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?

Categories
Policy

The Word “Mental” in Project 2025. (iii)

Just to formally close out the series on Project 2025 and its intersections with mental health, let me comment on the third instance where “mental” shows up in the document. (The series starts here.) In short, the authors advocate that parents have unconditional and prompt access to all information their children share with schools, including:

surveys, about political affiliations or beliefs; mental or psychological issues (emphasis mine); sexual behaviors or attitudes; critical appraisals of family members; illegal or self-incriminating behavior; religious practices or beliefs; privileged relationships, as with doctors and clergy; and family income, unless for program eligibility.

The section cites two laws, the Family Educational Rights and Privacy Act (FERPA) and Protection of Pupil Rights Amendment (PPRA), both of which reportedly “require[s] schools to obtain parental consent before asking questions”. However, it sounds like some schools do not routinely obtain parental consent to ask questions of students. The authors suggest that concerned parents don’t have many options to enforce these laws.

Here’s the entire (and lengthy) paragraph on page 344:

At the same time, Congress should also consider equipping parents with a private right of action. Two federal laws provide certain privacy protections for students attending educational institutions or programs funded by the department. The Family Educational Rights and Privacy Act (FERPA) protects the privacy of student education records and allows parents and students over the age of 18 to inspect and review the student’s education records maintained by the school and to request corrections to those records. FERPA also authorizes a number of exceptions to this records privacy protection that allow schools to disclose the student’s education records without the consent or knowledge of the parent or student. The Protection of Pupil Rights Amendment (PPRA) requires schools to obtain parental consent before asking questions, including surveys, about political affiliations or beliefs; mental or psychological issues; sexual behaviors or attitudes; critical appraisals of family members; illegal or self-incriminating behavior; religious practices or beliefs; privileged relationships, as with doctors and clergy; and family income, unless for program eligibility. The difficulty for parents is that FERPA and PPRA do not authorize a private right of action. If a school refuses to comply with either statute, the only remedy is for the parent or student (if over the age of 18) to file an administrative complaint with the U.S. Department of Education, which must then work with the school to obtain compliance before taking any action to suspend or terminate federal financial assistance. Investigations can take months if not years. The department has never suspended or terminated the funding for an educational institution or agency for violating FERPA or PPRA. In essence, Congress has granted parents and students important statutory rights without an effective remedy to assert those rights.

In an effort to prevent “perfect” from becoming the enemy of “good enough”, I’ve abandoned trying to learn more about FERPA and PPRA. Rules and regulations related to education are not my expertise. All of us who work in health care, though, can comment on why privacy related to a person’s health is valuable, even if they are not yet 18 years old.

Yes, in an ideal world, all people under the age of 18 have trusting, caring, and safe relationships with their parents or caregivers. Civil conversations about mental health, sexuality, politics, and religion would be norms within households.

However, we don’t live in an ideal world.

There are reasons why young people don’t share their thoughts and feelings with their adults or caregivers. Sometimes the reasons aren’t valid. Young people sometimes underestimate their parents or have unjustified fears about their caregivers’ reactions.

However, there are other instances where a youth’s best option is to withhold information from their parents. Sometimes children feel that they must protect their caregivers. Sometimes kids realize that their parents cannot tolerate another worry. Sometimes children understand that their own health and safety are at risk because of the behavior of their caregivers.

Sometimes kids feel safer and more secure at school.

The authors of Project 2025 start from the assumption that parents know best, that their authority is the ultimate authority. Maybe parents do know best, but they don’t always behave the best. Some adults can and do misuse their authority. (To be clear, this can happen at school, too.)

This push to keep parents as the center of a young person’s life makes me think of Erik Erikson’s stages of psychosocial development. Erikson was a psychologist who came up with a model of psychological developmental milestones. You can review the stages here, which are presented in pairs to highlight the tension of the stage. For young people in school, the relevant stages are:

  • Initiative vs. Guilt
  • Industry vs. Inferiority
  • Identity vs. Identity confusion

Erikson proposed that the stage before “initiative vs. guilt” is “autonomy vs. shame, doubt”. I can’t read the minds of the Project 2025 authors, though in reviewing where the word “mental” shows up in Project 2025, there seems to be an emphasis on limiting the autonomy of multiple groups of people (women, transgender people, youth). External forces can induce feelings of shame and doubt, which people can then internalize. The world gets smaller: You feel constrained in who you can be and what you can do. Shame and doubt are strong inhibitors. Your autonomy disappears.

If we believe that all people have the “unalienable rights of life, liberty and the pursuit of happiness“, that means that we must allow and help people develop their own thoughtful autonomy so they can exercise those rights. Instead of insisting that schools abstain from having conversations about real issues with students, parents and caregivers can help young people develop thoughtful autonomy. Shame and doubt are not inherently bad; these feelings foster social bonds and a cooperative society. We don’t need to fear either autonomy or shame. For our individual and community mental wellness we need both.

Categories
Consult-Liaison Observations

Observations from the Trump-Zelensky Meeting.

For your consideration, here are a few observations about the Trump-Vance-Zelensky argument in the Oval Office today from a psychiatrist:

Vice President Vance began attacking President Zelensky after Zelensky suggested that American diplomacy was not working. Vance started with: “What makes America a good country is America engaging in diplomacy. That’s what President Trump is doing.” After some back and forth, Zelensky said: “But after that, [Putin] broke the ceasefire, he killed our people, and he didn’t exchange prisoners. We signed the exchange of prisoners. But he didn’t do it. What kind of diplomacy, JD, you are speaking about? What do you mean?”

The insinuation here is that if the diplomacy of Trump, the face of America, was effective, Putin would have not broken the ceasefire and killed people. Vance reacted to Zelensky without providing an actual description of diplomatic efforts. He instead immediately pivoted: “Mr. President, with respect, I think it’s disrespectful for you to come into the Oval Office to try to litigate this in front of the American media.”

A couple things here: Zelensky’s body language prior to Vance’s reaction is open and engaged. He is leaning forward and making solid eye contact in Vance’s direction. He is making emphatic gestures. The tone of his voice when he asks, “What kind of diplomacy, JD, you are speaking about?” suggests disagreement, but not hostility.

When Vance responds, Zelensky’s body language immediately shuts down: He sits back and crosses his arms. He looks away. His eyebrows do heavy lifting here; he looks perplexed. His mouth hangs open a bit. Perhaps he is restraining himself from saying things he will later regret. Vance, for his part, gets pointy, both in his speech and with his index finger.

There is little that is respectful in Vance’s statement of “Mr. President, with respect, I think it’s disrespectful for you to come into the Oval Office to try to litigate this in front of the American media”. To criticize a leader’s character in front of cameras is not respectful. To physically point and wag the pointing finger at the president is not respectful. Just because you say “with respect” doesn’t make it respectful. Whenever speech and behavior contradict each other, behavior is more likely to convey the true sentiment.

President Trump began to attack President Zelensky after Zelensky used the word “feel”. Here’s the exchange:

Zelenskyy: “First of all, during the war, everybody has problems, even you. But you have nice ocean and don’t feel now. But you will feel it in the future. God bless –”

Trump: “You don’t know that. You don’t know that. Don’t tell us what we’re going to feel. We’re trying to solve a problem. Don’t tell us what we’re going to feel.”

It’s not even clear what feelings either man is talking about. Zelensky tries to elaborate by saying “You will feel influenced.” Trump immediately disagrees: “We are going to feel very good and very strong.”

Let me get pedantic here: “Influenced” is not an emotion. Neither is “very good” or “very strong”. In reading context clues, my guess is that Zelensky was trying to convey that the United States would feel “threatened” (which is not an emotion, either; fear is the emotion that underlies threats). Trump, whose behavior consistently reveals that he is obsessed with status, can’t tolerate the idea of feeling fear. He seems to believe that feeling fear means you are a beta.

Furthermore, Trump likely views Zelensky as having lower status than him. How dare someone who is “lower” than him tell him how he is going to feel! And in front of cameras! You are not the boss of me!

Maybe I am reading too much into Trump’s reactions to “feelings”, but…

President Trump gets red in the face as they continue to talk about feelings. They don’t linger on feelings for long; soon the conversation shifts to the metaphor of playing cards.

Trump becoming red in the face at this point is noteworthy because once Trump and Zelensky are talking at and over each other, Zelensky’s body language opens up. He uncrosses his arms, drops them to his lap, and makes some gestures. His eyebrows return to heavy labor; he again looks perplexed and ultimately looks away. These changes in body language indicate an effort (maybe nonconscious, though Zelensky has a history as an actor) to de-escalate the situation. What we learn here is that Zelensky is showing some deference to Trump that he did not show to Vance. Trump either doesn’t recognize or acknowledge Zelensky’s efforts to re-establish rapport. He gets red in the face, his voice gets louder, and he becomes more animated. What button did Zelensky push? Was the button labeled “feelings”?

President Trump settles down after Vice President Vance intervenes. What breaks the cross-talk between Trump and Zelensky is Vance asking Zelensky, “Have you said thank you once?”

I wonder if Vance has learned when to intervene to uphold Trump’s perceived status. Maybe Vance knew that, if this interaction continued, Trump would say or do something foolish that would result in an undeniable drop in his status in front of cameras. Zelensky’s body language was beginning to match Trump’s, suggesting that his deference from moments before was disappearing. What better way to artificially elevate one person’s status by coercing the other person to say “thank you”?

Among pro-social people, saying “thank you” is a gracious way to promote and sustain social bonds. We say “thank you” because it is an expression of cooperation, not conflict. However, some people view the phrase “thank you” as an act of submission: YOU are thanking ME because I bestowed something on YOU which means I have more power than YOU.

Following this cue, we hear Trump make comparisons to elevate his status because Zelensky does not say “thank you” to Trump; he does not submit. Trump says Biden is “not a smart person” (implying that he is); Trump asserts that “Obama gave sheets, and Trump gave Javelins”.

Zelensky, ambushed and outnumbered, looks resigned: His shoulders droop, he slowly rubs his fingers over his clasped hands. His eyebrows can no longer do all the work, so the worry spills all over his face.

What we witnessed today, like so many days in the past month, was ugly and cruel. Cowards only jeer when they are playing at home.