Education Homelessness Policy Public health psychiatry Systems

What I Talked About: Complexities.

Many thanks to those of you who left comments or sent me a note in response to my call for suggestions for a presentation about homelessness and mental illness.

I gave the presentation earlier this week and ended up presenting (a) homelessness data specific to Seattle-King County, (b) general data in in published research about rates of different psychiatric conditions in people experiencing homelessness (there’s actually not a lot of data about this; my understanding is that there is a national study underway right now to assess people experiencing homelessness through structured psychiatric interviews), and (c) the topic of “Involuntarily Removing Mentally Ill People from Streets“. I asked the group—students within various health professions schools—for their thoughts about New York City’s plan.

Many of the students were unfamiliar with involuntary detention for psychiatric reasons, along with the process for how that happens (the laws in Washington State differ from those in most other states in the nation; namely, physicians and other mental health professionals in Washington State cannot detain people directly; we must call a third party, called Designated Crisis Responders, and refer someone for detention). The initial group consensus favored civil liberties; they spoke of loss of dignity, the psychological and physical trauma that can result from involuntary detention, and the importance of autonomy.

When the scenario was adjusted so that the person who was experiencing homelessness and major psychiatric symptoms was someone that the students knew and loved, they quickly changed their arguments to support involuntary detention. When we love someone, we are more comfortable taking away their rights.

Like many complex issues, “right” answers escape us as more facets of the problem are illuminated. Involuntary detention itself is a complicated issue and, because most people are not experiencing homelessness, the majority of people who are detained are people who have an indoor place they call home.

Some research indicates that around 76% of people experiencing homelessness also have a psychiatric disorder, though the association is complex and likely goes in both directions: Some people have a psychiatric condition that contributes to poverty and then homelessness (e.g., losing a job); others become homeless and then develop a psychiatric condition due to the challenges of not knowing where you will sleep at night.

I continue to learn the complexities of working at the intersections of poverty and mental health. I am grateful that more people are interested in this work, too. I hope that things don’t have to get worse before we can offer better help and care to these individuals, who are ultimately our neighbors.

Consult-Liaison Education

On the Emotion of Anger.

I have no idea if the vicissitudes of life at this moment are more challenging than times past. Perhaps the intensity and quality of suffering in humanity remains unchanged, but now, due to technology and the increased breadth of our situational awareness, we are simply more aware of the degree and scale of human suffering. Our ancestors had no way of knowing as much as we do now.

(Humans, though, have suffered individual and local tragedies for as long as we have existed. Sometimes—often?—these individual tragedies induce greater suffering than we can ever imagine. Consider the parent whose spouse and child have both died. Surely deaths from disease and war affect this person, too, but how do those compare to the indescribable grief and heartbreak from the loss of kin? I don’t know. Someone out there does know. For them, I wish them peace, even if this wish is functionally just a spindly raft in a deep sea of sorrow.)

The range of human emotions is vast. In American culture, certain emotions are more acceptable than others. (This is likely true across all cultures.) And perhaps I should be more precise here: American culture tolerates the expression of certain emotions more than others. For example, American culture is intolerant of men weeping for any reason. We have been conditioned to consider that men who are crying—even for the most valid of reasons—are weak, incompetent, and incapable.

These social norms influence the individual and shape our behavior. If society cannot tolerate my tears, then I will do what I can to avoid crying. This can involve psychological acrobatics to avoid feeling the emotion that induces crying.

The problem is that emotions serve a function. Emotions give us information about the people we are around, the situations we are in, and what matters to us. They help us choose and express our behaviors, even if some of these choices don’t happen entirely consciously.

There’s a concept called “secondary emotions”, which are emotions we feel (and then express) as a result of other emotions. Some examples will help clarify this. (The emotion of anger—and we see so much anger these days—is what prompted this post, so I will use anger in these examples.)

American culture often discourages women from expressing anger. Women who express anger are often called “bitches”, even if their anger is justified. The (antiquated?) phrase “resting bitch face” illustrates this: That woman isn’t really an angry “bitch”, that’s just her face. If a woman feels and expresses the primary emotion of anger, she may then quickly feel and express the secondary emotion of guilt: “I shouldn’t feel anger; it makes me seem like I’m not a nice person. But I want to be a nice person. But maybe I’m not a nice person because nice people don’t get angry like this. So maybe I’m a terrible person. Oh no.” Society is more accepting of a woman’s deferential behavior that may follow. (Those familiar with CBT will recognize black-and-white thinking happening here.)

Similarly, American culture discourages men from expressing sadness. Our culture instead tolerates men expressing anger. Thus, men may actually feel a primary emotion of sadness, but the secondary emotion is anger. Maybe they express anger to counteract their perceived “weakness” for feeling sadness. Maybe they express anger because they know, whether consciously or not, that they are less likely to get want (including respect) if they express sadness.

Anger is also an activating emotion. Recall that emotions can and do drive behavior. When feeling sad, people are generally more likely to withdraw and isolate. Some people who feel sad will reach out to others for support, but sadness usually pulls people inward. When feeling angry, people are generally more likely to do something and take initiative. Feeling angry makes people feel more powerful.

Consider someone stomping down a hallway and throwing open a door while exiting. This behavior may seem like a withdrawal from people, but they busted out the door. Such a behavior requires initiative and energy, and often benefits from an audience. We turn our heads when we see someone storm out of a building while muttering profanity; we don’t when someone slips out the back door in tears.

There is little utility in denying our emotions. You feel what you feel. Sometimes, though, we resist feeling the primary, foundational emotion, maybe one that is too tender for us to acknowledge. It forces questions to the surface that we may not want to answer: What does it mean if I am unwilling or unable to feel sad? What would I discover if I sat with my anger and felt its sharp, jagged edges? What would I learn about myself if I explored this contempt? What things would I have to change about myself if I understood that there is something soft and vulnerable under this rage?

Education Public health psychiatry

What Should I Talk About?

Dear reader, what do you suggest I talk about during a presentation about homelessness and mental illness?

I’ve been invited to talk to a small class at the large local university about homelessness and mental illness. The overall course is about homelessness (I think) and the students apparently range from undergraduates to medical students to faculty. It sounds like it’s one of those seminar courses that is not required for anyone, which means that the students presumably have an active interest in this topic and want to be there.

It seems that an introductory overview, 101-level talk might make the most sense, but I only have one hour and this topic is vast. While I always do my best to make statistics and data interesting, I don’t know that rattling off percentages is the best use of time. Anecdotes and cases are compelling, though I worry about missing larger points about the intersection of homelessness and mental illness.

Some of you have been reading my writing online for years (decades?–thank you for the gift of your attention!) and some of you have not, though I get the sense that most of you have some interest in psychiatry and homelessness. If we work with the assumption that this class has similar interests as yours, what do you suggest I talk about? What would be most interesting or compelling to you about the topic of homelessness and mental illness? If I’ve written something here in the past on this topic that you found useful and could share in this class, could you let me know?

It’s been years since I’ve opened comments on my blog (due to spam comments and some veiled death threats), but it’s a new year and I would like to learn from you. Please leave a comment below with your advice and suggestions. Thank you!

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.