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.

Categories
Observations

A Pope’s Death.

If he views attention as a zero-sum game, then, today, he lost. To a dead man, no less—a man who did not even rule over a state. He was just a pope.

But he’s a president. What power he wields! World leaders must navigate around him. Stock markets tumble when words fall from his lips. His thumbs tap out a tweet, and the media pores over his words.

The Pope merely died — why did he get all the attention today?

Grief from the Pope’s death has led to his eternal life. When the newspapers aren’t writing about the president, why does it seem that he is no longer relevant? And if he’s not, has his power disappeared, too?

To confirm he exists, his presence must be felt. So he pulls levers. Some produce adoration; others produce anger. These emotional reactions are proof: He still exists. He still matters.

Here’s the betrayal: The absence of the Pope has cemented his presence forever. A dead man has stolen all the attention that the president believes is rightly his. What will he do now to get it back?

Today may remain quiet. But let’s see what happens tomorrow.

Categories
Funding Homelessness Policy Public health psychiatry

Geriatric Homelessness and Medicaid.

I submitted the following as an op-ed essay, though neither local publication accepted it. (I understand: Many people have many opinions about all the actions and inactions happening these days.) The tie-in with Medicaid is important, though I more want people to know this: There are people who are old enough to be your parents and grandparents who don’t have a place indoors to call home.

A van has been in the same parking spot in South King County for over six months. Inside are unopened water bottles, packages of adult diapers, trash bags—and a man. He is over 70 years old. Though he isn’t sure what year it is or the name of the current president, he knows that he wants to live in an apartment. He just doesn’t know how to make that happen. 

In another city park in South King County, a woman sits alone next to a trash can. Her black wire pushcart is stuffed with plastic bags. The stink of urine that surrounds her keeps people away. The trees are bare, a cold breeze is blowing, and she thinks it is a Saturday in June. She is also in her 70s. She slept outside last night, as she has for several years. The only topic she can speak of with confidence is her pet cat.

These are not isolated tragedies. They are alarms. If Congress follows through on its proposed Medicaid cuts, more vulnerable older adults—including those with dementia—will be forced onto the streets. This is unacceptable.

Older adults with memory problems who live outside seem like exceptions. In fact, they are part of a growing population. The US population is older than it has ever been. The number of Americans over the age of 65 is projected to increase by millions in the coming decades. Increasing age is the greatest risk factor for the development of dementia.

The California Statewide Study of People Experiencing Homelessness revealed that nearly half of single homeless adults were over 50 years old. Of them, over 40% became homeless for the first time at age 50 or older. Many of these older adults are eligible for Medicaid because they are poor. If they had more money or support, they would not be living outside. 

Dementia, like other chronic illnesses, drains savings. The costs of care add up fast. In Washington State, in-home caregiving services average over $31 an hour. Facility-based care, such as an assisted living facility, is also expensive–nearly $7000 per month. Skilled nursing facility costs are even higher. Many older adults run out of money.

This is where Medicaid funding for long-term care comes in. The federal government pays for over half of these Medicaid long-term care services and supports. For many, Medicaid is the only reason they have a place to call home.

Cuts to Medicaid would slash payments to long-term care providers. Staff would be laid off. Facilities would close. What about those with no family support or money? They will have nowhere to go. We will see more older adults, including those with dementia, living outside. No one wants this. Right now, Medicaid is the last safety net catching older adults before they fall into homelessness.

It is possible that Congress will protect Medicaid funds directed towards long-term care. President Trump has said that his federal administration will “love and cherish” Social Security, Medicare, and Medicaid. However, proposals from Congress show a clear desire to divert funds from these programs that thousands of older King County residents rely on. 

The man in the van ultimately agreed to go to a local hospital for brewing medical problems. From there, he was discharged to a skilled nursing facility. He was thankful: This is the first time he’s lived indoors in years. Medicaid made this possible. 

The woman remains outside. Without Medicaid, thousands more older adults will join her. That is the future Congress is choosing if it cuts Medicaid. 

Categories
COVID-19 Policy

Standing Up.

Five years ago I was working as the medical director at the largest homelessness services agency in Seattle.

My dad, who skimmed headlines from major newspapers in the US and China every morning, had been tracking news about a respiratory illness spreading in China. “It sounds bad,” he said in January.

On February 29th, 2020, the first death from Covid happened in the US. The death happened in a suburb of Seattle called Kirkland. (If you are a Costco member, those Kirkland jeans and Kirkland cookies and Kirkland laundry detergents are named after the city where the original Costco headquarters were located.) Without consulting the executive director, I sent out an e-mail to the entire agency that same day. I can’t remember what I wrote, though my intention was to offer information, presence, and transparency.

I couldn’t offer true reassurance. I knew nothing. I was worried.

At that time there were close to 50 medical professionals at the agency. During a meeting that happened shortly thereafter to consider next steps, one of the psychiatrists, his voice quavering, asked, “We’re going to shut down the [program he worked in], right?”

“No,” I said, perplexed. “People need that program — and they might need it even more because of what might come next.”

That psychiatrist then abandoned his job. No notice, no explanation. He just left.

Everyone else on the medical team stayed. Though I have expressed my gratitude to them many times, they will never fully understand the depth of my appreciation. There is no way the agency could have kept people — most currently or formerly homeless — well without their help. They applied their knowledge and skills in unknown territory, sought out patients wherever they were, and worked within and across disciplines. There were hundreds of staff at the agency and well over 2500 patients. By the summer of 2022, only five patients had died from Covid. (More died with Covid, but SARS-Cov2 was not the primary cause of death.)

During the Stand Up for Science rally in Seattle yesterday, the president of the Washington State Nurses Association spoke. He talked about the service of nurses during the pandemic, how they all continued to show up and work despite the threat of disease and death.

His point was two-fold: Nurses need science to do their jobs. Nurses also do the right thing: They don’t back down in the face of threats. They keep showing up, even when the situation is scary and hard.

This is true for the vast majority of people who work in health care.

Do I feel great annoyance with the current federal administration? Yes. Do I think people will suffer and die unnecessary deaths because of their policies? Yes. Does that enrage me? Yes.

Serving as the medical director at that homelessness services agency during the pandemic was the hardest thing I’ve ever done in my professional career. The fruit of that experience, though, is an unexpected equanimity.

It’s not that I don’t feel worry or sadness. I do. The actions of the federal administration just seem like a series of surmountable problems. Their triumph is not inevitable. All of us who were essential workers during the pandemic showed up, did our jobs, and supported the people in our communities. If we were able to do that when the threat was unknown, global, and indiscriminate, why would we be cowed by a shrinking faction of spiteful people?