Category: COVID-19

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COVID-19 Homelessness Nonfiction Seattle

Dear Maria in March 2020.

Dear Maria in March 2020,

Hi. This is Maria in March 2021. I just want to let you know that you will be alive and well a year into the Covid-19 pandemic. Said nicely: You aren’t prepared for the next 12 months. To be fair, no one is prepared. You and your colleagues who serve people living outside, in shelters, and in permanent supportive housing are going to have a rough year.

First of all, remember that relentless fatigue you felt while you were in training, particularly as an intern? The constant realization that there was so much you didn’t know, the chronic anxiety of what harm you might cause because of your inexperience, and the physical exhaustion that came from working long hours and trying to keep yourself together? There will be many days in 2020 when you will feel something like that. The quality, though, will be different for two main reasons: One, because you do have more experience now, you will have more confidence in what you do and do not know. Two, you unfortunately will not be able to escape this fatigue. It will only worsen as the year goes on. There will be no resolution in March 2021. You won’t be able go off service; there will be no “golden weekends”. You will think about the pandemic and consider what you could or should do about it every single day.

People who receive services in the agency you work in will die from Covid-19. The number will be small—not even double digits—which will surprise everyone, especially you. Initially, you will think the low numbers must be due to luck. Once a Covid outbreak happens in the White House, however, you will recognize the value of the policies and procedures you and the team enacted. You will feel bountiful gratitude to staff for their willingness to follow these protocols, as annoying and inconvenient as they will be. It is because of staff efforts that so few people will get sick.

An uplifting event—one of only a few, I’m sorry to say—will happen in early 2021. You and your teams will establish an in-house Covid-19 vaccination clinic! During those vaccination clinics, staff from all over the agency—older people with various medical conditions, young people who just got out of school, people who left other careers to work in social services, people who do not speak English as their primary language—will come to receive vaccinations. They will express the hearty thanks to you and your staff. You will recognize the depths of their thanks because you will have felt the same way when you get your vaccinations from the beloved county hospital. By March 2021, you and your teams will be eager to vaccinate people receiving care from the agency, but the agency won’t have either the supply or permission to do so just yet.

It will be a terrible year. For many weeks, you will worry you will burst into tears at work. Instead, you will weep at home. It’s the kind of crying where you need to breathe, but all the muscles in your torso contract, so nothing moves. Anger and frustration are your constant companions; what will happen if you let them go? Must you be alone with the grief that you and everyone else feels?

Though few people will die from Covid, people will die. Data will show that the number of people who died in 2020 isn’t greater than the number of people who died in years past, but there will be more deaths on site. People will tumble from windows. The Women in Black will state a stunning number of people—young people, all under the age of 30—died from apparent suicides. The medical examiner will report again and again that someone died from an overdose. Older people won’t exit their apartments; their bodies will be found inside when they don’t respond to door knocks and phone calls.

You will feel anger towards a federal administration that will not demonstrate any concern towards the health and well-being of the nation’s residents. You will witness multiple system failures because there will be no federal coordination or planning. In conversations with state and local public health officials, you will preface your comments with an acknowledgment that they cannot provide optimal support to the community when they are not receiving support or information from the federal government.

Despite your grief and anger, you will often feel gratitude. Is this is a coping mechanism or a genuine reaction? It doesn’t matter. You will be grateful for the generous, non-reactive, and dedicated natures of the colleagues on your teams. You will express thanks that staff don’t quit in droves. You will feel gratitude to people under your care who follow guidance and demonstrate astonishing resilience. You will feel ongoing thanks that no one on staff gets sick and dies. You will be grateful that you still have a a job and are able to buy food and pay your bills when so many others cannot.

I am sorry to say that the pandemic is still ongoing in March 2021. Maria in March 2022 may be able to say more about how much you (and I) have learned and changed. (Perhaps it will be Maria in 2023 or 2025 who will comment on this.)

Do what you can to take care of yourself every day. I might even suggest that you write more, though will understand why if you don’t.

Sincerely,
Maria in March 2021

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COVID-19 Education Medicine Seattle

Information about the Covid-19 Vaccines for a Non-Medical Audience.

For work, I created a presentation about the current Covid-19 vaccines for a non-medical audience. Maybe you will find it helpful, too. Here’s the agenda:

… where King County refers to the county in Washington State where Seattle is located. The presentation reviews the New England Journal of Medicine paper on the vaccine from Pfizer, as well as the data Moderna shared with the FDA. (Note that I made this slide deck near the end of December, so, if you are reading this in the distant future, data included may be different.)

I usually don’t include so much text in my slides. I made an exception here, as there are nearly a thousand people working at the agency and many may not be able to watch and hear me present this live. Enjoy.

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Consult-Liaison COVID-19 Systems

Protecting Mental Health During a Pandemic.

For context for this post: In my opinion, the federal government under the 45th President failed in its pandemic response. The lack of federal leadership, coordination, and interventions have led to ongoing disorganization that adversely affects every single essential worker who currently provides health care and social services.

As the federal government has not provided any coherent response to the actual disease pandemic, I do not expect that it will provide any response to the psychological suffering that has already occurred and will continue to occur due to Covid-19. Since this administration ignored the National Security Council playbook on fighting pandemics, it seems likely that they will ignore resources that describe how to boost the morale and promote the mental health of its citizens.

As I work as a psychiatrist, I wondered in the early months of the pandemic what strategies nations had used in the past to support psychological health. My hope had been to apply these nation-level strategies to the organization I work in.

The resources weren’t hard to find. There were three documents that I found helpful:

Of the three, I found the Pan American Health Organization document to be the most useful. (One wonders if U.S. officials did not deign to read something from “those” countries.) It helped me frame challenges when talking with individuals and teams. It also helped me grasp the horrifying reality and anticipate heartbreaking consequences.

… not all the psychological and social problems that occur can be described as diseases; the majority are normal reactions to an abnormal situation.

This JAMA paper describes an increase in the prevalence of depression symptoms due to the pandemic. I appreciate that the authors did not state that there has been an increase in the prevalence of major depressive disorder. The pandemic is an abnormal situation. We cannot apply our usual definitions when nothing about this year is usual.

In a major catastrophe, grieving means dealing with many other losses and implies a broader, more community-oriented feeling. It implies interrupting a life plan that not only has a family dimension, but also a social, economic, and political one.

We’ve all lost so much. Some people have lost their lives; others have lost their health and wonder if they will ever get it back. People have lost jobs and are distressed about how they will pay for rent and food. Others have lost time and wonder how they will pay attention to things other than work and disease. Kids miss their friends and classmates; parents miss things that their kids don’t realize they’re missing. The use of screens has made life more two-dimensional, though many have lost more than one dimension in their lives.

… mental health plans cannot be limited to expanding and improving the specialized services offered directly to the people affected…

There are multiple reasons for this:

  • There aren’t enough mental health professionals to serve the entire population.
  • Many (most?) people do not need specialized services; they (we) just need more support.
  • Some professionals will diagnose illness and treat accordingly, when illness may not be present. (“When you only have a hammer, everything is a nail.”)
  • Specific communities will often provide more tailored and meaningful support to their members than professionals, specifically when grief is the diagnosis and support is the treatment. (What I say to an Irish dancer may not be as helpful as the support from the rest of the Irish dance troupe.)
  • Mental health professionals should focus their specialized expertise on people who are experiencing more severe symptoms and conditions.

Can and should people with specialized expertise, like psychiatrists, teach and train laypeople to provide support to their communities during and after a pandemic? I think so. (While not related to a pandemic, the Friendship Bench is an excellent example of training laypeople to provide valuable support to others.)

There are three basic messages:
1. We should not think only in terms of psychopathology, but also in broad terms about collective problems.
2. The area of expertise of mental health professionals needs to be expanded.
3. The majority of psychosocial problems can and should be addressed by nonspecialized personnel.

Most psychiatrists, like most physicians, are trained to treat individuals. Pandemics affect populations and our individual interventions are often ineffective and do not scale. Furthermore, some interventions done without care can cause harm (“benzos for everyone!”). Collective problems require collective solutions; expertise must be decentralized and shared; community members can provide good enough, if not better, support. The Psychological first aid during Ebola virus disease outbreaks provides a useful framework for this support.

A good mass communication strategy is critical to maintaining calm and an appropriate emotional state; a well-informed population can act appropriately, protect itself better, and be less vulnerable in terms of psychosocial aspects.

The federal administration has already demonstrated no interest in a “good mass communication strategy”, whether related to Covid-19 or other events. It didn’t have to be this way.

My hope is that, as the “C.D.C. and other public health institutions awaken from their politics-induced coma,” we will see not only the execution of a federal strategy to address the Covid-19 pandemic, but also the implementation of a federal strategy to support the nation’s mental health. We’ve already witnessed psychological stumbling across the population; none of us want to see ourselves, our neighbors, our communities, and those beyond beyond fall further.

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Consult-Liaison COVID-19 Education

Triangle of Thoughts, Behaviors, and Emotions.

diagram showing that thoughts, behaviors, and emotions are all interlinked

(T) = thought
(E) = emotion
(B) = behavior

All are interrelated and we can intervene at any point of the triangle to change the other factors.

Starting with THOUGHTS:

(T) “The federal government, in providing no support or interventions for the pandemic, has abandoned the people of this nation.”
(E) Anger, sometimes rage.
(B) Eat six servings of cookies.
Result? Fleeting pleasure (E) from the taste and texture of cookies, leading to thoughts of, “I ate too many cookies; I should have done something different” (T), which can lead to disappointment and guilt (E).

(T) “The federal government, in providing no support or interventions for the pandemic, has abandoned the people of this nation.”
(E) Anger, sometimes rage.
(B) Write a blog post about it.
Result? Satisfaction (E) from accomplishing a task that helps me feel more calm (E) and may help other people try something different so they can feel less anger (T).

(T) “The federal government, in providing no support or interventions for the pandemic, has abandoned the people of this nation.”
(E) Anger, sometimes rage.
(B) Go out for a walk.
Result? Sense of calm (E) due to changing my enviroment and recognizing that I am doing something to improve my health (T).

Sometimes we don’t recognize our emotions, which could result in events like this:

(T) “The federal government, in providing no support or interventions for the pandemic, has abandoned the people of this nation.”
(B) Throwing something across the room.

Starting with EMOTIONS:

(E) Grief and anger.
(B) Pull the blankets over your head.
(T) “I don’t want to get out of bed and deal with all the things related to the pandemic.”
Result? Loitering in bed (B) because the world feels overwhelming and I feel helpless (E), which makes me believe that things won’t get better (T).

(E) Grief and anger.
(B) Go out for a walk.
(T) “Look at the leafless trees, how the color of the fog matches the color of the water, how the world seems to reflect our collective mood….”
Result? Recognizing that I at least took a step to take care of my mind and body (T), which helps me feel some measure of serenity and gratitude (E).

(E) Grief and anger.
(T) Think about the how the emotions of grief and anger affect my thoughts and behaviors.
(B) Write a blog post to clarify my thoughts, emotions, and behaviors.
Result? Feeling hope (E) that maybe these words will help other people feel more empowered, less lonely, and less angry (T).

There are some professionals who believe in the “primacy of thought”, meaning that they believe that thoughts precede all emotions and behaviors. I do not hold this view, as (a) our current understanding of thoughts center on the use of language, and sometimes we all struggle to name the emotions we feel and (b) reflexes circumvent thoughts (i.e., we yank our hands away from the flame without thinking about the fire burning our fingers).

Starting with BEHAVIORS:

(B) Clenching my jaw and shoulders.
(E) Anxious. Maybe angry. Maybe sad, particularly since many cultures tolerate and accept anger more than sadness.
(T) “Let’s get up and drink some water. Changing positions will help me relax my jaw and shoulders.”
Result: Momentary release of muscle tension (B) that may help reduce anxiety (E).

(B) Checking e-mail way too many times in an hour to learn updates about people staying in the shelter who may have tested positive for Covid-19.
(T) “Oh, please say that no one tested positive, please don’t let anyone have Covid….”
(E) Anxiety and fear. Probably an attempt to limit prevent guilt, too.
Result: Feeling annoyed (E) with myself for trying to control things that I cannot control (T), then resolving to get up and do something else away from the computer (T) and encouraging myself to adhere to a schedule of checking e-mail (B) so I don’t clench my jaws and shoulders (B) due to anxiety (E)

Thanks for reading this and working through this triangle with me. (This triangle forms the basis of cognitive-behavioral therapy (CBT), in case you wish to learn more.)

Categories
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.