Categories
Policy Reading

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

The word “mental” appears 16 times in “Mandate for Leadership: The Conservative Promise”, better known as Project 2025.

It first appears in the foreword on page 4, under the first promise to “restore the family as the centerpiece of American life and protect our children”:

Today, the American family is in crisis. Forty percent of all children are born to unmarried mothers, including more than 70 percent of black children. There is no government program that can replace the hole in a child’s soul cut out by the absence of a father. Fatherlessness is one of the principal sources of American poverty, crime, mental illness, teen suicide, substance abuse, rejection of the church, and high school dropouts. So many of the problems government programs are designed to solve—but can’t—are ultimately problems created by the crisis of marriage and the family. The world has never seen a thriving, healthy, free, and prosperous society where most children grow up without their married parents. If current trends continue, we are heading toward social implosion.

Let’s take a closer look at this with a critical eye:

Yes, according to the CDC, in 2022, about 40% of all children in the US were born to unmarried women. Let’s be charitable and assume that the author made a rounding error: Just under 70% of these “nonmarital births” occurred in Black women. For what reason did he highlight the percentage for Black women? The percentage for American Indian and Alaska Native women was about 68%. The second lowest percentage was among White women, which was just over 27%.

It is beyond the scope of my expertise to remark if fatherlessness is “one of the principal sources of American poverty, crime… rejection of the church, and high school dropouts”, but I can comment on “mental illness, teen suicide, [and] substance abuse”.

(A quick skim of data, though, shows that “Christian women in the U.S. are more religious than their male counterparts” and “women are more likely than men to say they attend worship services regularly”. From this data it seems that fathers are more likely to reject the church.)

This paper from 2013, The Causal Effects of Father Absence from the Annual Review of Sociology, tries to correct for flaws of past studies that tried to discern what happens to kids when their fathers are absent. From their work the authors conclude there is:

  • strong evidence that father absence negatively affects children’s social-emotional development, particularly by increasing externalizing behavior (where “externalizing behavior” means aggressive and attention-seeking behavior, in contrast to “internalizing behavior”, which manifests as anxiety and depression)
  • strong evidence that father absence increases adolescents’ risky behavior, such as smoking or early childbearing
  • [some suggestion] that the psychological harms of father absence experienced during childhood persist throughout the life course

Again, let’s be generous towards the author and assume that he equated “externalizing behavior”, “internalizing behavior”, and “risky behavior” to “mental illness[es]”. (Behaviors alone do not always constitute mental illnesses.) Yes, research supports the idea that an absent father results in behavioral problems in children. However, fatherlessness itself may not be a “principal source”. I could not find robust studies that examined any relationship between motherlessness and mental illness. (Single mothers are far more common than single fathers. Motherless children may exhibit these same worrisome behaviors.)

I am not able to find data that directly links absent fathers to teen suicides in the US. (There is a paper that describes “parental absence predicts suicide ideation through emotional disorders” in China, though this doesn’t focus solely on absent fathers. A paper from the US in 1998 concludes that “dramatic increase in youth suicide during the past three decades seems unlikely to be attributable to the increase in divorce rates”.) If there is an indirect linkage, it is likely mediated by other factors that led to the absence of the father.

While it is true that no governmental program can “replace the hole in a child’s soul cut by the absence of a father”, it is not only the absence of a father that cuts holes in children’s souls. No program, whether offered by the government or a church, can replace a missing father, mother, or other parental figure. Programs are not people. So let’s talk about actual people.

Over two-thirds of children live with married parents. The nonmarital birthrate continues to decrease over time. Divorce rates are also decreasing. In light of these facts, that “fatherlessness” is actually decreasing, what “crisis of marriage and the family” and pending “social implosion” is the author talking about?

The authors of Project 2025 do not seem to recognize what the authors of “The Causal Effects of Father Absence” declare: “family disruption is not a random event and because the characteristics that cause father absence are likely to affect child well-being through other pathways.” (emphasis mine)

If they are concerned about “poverty, crime, mental illness, teen suicide, substance abuse, rejection of the church, and high school dropouts”, there are more fruitful ways to address these problems:

Reduce the likelihood that children experience adverse childhood events. People with fewer adverse childhood events are less likely to develop mental illnesses, like depression, and less likely to attempt or die by suicide. (Fathers can be sources of adverse childhood events. There is research that shows that youth with “harsher fathers” engaged in more offending behaviors and used more substances than youth with “absent fathers”. Sometimes, unfortunately, fatherlessness is the better option.)

Promote health equity. Improving physical environments where people live, work, and play improves mental health and well-being, as does access to education. People want to work and learn in healthful spaces. Reducing income equality also improves physical and mental health. People want enough money to live in safety and comfort. Ensure that people have easy access to health care when they need it, but, even better, create a healthy nation where people won’t need to routinely see a doctor.

Promote social connections to reduce loneliness. People who are socially isolated are more likely to develop physical illnesses, such as heart disease and diabetes, as well as mental illnesses, such as anxiety and depression.

Note that these interventions require looking beyond the immediate family, and certainly beyond the presence or absence of a father. We live in communities. Because we all live in an interdependent networks, if the community is experiencing crisis, it will impact families. So why does Project 2025 instead put so much focus on the father?

Categories
Homelessness Observations

Tents.

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.

Categories
Homelessness Policy Public health psychiatry Systems

Homelessness and the Supreme Court.

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?

Categories
Education Observations Public health psychiatry

What is Mental Health? (03)

Let’s take a look at the last figure from the paper What is mental health? Evidence towards a new definition from a mixed methods multidisciplinary international survey. The authors call this the Transdomain Model of Health:

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.

Contrast this Transdomain Model of Health with this recent Psychiatric News article, Lifestyle Psychiatry Emphasizes Behaviors Supporting Mental Health.

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.

Categories
Education Medicine Policy Public health psychiatry Systems

What is Mental Health? (02)

To continue from my last post about “what is mental health?” and “what am I doing?”, let’s look at another figure from the paper What is mental health? Evidence towards a new definition from a mixed methods multidisciplinary international survey:

Figure 2C

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.

(3) While media reporting often focuses on guns and homicide, firearms cause more suicides than homicides.