Author: Maria Yang, MD

Categories
Reflection

Words Have Meaning.

Shortly after I learned of the murder of Charlie Kirk, I thought of the manifesto from People Reluctant To Kill for an Abstraction. George Saunders wrote it in 2004:

Last Thursday, my organization, People Reluctant To Kill for an Abstraction, orchestrated an overwhelming show of force around the globe.

At precisely 9 in the morning, working with focus and stealth, our entire membership succeeded in simultaneously beheading no one. At 10, Phase II began…

It’s true. Millions of people around the world, despite whatever grievances they hold, somehow refrain from killing other people. Most people go through their entire lives without murdering a single person! If only this could be true for all people.

Since the world began, we have gone about our work quietly, resisting the urge to generalize, valuing the individual over the group, the actual over the conceptual, the inherent sweetness of the present moment over the theoretically peaceful future to be obtained via murder.

Do we all agree that words have meaning? Jamelle Bouie comments:

It is sometimes considered gauche, in the world of American political commentary, to give words the weight of their meaning. As this thinking goes, there might be real belief, somewhere, in the provocations of our pundits, but much of it is just performance, and it doesn’t seem fair to condemn someone for the skill of putting on a good show.

Cognitive behavioral therapy (CBT) uses this triangle as a model for our minds:

(from Beacon)

We can’t read minds, but we can infer what people are thinking about through their speech. Thoughts influence feelings and behaviors—and not just in ourselves, but in those who listen to what we say.

To be clear, no one deserves to be murdered because of what they say.

It is also true, though, that the words we use have the power to unite or divide, to cultivate love or hate. don Miguel Ruiz notes, “The first and most important of The Four Agreements is be impeccable with your word” because:

The word, as a symbol, has the magic and power of creation because it can reproduce an image, an idea, a feeling, or an entire story in your imagination. Just hearing the word horse can reproduce an entire image in your mind. That’s the power of a symbol.

We can cast magical spells with our words. How do you want to use the power of your words? What emotions or behaviors might manifest from the spells you cast?

Brian Kilmeade of Fox News cast a vile spell earlier this week in advocating that mentally ill homeless people should be executed:

Jones was talking on “Fox & Friends” on Wednesday about public money spent on trying to help homeless people and suggested that those who didn’t accept services offered to them should be jailed.

“Or involuntary lethal injection, or something,” Kilmeade said. “Just kill ‘em.”

Should Kilmeade be killed for making this obscene remark? No.

If we believe words are thoughts embodied, then we must believe that these words have meaning and can manifest in behaviors. What we say can affect what we and others do.

This is why we hold Kilmeade and all others who make hateful comments accountable for what they say. We will not repeat the mistake that Kilmeade made: We will recognize the humanity of all people, including him. One of the best ways we can humanize other people is to believe they meant what they said, even if we don’t agree with it. What Kilmeade said is abhorrent.

Millions of people around the world, despite whatever grievances they hold, somehow refrain from talking about killing other people. Many people go through their entire lives without talking about murdering a single person! If only this could be true for everyone.

Categories
Homelessness Nonfiction Public health psychiatry

Opening Doors.

For our first appointment, she didn’t come downstairs. The building staff, who described her as a high-priority patient, had predicted this.

After I knocked on her door, a gruff voice shouted back, “What do you want?!”

She eventually opened her door. Inside, the room was furnished with only a bed and nightstand. The mattress still looked brand new; no linens or blankets were on it. The only item on her nightstand was a lamp, the shade still wrapped in plastic. The walls were bare; her closet was empty. Blinds kept the sunlight out.

The only personal item in her room was a flattened cardboard box. It was next to her bed. Though she had lived in that unit for almost a full year, she was still sleeping on the floor. She preferred the cardboard to the mattress.

“I don’t need anything, I’m fine, I’m fine,” she grumbled. She pointed an arthritic finger at the door before announcing, “I’m leaving now.” I stepped to the side. She hobbled past me towards the elevator, mumbling to herself. She didn’t close the door to her apartment. I did.

That first appointment was a success! Not only did she open her door, but she also spoke to me. Sure, it was a short and superficial conversation. Her primary goal, it seemed, was to get away from me. But she didn’t yell at me, despite my introduction: “Hi, my name is Dr. Yang. I work as a psychiatrist. I just wanted to introduce myself. How are you doing?”

There was a fair chance that she would talk to me again in the future. I had two goals now: Create conditions so that she would (1) talk with me again and (2) tolerate a longer conversation with me. Maybe two to three minutes next time?

Back downstairs, I tapped out a quick note:

This is a 79yo woman with a historical diagnosis of schizophrenia. She reportedly has a history of street homelessness of at least twenty years, though housing staff believe that she had been homeless for longer. She finally moved into housing about a year ago….

Categories
Blogosphere

Encouragement.

Some pieces that have brought me encouragement and made me think in the past few weeks:

The Power We Use and the Power We Give. (Philip Bump) “Your engagement and your work, not unlike your vote, is a form of power, something you can choose to grant to others. Those others, particularly organizations and companies, accrue that power to use as they see fit.” (As an aside, this is precisely why I have not put my writing on Substack.)

The Courage to Be Decent. (Radley Balko)

“My guess is that this was just a couple officers’ dorky attempt to intimidate me,” Jackson tells me. “But if it’s happened to me, it’s probably happened to other attorneys. So I wanted to reach out to you to get the word out and see how often this is happening. Because it needs to stop.”

Ciclovia: Bogotá, Colombia (Streetfilms) Even if you don’t have any interest in biking, this is an inspiring video. I had the good fortune to witness Ciclovia in person a few months ago. What an example of what the community can accomplish together despite what the government does or does not do. (Also, at no point did I feel unsafe in Bogotá. If you have the opportunity to go, please go.)

you’re still free (Jamelle Bouie) Mr. Bouie writes with conviction, but he’s even more emphatic on video. His comments align with what Timothy Snyder has exhorted: Do not obey in advance.

on persistence vs consistence. (Liz Neeley)

… I believe that two things are all extremely likely at the same time: 1) some of our contributions will make an enormous difference, and 2) many (most?) of our contributions will go absolutely nowhere at all, even the really clever, theoretically sound ones.

Her newsletter, Meeting the Moment, is excellent because she and her team are tracking all the (destructive) actions the federal government is taking towards science. However, she has built a digital community to encourage us to keep going.

Kicking a Nazi out as soon as they walk in. (Reddit)

And then THEY bring friends and the friends bring friends and they stop being cool and then you realize, oh shit, this is a Nazi bar now. And it’s too late because they’re entrenched and if you try to kick them out, they cause a PROBLEM. So you have to shut them down.

Return to Fundamentals. (Paul Jun)

This is where sanity resides. This is the springboard for real progress and mastery. This is where the greats have toiled away entire lifetimes. And in devotion to their craft, they found the path to beautiful, fulfilling lives. Not because they’re more talented or lucky than us, but because they were able to stay sane. To stay focused on what matters.

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.