Category: Consult-Liaison

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Consult-Liaison COVID-19 Homelessness Medicine Nonfiction Seattle Systems

“The Impact of Covid-19 on Homeless Services in Seattle.”

On Friday, I presented Grand Rounds to an agency in New York City. The title of my presentation was “The Impact of Covid-19 on Homeless Services in Seattle, Washington”. The audience was comprised mostly of psychiatrists who also work with people who are currently unhoused or have been homeless in the past.

In some ways, this presentation was easy to create: I simply described the agency I work for and walked the audience through the timeline of events:

While the Seattle-King County region was scrambling due to the first death from Covid-19, the first case of Covid-19 was diagnosed in New York City on March 1.

In other ways, this presentation is the only one I’ve made where I had to take breaks while making it because of anger, grief, and sadness.

The month of March was hectic for us and everyone else: We tossed routine policies out the window and scribbled new ones down. We shattered many of our old habits and hastily introduced new practices. Our collective workload increased significantly as we tried to be as flexible and responsive to the changes that were coming at us. We watched systems grind to a halt because systems can’t change that fast: We had to buy hand sanitizer from local distilleries and we donated N95 masks to hospitals. Systems that had long failed us suddenly had the harsh glow of media light on them: In all of Seattle, there were only five bathrooms with hand-washing sinks that were open 24/7. Congregate shelters, where over 200 people had no choice but to share one giant room and one bathroom, suddenly became unacceptable because the beds were not at least six feet apart.

And, yet, eight months later, not much changed. We haven’t had the opportunity to abandon restrictions; many of these new practices are now status quo because the situation hasn’t gotten better. I was honest with the audience: There was no resolution or hopeful conclusion at the end of my talk. Why was that? How could it be that, eight months later, things hadn’t actually changed much?

The audience said nothing. What is there to say? The lack of ownership and coordination at the federal level is the same now as it was in March/April. New York City has significantly more resources than Seattle, though those resources only go so far while SARS-CoV2 can cross state lines and national boundaries when no barriers are erected and no interventions happen. If people in a boat are not rowing in the same direction—or if people aren’t rowing at all—then the boat and everyone in it wastes a lot of time and energy.

I was surprised by the gifts of validation from the audience. Yes, we all work as psychiatrists and the last time most of us saw someone get intubated was when we were residents. However, we all recall doing consults on people in the ICU who were sick. Ostensibly, we were there to take care of the patient and maybe their family members. We also know, though, that an important (and often unspoken) part of psychiatric consults is to support the treating team.

We all have a sense of how terrible it is for the treating teams. These are the reasons why we desperately try to keep people healthy and out of hospitals. We know that our contributions are small—most people don’t live on the streets, in shelters, or in supportive housing; most people don’t have diagnoses of schizophrenia or severe substance use disorders—but we also know that our people are often maligned when they pass through the doors into traditional health care systems. We all have a sense of how terrible it is for our people. We also know that, due to the stress of living marginalized lives, our people often have more severe health conditions. They already have many risk factors that increase the likelihood of complications and death due to Covid-19. We’re trying to mitigate the stress of everyone involved.

It’s heartbreaking, terrible, and unfair.

To end the talk on a positive note, I mentioned several things I am grateful for:

  • The rainy season has arrived in Seattle and I get to sleep in a dry bed indoors.
  • I have confidence in where I am going to sleep tonight.
  • I have a job and can pay my bills.
  • I know I will eat (again!) today.
  • There now exists technology where I can speak to an audience of colleagues on the other side of the continent!

These both mean a lot and nothing at the same time.

In the meantime, we continue to do what we can while we wait.

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Consult-Liaison COVID-19 Homelessness Nonfiction Reflection

How One Psychiatrist is Coping with the Pandemic.

Context: I work as the medical director for an agency that provides shelter, permanent supportive housing, and crisis and behavioral health services. I also do clinical work there as a psychiatrist, where I see people in shelter, housing, and in clinic.[1. A few of the people I see agree to use telehealth, but those who have phones tend to prefer telephone over video.]

Like many other essential workers, my colleagues and I have worked long hours, spent even more hours worrying and planning, and have had to figure out how to manage ourselves in the midst of uncertainty. Though we have been fortunate to be able to move many people out of congregate settings into motel and hotel rooms,[2. Here are some anecdotes about what happens when people move from a congregate setting into their own room with a private bathroom, a bed, and a door that locks: 911 calls go down. People who previously did not routinely take showers start showering daily. Some people use less drugs; some people stop using drugs and alcohol completely. People start planning and taking steps towards goals, such as school, employment, financial planning, relationships.…] we still have some people staying in congregate settings, which is undesirable during a pandemic. Many of the people who stay in shelter and housing have significant and chronic medical problems, which makes us nervous that they will have worse outcomes if they contract Covid-19. I express gratitude every day—though maybe not out loud—for the very few cases that have occurred within the agency. With over 500 people in shelter (though, again, many have moved into motel and hotel rooms) and over 1000 people in permanent supportive housing, plus hundreds who have different living circumstances but are enrolled in our clinics, we thus far have had fewer than 50 positive cases of Covid-19.

The strain on staff is significant. People will have different memories of this pandemic: Some people (reportedly; I don’t personally know anyone who falls into this group) have expressed some relief during this time, as they have the time and resources to do things like learn new languages, travel to cute cabins in remote places, and other things that seem like fiction to me. Others have had to learn how to navigate congregate settings and provide care to people with significant health conditions in the absence of national guidelines and plans.[3. Do I sound resentful? I think the underlying emotion is disappointment.]

I don’t think people who are trained as psychiatrists are necessarily more skilled at coping during a pandemic, as none of us in the US[4. Recall that there have been epidemics in the recent past. I found Mental health and psychosocial support in ebola virus disease outbreaks and Protecting Mental Health During Epidemics helpful… and don’t get the sense that the CDC or other federal agencies have reviewed these articles and/or are interested in providing this sort of support to any of us. Am I still sounding resentful?] have ever lived through one. Here’s what I’ve been doing (or at least trying to do) to manage myself:

Get up early to do stuff to take care of me. (Because I wasn’t born a doctor and, God willing, I will be able to retire before I die.) I aim to get out of bed at 5am. This tends to be the quietest time of day and few, if any, people want or need my attention. The long summer days in Seattle make getting up that early easier, but, let’s be real: Sometimes the spirit is willing, but the flesh is weak.

Exercise. Sometimes this means what most people mean by the word “exercise”, like push-ups, squats, etc. Sometimes this means “movement”, which can be a one-person dance party. The face covering mandate has interfered with my willingness to run. I do want to run, but I haven’t been able to get over the hump of running while wearing a mask. (I live in a neighborhood where there are at least some people around, even at 5am. I am committed to wearing a mask when I am out and about.)

Invest time on hobbies. During those early morning hours I study Chinese to improve my literacy. Though I haven’t posted much here, I am trying to write daily (I continue to use 750 Words, which helps me with quantity, even if the quality is terrible).

Eat cookies. Sometimes I eat only a few; sometimes I end up eating over half the box. This is not the greatest coping mechanism, though it is something I have done because my frustration tolerance is sometimes low and impulse control is hard.

Walk during meetings. I’m that person who often joins a video call by telephone. This is related to technological deficits, as well as willfulness: If the meeting doesn’t require video presence, then I will take the less stimulating option of audio only. I occasionally quip that I’m like tuna: If I stop moving, I will die. If I’m able to walk during a meeting, that not only helps me dispel anxious energy, but also reduces the likelihood that I will get distracted by e-mail or other tasks during the meeting. This also helps me feel like I’m taking advantage of the summer weather while we still have it.

Talk to myself. Out loud. And often in an effort to meet and greet whatever emotion I’m feeling. (Hang in there with me.) Earlier this week I exclaimed much louder than I intended, “I feel so anxious!!!” and then proceeded with this conversation:

Hello, Anxiety! What brings you here today? Are you enjoying this summer weather? What are you worried about? What are you trying to tell me today? What can I do to help you feel better?

This is a concrete way to acknowledge whatever it is I am feeling because avoiding emotions is generally impossible and ineffective: It’ll come out some other way (e.g., eating half a box of cookies).

Observe the sky. The sky is bigger than me. The pandemic is bigger than me. The sky changes. The pandemic will change. I want to witness the sky. I want to witness the pandemic. To stop and look at the sky—the clouds, the moon, the sun, the colors—allows me to pause and claim time that sometimes never feels like mine.

Try to make other people laugh. During this time of differing degrees of isolation, sharing laughter with someone is a treasure. Sometimes the humor is admittedly dark, though I much prefer that people get it out of their systems with trusted confidants, rather than on others (like patients).

Sleep. Sometimes sleep doesn’t feel restful—I am sorry to confess that, sometimes, my dreams center on Covid-19—and occasionally I wake up from sleep thinking about all the things I should do related to the pandemic. Having a fixed “get out of bed” time helps with regulating sleep.

Thank people. There is no way any of us could manage this ridiculous time by ourselves. There are so many people to thank: The janitors who clean and sanitize spaces to keep us all healthy. The grocer who is there so you can buy food. The doctors and nurses who provide Covid-19 testing and counseling. The sanitation staff who continue to empty out the garbage and recycling bins. The plumbers who fix emergency sewage leaks. The person on the street who acknowledges you and makes an effort to stay at least six feet away. The bus drivers who continue to transport essential workers around the city. The first responders, including police, who are kind to the seemingly increasing number of people who are sleeping outside. God/the Universe/whatever Deity that I still have a job, a stable place to live, and, thus far, good health.

Do you have other suggestions?

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Consult-Liaison Medicine Nonfiction Reflection Systems

Mental Health Awareness Month During a Pandemic.

It’s been Mental Health Awareness Month during a pandemic.

When we look back at this time, people will have different memories of their experiences: Some will remember changes in job duties and extra time for leisure. Others will remember intense pressure and stress as essential workers. Still others will remember the despair due to unemployment and financial worries. We all will remember how the COVID-19 pandemic disrupted our routines and affected our mental well-being: It impeded our freedom to go outside, abilities to pursue the activities we want to do, and usual opportunities to express ourselves.

Wearing a face covering may mask the expressions of displeasure and anxiety on our faces, but it does not diminish the discomfort and worry we feel within. As many in our community try to avoid illness, some will fall ill and and others will succumb to death. There are reasons to grieve.

Because discomfort and anxiety are internal experiences, our culture often frames these reactions as a personal problem—a disorder of one individual mind. However, this pandemic has had adverse effects on everyone. Many of us are feeling the same emotions. These are unsurprising reactions to an unexpected and (hopefully) once-in-a-lifetime situation.

We must avoid medicalizing these reactions. Individuals receive psychiatric diagnoses within specific contexts. Our reactions as a result of the the pandemic are collective experiences within the same context. It is unfair to argue that all people experiencing distress during this pandemic have psychiatric disorders. This argument also undermines opportunities for communities to support their own members who are suffering.

Not all distress reaches the threshold for a clinical diagnosis, especially during extraordinary times. While mental health professionals can help people who feel anxiety and sadness, that doesn’t mean that increasing the number of mental health professionals and their services is the primary solution during this pandemic. Most people feeling worry and anguish now will not need specialized services. Support from people from the same culture or context can and will help people tolerate and then grow from these emotional experiences. Relationships, stemming from faith traditions, hobbies, cultural groups, and friendships, are invaluable during these times of stress, loss, and grief. Providing education and resources to the community at large, such as through programs like Mental Health First Aid,[1. You can learn more about Mental Health First Aid here. I have no affiliation with them.] can help ensure that those in our community receive attention and emotional support. Communities can also provide support through other concrete means, such as financial donations, food assistance, and employment opportunities. Though individuals should remain six feet apart, the distance does not dilute the healing power of relationships.

To be clear, some individuals do experience levels of distress due to the pandemic that warrant professional mental health intervention and support. This does not mean that they have meaningless relationships or are “weak”. We often do not know the struggles people endure. Complications from the pandemic can overwhelm already strained internal and external resources.

We are living through an extraordinary time in history. We are all experiencing psychological stress, though perhaps at different frequencies and intensities. There is nothing routine about our external circumstances, so there is nothing routine about our internal experiences, either. The pandemic has demonstrated how interconnected we are. Let us focus not on individual distress, but focus instead on how we can all help each other during this difficult time. This will not only bolster the mental well-being of others, but will help our mental health, too.

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Consult-Liaison COVID-19 Education Medicine

Vulnerability and Resilience.

We had our medical staff meeting on Friday, which was the first time we had all convened since the COVID-19 epidemic was announced in Seattle-King County.

I shared with the team the following framework, which is from a paper about demoralization.[1. It is common for other medical specialties to request a psychiatric consult for a patient who seems depressed. Consultation psychiatrists often learn that it is demoralization, not depression, that results in consult requests. (Though demoralization and depression share features, most psychiatrists agree that they are distinct conditions. These distinctions are discussed further in the paper.)]

The authors note that:

Demoralization refers to the “various degrees of helplessness, hopelessness, confusion, and subjective incompetence” that people feel when sensing that they are failing their own or others’ expectations for coping with life’s adversities. Rather than coping, they struggle to survive.

and later comment that “[a]cknowledging suffering and restoring dignity are potent in strengthening a patient’s resilience to stress.”

This is the valuable table from the paper:

During this extraordinary time of the COVID-19 pandemic, this framework may help you, whether you work in medicine or not. Sometimes the act of putting words to our emotions can alleviate our discomfort and help us feel more empowered.

We may all feel overwhelmed with the emotions and experiences on the left side of the table. Many, if not all, of us during the past few weeks have felt confused, helpless, and resentful. We have felt lonely and isolated, though we may recognize that we’re lonely and isolated all together. Sometimes fear gets the best of us and we wonder if anything we do matters. Vulnerability is often an uncomfortable position.

Remember that there are things we can all do to nudge us over to the right side of the table. Thanking others helps us reconnects us with people. Looking for the helpers can inspire us and give us hope. Taking a breath (or two or three) and slowing down helps us pursue clarity so we can find the signal in the midst of all the noise. The choices we make in each moment can help us recognize and cultivate our own courage and resilience. How we choose to react to what’s happening around us can shape our purpose. Do we react in anger or kindness? Do we have faith that we will do the best that we can in face of uncertainty, or do we assume the worst in others and ourselves?

To those of you who work in emergency departments and hospitals, regardless of your role, we thank you for your courage and efforts. We in outpatient settings are doing our best to keep people healthy and out of EDs. We all look forward to the time when this will be just a memory.

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Consult-Liaison Education

Most People Do Okay Most of the Time.

Because May is Mental Health Month, I was asked to present information about mental health to a lay audience. This is both an exciting and daunting task. I imagine it’s like asking someone to talk about fish. There are so many kinds of fish! They live in many habitats! Some of them look more like snakes than fish! There are so many directions to go.

I have given a “psychiatry 101” talk to many non-clinical audiences in the past. While reviewing my notes, it became clear that, while this presentation offers useful introduction, the underlying message is that psychiatry focuses on pathology. (This is a common theme in medicine: Doctors are often much better at looking for and finding things that are wrong than at pointing out and supporting things that are going well.)

So, here are three things about psychiatry that don’t focus on pathology:

People are resilient. I remain amazed with the capacity people have to take care of themselves and others when everything is falling apart.

Even though the majority of people experience terrible trauma—war, rapes, natural and unnatural disasters, etc.—most of them will not develop post-traumatic stress disorder. Most people at some point will experience heartbreaking grief following the death of a loved one, but the vast majority will not develop major depression or complicated grief.

People go to work, take care of children, and support their friends despite hearing disturbing voices, thinking about suicide, and feeling unsafe in public. They find ways to help themselves that have nothing to do with formal psychiatric interventions: The man hearing disturbing voices might put on headphones and play the same song over and over again. The woman thinking about suicide might sign up for an extra volunteer shift at the animal shelter so she is around other people. The military veteran might sit in the rear corner of the movie theatre.

Most people do okay most of the time.

It’s okay to not feel good. The goal of feeling happy or serene all the time is an impossible goal. Everyone at some point thinks disturbing thoughts. Just because it seems like everyone else is happy or serene doesn’t actually mean that they are happy or serene.

While our thoughts and emotions may seem illogical at times (“why am I thinking about that?” “why do I feel this way right now?”), that doesn’t mean that something is wrong. Sometimes your thoughts and emotions are treasure troves of information: Your internal experiences give you information about the person you’re talking to, the situation you’re in, and what your next steps should be.

The definitions of psychiatric disorders are not solely limited to “not feeling good” or disliking an emotional experience. Sometimes we don’t feel good. Sometimes that lasts longer than we want. But that doesn’t mean you have a terminal emotional illness.

Most people do okay most of the time.

Behaviors serve a purpose. We all do things that other people think are weird. The spectrum of weirdness is wide, but, if we are lucky to learn more, we can find out the basis behind the behavior.

Why doesn’t she speak up more? Because she believes that no one will find her remarks helpful.

Why won’t he wear anything other than sweatpants? Because he wants to spend his money on fancy cars.

Why won’t she stop smoking methamphetamine? Because it helps her stay awake at night so the men won’t rape her.

Why does he apologize all the time? Because, as a child, he learned that if he apologized a lot, he might be able to stop his father from beating him.

Why does he say things like, “I know a lot about wind” and “I know more about drones than anybody”? I mean, who knows. Is this the only way he knows how to interact with other people? Have these sorts of boasts helped him succeed in the past in relationships and business deals?

The definitions of psychiatric disorders are not solely limited to “doing weird things”. If we do certain things that help us or get things that we want, we will continue to do those things. Sometimes we continue to do those things even when they no longer help us as they once did. But that doesn’t mean you have a terminal psychiatric illness.

Most people do okay most of the time.