Category: Homelessness

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Homelessness Observations Public health psychiatry Systems

Psychiatry in Context.

A few reactions on topics related to psychiatry from the past week:

An example of a transitional object in baseball. The catcher for the Seattle Mariners, Cal Raleigh, did not play a few games due to injury concerns. Early in the game against the Atlanta Braves, the camera operator lingered on him in the dugout:

Cal Raleigh leaning against the dugout railing while holding a baseball (transitional object) in his right hand. A water bottle is directly in front of his face on the railing.

Notice that he’s not dressed to play. An unmarked bottle keeps him company. In his right hand is a baseball.

The Wikipedia page about transitional objects is pretty good (though psychobabbly). The best explanatory example of transitional objects is Linus and his security blanket:

Transitional objects give us comfort and a sense of security. Maybe the baseball gave Cal comfort and security during his mandatory time off. (Some players can hold six or seven baseballs in one hand. That’s probably more about showing off!)

The MAHA Action Plan to Curb Psychiatric Overprescribing. Per the HHS press release:

HHS Secretary Robert F. Kennedy, Jr. laid out a new action plan to promote appropriate psychiatric prescribing and drive deprescribing when clinically indicated.

Does “inappropriate” psychiatric prescribing happen? Yes. Does deprescribing, whether clinically indicated or not, already happen? Yes.

Back in 2015, while mulling over the value of psychiatrists, I commented:

When people think about medication management, they often think only of adding medications or exchanging one for another. Medication management also includes helping people come off of medications.

Many psychiatrists practice “deprescribing”. In 2019 I wrote about the ongoing difficulties in treating psychosis. There I commented on my own deprescribing experiences:

One of my early jobs was working in a geriatric adult home. My work there taught me that people with psychotic disorders can and do get better. The burdens of antipsychotic medications—paying for medications, the actual act of swallowing the pills every day, the side effects, some mild, some intense—add up. I was fortunate to work with some people to successfully reduce the doses of their antipsychotic medications and, in some cases, stop them completely! (There [was] also at least one instance when tapering medications was absolutely the wrong thing to do; that person ended up in the hospital. I felt terrible.)

Psychiatry is an easy target. Psychiatric medications, especially antidepressants, are common prescriptions. Many factors contribute to this: Health care appointments are short. (There’s not enough time for deep conversations.) It’s hard to access non-medication treatments. (Most rural areas do not have experts in evidence-based therapies.) Emotion literacy is not where we all want it to be.

For several decades psychiatry has focused on biological causes of psychological symptoms. The natural corollary is medications fix biological problems. As I noted in 2019, “Medications are a biological solution, though our understanding of the biology of the brain and mind remains limited.”

To be clear, I am not anti-medication. Psychiatric medications can not only save lives, but also improve quality of life. However, medications are not the only tool psychiatrists have to help people. Most of us do prescribe appropriately. (Some people are vexed when we decline to write prescriptions.) Many of us do deprescribe when clinically indicated. (Some people express anxiety when they want to stay on their medications.)

Ongoing hypocrisy related to “ending crime and disorder on America’s streets”. The primary community psychiatry journal published this (free) article: The Executive Order on “Crime and Disorder”: An Affront to Policy, Law, and Ethics.

I agree with the authors. I previously shared my reactions to the executive order here.

It’s fresh that the federal administration cannot recognize the crime and disorder they bring to America’s streets:

… among many other federal actions that reduce stability and increase anxiety. Choose your issue.

Categories
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.