Categories
Nonfiction NYC Observations

Creation and Destruction.

During a recent visit to New York City I went to the Society of Illustrators. Despite living in the city for three years, I had never heard of this museum. The newest exhibit featured botanical art. Who doesn’t like to look at drawings of plants?

It’s a small museum on the eastern side of Central Park, surrounded by stately apartment buildings and schools. On the third floor is a bar and a handsome patio. Between the two on brick walls hang illustrations of plants. 

The drawings are astounding! These dramatic tulips, created from chalk and charcoal, look like a photograph. I felt certain I could reach out and pick up these gleaming red onions, even though they are simply watercolors on paper. 

I kept returning to the only two illustrations that featured decay. This persimmon leaf (scroll down) radiates warmth and life despite the signs of infection. 

My favorite from the collection is this autumn leaf, made entirely from just colored pencils. What?! How can colored pencils create such texture and vibrancy? I was pleased to learn that the artist, Crystal Shin, is from Seattle. No wonder the deteriorating leaf looked familiar; they regularly litter sidewalks and trails in October. Even now, I can’t believe that’s just a drawing.

Illustration of a decaying Pyrus calleryana leaf, which is mostly red and brown, with some green spots, along with black blemishes of decay.

After I moved on from this leaf, I stopped in front this drawing of wild blackberries, another common sight here in Seattle during the late summer. I heard an excited voice approach me: It was the artist, Catherine Park! She couldn’t believe that her piece was in the exhibition. “I’m so happy to see people looking at it,” she said, beaming. She was gracious enough to answer my question about how long it took her to create this. 

“Six months,” she answered with what sounded like mild disappointment. 

“Six months!” I exclaimed. That was far beyond my expectations.

Catherine then explained the process behind her work (which entirely aligns with what she said about the piece here). Her enthusiasm for light, detail, and the lifecycle of the blackberry made me smile. 

That chance encounter with a professional botanical artist was a potent reminder that creation takes time. Destruction is fast. Creating beauty—even the beauty in decay—takes time, planning, and energy. What a way to honor the fullness and blessings of life. The act of creating is time well spent.

“Do you know who Duncan Sheik is?” my spouse asked me. 

“Yes, of course,” I answered. It was unfair of me to expect him to remember my tastes in music before he and I met. 

“He died.”

“What?!”

So he must’ve had a sense that Duncan Sheik meant something to me.

His was the first concert I ever attended, somewhere in Los Angeles when I was in college. (I remember Paula Cole, who hopefully found her cowboy at some point, opened for him.) It’s true, I did like “Barely Breathing”, though I soon recognized that this pop song was an anomaly in his work. (His album, Humming, is what kept me a fan.) I ultimately bought five of his albums, which means Duncan Sheik was part of my life soundtrack for 12 years: College, medical school, and psychiatry residency. 

The New York Times obituary for him is syrupy. Sure, maybe he was “soft-spoken and cerebral”, but “heart-rending melodies” and lyrics “[brimming] with existential angst”? Really?

I will concede that the obituary writer’s comment resonated with me:

[Barely Breathing], along with so much of his work from the ’90s, really strikes a chord with my Gen X soul; it’s a reminder of that moment when we twentysomethings really did think that authenticity would rule the world…

To my ear, his layering of orchestral string instruments with guitars, electronic beats, and his voice naturally led him to composing music for Broadway. I haven’t seen any of them, but now hope to. 

I remember it was with great reluctance that I threw away the shirt I got from his concert. It had difficult colors: The shirt was brown with cyan text and featured his unsmiling face. After years of wear, the seams were unravelling and there were holes in the armpits.

Destruction is fast. I hope Duncan felt that his time creating music was time well spent. 

Categories
Homelessness Policy Public health psychiatry Seattle

Housing as the Most Effective Treatment.

(I know it’s been a minute since my last post. The announcement from HHS about “HHS, ONDCP, and HUD Launch First-Ever ‘Treatment First’ Toolkit to Combat Homelessness and Addiction” reminded me that I submitted the op-ed below at the end of June. The newspaper chose not to publish it, so I’m sharing it here. I’ll review the toolkit above next, though I have a feeling that I may reiterate what I’ve already written below.)

The Trump administration believes that mental illnesses and substance use disorders are the root causes of homelessness. Thus, HHS Secretary Kennedy recently announced funding for the Safety Through Recovery, Engagement, and Evidence-based Treatment and Support (STREETS) program. Because of the “unprecedented burden and impact of addiction and mental illness among the homeless population”, he asserted that this funding “aligns with President Trump’s Executive Order on Ending Crime and Disorder on America’s Streets”.

STREETS may help people with mental illnesses and substance use disorders, but it will not end homelessness. People need safe places to call home to recover.

The vast majority of people with mental illnesses and substance use disorders are not homeless. In Washington State, over 2.2 million adults have had any mental illness and over 1.4 million people over the age of 12 have had a substance use disorder in the past year. Compare these numbers with the 163,000 Washingtonians who are homeless. If we (incorrectly) assume that every person became homeless because of a mental illness or substance use disorder, that means over three million Washingtonians will lose their housing. This is wrong. Someone in a Mercer Island mansion drinks bottles of wine between meetings, just as someone in an Auburn apartment takes medication for schizophrenia before going to work. 

I work as a psychiatrist in Seattle with people who are currently and formerly homeless. Psychiatric conditions that are common in the general population, like anxiety and depression, are also common among those who are homeless. For many of them, housing is the most effective treatment. Having reliable access to one’s own bathroom and bed reduces stress. A lock on the door assures safety and security. 

Practically everyone who is homeless now has had a place to call their own in the past. Because of rising rents, reduced incomes, and the onset of health problems, nearly half of people becoming homeless for the first time are over the age of 50. With older age often comes increased physical and cognitive vulnerability. Anxiety and depression often follow. The loss of health and housing can tip people into major mental illnesses and substance misuse. 

In a minority of people, severe mental illnesses and substance use disorders are the primary drivers of their homelessness.  Because of their symptoms, they sometimes are unwilling or unable to work with traditional health care systems. Finding these individuals is often the hardest part of my job. I cannot build relationships and then offer treatment if I cannot find my patients. When someone has a stable and safe place to live, it is far more likely we will connect. Only then can people participate in care.

For those who are unable or unwilling to engage in outpatient treatment, civil commitment is the last option. Laws for involuntary hospitalization already exist. Every day, someone is hospitalized against his will. In many instances, this is lifesaving. However, recovery quickly unravels if people have nowhere to go when they are discharged from the hospital. It is hard to attend appointments, take medication consistently, and build a life you want to live when you don’t know where you will sleep.

To be fair, STREETS funding will help the health and wellbeing of some people, including individuals who are homeless. Prevention and early intervention work. Some people at risk of becoming homeless because of mental illnesses and substance use disorders will remain housed. However, psychotherapy and medications are often no match for the stress and chaos that comes with homelessness. Housing is health care.

RFK Jr. has shared his own history with drug use and depression. As far as we know, he never experienced homelessness. Having a stable place to call home was foundational to his recovery. He knew where he could go after attending 12-step meetings; he had a safe place indoors to read books by Carl Jung. Housing alone does not treat mental illnesses and substance use disorders. But treatment alone also doesn’t solve homelessness. People need both. 

Categories
Education Reflection

Seen Around the Internet.

Three recent items for your consideration:

Psychiatry in the Public Square. As if in response to my post asking for post suggestions, this essay appeared. The author, Adrian Preda, argues:

Psychiatry and mental illness remain inadequately represented in public discourse, and when they do appear, the representations are often partial, distorted, and repetitive.

He offers “four principles of engagement”:

Visibility. “Psychiatry needs to be present where the public already is—not only in newspapers and medical journals, but on podcasts, YouTube, social media, and the other platforms that increasingly function as people’s primary sources of health information.”

Correction. “When mental illness or psychiatric treatment is portrayed inaccurately—as they regularly are—psychiatry should react quickly, clearly, and constructively.”

Education. “Beyond correcting myths, psychiatry should proactively use media to provide practical, accessible information.”

Collaboration. “Psychiatry cannot improve its public presence by speaking alone.”

I am trying! (It is also true that I am ambivalent.)

Thanks to those of you who responded to my request for suggestions. I may not have the largest audience, but it seems that I have a devoted one. Thanks the gifts of your ongoing attention.

Drowning Doesn’t Look Like Drowning. Please be generous and share this. Here’s a 1:20 video that covers the same information, but it induces way more anxiety than the article.

“I Feel Good”: The Many Flaws of the Wellness Movement. Arthur Caplan is a giant within bioethics. This article is a book review, but he throws in plenty of grouchy editorial comments. His opinions about the wellness industry are clear.

He rightly points out:

… proponents of wellness have one thing in common—it is up to you to do something. Social determinants and economic conditions that drive health just don’t get much attention.

And even when it is up to you to do something, the wellness industry tends to gloss over the unsexy basics: Sleep enough. Eat just enough. Get outside and exercise every day. Cultivate and maintain relationships. These activities don’t sound as alluring as putting a stone egg in your vagina. (Look who’s grouchy now?)

Caplan closes his essay with sound and exhausting counsel: “Being well means taking steps to change your behavior and demanding the EPA go back to its mission of protecting you from pollution and environmental hazards.”

Categories
Uncategorized

Wanted: Your Suggestions.

Dear reader, what topics would you like me to write about?

Some of you have given me the gift of your attention for months, if not years. (Thank you!) I’m never sure what draws people back here to read my writing.

Now that I am clearly a “middle career” psychiatrist, I feel a duty to share what I know. This moment in time feels unstable. My professional niche seems atypical. It feels important to contribute what (little) I know in case it can help someone, somewhere. (Sharing what I know here also helps me improve my writing skills.)

So, I welcome your feedback and suggestions. What would you like to read here? What questions do you have? How can I be useful within this context?

Comments are open, so feel free to share your ideas there. You can also send me an e-mail at maria at mariayang dot org. If you’re reading this through the e-mail newsletter, you can reply to the e-mail.

Thank you!

Categories
Homelessness Observations Public health psychiatry Systems

Psychiatry in Context.

A few reactions on topics related to psychiatry from the past week:

An example of a transitional object in baseball. The catcher for the Seattle Mariners, Cal Raleigh, did not play a few games due to injury concerns. Early in the game against the Atlanta Braves, the camera operator lingered on him in the dugout:

Cal Raleigh leaning against the dugout railing while holding a baseball (transitional object) in his right hand. A water bottle is directly in front of his face on the railing.

Notice that he’s not dressed to play. An unmarked bottle keeps him company. In his right hand is a baseball.

The Wikipedia page about transitional objects is pretty good (though psychobabbly). The best explanatory example of transitional objects is Linus and his security blanket:

Transitional objects give us comfort and a sense of security. Maybe the baseball gave Cal comfort and security during his mandatory time off. (Some players can hold six or seven baseballs in one hand. That’s probably more about showing off!)

The MAHA Action Plan to Curb Psychiatric Overprescribing. Per the HHS press release:

HHS Secretary Robert F. Kennedy, Jr. laid out a new action plan to promote appropriate psychiatric prescribing and drive deprescribing when clinically indicated.

Does “inappropriate” psychiatric prescribing happen? Yes. Does deprescribing, whether clinically indicated or not, already happen? Yes.

Back in 2015, while mulling over the value of psychiatrists, I commented:

When people think about medication management, they often think only of adding medications or exchanging one for another. Medication management also includes helping people come off of medications.

Many psychiatrists practice “deprescribing”. In 2019 I wrote about the ongoing difficulties in treating psychosis. There I commented on my own deprescribing experiences:

One of my early jobs was working in a geriatric adult home. My work there taught me that people with psychotic disorders can and do get better. The burdens of antipsychotic medications—paying for medications, the actual act of swallowing the pills every day, the side effects, some mild, some intense—add up. I was fortunate to work with some people to successfully reduce the doses of their antipsychotic medications and, in some cases, stop them completely! (There [was] also at least one instance when tapering medications was absolutely the wrong thing to do; that person ended up in the hospital. I felt terrible.)

Psychiatry is an easy target. Psychiatric medications, especially antidepressants, are common prescriptions. Many factors contribute to this: Health care appointments are short. (There’s not enough time for deep conversations.) It’s hard to access non-medication treatments. (Most rural areas do not have experts in evidence-based therapies.) Emotion literacy is not where we all want it to be.

For several decades psychiatry has focused on biological causes of psychological symptoms. The natural corollary is medications fix biological problems. As I noted in 2019, “Medications are a biological solution, though our understanding of the biology of the brain and mind remains limited.”

To be clear, I am not anti-medication. Psychiatric medications can not only save lives, but also improve quality of life. However, medications are not the only tool psychiatrists have to help people. Most of us do prescribe appropriately. (Some people are vexed when we decline to write prescriptions.) Many of us do deprescribe when clinically indicated. (Some people express anxiety when they want to stay on their medications.)

Ongoing hypocrisy related to “ending crime and disorder on America’s streets”. The primary community psychiatry journal published this (free) article: The Executive Order on “Crime and Disorder”: An Affront to Policy, Law, and Ethics.

I agree with the authors. I previously shared my reactions to the executive order here.

It’s fresh that the federal administration cannot recognize the crime and disorder they bring to America’s streets:

… among many other federal actions that reduce stability and increase anxiety. Choose your issue.