A tent in the woods is a symbol of defiance. Whether among towering trees, on a rocky beach, or next to an icy lake, it is a marker of someone intruding upon the natural world. Even if the tent and its occupants leave no trace, the tent itself is a trace, a brightly colored sign of someone who is passing through and does not naturally belong there.
A tent on a cracked sidewalk, underneath a concrete bridge, or tucked into the corner of a parking lot is a symbol of resignation. The tent and its occupants often have no other place to go. They do not belong there and everyone—including them—wishes that they were only passing through. Alas, the tent is their home.
A tent on a college campus is a symbol of defiance. It is not their home. The tent is a vivid icon of someone who is expressing their displeasure with the status quo. The occupants want progress, they want change. Through occupying their tent in a place where it does not belong, they hope that change will come to pass.
A tent in a besieged city, its buildings in ruins and its surviving residents terrified, is a symbol of resignation. They, too, have nowhere to go. Alas, the tent is their home.
I worry how people in power, people who lie, and people who have agendas kept in shadows will manipulate the symbol of the tent. It is much easier to target tents than to recognize the humans within.
Tomorrow (April 22) the United States Supreme Court will hear oral arguments in the case City of Grants Pass, Oregon, v. Gloria Johnson. This article, 5 things to know about the Grants Pass homelessness case before the US Supreme Court, summarizes the issue well: “The repercussions could have national implications for how cities can regulate homelessness.” In short, if the Supreme Court sides with the City of Grants Pass, it could essentially be a crime to be homeless. (Note: “Homelessness” here refers strictly to street homelessness. The federal definition includes other populations that are not as visible, such as people living in shelters, people about to be evicted, etc.)
This brings to mind other information:
California Statewide Study of People Experiencing Homelessness. This came out in June of 2023. It’s one of the few recent surveys that examines mental health conditions and substance use among people experiencing homelessness. Over 3,000 people in various parts of California answered surveys and over 300 people participated in detailed interviews. They didn’t administer technical interviews to determine whether people met diagnostic criteria for psychiatric conditions. They instead asked people if they had ever experienced certain symptoms (e.g., hallucinations, anxiety, depression) or engaged in certain behaviors (e.g., used any substance three or more times a week) in the past or at the time of the interview. More than half of the people who responded said that they either had a mental health condition in the past or were experiencing one now. More than half reported that they had used substances in the past; about one-third reported that they were currently using any substance at least three times a week. (Note that “substance” here does not include alcohol or tobacco.)
JAMA Psychiatry: Prevalence of Mental Health Disorders Among Individuals Experiencing Homelessness.I have yet to read this paper. It’s a review and analysis of past research related to this topic (a research study of past research studies, if you will). It looks like they looked at specific diagnoses, with a call out of 44% of people experiencing homelessness experiencing any substance use disorder. Other highlights included in the abstract include prevalence rates for antisocial personality disorder (26%) (one of my most popular posts—from 2013!—is about this condition, for whatever reason… and I’ve been wondering about this one again), major depression (19%), schizophrenia (7%), and bipolar disorder (8%).
Open drug scenes: responses of five European cities. This paper is from 2014, though it holds lessons that we in the US can and should learn from. The information within disappoints everyone, which means it is probably a reasonable map to use.
Open drug scenes are gatherings of drug users who publicly consume and deal drugs.
To be clear, as evidenced by data shared above and from anecdotes from those of us who do this work, not everyone who is homeless uses drugs. Not everyone who uses drugs is homeless, either. Much of the current discourse about homelessness is related to drug use, though, which is why I bring up this paper.
The five cities described in the paper vary in size (Zurich, Switzerland, at around 415,000 people to Lisbon, Portugal, at 2.7 million people), though they each use similar strategies to reduce and eliminate open drug scenes:
drug dependence is a health problem
drug use behavior is a public nuisance problem
need for low threshold health services, outreach social work, and effective policing
appropriate combinations of harm reduction and restrictive measures
Law enforcement is needed to address the public nuisance problem. Robust health and social services that include harm reduction are needed to address the health problem. (At least two of the cities legalized heroin so people can use drugs safely in monitored settings, with hopes that they will one day use less and perhaps stop. Recall that this paper came out before the destructive wave of fentanyl overcame us.) Most cities have yet to find the “appropriate combinations” to reduce open drug scenes. (Just to reiterate, these strategies did not eliminate homelessness, only open drug scenes.)
Textbook Talk: Dr. Van Yu on Housing First and the Role of Psychiatry in Supported Housing.One significant way to eliminate homelessness is to ensure that people have places to live. Lemme tell ya: It is hard to effectively treat someone’s mental health or substance use disorder if they don’t have a stable place to live. If the person can’t or won’t come to you, that means you have to go to them. If you can’t find them (because they don’t have a place to live so they move around a lot), it’s hard to make a connection to help them. Even if they want to participate in treatment, it’s challenging to Do All the Things when you don’t know where you are going to sleep. Can you imagine what you’d do or how you’d feel if you didn’t know where you were going to sleep tonight? Seeing a health care professional likely won’t be your priority. Working in a Housing First or other public setting also changes the way you think about health care: Your interventions don’t just affect one person; they affect a whole community. Conversely, the community influences your interventions as a health care professional. We naturally become systems thinkers. (Full disclosure: Dr. Yu was once my boss. I learned and continue to learn a lot from him.)
I will follow the City of Grants Pass, Oregon, v. Gloria Johnson case with interest. The problem of homelessness is complex because people experiencing homelessness each have distinct challenges. They are not a monolith. I believe that there are government officials who are sympathetic to their circumstances. I still wonder, though, what problem are they trying to solve? Is it that they don’t want people to live outside? Or that they don’t want to see people living outside?
I like this model. (Do note, though, that the map is not the territory.) It reminds us of the interdependencies between and within ourselves. If our community isn’t doing well, that will affect our individual mental health. To intentionally use a trivial example (because there are WAY too many heavy things happening these days), consider a city’s baseball team. A not-so-fictional team called the Tridents has had some embarrassing games; hits are uncommon, fielding errors abound, and pitchers are giving up a lot of runs. Grumpy viewers write corrosive comments about the Tridents in the city’s newspaper. Suckers like me read the comments and feel a disjointed sense of “us”. Maybe some of these grumpy viewers are in foul moods for other reasons and they direct their ire at the Tridents because that’s easier to talk about than their alcohol or gambling problems. They would go to Cell Phone Carrier Stadium to grumble at the Tridents directly, but they are dealing with illnesses that limit their abilities to navigate social spaces. Most of us don’t feel psychologically fine when we are physically unwell.
The authors define “lifestyle psychiatry” as seeking
to cultivate well-being and support individuals in preventing and managing psychiatric disorders and optimizing their brain health.
(Editorial comment: I feel some vexation about “lifestyle psychiatry” because I don’t think “lifestyle psychiatry” should be a specialty with its own textbook. Every psychiatrist should practice “lifestyle psychiatry”.) While the authors concede that “patients may have cost or access barriers to traditional care” and conclude the article with a proclamation that lifestyle psychiatry is “a vital component in improving the health and well-being of people around the world”, the final sentence gives away the underlying sentiment of bootstrapping: supporting “individuals in taking ownership of their mental health and well-being” (emphasis mine).
The “social health” component from the Transdomain Model of Health is missing from “lifestyle psychiatry”, even though addressing social health will make it much easier for people to succeed in the “lifestyle psychiatry domains”:
It’s much easier to get physical exercise when there are generous green spaces, plenty of intact sidewalks, and public safety isn’t a concern. Healthy diets and nutrition are easier to achieve when fresh food is available and affordable. It’s easier to be mindful and take yoga classes when you don’t have to work two jobs to make rent. People sleep better when there’s no noise pollution; what if the affordable housing wasn’t only close to airports, trains, and freeways? Neighborhoods with “third spaces” make social relationships more likely to bloom.
To be fair, the lifestyle psychiatry authors do write of “consultation and leadership to governments, corporations, and health care systems” and informing “public education programs and community planners to support the creation of healthy communities [and] employers in creating healthy workplaces”. Their definitions, though, ultimately focus on individuals and do-it-yourself interventions with some consultation with your local lifestyle psychiatrist. (And, to be clear, I’m not saying that systems are the only issue. People do still need to make their own choices, but we can shift systems so it’s not as hard for people to make healthier choices. Life is already hard enough.)
Seattle was not anywhere near the path of totality for the total solar eclipse today. Over lunch I watched part of NASA’s live broadcast. And what a mush ball I am: I cried into my meal as I watched the skies turn to black, heard the crowds cheer and gasp, and saw the dancing corona of the Sun.
I’m not so naive to believe that being in community solves everything. However, I do believe that being in community–contributing to social health–can powerfully change the way we view and feel about ourselves, others, and the world around us. Millions of people witnessed a total solar eclipse in person or in two-dimensions today. I’m pretty sure I wasn’t the only one who cried while watching the broadcast. Three things had to be in place for this celestial event to occur: The Sun, the Moon, and the Earth. To witness this stellar occasion, we all had to be on the same planet. Maybe this is naive: I’d like to think that the shared experience of a total solar eclipse boosted our planetary social health. And, as a result, we individually experienced higher mental health today.
This model argues that an individual’s mental health isn’t the sole product of that single person (because, yes, things are complex). “Society” also contributes to and affects a person’s mental health.1
The Covid pandemic provided plenty of empirical evidence that “society” has enormous influence on the mental health of individuals. Over a third of young people reported “poor mental health” and nearly half reported they “persistently felt sad or hopeless” in 2021. There were nearly 30,000 (!) more deaths related to alcohol when comparing 2019 to 2021. Two out of every five adults reported “high levels of psychological distress” at some point during the pandemic.2
The pandemic isn’t the only example of the power of “society” on mental health. Survivors of mass shootings can develop psychiatric symptoms or disorders. Residents of Flint, Michigan, could only access drinking water contaminated with bacteria, disinfectants, and lead. This contributed to elevated rates of psychological conditions like depression and PTSD. Poverty increases the likelihood of depression and anxiety.
“Imagine how many people I wouldn’t need to see if people never experienced homelessness!” I mutter (or exclaim) at least once a month. It’s not just homelessness: It’s working three jobs to make rent; it’s trying to keep the family fed and housed when one parent has major medical problems; it’s trying to leave an abusive partner; it’s trying to keep things together when a family member has an alcohol or gambling problem. Because much of my career has been in the “deep end” of the system, I often witness how misaligned and rigid institutions often bruise and scar the psyches of individuals and populations of people.
Maybe context matters more in psychiatry than in other fields of medicine. When I think, “What am I doing?”, I often wonder if I should work “upstream” in prevention and early intervention to help change these contexts. This includes advocacy for action that is outside the purview of medicine, such as lowering barriers to housing or increasing regulation of firearms.
Some physicians (and others) have argued that doctors should “stay in our lane”, that we should focus on treating conditions that we are trained to treat. Medical school didn’t teach me how to prevent psychotic disorders; it trained me to identify and treat schizophrenia. In residency I didn’t learn how to develop policy and programming to prevent war and rape; I was trained to provide care and support to someone with PTSD. I can help someone choose to put their gun away so they don’t shoot themselves; I don’t know how to organize people to persuade elected officials to change gun regulations.3
Of course, there’s a middle ground. My clinical experience and expertise give me the anecdotes and data to advocate for system changes. These system changes can improve the health of individual people. Furthermore, there are real people who have real psychiatric problems who need real help right now. As Paul Farmer said,
To give priority to prevention is to sentence them to death—almost to urge them to get out of the way so that the serious business of prevention can start.
I once worked for a medical director who often said, “I’d love to work myself out of a job.” It sounds disingenuous, but it’s true: I completely agree. How wonderful would it be if fewer people experienced psychological distress and problems with living! (Given the ongoing shortage of psychiatrists and other mental health professionals, this would be a win for literally everybody.) What if people didn’t believe that suicide was the best option? Or if people didn’t have to grapple with unending worry about where they will sleep tonight or when their next meal would be? I wholeheartedly concede that crafting legislative language and designing policies and programs are not my strengths. However, it also makes little sense to me to keep my head down and simply treat illnesses and suffering that can be prevented. Things don’t have to be this way.
(1) Again, if we’re going to be picky about words, I prefer the word “context” over “society”. “Society” suggests something uniform, when there exist microcultures within one society. For example, I’ve worked as a homeless outreach psychiatrist in New York City and Seattle. In New York I wore bright blouses with large ascots. In Seattle I wear dark hoodies. Same job, same society, different contexts.
(2) We can argue about whether these reports of distress and their associated behaviors reflect “mental illness” versus “mental unwellness”, in reference to part one of this series.
As a psychiatrist1, do I treat mental illness? What is mental illness? What is mental health?
The paper comments on the ambiguity in the definition of “mental health”:
Mental health can be defined as the absence of mental disease or it can be defined as a state of being that also includes the biological, psychological or social factors which contribute to an individual’s mental state and ability to function within the environment.
Upon reading this I recognized that I define “mental health” according to the second definition, “a state of being…”. This also explains why I internally bristle when people say “mental health” when they actually mean “mental illness”. (Example: The Lancet Commission on ending stigma and discrimination in mental health.)
Figure 2B, the Two Continua Model, resonates with me:
There are people with diagnoses of significant mental illnesses who have “high mental health”. (If we’re going to be picky about words, I’m not sure that I like grading mental health as “high” or “low”. Maybe “well” versus “unwell”? It is more common to hear “I’m physically doing well,” rather than “My physical health is high.”)
Consider the person with a diagnosis of schizophrenia who has been hospitalized multiple times in the past. However, now they go about their lives and only make contact with their healthcare team every few months for routine check-ins.2
Then there are people with no diagnosable mental illness who have “low mental health”. Consider the many people who felt psychologically unwell during the Covid pandemic.
I started doodling to try to determine where psychiatry should intervene along the axes of mental illness and mental wellness:
I have yet to come up with any convincing answers. This doodling did offer clarity, though:
My professional interest has been the diagnosing and treatment of (often severe) mental illness. There are many reasons for this. One compelling reason is that the severity of symptoms makes it unmistakable that professional intervention is warranted.3
Only after years had passed did I recognize that this worldview is why I chafed at some requests patients brought to me early in my career. I once went through an entire diagnostic interview with a guy who worked as a game designer. Nothing came up; according to the Two Continua Model, he had neither a mental illness nor low mental health. Only at the end did he reveal why he had sought care from a psychiatrist: “My girlfriend takes Prozac and it made her more creative. I thought that if I take Prozac, that might make me creative, too, which can help me with my work.”
My goal was to diagnose and treat a mental illness. His goal was mental enhancement.
Are these two goals mutually exclusive? I don’t think so, though I want to noodle on this more.
The history of psychiatry holds these two goals in tension, too: On one end are the state psychiatric hospitals (also called asylums) where some people with severe symptoms (or not) were held (warehoused?) prior to the elimination of these institutions. On the other end are the psychoanalysts, where the typical patient was “a college-educated, upper-middle class professional who paid for service out of pocket.”
More to follow as I continue to wonder what I am doing.
It was never part of The Plan to become a psychiatrist. This is part of the reason why I ask myself the perennial question, “What am I doing?”
When asked, “What is your best life?”, no one responds, “I want to spend as many precious moments of my existence in hospitals and clinics.”
A choice quote from the paper that highlights why I personally like clarity about where professional intervention is warranted: “Lots of things can cause people problems—poverty, vices, social injustice, stupidity—a definition of health should not end up defining these as medical problems.”
Maria Yang, MD 