Consult-Liaison Education Observations

Racial Slurs and Psychiatric Illness.

Photo by Mary Jane Duford

It doesn’t happen often, but it does happen: People have directed racial or misogynist slurs at me. (I’m an equal opportunity target!) When they announce their perspectives, they are almost always shouting and their tones of voice suggest anger and disgust.

Rarely do people with psychiatric conditions, such as schizophrenia or bipolar disorder, express displeasure with my race or sex. I can only think of three examples when this occurred (though, to be fair, I just don’t remember the other times when this has happened):

  • A woman in a crisis center who insisted that I was Bruce Lee’s sister, then proceeded to scream, “Chink!“, when I told her I was not;
  • A man with dementia in a hospital who felt compelled to tell me (and only me) in a loud voice about the “gooks” he killed during war; and
  • A man in a jail cell in psychiatric housing who, upon seeing me walk onto the unit, made loud comments about “fucking dykes with short hair“.

It is far more common for people out in the community to shout racial and misogynistic slurs to me in passing. Sometimes their apparel is shabby and soiled; more often, their clothes are clean and their cars are shiny.

My data comes from an N of 1, but this is how I think about it: Yes, it is possible for someone with a psychiatric condition to use speech brimming with prejudice only when they are experiencing acute symptoms. However, most people with psychiatric conditions, in my anecdotal experience, do not, regardless of acute or chronic psychiatric symptoms. If they do have prejudices, they are able to keep them to themselves, even when they are unable to contain any delusions. If they are expressing ideas about people, they tend to be specific to how an individual relates to them (e.g., that person is trying to kill me; that person knows I don’t have internal organs; those people can hear my thoughts; etc.).

Could it be that the use of racial slurs in of itself reflects mental illness? I don’t think so. Humans are adept at creating and using categories. We have all created and applied useless categories. For example, I am on Team Candy Corn. This team serves no purpose and it should not be a point of pride, but here we are. There is, of course, a difference between Team Candy Corn and Team Nazis, though the underlying principle of creating categories and then putting people into them is the same. (On Team Candy Corn, we do not hate and dehumanize.)

People with psychiatric conditions like schizophrenia, like most other people, can feel hate. People with psychiatric conditions like schizophrenia, like most other people, are not hateful.

COVID-19 Education Medicine Nonfiction Observations

Three Observations.

I. He was standing outside of the homeless shelter. The bouquet of bright tulips in his hand were splashes of color against the tired cement walls and grey skies.

A man staying in the shelter ambled towards him. “Hi,” he greeted, his eyes gazing at the buds of the young tulips. “Is today a good day or a bad day?”

The shelter manager laughed and warmly responded, “Why are you asking me that?”

“Because you got flowers….” the man said.

After a pause, the shelter manager reassured, “These are ‘congratulations’ flowers.”

“Oh, okay, good,” the man said. The wrinkles around his eyes revealed the smile that his mask obscured. “Congratulations.”

II. Earlier this year, I wrote:

We know from history that pandemics do not last forever. The 1918 flu pandemic lasted just over two years. The 2002 SARS outbreak was declared over in less than two years. The 2013 Ebola epidemic persisted for less than three years. All things change, all things end.

By the end of 2020, I had already read some literature about protecting mental health during epidemics. This information gave me confidence to share with others that, yes, pandemics do end in two to three years’ time.

Last month, I finally embraced “that the Covid pandemic will likely end for the majority of people in the US before it ends for those of us who work in and use safety net programs“. And only in the past week did I finally recognize that these past epidemics and pandemics of course did not end in two to three years. That just seems to be the duration of time that societies can tolerate abrupt social restrictions and consequences.

I interpreted the published timelines as start and end dates of biological phenomena.

I feel foolish for having done so. Time is an artificial construct, so of course the expiration dates of pandemics are artificial constructs, too.

Someone somewhere can explain why two to three years is the maximum amount of time that people and societies can tolerate drastic changes before reverting “back to normal”. Of course, there is no way any of us can ever go “back”, pandemic or not.

III. The author of this tweet has since deleted it for reasons that will be apparent (profile photo modified by yours truly):

The tweet is dehumanizing, but that’s not actually the chief reason why this struck me.

The author of this tweet is a Big Name in the field of psychiatry. He is the chair of a Fancy Pants psychiatry department at a Hoity-Toity institution. He’s published seminal papers in the field related to psychotic disorders.

Over ten years ago I completed a fellowship at this institution (this is not meant to be a humblebrag, I promise) and I have a distinct memory from when Dr. Big Name when he spoke at the graduation ceremony. He grasped both sides of the lectern, leaned forward in his dark suit, and glowered at the audience.

“As a graduate of This Place, you now have a responsibility to This Place. Whatever you say, whatever you do, is a reflection on us. Make sure you don’t ever do anything that will reflect poorly on This Place.”

It was strange and uncomfortable. His warning about reputation management during a rite of passage was, in of itself, something that didn’t reflect well on That Place. Which is exactly why this memory resurfaced when I saw his tweet.

May God spare all of us and may we all avoid these errors, in public and in private.

COVID-19 Education Public health psychiatry

Reactions and Behavioral Health Symptoms in Disasters.

The Washington State Department of Health started posting Behavioral Health Monthly Forecasts in April 2020. Two disaster psychologists, along with other staff, compile and share useful information such as the anticipated course of psychiatric symptoms across the population, how different populations might manifest their distress (e.g., children), and data related to changes in substance use and firearm purchases. It makes for interesting reading, though it’s frequently a bummer.

One chart that appears every month is “Reactions and Behavioral Health Symptoms in Disasters”. In the inaugural issue in April 2020, the forecast oriented readers to general model from SAMHSA[1. SAMHSA is the Substance Abuse and Mental Health Services Administration. What a shame that it is a distinct department from the Centers of Disease Control and Prevention (CDC). The mind remains split from the body in our administrative and health care systems, which is why there is no formal framework for public health psychiatry.] of reactions in disasters:

Note that there is no indicator here about where Washingtonians were at that time. The Y axis uses color to depict emotional states and the X axis, so optimistic, has only a notation to mark one year.

In May 2020, the forecast made a proclamation about where Washingtonians were. It was a warning: We were on the precipice of disillusionment:

We braced ourselves for this. Yes, we had witnessed heroism from so many, whether health care workers or first responders or neighbors dropping off food for those who were medically vulnerable or distilleries producing hand sanitizer or seamsters and seamstresses joining brigades to make cloth masks. Of course this level of concern and anxiety was unsustainable. How bad could it get?


By December 2020, we were in a trough of disillusionment and it felt like it:

Thousands of people were dying a day in the US and other countries around the world. Hospitals were overrun with sick people. People were starting to leave their jobs due to overwhelm. When would the vaccines become available? I remember looking at this graph and thinking, “I thought the graph last month had us in the nadir of disillusionment.” But there was a branching of lines! Maybe we, as a state, would follow the yellow line and things would improve for us all, regardless of station in life.


A terrible winter passed. The days got longer, there were more opportunities to be outside, many people got vaccinated… but the yellow line never manifested for those in my professional and personal communities. By June 2021, we were still in a trough:

In retrospect, that “secondary honeymoon” was accurate. All the numbers we hoped would drop, did: Reproductive number, cases, hospitalizations, and deaths. People in the Seattle-King County area were getting vaccinated. But so many of the people under our care were dying from overdoses, suicide, and chronic medical diseases.

Then came Delta, Omicron, more cases, hospitalizations, and deaths. Health care workers and others left their jobs out of frustration and demoralization. A contingent of people continued to decline vaccinations, despite knowing the possible outcomes… including chronic disease and impairment that still has no effective treatment.

When the December 2021 graph came out, someone observed, “The trough just keeps getting longer.” I wondered who on Earth was experiencing the benefits of “reconstruction”.

I have never had so many people under my care die during a comparable period of time. At least 10 of my patients have died since the beginning of the pandemic; the first death occurred in July 2020. The most recent death (that I am aware of) happened in November 2021. None of these people died from Covid. They either died by suicide, overdose, or their chronic illness collided with an acute, fatal event.

We know from history that pandemics do not last forever. The 1918 flu pandemic lasted just over two years. The 2002 SARS outbreak was declared over in less than two years. The 2013 Ebola epidemic persisted for less than three years. All things change, all things end.

I, like so many others, hope that we all will exit this trough sooner than we anticipate. I worry about the psychological consequences of this pandemic in the years to come. We continue to focus on the viral pandemic; the psychological pandemic has already arrived. We have yet to see an organized response to that.

COVID-19 Education Nonfiction

The Pandemic and DBT Skills.

If you look at my archives, you can tell when the burden of the pandemic (whether due to the pandemic itself or the consequences of it) became great: Weeks or months went by without a post. This doesn’t mean I stopped writing; I just stopped posting. Though it is true that some writing (i.e., ranting, rambling) is better kept private, my lack of posting was chiefly due to fatigue. One must think about something to write about something and, you know, I, along with everyone else, am tired and cognitively impaired.

While walking along the still waters of Lake Washington with a friend recently, we reflected on the endless opportunities to practice dialectical behavior therapy (DBT) skills throughout the pandemic. I had the good fortune to learn about and practice DBT for a full year of my psychiatry residency training; I also led the DBT skills training group. As such, I taught the skills to myself over and over again (as that, for me, is the only way I feel comfortable teaching these skills to other people). To the group I often said, “I use these skills all the time.” They may have thought I was telling a white lie, though I was not: I used them all the time and continue to use them now.

Mindfulness. In DBT, this refers to paying attention, without judgment, to what’s happening right now. (See “Right now, it’s like this.”) When we give our attention to what is happening right now, we can witness the events that are (or are not) happening, our reactions to those events, and other “things” we might be adding to the situation. (Our minds are miraculous thought-generating machines, just as our hearts are amazing pumpers of blood. That’s just what they do.) We cannot take next steps if we don’t know what’s happening right now. For example, if a friend is trying to give you directions, but you have no idea where you are, you and your friend will have a hard time finding each other.

The underlying dialectic in DBT is acceptance versus change. If you don’t accept that you don’t know where you are, you cannot change. If I insist that I’m in Los Angeles, even though I’m actually in Seattle, then I am in for a lot of suffering as I try to get to Diddy Riese Cookies by public transport. It is only when I accept that I’m in Seattle that I change and, instead, go to Hello Robin Cookies.

Yes, it’s hard to give our attention to the pandemic and the illness and deaths it has caused, American politics and the ensuing vitriol, and the suffering that both (and other events) have wrought. Acceptance doesn’t mean agreement. Without acceptance, we cannot take next steps.

Distress tolerance. The acceptance described above is a form of distress tolerance (and, in DBT parlance, is called “radical acceptance”). Distress is difficult to tolerate; who among us wants to feel distressed? Wouldn’t you rather feel serene or joyful? Sometimes we worry that the distress will overwhelm us, that the shame or anger will consume us and never go away. Distress tolerance involves mindfulness to attend to what is happening right now, accepting that right now, it’s like this, and then choosing how to cope with the current reality. (See Viktor Frankl’s comment about the space between stimulus and response.) We can’t evade distress. We can choose how we respond to it.

Last winter, one strategy I used to manage my distress was eating a lot of carbohydrates: Pizza, burgers, noodles, dumplings, and my beloved cookies. I understand why I chose that strategy (and it’s one I still fall into on occasion), but it’s not one I want to repeat this year (largely because it didn’t actually reduce my distress much). Oddly enough, the distress feels less acute and piercing this year, perhaps because it is impossible to maintain those physiological and psychological levels of stress for a prolonged period of time. It may also be that I have come to embrace that yes, we all can die at any moment and, thus, we must enjoy all the little things that are lovely while they are happening.

Interpersonal effectiveness. When we don’t feel at our best, our communication and interactions with other people can sour. Not even because we want to come across as aloof or jerky; it just takes energy and mindfulness to assert ourselves and maintain harmonious relationships. Often interpersonal effectiveness skills focus on asking for what you want, managing perceived (and sometimes real) conflict, and boundaries.

If I am alone when I learn of new Covid cases at work, it is not uncommon for me to groan and mumble words that may or may not be profane. Sharing such sentiments with colleagues, though, isn’t helpful and doesn’t increase my effectiveness. Crabbiness generally isn’t charming. Assertiveness scripts or nonviolent communication templates may seem unnatural, though, with practice and personal tailoring, help all of us get along when we’re all feeling tired and cranky.

Emotion regulation. Though internal and external voices may tell you otherwise, your emotions, regardless of what they are, are valid. You feel what you feel. There are, however, things we all can do to increase the likelihood that we will feel certain emotions. In 12-step groups, people often refer to “HALT”: Hungry, Angry, Lonely, and Tired. If we are already experiencing one of those four things, we are more likely to feel worse if another stressor comes our way. (Hence the value of eating and sleeping regularly, as well as building and sustaining community—whatever that may mean to you.) Naming emotions (with the help of mindfulness) is also a skill, as that helps us recognize that we are feeling an emotion, we are not actually the emotion. Emotions give us vital information, though sometimes we realize that there are no logical reasons that underlie how we feel. If I feel anxious because I believe I’m in the way, but I’m not actually in anyone’s way, then the task is to do the thing that will make me feel more anxious… so I eventually stop feeling anxiety due to thoughts about being in the way.

The duration of the pandemic and its consequences makes emotion regulation hard. We can try to reduce our vulnerabilities by eating, sleeping, and connecting with others as well as we can, though ongoing news of illness, death, conflict, and violence reduce our resilience. There are real problems in the systems we live in and under in the US. It is unfair and inaccurate to ask individuals to keep their chins up and “just be happy” when our current context is so abnormal. We, however, can still make choices in that space between stimulus and response.

I often quip (with decreasing levels of energy) that the pandemic is developing my character, though I’m ready to be done with personal growth. Right now, though, it is like this. We also know that everything changes. The pandemic will end (just not when we want it to), things will change (though perhaps not in the way that we anticipate), and many of us enjoy blessings right now that we take for granted (e.g., you are able to read these words! you have access to the internet! most, if not all, of you know where you will sleep tonight! you haven’t died from Covid!).

If you’d like to learn more about dialectical behavior therapy and the four skills above, this website is pretty good and covers the four core skills with plenty of examples.

COVID-19 Education Reflection Seattle

On Pushing Vaccines.

This summer is like last summer: We (a homelessness and housing agency) have had very few Covid cases in the past month or so. If this year is like last year, our reprieve will end in mid-autumn.

With this lull, I received recommendations to send out information about the current state of the pandemic as it relates to our agency. I hemmed and hawed before writing the crappy first draft: Everyone is tired and no one wants to read another e-mail. In this draft I waffled about commentary about vaccinations.

While vaccination rates in the Seattle-King County area are around 70% (and thus higher than other parts of the country), this doesn’t mean that everyone has been eager to receive a vaccine. There are people who have made a firm decision to forever decline it. There are also people who remain unsure.

I have felt disappointed and weary upon hearing the disdain of leaders and experts towards people who have not gotten vaccinated. I understand their frustration: No one wants to see people get sick and die. There are many ways to die and dying from Covid-19 is an undesirable way to leave this world.

That being said, scolding or berating people to make a specific choice is rarely (if ever) effective. If someone tells you that you are selfish because you won’t eat vegetables, that probably won’t increase the chances that you will eat vegetables. You might instead avoid this specific someone: Who wants to hear that they are a selfish person? (You can replace eating vegetables with any other behavior, identity, or choice: You are a selfish person because you choose to believe in liberal political ideas. You are a selfish person because you think abortion is wrong. You are a selfish person because you want to defund the police. You are a selfish person because you believe that Jesus was crucified for your sins. Calling someone selfish rarely promotes inquiry or conversation.)

People have shared with me a wide variety of reasons as to why they don’t want to get vaccinated. Some of those same people end up getting vaccinated… maybe because of our conversation, maybe not. I suspect that most didn’t even share all of their reasons with me because they might have felt embarrassment if they did.

If someone is willing to talk with you about a choice they want to make, that also means that they are talking with themselves about that very choice. Any conversation you have with them may carry on in your absence.

I don’t know if this is actually an adage in psychiatry, though I recall several people sharing this while I was in training: As long as someone is alive, there is still hope. Things can still change. People want to make their own choices, though; no one likes coercion. People aren’t stupid, either: They often know when someone is using force to try to change their minds or behaviors. (This use of force doesn’t have to be dramatic either: It can be a simple statement like, “I need loyalty.“)

As long as someone is still alive, there is still hope, and we can use that hope to keep the conversation going. People will share their worries with you if they are willing to give you the chance to change their minds. They will only give you that chance if they have some trust in you. They will have some trust in you if you have genuine interest in their worries and beliefs. People want to be understood. People want dignity.

You may fear that there isn’t enough time: What if they get infected with Covid-19 tomorrow and die next week? Maybe if we put more pressure on people, they will move faster.

Alternatively, if we put undue pressure on people, they may choose to never speak to us again. Any time that we did have is now completely gone. You can play the long game or you can prematurely end the game.

To be clear, I’m not saying any of this is easy or that a select few of us have magical abilities and endless patience to help people change their minds. I do, however, have experience working with people who were not making choices that I wish they would make: People who were living outside and refused to move into housing due to beliefs that were not rooted in reality. People who were using drugs and alcohol for many years. People who declined to take medication even though literally everyone else witnessed their improved health, wellbeing, and function when they did so.

Sighing and making exasperated comments at people who are living outside rarely makes them move into housing faster. Yelling at people who are using drugs and alcohol almost never makes them stop using. Forcing people to take medications does not make medications suddenly more appealing to people who usually refuse them.

Am I fully vaccinated? Yes. Do I wish more people would accept the Covid vaccines? Yes. Do I think threats or domination, even in slight forms, will succeed? No. At this point, efficiency no longer seems effective.