Category: Homelessness

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Homelessness Policy Public health psychiatry

More on the Government’s Potential Use of Psychiatry.

There has been increasing amounts of conflict and violence within the United States. It saps attention and energy; of course people feel irritable and glum. This can lead to pronouncements that things will never get better, we’re doomed, etc.

Oliver Burkeman (I recommend his newsletter with enthusiasm!) quotes futurist and environmentalist Hazel Henderson and then himself comments:

“… if we can recognise that change and uncertainty are basic principles… we can greet the future… with the understanding that we do not know enough to be pessimistic.” You can take a crisis very seriously indeed without fooling yourself that you know the worst outcome is certain.

Please keep that in mind as we proceed here.

I haven’t forgotten about China’s use of psychiatrists as agents of social control. There’s stuff happening now in the United States that warrants concurrent commentary. It’s still important to know what has happened in the past. If you are itching to learn more and can’t wait for me, you can read the report from Human Rights Watch and Geneva Initiative on Psychiatry entitled Dangerous Minds: Political Psychiatry in China Today and its Origins in the Mao Era. The themes are similar to what we’re already learned together here.

The internet has been to good to me. I recently reconnected with an internet friend from the days of intueri. (Longtime readers will understand what that means.) This person has attended the protests in Minneapolis; from them I learned about Riot Medicine. Written by an anarchist medic, this manual “for practicing insurrectionary medicine” describes how medics can work in atypical settings. During protests, traditional emergency medical services may not be available. (For example, law enforcement may delay or block vehicles from entering a scene. We already know federal agents did this in Minneapolis.) It includes a short section on “Psychological Care”. It’s a summary of Psychological First Aid (introduced in my last post).

If you want to learn more about ICE Watch and Community Defense, whether in the context of protests or not, I strongly recommend this free training. What I most appreciated about the webinar was its lack of histrionics. The trainers emphasized serving as observers and avoiding escalations. Keeping a cool head is a valuable superpower during these times of dismay.

Within the deluge of actions from the federal government was this announcement: Secretary Kennedy Announces $100 Million Investment in Great American Recovery. The stated goal is to “solve long-standing homelessness issues, fight opioid addiction, and improve public safety by expanding treatment that emphasizes recovery and self-sufficiency”. This includes a new initiative:

The Safety Through Recovery, Engagement, and Evidence-based Treatment and Supports — or STREETS — Initiative will fund targeted outreach, psychiatric care, medical stabilization and crisis intervention, while connecting Americans experiencing homelessness and addiction to stable housing with a clear focus on long-term recovery and independence.

The funding attached to this is a mere $100 million. The language of this initiative is vague, so maybe $100M is enough. But if this is meant to fund a comprehensive plan for the entire nation, that sum won’t do.

Tucked further down in the announcement is this:

Secretary Kennedy also announced the $10 million Assisted Outpatient Treatment (AOT) grant program to support adults with serious mental illness. AOT is a civil court-ordered, community-based outpatient mental health treatment program for adults with serious mental illness who are unable to engage with conventional outpatient treatment and are unlikely to be able to live safely in their community.

AOT already exists in many jurisdictions, including here in Seattle-King County. While there is some evidence that AOT improves treatment adherence and reduces hospitalizations, more evaluation is needed to explain how this happens.

When I saw this news, I wondered if this was another step to use psychiatry as an agent of social control. The executive order to “end crime and disorder on America’s streets” conflates mental illnesses, substance misuse, homelessness, and crime. Now there’s funding announcements for homelessness services and court-ordered, community-based outpatient psychiatric services.

Maybe this is confirmation bias. My skepticism about the federal government’s intentions, though, is a reaction to what has already happened. May hope spring eternal and may the worst outcome never come to pass.

Categories
Homelessness NYC Policy Public health psychiatry

Trump Talked About Community Psychiatry Today.

Guys, I know we’re all tired for many different reasons. But we should probably review what President Trump said today. During his press conference he talked about community psychiatry!

I’ll go over the transcript below, but if you want to watch the video, it starts at 51:34 on C-SPAN.

As he was listing his accomplishments, he said the following. My commentary follows in the numbers below.

Signed an executive order to bring back mental institutions and insane asylums. [1] We’re going to have to bring them back. Hate to build those suckers, [2] but But you got to get the people off the streets. [3] You know, we used to have when I was growing up. We had it in my area in Queens. I grew up in Queens. We had a place called Creedmoor. Creedmore. Did anybody know that Creedmore? It was a big, [4] I said, Mom. Why are those bars on the building? I used to play Little League baseball. They’re at a place called Cunningham Park. Who’s quite the baseball player, you wouldn’t believe, but I said to my mother, Mom, she would be there, always there for me. She said, uh, son, you could be a professional baseball player. [5] I said, thanks, Mom. I said, why are those bars on the windows? Big building, big. Powerful building. It loomed over the park [6] actually she said, well, People that are very sick are in that building. [7] I said, boy, I used to always look at that building and I’d see this big building, big tall building. It loomed over the park. It was sort of, now that I think it was a pretty unfriendly sight, but I, I’ll never forget, I don’t know if it’s still there. [8] Because they got rid of most of them, you know, they, the Democrats in New York, they took them down, [9] and the people live on the streets now. That’s why you have a lot of the people in, in California and other places, they live on the streets. They took the mental institutions down, they’re expensive, [10] but I’d say, why does that building have those bars, boy. It didn’t, it wasn’t normal, you know, you’re used to looking at like a window. But this one you’re looking at all the steel, vicious steel, tiny windows, bars all over the place, nobody was getting out. [11] It’s called the mental institution. That was an insane asylum.

(sigh) Okay, let’s go over this:

  1. The executive order he signed has the formal title of “Ending Crime and Disorder on America’s Streets”. There’s a major cognitive error in the order, which I wrote about here.
  2. Never before have I heard anyone refer to mental institutions as “suckers”.
  3. Are there people who are homeless who would be best served in a mental institution? Yes. Do all people who are homeless need to be in a mental institution? No. Another way—more humane and cost effective!—to “get people off the streets” is to create and sustain conditions where people can afford and remain in housing.
  4. It looks like the highest census at Creedmoor was around 7,000 patients in 1959. President Trump would have been 12 years old at that time.
  5. Of course, someone did a deep dive about Trump’s record as a baseball player. If he were that good, surely he would throw out a first pitch at a major league game? (He has not.)
  6. A quick peek at a map shows that Creedmoor does not “loom over” Cunningham Park. They’re three miles apart. There are two athletic fields nearby. Creedmoor is visible from Alley Athletic Playground.
  7. I wonder if Trump’s mother spoke of the “very sick” people with disdain, pity, or compassion. Is it possible that all 7,000 people were “very sick”? Maybe. Is it possible that some of those 7,000 people did not need to be in an institution? Yes.
  8. Yes, Creedmoor still exists. It’s unclear what the census is now (it’s certainly not 7,000), but it’s not just an inpatient unit. They provide an array of outpatient services, too.
  9. There are multiple reasons why psychiatric institutions closed. One major reason was the advent of antipsychotic medication, which allowed more people to be treated in the community. There were also reports of abuses within these behemoth institutions. Long Island, a suburb of New York City, was the site of three major psychiatric institutions. Around 1954 Pilgrim State Hospital was probably the largest psychiatric hospital in the nation; there were over 13,000 patients there. I don’t know the history of New York State well enough to know if “Democrats in New York… took them down”. Recall that Trump was a Democrat for much of his life prior to running for President.
  10. Historically, states had to fund mental institutions. Medicaid (federal money) could not be used to pay for hospital services. This is another reason why states shut down psychiatric institutions; they didn’t have enough money to keep them running. If this policy discussion excites you (…), learn more about the IMD exclusion here.
  11. Yeah, man. If you don’t like “steel, vicious steel, tiny windows, bars all over the place”, then you’re like everyone else who doesn’t want a proliferation of mental institutions.
Categories
Homelessness Medicine Nonfiction Policy Public health psychiatry Seattle

Who Gets to Be Sad?

For those of you who don’t follow baseball, the Seattle Mariners were in the running to go to the finals in baseball, called the World Series. (So American, of course, to call the finals the “World Series” when it doesn’t involve the entire world!) The Mariners are the only team in all of Major League Baseball that has never been to the World Series.

As such, you can imagine how much of a frenzy the city was in. The Mariners flag was hoisted to the top of the Space Needle twice! The downtown skyscrapers coordinated their night lights to glow in Mariners colors. The mayor raised the Mariners’ flag at City Hall.

Game 7 in the semi-finals, which happened last week, was the “win and go to the World Series, or lose and go home” game. The Seattle Mariners lost.

Over the past week, since that loss, the city has been distraught.

Immediately following game 7, there were brutal postgame interviews. Sports journalists, for obtuse reasons, asked weeping baseball players how they felt.

Here’s Cal Raleigh, our inimitable catcher, showing what his face looked like when he was seven years old and heartbroken:

See how he ran his hand through his hair? That was a desperate act of self-soothing while multiple cameras gave him no place to hide his flushed face and wet eyes.

Meanwhile, here’s Bryan Woo, who turned out to be the team’s ace pitcher this year. He’s not crying, but he is also just trying to get through the interview. A wail of despair interrupts him:

The man whose heartache was heard, but not seen, was our cool center fielder, Julio Rodriguez.

So, are grown men allowed to cry or not? Here were professional athletes caught in the throes of disappointment and sadness. They were crying. Sports journalists pushed microphones into their faces and asked them how they were feeling.

On the one hand, I appreciate this exercise: It’s a chance for these robust young men to model (to other males) how to use words to describe internal experiences. They’re not smashing bats into the walls or punching the journalists. You can talk about unpleasant emotions without resorting to violence or destruction.

On the other hand, asking people about their feelings on camera when they are obviously distressed seems unkind. Sure, baseball players, as public figures, have training about and responsibilities to the media. But such pointed questions do nothing to soothe or support the person. Reporters can also learn the exact same information — how do you feel about losing the biggest game of your professional career to date? — an hour later, when people have had the chance to cry and wail in private. Show some respect, give people some dignity!

But we apparently want to see our heroes cry. We want to know that they feel just as sad as we do.

There are many other people throughout the nation who are crying. They are not professional baseball players; they are not famous. Many of us will never know any of their names.

Some of them were looking forward to leaving the street and moving into an apartment! With winter right around the corner, the anticipation of living somewhere dry and warm was thrilling. Because of the government shutdown, though, the mainstream vouchers that would have paid for those apartments are invalid. So they will have to wait for the government to open before they can move inside.

Many of these same people have Medicaid for health insurance. There are also millions of other people with Medicaid who do know where they will sleep tonight.

The federal government has somehow concluded that it’s not worth it to spend money on health insurance for poor people. But, it is somehow cool to take that money to give tax cuts to people who are wealthy. Yes, it is true that, one day, we will all die. Taking health insurance away from poor people, though, is spiteful. It only makes it more likely that they will needlessly suffer while they are alive.

You know what makes suffering worse? Hunger.

The government shutdown, if not resolved by November 1st, will also shut down the Supplemental Nutrition Assistance Program (SNAP). This program, also called “food stamps”, gives financial aid to poor people to help them buy nutritious food. Food banks are already struggling to provide enough food to visitors. Furthermore, here in Washington State, many grocery stores have closed.

Some people are already hungry. More people will join them.

Yes, you’re reading this right: Soon, the same group of people will have increasing struggles to access food, health care, AND housing. What they all have in common is poverty. Literally no one ever says, “When I grow up, I want to be poor and rely on welfare!” Being poor is not a moral failing. No one, regardless of how much money they have, deserves to have the foundations of wellbeing — food, shelter, and health — taken from them.

But we apparently don’t want to see poor people cry. We don’t want to know their sadness. Some people think poor people deserve to be sad. Others think that poor people are not people.

What would we have to admit to ourselves if we felt their sadness? What would we have to change if we acknowledged that their sadness is real?

Categories
Homelessness Nonfiction

Neither Sex Nor Drugs.

While it was happening I recognized that it didn’t look great.

My outreach colleague was driving and slowed down. After rolling down my passenger side window, she leaned over and shouted a name.

The Woman she was shouting at was walking on the sidewalk towards us. Her stiletto knee-high boots were the same color as her miniskirt. The bustier did not fully cover her waist. Bright eyeliner and false eyelashes made her eyes pop. The purse slung over her shoulder swung with each confident step she took.

The Woman didn’t hear my colleague, so I shouted the same name out the window. She turned and took a few steps towards the car. I pointed at the driver. The Woman smiled in recognition, revealing many missing teeth, and came to talk with us through the window.

It could have looked like we were negotiating money for sex.

“I’ve been looking for you,” my colleague said, turning on the emergency lights. “I have a lot of mail for you.”

The Woman and my colleague discussed meeting at the office so she could get her letters. A toothless smile again bloomed on The Woman’s face as she blurted out, “Oh! I haven’t used fentanyl in 14 days!”

Dear reader, I had no idea who this person was; I just met her. That didn’t stop me from bursting into applause. I was the only one clapping. It was a reason to celebrate! She beamed.

“Where are you staying now?” my colleague asked after congratulating her.

“I live in That Neighborhood now,” The Woman said. “Near That Street and That Avenue. There’s a hole in the fence near that intersection. Go through that hole and a little further back through the trees, and you’ll find me there.”

Through a fence and then on a dirt path in stiletto heels!

Don’t judge a book by its cover.

Categories
Homelessness Nonfiction Policy

The Man in the Tiny Village.

Almost 30 minutes had passed, but The Man was still standing outside in the grey morning chill. His soiled tee shirt and loose pants hung from his tall frame. Over the next few minutes, he rarely shifted his feet while staring at a distant point on the ground.

“Hi,” I greeted again. He did not move.

“I’m worried about you,” I offered, hoping for any sign of acknowledgment. None came.

It no longer feels uncomfortable to talk to someone who doesn’t respond. Remember the people in the ICU, their bodies puffy from inflammation and fluid, their respiratory tubes hissing with each mechanical breath? Or the young men tucked into the corners of their jail cells, their heads cradled in their slender arms? Or the people so preoccupied with voices only they heard, their unblinking eyes quivering?

“I’m going to prescribe medicine for you. The goal is to help you think better. I’ll ask the staff to remind you about it. I hope you’ll try it, but if you don’t want to take it, that’s fine. I’ll see you again soon.”

His gaze remain fixed on the ground.

“It’s cold outside. Go back in,” I said. He stirred and mumbled something.

“Go back inside,” I repeated, pointing and taking a step towards his Tiny House. After a beat, he lifted a leg and meandered back to his unit.

Tiny Villages are clusters of small wooden structures, called Tiny Houses. A Tiny House is less than 100 square feet, so most people have only a bed and a storage rack inside. Each unit has heat and electricity, along with at least one window. The door locks. Outside of the two dozen or so Tiny Houses are shared bathrooms, an enclosed kitchen and dining area, plus covered laundry facilities. The houses are usually painted in bright colors. Residents often add personal touches to the small area in front of their house: Wild flowers in small pots; stickers and signs; sometimes inflatable yard decorations. Surrounding the entire Tiny Village is a wood or chain-link fence. Visitors must check in before they enter the front gate.

Village staff had introduced me to The Man about an hour earlier. When The Man opened the door to his Tiny House, the stench of body odor rushed out. For nearly five minutes he stood in the doorway and looked around at the ground. His face was scrunched up in confusion while he mumbled under his breath.

With repeated coaxing we got him out of the morning chill and into a Tiny Office. He didn’t talk to me; he instead talked with someone that only he could see. While seated in the folding chair he laughed, made animated gestures, and muttered about truth and lies. I ended our time together. We all exited the office.

Village staff pulled me aside to tell me more about The Man: Just a few months ago he was able to have a coherent conversation. Before moving into the Tiny House, he lived in a trailer. Before that, he worked in warehouses and lived in an apartment. Alcohol overuse led to problems at work and dismissals. Now he smoked methamphetamine once in a while. Other people in the Tiny Village were worried about his wellbeing, too.

It was when I was leaving the Tiny Village that I saw that The Man was still standing outside. Had he been there, motionless, for almost 30 minutes?

The medications came in a bubble pack, each row marked with the date. One pill for each day, at any time of day, for one week.

On day one, The Man popped a tablet out of its bubble, then swallowed it. Nothing changed.

The e-mail I received a week later contained exclamation points: The Man took the medicine most days that week! He was making more sense! He wanted to take more medication!

Of course I obliged.

The next time I saw him, his unit still didn’t smell fresh. However, he immediately came out and walked with us to the office.

“I’m sorry for having an attitude when we last talked,” he offered. I shook my head; he didn’t need to apologize. What he thought was an “attitude” was actually symptoms of psychosis.

When I asked him what was happening when we last spoke, he replied, “I was annoyed. People kept talking to me.”

“Who?”

He shifted uncomfortably in his chair. “I don’t want to snitch on them…”

I waited. He looked up, took a breath, and continued.

“… but I hear them all the time, 24/7, on and off, it doesn’t matter.” He shared that he had been hearing those voices since he was a kid. “Sometimes I want to tear them apart, I get so annoyed.”

What did he think of the medication? “It helps me ignore them better. When I get annoyed I take it, so I’ll take two a day.”

I nodded serenely. Thank The Universe that nothing harmful happened with his doubling of the dose!

As our time together came to a close, I asked, “Is there anything else I can help you with today?”

A moment passed. He scratched his head. He then quietly asked, “Is there anything that can help me stop using meth?”

When we bring services to where people are, they can make great gains in building the lives they want to lead.

I was worried that, because of The Man’s symptoms, we would have to tread down the road of involuntary treatment. But, the interventions and support of the team prevented this. We avoided the circus of the police and medics coercing him into an ambulance. He escaped the chaos of waiting in an emergency department while restrained to a gurney. Residing in a Tiny Home is not an ideal living situation, but at least he was able to keep the freedoms there that are absent in a psychiatric hospital.

In addition to preserving his dignity, these interventions saved costs throughout the system. First responders were freed up to attend to other emergencies. Because The Man never went to the emergency department, he never received an ambulance or hospital bill. All together that would have summed in the thousands of dollars.

This man, like the women described here, was homeless. Like them, he did not contribute to crime and disorder on America’s streets. He was not a safety threat.

Who was truly unsafe: Us, or him?