Categories
Policy Reading

The Word “Mental” in Project 2025. (xiv + xv + xvi)

Guys, we’re getting to the end of this project! We’ve made it to the last three instances (14, 15, and 16) of the word “mental” in Project 2025. (I still need to return to the third instance; that will follow soon.) This will also be a short post because there’s not much to analyze in these last three instances.

The 14th instance of the word “mental” in Project 2025 is on page 879, in the closing section about the FTC:

Conservative approaches to antitrust and consumer protection continue to trust markets, not government, to give people what they want and provide the prosperity and material resources Americans need for flourishing, productive, and meaningful lives. At the same time, conservatives cannot be blind to certain developments in the American economy that appear to make government–private sector collusion more likely, threaten vital democratic institutions, such as free speech, and threaten the happiness and mental well-being of many Americans, particularly children. Many, but not all, conservatives believe that these developments may warrant the FTC’s making a careful recalibration of certain aspects of antitrust and consumer protection law and enforcement.

The 15th instance is a footnote at the end of the FTC chapter:

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) is the authoritative publication of the American Psychiatric Association.

(Comment: Yes, the DSM-5-TR is an authoritative publication, though it’s not without problems.)

The 16th instance is also a footnote and contains a reference:

Allcott, supra note 19; see also Jean M. Twenge, Jonathan Haidt, Jimmy Lozano, and Kevin M. Cummins, “Specification Curve Analysis Shows that Social Media Use Is Linked to Poor Mental Health, Especially Among Girls,” Acta Psychologica, Vol. 224 (2022), p.103512, https://doi.org/10.1016/j.actpsy.2022.103512 (accessed March 23, 2023).

I don’t have anything more to add to what I noted earlier:

… there’s ambivalence in this chapter about the role of the FTC. Children’s mental health is used chiefly as a potential subject of regulation. Who is better poised to regulate social media and its effects on children? The government? Or parents? Surprisingly, this seems open to debate in this section.

The reference to the Acta Psychologica journal article (16th instance) is also interesting. We’ve discussed elsewhere in this series how the authors of Project 2025 have often ignored published data because it does not support their policy platform. We’ve also observed that this chapter on the FTC is notably less inflammatory than other chapters. Of all the articles they could have referenced that draws associations between social media and adverse mental health, they chose that one? (And only one?) Yours truly wasn’t put on retainer to find evidence to support that argument and found more than one robust and relevant resource to do so.

The Presidential inauguration is happening in less than one month. Thanks for reading along with me. We together can watch how the new administration implements policies from Project 2025 and uses “mental health” as the reason why. We will know if they are using data and evidence, or just making things up because they can. If you have found this series useful, please share with others what you’ve learned.

Categories
Policy

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

The twelfth (and thirteenth) instance of the word “mental” in Project 2025 is on page 876, still in the section about the Federal Trade Commission:

Other conservatives are more skeptical concerning the effect of online experience on the young, comparing the concern about social media to concern about video games, television, and bicycle safety. They point out, as does Cato fellow Jeffrey A. Singer, that the psychiatric profession has yet to designate “internet addiction” or “social media addiction” as a mental disorder in the authoritative Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). These conservatives also maintain that calling for regulation undermines conservatives’ calls for parental empowerment on education or vaccines as well as personal parenting responsibility.

Although Project 2025 already decries social media companies in at least two earlier sections in the text, here the authors equivocate: Maybe social media isn’t that harmful to young people. Or maybe it’s better if we leave the regulation of kids’ social media use to parents.

The topic here is about the internet, but they make a comparison to earlier forms of media, namely video games and television. There are, in fact, multiple studies that confirm a linkage between video games and television and violent behavior among children:

Prior to the publication of DSM 5, the most recent edition of the text that lists all psychiatric diagnoses in use, some psychiatrists expressed concerns for a diagnosis that seemed like “internet addiction”:

the diagnosis is a compulsive-impulsive spectrum disorder that involves online and/or offline computer usage and consists of at least three subtypes: excessive gaming, sexual preoccupations, and e-mail/text messaging.

This came from growing concerns of youth spending a lot of time online in China and South Korea. That article was published in 2008, when social media, though common, had yet to hit its peak.

Some advocated more research into this possible condition because “it is not clear whether internet addiction usually represents a manifestation of an underlying disorder, or is truly a discrete disease“. For example, were people addicted to the internet because they actually had social phobia? Or did people actually have a gambling disorder, and gambling on the internet was easier to access?

From a paper entitled “Chaos and confusion in DSM-5 diagnosis of Internet Gaming Disorder: Issues, concerns, and recommendations for clarity in the field”:

The umbrella term “Internet addiction” has been criticized for its lack of specificity given the heterogeneity of potentially problematic behaviors that can be engaged in online as well as different underlying etiological mechanisms. This has led to the naming of specific online addictions, the most notable being Internet Gaming Disorder (IGD).

It’s true: People use the internet for a variety of reasons. Some people return to and seemingly cannot leave certain sites: Social media; porn; gambling; games. Would “internet addiction” include both an older person who spends eight hours a day checking their bank balance (because of anxiety? paranoia? dementia?) AND a young man who plays Fortnite for hours instead of sleeping?

“Internet gaming disorder” does appear as a “condition for further study” in DSM-5 (here’s a public-facing page with less detail):

The essential feature of Internet gaming disorder is a pattern of excessive and prolonged participation in Internet gaming that results in a cluster of cognitive and behavioral symptoms, including progressive loss of control over gaming, tolerance, and withdrawal symptoms, analogous to the symptoms of substance use disorders.

The diagnosis excludes social media. This suggests that there was already some question that social media overuse could be its own diagnostic entity:

Excessive use of the Internet not involving playing of online games (e.g., excessive use of social media, such as Facebook; viewing pornography online) is not considered analogous to Internet gaming disorder, and future research on other excessive uses of the Internet would need to follow similar guidelines as suggested herein. Excessive gambling online may qualify for a separate diagnosis of gambling disorder.

The only other place “social media” shows up in DSM 5 is under the proposed condition of “Nonsuicidal Self-Injury Disorder”:

The essential feature of nonsuicidal self-injury disorder is that the individual repeatedly inflicts minor-to-moderate, often painful injuries to the surface of his or her body without suicidal intent. Most commonly, the purpose is to reduce negative emotions, such as tension, anxiety, sadness, or self-reproach, or less often to resolve an interpersonal difficulty.

Additional prospective research is needed to outline the natural history of nonsuicidal self-injury disorder and the factors that promote or inhibit its course. Individuals often learn of the behavior on the recommendation or observation of another, through media outlets, and through social media.

Some literature describes the phenomena of “copycat suicides” and “suicide contagion”, which has prompted the American Foundation for Suicide Prevention to issue safe reporting guidelines for media. The goal is, in part, to help journalists reduce this contagion in their publications. It is unclear if such a contagion exists for nonsuicidal self-injury. It is indeed true that some young people learn about this destructive behavior through social media.

Do I appreciate the deference the authors of Project 2025 show here towards the profession of psychiatry and DSM-5? Not really. I find the overt deference jarring because, as we have seen, the authors of Project 2025 haven’t deferred to scientists and available data to inform other policy positions (e.g., abortion, gender-affirming care, homelessness).

As a reminder, the only reason why the subject of mental health even shows up in the FTC section is to insert parents into any contracts kids might make over the internet:

The FTC can and should institute unfair trade practices proceedings against entities that enter into contracts with children without parental consent.

But, again, the authors here seem to wobble about who is better poised to regulate the internet here: Parents? or the government?

And, like we’ve already seen in this document, the approach seems to be all or nothing. It’s either parents or the government, not both. (This sort of all-or-nothing, black-or-white thinking isn’t limited to people with conservative persuasions alone. Silence doesn’t always mean violence; defunding the police has increased problems for some of the most vulnerable populations; etc.)

Categories
Policy Systems

The Word “Mental” in Project 2025. (ix + x + xi)

The ninth, tenth, and eleventh instances of the word “mental” in Project 2025 are on page 875 in the section about the Federal Trade Commission:

Protecting Children Online. The FTC has long protected children in a variety of different contexts. Internet platforms profit from obtaining information from children without parents’ knowledge or consent—and social media’s effect on the well-being of American children is well-documented. Around 2012, American teens experienced a dramatic decline in wellness. Depression, self-harm, suicide attempts, and suicide all increased sharply among U.S. adolescents between 2011 and 2019, with similar trends worldwide. The increase occurred at the same time that social media use moved from rare to ubiquitous among teens, making social media a prime suspect for the sudden rise in mental health issues among teens. In addition, excessive social media use is strongly linked to mental health issues among individuals. Several studies strongly support the notion that social media use is a cause, not just a correlation, of subjective well-being and poor mental health.

This harkens back to the second time the word “mental” appears in the text, where the authors accuse Big Tech of engineering social media for industrial-scale child abuse. The punchline is, yes, the authors of Project 2025 have legitimate and evidence-based concerns about the adverse effects of social media on kids. I appreciate that this section here at least includes people of all ages (i.e., parents) in asserting that “excessive social media use is strongly linked to mental health issues among individuals”.

After this brief foray into children’s mental health, the text veers back towards its point: Trade and contracts.

Targeting children to create potentially harmful contracts or making parents responsible for such contractual relationships is an unfair trade practice.

… leading to this recommendation:

The FTC should examine platforms’ advertising and contract-making with children as a deceptive or unfair trade practice, perhaps requiring written parental consent.

While a perspective of interdependency views everything as being related to everything else, bringing up the mental health of children within the context of the Federal Trade Commission is curious. As we will see in the next instance of the word “mental” in this document (we’re nearing the end — “mental” only shows up 16 times), there’s ambivalence in this chapter about the role of the FTC. Children’s mental health is used chiefly as a potential subject of regulation. Who is better poised to regulate social media and its effects on children? The government? Or parents? Surprisingly, this seems open to debate in this section. (This entire chapter on the FTC uses notably less inflammatory language, too.)

It is clear, just from reviewing the appearance of the word “mental” in this text, that the authors of Project 2025 have opinions about who should have the power and authority to regulate other people. It is apparent who they believe should (cis male, heterosexual fathers) and who should not (women, children, and everyone else). Because Project 2025 makes multiple references to the authority of Judeo-Christian faith, which worships the Father (dude), the Son (dude), and the Holy Ghost (do spirits have genders?), this is presumably why.

Instead of struggling with how to reconcile the agency that all humans can and could have at this current time and place, the authors of Project 2025 have elected an “all or nothing” approach. This is also reflected in the black-or-white, provocative language used in many portions of this enormous document.

Categories
Medicine Policy Systems

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

The eighth instance of the word “mental” in Project 2025 is on page 648 in the section about the Veterans Health Administration:

Examine the surpluses or deficits in mental health professionals throughout the enterprise, recognizing that the department needs a blend of social workers, therapists, psychologists, and psychiatrists with a focus on attracting high-quality talent.

This chapter advocates for “Veteran-centric” care and wants military veterans to have easier access to high quality services. This recommendation is part of a list that calls for bolstering health care personnel to reduce wait times for veterans. This is completely reasonable.

(There are some highly biased comments in this section, such as “the Left’s pernicious trend of abusing the role of government to further its own agenda”, even though the preceding sentence is literally “rescind all departmental clinical policy directives that are contrary to principles of conservative governance”, as if “conservative governance” isn’t an agenda???)

I do wonder how the arbiters will know what numbers of mental health professionals are a “surplus” versus a “deficit”. Most (all?) health systems struggle with a “scarcity” or “substantial shortages” of behavioral health professionals. Perhaps the authors of Project 2025 are aware that mental health professionals, such as psychiatrists, are far more likely to be registered Democrats. The VA directives they want rescinded are ”abortion services and gender reassignment surgery”, so perhaps the “surplus” of mental health professionals are the pernicious Lefties who support those services.

Like most other physicians who trained in the US, I spent time in residency and fellowship working in VA hospitals. (As a medical student I did not train at a VA, but was instead sent to an Air Force base for part of my pediatrics rotation!) We were in the midst of the Iraq War. The VA patients under my care at that time were around my age. (How did fate send us on such different paths, only to intersect in the hospital?) The psychological wounds of these young men from fighting in the war were still gaping. I also saw Vietnam War- and World War II-era patients whose memories were deteriorating, their bodies not yet as infirm as their minds.

Apart from one unfortunate experience, I found my work experiences at the VA meaningful. I know it sounds corny, but it truly is a privilege to provide care to people who have served in the military. (We’ll put aside for now the vexing reality that trainees spend so much time learning their health care profession on patients who don’t have much money in publicly-funded institutions. Never did I nor a colleague treat an Admiral, Commander, or other high-ranking, presumably not poor, officer.) While not routine, I continue to encounter veterans now who are homeless and have significant psychiatric conditions. My primary goal in those instances is to get them connected to the local VA if possible, since the VA, for all of its bureaucratic problems, often offers many more resources than other public programs.

When I consider the provision of mental health services at the VA, I can’t help but think that the best way that we can protect the mental health of veterans is to limit their exposure to war. We can’t prevent all bad things from happening, but war is an especially bad thing. It messes people up. I’m not even talking about formal psychiatric disorders. War induces heartache. I think about the various veterans I’ve worked with as colleagues (some as health care professionals, most not), and what stands out to me is how much loss they carry. They’re “fine”: They are married, they have kids, they have fun hobbies, they do satisfactory to exemplary work at their jobs, some have even achieved high status in their professions.

And then I see artifacts from a comrade who died, sense their guardedness, hear their reluctance to speak about their time in service.

There are things that civilians may never understand. Here I agree that veterans deserve high quality health care. The issue is that the authors of Project 2025 apparently believe that some people do not deserve certain kinds of health care, high quality or not.

Categories
Homelessness Policy Public health psychiatry

The Word “Mental” in Project 2025. (vi + vii)

The sixth instance of the word “mental” is on page 509 in the section about “First-Day and First-Year Administrative Reforms” for The Department of Housing and Urban Development (emphasis mine):

The Office of the Secretary should execute regulatory and subregulatory guidance actions, across HUD programs and applicable to all relevant stakeholders, that would restrict program eligibility when admission would threaten the protection of the life and health of individuals and fail to encourage upward mobility and economic advancement through household self-sufficiency. Where admissible in regulatory action, HUD should implement reforms reducing the implicit anti-marriage bias in housing assistance programs, strengthen work and work-readiness requirements, implement maximum term limits for residents in PBRA and TBRA programs, and end Housing First policies so that the department prioritizes mental health and substance abuse issues before jumping to permanent interventions in homelessness. Notwithstanding administrative reforms, Congress should enact legislation that protects life and eliminates provisions in federal housing and welfare benefits policies that discourage work, marriage, and meaningful paths to upward economic mobility.

The seventh instance of the work “mental” is on page 516 as a footnote to the paragraph above (emphasis again mine):

The U.S. Interagency Council on Homelessness (USICH) was established in the 1990s, and numerous Administrations have devoted enormous resources to the Housing First model, experimenting with various ways to provide federally financed rapid rehousing and permanent housing opportunities. Housing First is a far-left idea premised on the belief that homelessness is primarily circumstantial rather than behavioral. The Housing First answer to homelessness is to give someone a house instead of attempting to understand the underlying causes of homelessness. Federal intervention centered on Housing First has failed to acknowledge that resolving the issue of homelessness is often a matter of resolving mental health and substance abuse challenges. Instead of the permanent supportive housing proffered by Housing First, a conservative Administration should shift to transitional housing with a focus on addressing the underlying issues that cause homelessness in the first place.

    Long-time readers will recognize that this falls right into my professional bailiwick…

    (cracks knuckles)

    … but I won’t spend too much time on the data because there are excellent summaries elsewhere. For example, the Office of Policy Development and Research published Housing First: A Review of the Evidence. There they describe the stance the federal government took in the 1990s, summarized as “treatment first”:

    housing was available only to individuals experiencing homelessness who were willing to work for it.

    This is exactly what the authors of Project 2025 want. If they know this history, they know that this “treatment first” model did not reduce homelessness, but an alternate model called “housing first” did, and for various populations:

    Overwhelming evidence from several rigorous studies indicates that Housing First programs increase housing stability and decrease rates of homelessness. The best available evidence indicates that Housing First programs successfully house families and individuals with intersecting vulnerabilities, such as veterans, individuals experiencing substance use or mental health issues, survivors of domestic violence, and individuals with chronic medical conditions such as HIV/AIDS. 

    While the authors of Project 2025 argue that “mental health and substance abuse challenges” are the “underlying issues that cause homelessness in the first place”, they again are ignoring data that illuminates the actual underlying issue (emphasis again mine):

    Much of the research looks at the variation in homelessness among geographies and finds that housing costs explain far more of the difference in rates of homelessness than variables such as substance use disorder, mental health, weather, the strength of the social safety net, poverty, or economic conditions.

    Is it true that there are some people who are homeless because of their “mental health and substance abuse challenges”? Yes. However, their common denominator is not having enough money. There are people with “mental health and substance abuse challenges” who are not homeless and that’s because they have enough money, or someone else has enough money, to pay their rent. (Think of the depressed ladies who buy cases of wine from Costco and return to their suburban homes to drink 20 bottles of wine a week….)

    So that’s the data. But, as a psychiatrist who works with people who are or were homeless, let me share some some “n of 1” perspectives about the work.

    Importantly, most people who are homeless don’t need the services of a psychiatrist. Could they use mental health support? Sure: When you don’t know where you’re going to sleep tonight, anxiety is a natural reaction. If you find a place to sleep, but there isn’t a door you can lock (or a door, period), you probably won’t sleep well. Without routine access to a bathroom or running water, you can’t keep yourself as clean as you would like, so you start feeling self-conscious about it. It’s hard to perform well at work if you aren’t sleeping well, you don’t feel your best, and you don’t have a place to call home. You know what solves these psychological problems better and faster than a psychiatrist? Housing.

    A psychiatrist can help people with significant psychiatric conditions (like schizophrenia) who are homeless. Among the reasons some people have shared with me about why they will not move indoors:

    • The aliens will assassinate me if I move inside.
    • I want an apartment, but God tells me that I don’t deserve to be indoors.
    • If I move in, they will turn on the parametric speakers to make me insane.

    Most of these people don’t have jobs because their symptoms get in the way of their ability to show up on time, work with customers, etc. Because many of them have had terrible experiences with the traditional health care system, some are reluctant to talk with me. But, with the essential help of my non-medical colleagues, many will. Some people, with time and relationship-building, will agree to try medication to treat their symptoms. (Yes, this really happens.)

    When you don’t have a stable place to live with a door to lock and easy access to cabinets and calendars, it’s hard to take medication as prescribed. Pills get lost. Other people might pilfer them. Someone might run off with your bag. Plus, if medications make you sleepy, you might only take them when you know you can sleep safely. You know what makes it easier to take medication on a regular basis and manage side effects like sedation? Housing.

    Maybe you’ve heard about long-acting injectable medications. Instead of having to take a pill every day, you can get a shot once a month. This sounds like an elegant solution, right? Some people are cool with shots, but a lot of people aren’t. (Would you want to get a shot every month instead of taking pills?) But let’s say our hypothetical patient who doesn’t have a place to live is willing to get a shot every month. (This really happens, too, but not as often.) The challenge here is finding the person every month to administer the shot. Maybe they will come to a clinic or other meeting spot, but their symptoms can make tracking time (and appointments) a challenge. I can go out and try to find them, but if they move around (because of their symptoms, privacy, safety, etc.), there is no guarantee that I will. You know what helps people receive their medications like monthly shots on a routine schedule? Housing.

    But let’s go to an extreme. Let’s say that I’m working with someone who is homeless whose psychiatric symptoms are severe and dangerous. Maybe they have stopped eating because they are certain that they don’t have internal organs. Or how about this: A man is chasing children with a lead pipe because he believes that the kids are government agents trying to kill him. Here I exercise my coercive power: I go through the steps to hospitalize both people against their wills for psychiatric reasons.

    So now they’re not on the streets, they are in a hospital somewhere. Time passes, treatment works, and they no longer need to be in the hospital. So where are they supposed to go upon discharge? They didn’t have a place to live before the hospitalization. In this Project 2025 universe, they don’t deserve housing because they’re not working, so back out onto the streets they go. And the cycle begins all over again.

    Let me also tell you that most people under my care want to work. Because people who are homeless live in the same culture as those of us who have housing, we are all indoctrinated in the idea that there is value in work, and your value as a person involves work. The jobs they often want are often completely reasonable. The person who thinks the aliens will assassinate her? She wants to work as a bookkeeper again. The person who fears the parametric speakers? He’s open to working in the print shop. The person who hears God telling him that he can’t move indoors? He’d like to be a barber. But when you don’t have an address to put on your job application, or you don’t have the money to apply for classes or a business license, how can you make your employment dreams a reality?

    If the goal is to reduce the number of people who are homeless, then accept the research data and make housing more affordable for all. If the goal is to reduce the number of psychiatrically ill people who are homeless, then ensure that they have stable places to live so they can meaningfully participate in treatment.

    But if the goal is to coerce people, with the threat of homelessness as the cudgel, to live according to the values of the Project 2025 authors, then just be up front about it. Just make sure you follow that line of reasoning to its logical conclusion: Put it in writing that you believe some people deserve to be homeless — and thus deserve to die.