Categories
COVID-19 Public health psychiatry Seattle

StoryCorps Interview.

I wasn’t familiar with StoryCorps until I received an invitation to record with them. They were looking for people who were front-line workers during the Covid-19 pandemic. Once I learned that the recording would be archived in the Library of Congress, I signed up.

Here’s the recording of the interview. It’s about 48 minutes long.

I still believe that most people don’t want to hear anything about the pandemic. Prior to the recording, I have said little about it. (My conversation partner in the recording has been a close friend of mine for over 20 years. Almost everything I shared during our recording she had never heard before.)

There was a time when I literally could not say anything about it: my mind would go blank, my chest would tighten, and no speech would come out.

“I don’t know,” I’d finally say. The blankness—how expansive it was, how it encompassed everything—was overwhelming.

I myself have not listened to the recording and don’t expect that I will anytime soon. Even though the recording was nearly an hour, it still wasn’t enough time. (Enough time for what?) Working as the medical director during the pandemic was the hardest thing I’ve ever done in my professional career. I am thankful that I was given the chance to talk about it.

If one person, 100 years from now, before, during, or after another pandemic, benefits from hearing my experiences, then it will have been worth it. May they learn from my experiences and errors.

Categories
Lessons Nonfiction Policy Systems

How to Avoid Becoming an Agent of Social Control: Communist China.

The Year of the Horse has arrived! How delighted I was to see the New York Times show Lunar New Year Across America (free gift link). I remain struck with how representation matters. It is some kind of dazzling to see people who look like me in a major newspaper celebrating the same holidays I do! (For the past few years, Asian representation has looked more like this. I admire R. Kikuo Johnson’s art, though that vibe is the antithesis of the joy and connection of Lunar New Year.)

With Lunar New Year festivities about over, it’s time to talk about China using psychiatrists as agents of social control. There are many similarities between China and the Soviet Union (see the post I wrote about Anatoly Koryagin). The Human Rights Watch and Geneva Initiative on Psychiatry describes this in Dangerous Minds: Political Psychiatry in China Today and its Origins in the Mao Era.

In the Soviet Union, the government passed laws that recognized “anti-Soviet” speech and activities as crimes. In China, “political dangerousness” was incorporated into Chinese psychiatric diagnoses. This creation of “political-psychiatric dangerousness” allowed psychiatrists to detain people for psychiatric reasons. It also resulted in law enforcement charging people with crimes, amplifying

the more intractable problem of the Chinese authorities’ longstanding insistence upon viewing the peaceful expression of dissident or nonconformist viewpoints as constituting “political crimes” that must be sternly punished by law.

The authors further note:

most of these people should not have been arrested or brought for forensic psychiatric evaluation (formal or otherwise) in the first place, since in the overwhelming majority of recorded cases their only “offense” was to have expressed views or beliefs which served to offend the political sensitivities of the Chinese Communist Party.

Like psychiatrists in the Soviet Union, Chinese psychiatrists shifted clinical definitions:

individual mental problems soon came to be seen, in simplistic and reductionist fashion by the ultra-Maoists, as being not merely reflective of, but actually caused by, incorrect or deviant political thinking on the part of the sufferer.

One of the Chinese psychiatrists, Yang Desen, was a whisteblower. He said:

Eventually, [the ultraleftists] began claiming that the real reason people became mentally ill was that their heads were filled with an “excess of selfish ideas and personal concerns” and that it was the product of “an extreme development of individualism.

Believe in the wrong political system and the authorities believe there is something wrong with your mind.

Psychotic disorders were most associated with this political and psychiatric dangerousness:

the most frequent diagnosis made by police psychiatrists in this context is of either “schizophrenia” or “paranoid psychosis” leading to the following kinds of “crimes” by the alleged sufferers: “sending reactionary letters,” “writing reactionary slogans,” “petitioning and litigating,” “shouting reactionary slogans” and “spreading rumors to delude the masses.”

Mental acrobatics are necessary to argue that these individuals were dangerous to others. But, once the government defines anti-government speech as a crime and evidence of a mental illness, a warped internal coherence follows. The “police psychiatrists” concluded:

Cases of political crime created by the mentally ill usually exert a highly negative influence in society and have extensive ramifications. They take up large amounts of human and material [police] resources and pose a definite disruptive threat to the normal functioning of state offices and to the political stability of the country.

Ideas are potent. It’s hard for one person to kill hundreds of people at once. The police never have to worry about that problem. It’s far easier for one person to introduce ideas to hundreds of people at once through books, radio, and television (and, these days, social media!). Even a man silently holding a sign on the street has the potential to “infect” dozens of people. A government ruled by fear, not confidence, wants to quash the expression of diverse ideas.

Like in the Soviet Union, the goal of detention wasn’t humane treatment. There was “a very high patient-to-doctor and nurse ratio, severe underfunding by the government, and serious lack of capacity leading to a dense overcrowding of inmates” and

the form of psychotherapy actually used from early 1996 onwards consisted of increasingly intense political indoctrination sessions in which mental patients were exhorted to cure themselves by studying the works of Mao and adopting a “proletarian” political outlook.

The US government has yet to outlaw free speech (and may we work together to prevent this from happening!).

May we continued to recognize and insist on the value of free speech. May we all continue to act with courage, even as those in power have tantrums and rely on violent tactics. Let us use the power that we do have. Everyday heroes may be nameless to you, but they are everywhere: people with integrity who are doing the right thing within their six-foot radius of influence. You can be one of them, too.

Categories
Homelessness Policy Public health psychiatry

More on the Government’s Potential Use of Psychiatry.

There has been increasing amounts of conflict and violence within the United States. It saps attention and energy; of course people feel irritable and glum. This can lead to pronouncements that things will never get better, we’re doomed, etc.

Oliver Burkeman (I recommend his newsletter with enthusiasm!) quotes futurist and environmentalist Hazel Henderson and then himself comments:

“… if we can recognise that change and uncertainty are basic principles… we can greet the future… with the understanding that we do not know enough to be pessimistic.” You can take a crisis very seriously indeed without fooling yourself that you know the worst outcome is certain.

Please keep that in mind as we proceed here.

I haven’t forgotten about China’s use of psychiatrists as agents of social control. There’s stuff happening now in the United States that warrants concurrent commentary. It’s still important to know what has happened in the past. If you are itching to learn more and can’t wait for me, you can read the report from Human Rights Watch and Geneva Initiative on Psychiatry entitled Dangerous Minds: Political Psychiatry in China Today and its Origins in the Mao Era. The themes are similar to what we’re already learned together here.

The internet has been to good to me. I recently reconnected with an internet friend from the days of intueri. (Longtime readers will understand what that means.) This person has attended the protests in Minneapolis; from them I learned about Riot Medicine. Written by an anarchist medic, this manual “for practicing insurrectionary medicine” describes how medics can work in atypical settings. During protests, traditional emergency medical services may not be available. (For example, law enforcement may delay or block vehicles from entering a scene. We already know federal agents did this in Minneapolis.) It includes a short section on “Psychological Care”. It’s a summary of Psychological First Aid (introduced in my last post).

If you want to learn more about ICE Watch and Community Defense, whether in the context of protests or not, I strongly recommend this free training. What I most appreciated about the webinar was its lack of histrionics. The trainers emphasized serving as observers and avoiding escalations. Keeping a cool head is a valuable superpower during these times of dismay.

Within the deluge of actions from the federal government was this announcement: Secretary Kennedy Announces $100 Million Investment in Great American Recovery. The stated goal is to “solve long-standing homelessness issues, fight opioid addiction, and improve public safety by expanding treatment that emphasizes recovery and self-sufficiency”. This includes a new initiative:

The Safety Through Recovery, Engagement, and Evidence-based Treatment and Supports — or STREETS — Initiative will fund targeted outreach, psychiatric care, medical stabilization and crisis intervention, while connecting Americans experiencing homelessness and addiction to stable housing with a clear focus on long-term recovery and independence.

The funding attached to this is a mere $100 million. The language of this initiative is vague, so maybe $100M is enough. But if this is meant to fund a comprehensive plan for the entire nation, that sum won’t do.

Tucked further down in the announcement is this:

Secretary Kennedy also announced the $10 million Assisted Outpatient Treatment (AOT) grant program to support adults with serious mental illness. AOT is a civil court-ordered, community-based outpatient mental health treatment program for adults with serious mental illness who are unable to engage with conventional outpatient treatment and are unlikely to be able to live safely in their community.

AOT already exists in many jurisdictions, including here in Seattle-King County. While there is some evidence that AOT improves treatment adherence and reduces hospitalizations, more evaluation is needed to explain how this happens.

When I saw this news, I wondered if this was another step to use psychiatry as an agent of social control. The executive order to “end crime and disorder on America’s streets” conflates mental illnesses, substance misuse, homelessness, and crime. Now there’s funding announcements for homelessness services and court-ordered, community-based outpatient psychiatric services.

Maybe this is confirmation bias. My skepticism about the federal government’s intentions, though, is a reaction to what has already happened. May hope spring eternal and may the worst outcome never come to pass.

Categories
Public health psychiatry

Psychological First Aid.

My plan over the past week was to craft a post about psychiatrists becoming agents of social control in China. Then federal agents killed another person in Minneapolis.

During the Covid-19 pandemic, I posted few entries here. This was a natural consequence of me not writing in general. Fatigue and anxiety were constant companions. Why was a psychiatrist working as the medical director for one of the largest homelessness services agencies in the county during a public health crisis? The pressure felt relentless.

By December 2020, I also felt anger because I was disappointed:

As the federal government has not provided any coherent response to the actual disease pandemic, I do not expect that it will provide any response to the psychological suffering that has already occurred and will continue to occur due to Covid-19.

Nearly a year had passed since the first US death from Covid. There was no indication that this federal government had any interest in applying lessons learned from epidemics elsewhere. The Pan-American Health Organization published a free document—free!—entitled, Protecting Mental Health During Epidemics.

At that time, though, I still held hope in my heart. Government often does not move fast. This is desirable: If government moves too fast, smaller jurisdictions don’t have the chance to give feedback or adapt.

By 2025, we would all learn that this government would use speed against its people.

By January 2022, my anxiety, anger, and disappointment had disappeared. The chronic anxiety and fatigue had squashed everything else.

I recognized at the time that this was a problem.

Worry had become an ingrained habit, so it was easy to express this concern:

I worry about the psychological consequences of this pandemic in the years to come. We continue to focus on the viral pandemic; the psychological pandemic has already arrived. We have yet to see an organized response to that.

Months ago I had already reluctantly recognized that we could not rely on this government to help us. We crafted our own best practices; we cobbled together our own policies and procedures. Within the community we shared information and ideas. We pooled together what power we had to push local government authorities to meet our needs.

You, dear reader, are gracious to give me the gift of your attention. I know some of you work as psychiatrists, psychologists, and other health professionals. Because this federal government is moving fast and has shown that it is unreliable, let me share with you the manual for Psychological First Aid:

Gives guidance on responding to disaster or terrorism events using the Psychological First Aid intervention. This evidence-informed approach helps to assist children, adolescents, adults, and families in the aftermath of disaster and terrorism.

Here’s the two-page overview.

I wish it had a stronger evidence base, and I don’t like that the last update was in 2006. (WHO has a similar psychological first aid manual, though its last update was in 2011.)

People other than mental health professionals can administer psychological first aid. Much of it seems like common sense, but if you have made it this far in this post, you’re probably feeling generally calm. Common sense often disappears during times of stress. The time to learn how to manage yourself, to practice having equanimity in the face of calamity, is when you are calm.

May what is happening in Minneapolis not happen in your city. May you already be a member of PRKA (People Reluctant to Kill for an Abstraction):

resisting the urge to generalize, insisting upon valuing: the individual over the group; the actual over the conceptual; the small, decent act over the sudden violent lunge; the complicated reality of the present moment over the theoretically euphoric future supposedly to be obtained via murder or massacre.

Categories
Homelessness NYC Policy Public health psychiatry

Trump Talked About Community Psychiatry Today.

Guys, I know we’re all tired for many different reasons. But we should probably review what President Trump said today. During his press conference he talked about community psychiatry!

I’ll go over the transcript below, but if you want to watch the video, it starts at 51:34 on C-SPAN.

As he was listing his accomplishments, he said the following. My commentary follows in the numbers below.

Signed an executive order to bring back mental institutions and insane asylums. [1] We’re going to have to bring them back. Hate to build those suckers, [2] but But you got to get the people off the streets. [3] You know, we used to have when I was growing up. We had it in my area in Queens. I grew up in Queens. We had a place called Creedmoor. Creedmore. Did anybody know that Creedmore? It was a big, [4] I said, Mom. Why are those bars on the building? I used to play Little League baseball. They’re at a place called Cunningham Park. Who’s quite the baseball player, you wouldn’t believe, but I said to my mother, Mom, she would be there, always there for me. She said, uh, son, you could be a professional baseball player. [5] I said, thanks, Mom. I said, why are those bars on the windows? Big building, big. Powerful building. It loomed over the park [6] actually she said, well, People that are very sick are in that building. [7] I said, boy, I used to always look at that building and I’d see this big building, big tall building. It loomed over the park. It was sort of, now that I think it was a pretty unfriendly sight, but I, I’ll never forget, I don’t know if it’s still there. [8] Because they got rid of most of them, you know, they, the Democrats in New York, they took them down, [9] and the people live on the streets now. That’s why you have a lot of the people in, in California and other places, they live on the streets. They took the mental institutions down, they’re expensive, [10] but I’d say, why does that building have those bars, boy. It didn’t, it wasn’t normal, you know, you’re used to looking at like a window. But this one you’re looking at all the steel, vicious steel, tiny windows, bars all over the place, nobody was getting out. [11] It’s called the mental institution. That was an insane asylum.

(sigh) Okay, let’s go over this:

  1. The executive order he signed has the formal title of “Ending Crime and Disorder on America’s Streets”. There’s a major cognitive error in the order, which I wrote about here.
  2. Never before have I heard anyone refer to mental institutions as “suckers”.
  3. Are there people who are homeless who would be best served in a mental institution? Yes. Do all people who are homeless need to be in a mental institution? No. Another way—more humane and cost effective!—to “get people off the streets” is to create and sustain conditions where people can afford and remain in housing.
  4. It looks like the highest census at Creedmoor was around 7,000 patients in 1959. President Trump would have been 12 years old at that time.
  5. Of course, someone did a deep dive about Trump’s record as a baseball player. If he were that good, surely he would throw out a first pitch at a major league game? (He has not.)
  6. A quick peek at a map shows that Creedmoor does not “loom over” Cunningham Park. They’re three miles apart. There are two athletic fields nearby. Creedmoor is visible from Alley Athletic Playground.
  7. I wonder if Trump’s mother spoke of the “very sick” people with disdain, pity, or compassion. Is it possible that all 7,000 people were “very sick”? Maybe. Is it possible that some of those 7,000 people did not need to be in an institution? Yes.
  8. Yes, Creedmoor still exists. It’s unclear what the census is now (it’s certainly not 7,000), but it’s not just an inpatient unit. They provide an array of outpatient services, too.
  9. There are multiple reasons why psychiatric institutions closed. One major reason was the advent of antipsychotic medication, which allowed more people to be treated in the community. There were also reports of abuses within these behemoth institutions. Long Island, a suburb of New York City, was the site of three major psychiatric institutions. Around 1954 Pilgrim State Hospital was probably the largest psychiatric hospital in the nation; there were over 13,000 patients there. I don’t know the history of New York State well enough to know if “Democrats in New York… took them down”. Recall that Trump was a Democrat for much of his life prior to running for President.
  10. Historically, states had to fund mental institutions. Medicaid (federal money) could not be used to pay for hospital services. This is another reason why states shut down psychiatric institutions; they didn’t have enough money to keep them running. If this policy discussion excites you (…), learn more about the IMD exclusion here.
  11. Yeah, man. If you don’t like “steel, vicious steel, tiny windows, bars all over the place”, then you’re like everyone else who doesn’t want a proliferation of mental institutions.