

”Can we not talk about soup? There are patients waiting and work we need to do,” I snapped. My fellow intern, a future emergency physician and more accepting of reality than me, didn’t stifle his laughter in time.

Both the chief resident and frowning attending physician shot me a look. “I know you’re focused on getting work done, Dr. Yang,” the chief resident chided, “but there is time to talk about other things.”

My cheeks burned. But no one spoke more of soup. We started talking about the patient waiting in the room. 



Three years later, I myself became a chief resident. Junior residents shared with me that one of the attending psychiatrists, another decorated physician considered a national expert in his field, wasn’t meeting with them for supervision. This was one of his responsibilities. Esteemed professors were supposed to spend time with us trainees so we could learn from them. He wasn’t doing his job.

Chief residents have some responsibility to advocate for junior residents. Annoyed, I asked to meet with him. This flavor of advocacy was spicy.

He didn’t ask for an agenda ahead of time and I didn’t think to provide one. After sharing with him what residents told me, I said, “It is your responsibility to meet with residents for supervision. Why isn’t this happening?”



Well, you can imagine how that went. He became shouty, waved his arms, and wondered how I, a mere resident, had the audacity to talk to him that way.

My cheeks burned again. However, he didn’t deny the allegation.

My program director was dismayed—maybe embarrassed on my behalf?—when I told her what happened. “You didn’t need to tell him yourself!” she exclaimed. “You could have told me and I could have spoken with him.”

The junior residents told me later that he had reached out to schedule regular supervision with them all. 



With additional experience (read: missteps and errors), my advocacy is now more mellow. I’ve learned to ask more questions, orient people ahead of time, and be more mindful of power and status. When all else fails, be direct.

The word “advocacy” often conjures political images: chanting slogans at rallies or calling elected officials.

But those aren’t the only ways to advocate for ideas you value. Effective advocacy can happen within our six-foot radius. It’s asking questions or making statements. Sometimes, it only takes a short conversation to start shifting long-held assumptions:

“Quite frankly, I wish the president would give us a purge [of homeless people]. Because we do need to purge these people.”

“I wonder what the parents and friends of homeless people would think of that plan. What hopes and dreams do you think they had as kids? Surely they didn’t aspire to be homeless.”

“Every time I find one of these lunatics, I take away their visas.”

“When you say ‘lunatic’, what does that mean? What is the process for applying for a visa, anyway? It’s following the law, right?”

“The probability of a trans person being violent appears to be vastly higher than non-trans.”

“I don’t think that’s true, but let’s look at the data together. Where can we look to learn accurate information?

Advocacy can look like curiosity. At its sweetest, advocacy illuminates the humanity of others. Such reminders can take just a few seconds.

To be clear, this doesn’t mean talking to anyone and everyone who enters your six-foot radius. A small minority of people are not curious and not interested in dialogue. They seek targets for their frustration and anger. If you’ve tried to make a connection in good faith, but the effort is not reciprocated, stop. Sometimes, quitting is the best option.

In times—these times—when problems feel too big for us to understand or solve, when we feel like nothing we do makes a difference, speaking up still matters. Your statements (or silence!) affects other people.

Advocacy doesn’t have to involve bullhorns or giant signs. Do not obey in advance. Have faith in what you can accomplish within your six-foot radius.