Category: Nonfiction

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Consult-Liaison COVID-19 Homelessness Nonfiction Reflection

How One Psychiatrist is Coping with the Pandemic.

Context: I work as the medical director for an agency that provides shelter, permanent supportive housing, and crisis and behavioral health services. I also do clinical work there as a psychiatrist, where I see people in shelter, housing, and in clinic.[1. A few of the people I see agree to use telehealth, but those who have phones tend to prefer telephone over video.]

Like many other essential workers, my colleagues and I have worked long hours, spent even more hours worrying and planning, and have had to figure out how to manage ourselves in the midst of uncertainty. Though we have been fortunate to be able to move many people out of congregate settings into motel and hotel rooms,[2. Here are some anecdotes about what happens when people move from a congregate setting into their own room with a private bathroom, a bed, and a door that locks: 911 calls go down. People who previously did not routinely take showers start showering daily. Some people use less drugs; some people stop using drugs and alcohol completely. People start planning and taking steps towards goals, such as school, employment, financial planning, relationships.…] we still have some people staying in congregate settings, which is undesirable during a pandemic. Many of the people who stay in shelter and housing have significant and chronic medical problems, which makes us nervous that they will have worse outcomes if they contract Covid-19. I express gratitude every day—though maybe not out loud—for the very few cases that have occurred within the agency. With over 500 people in shelter (though, again, many have moved into motel and hotel rooms) and over 1000 people in permanent supportive housing, plus hundreds who have different living circumstances but are enrolled in our clinics, we thus far have had fewer than 50 positive cases of Covid-19.

The strain on staff is significant. People will have different memories of this pandemic: Some people (reportedly; I don’t personally know anyone who falls into this group) have expressed some relief during this time, as they have the time and resources to do things like learn new languages, travel to cute cabins in remote places, and other things that seem like fiction to me. Others have had to learn how to navigate congregate settings and provide care to people with significant health conditions in the absence of national guidelines and plans.[3. Do I sound resentful? I think the underlying emotion is disappointment.]

I don’t think people who are trained as psychiatrists are necessarily more skilled at coping during a pandemic, as none of us in the US[4. Recall that there have been epidemics in the recent past. I found Mental health and psychosocial support in ebola virus disease outbreaks and Protecting Mental Health During Epidemics helpful… and don’t get the sense that the CDC or other federal agencies have reviewed these articles and/or are interested in providing this sort of support to any of us. Am I still sounding resentful?] have ever lived through one. Here’s what I’ve been doing (or at least trying to do) to manage myself:

Get up early to do stuff to take care of me. (Because I wasn’t born a doctor and, God willing, I will be able to retire before I die.) I aim to get out of bed at 5am. This tends to be the quietest time of day and few, if any, people want or need my attention. The long summer days in Seattle make getting up that early easier, but, let’s be real: Sometimes the spirit is willing, but the flesh is weak.

Exercise. Sometimes this means what most people mean by the word “exercise”, like push-ups, squats, etc. Sometimes this means “movement”, which can be a one-person dance party. The face covering mandate has interfered with my willingness to run. I do want to run, but I haven’t been able to get over the hump of running while wearing a mask. (I live in a neighborhood where there are at least some people around, even at 5am. I am committed to wearing a mask when I am out and about.)

Invest time on hobbies. During those early morning hours I study Chinese to improve my literacy. Though I haven’t posted much here, I am trying to write daily (I continue to use 750 Words, which helps me with quantity, even if the quality is terrible).

Eat cookies. Sometimes I eat only a few; sometimes I end up eating over half the box. This is not the greatest coping mechanism, though it is something I have done because my frustration tolerance is sometimes low and impulse control is hard.

Walk during meetings. I’m that person who often joins a video call by telephone. This is related to technological deficits, as well as willfulness: If the meeting doesn’t require video presence, then I will take the less stimulating option of audio only. I occasionally quip that I’m like tuna: If I stop moving, I will die. If I’m able to walk during a meeting, that not only helps me dispel anxious energy, but also reduces the likelihood that I will get distracted by e-mail or other tasks during the meeting. This also helps me feel like I’m taking advantage of the summer weather while we still have it.

Talk to myself. Out loud. And often in an effort to meet and greet whatever emotion I’m feeling. (Hang in there with me.) Earlier this week I exclaimed much louder than I intended, “I feel so anxious!!!” and then proceeded with this conversation:

Hello, Anxiety! What brings you here today? Are you enjoying this summer weather? What are you worried about? What are you trying to tell me today? What can I do to help you feel better?

This is a concrete way to acknowledge whatever it is I am feeling because avoiding emotions is generally impossible and ineffective: It’ll come out some other way (e.g., eating half a box of cookies).

Observe the sky. The sky is bigger than me. The pandemic is bigger than me. The sky changes. The pandemic will change. I want to witness the sky. I want to witness the pandemic. To stop and look at the sky—the clouds, the moon, the sun, the colors—allows me to pause and claim time that sometimes never feels like mine.

Try to make other people laugh. During this time of differing degrees of isolation, sharing laughter with someone is a treasure. Sometimes the humor is admittedly dark, though I much prefer that people get it out of their systems with trusted confidants, rather than on others (like patients).

Sleep. Sometimes sleep doesn’t feel restful—I am sorry to confess that, sometimes, my dreams center on Covid-19—and occasionally I wake up from sleep thinking about all the things I should do related to the pandemic. Having a fixed “get out of bed” time helps with regulating sleep.

Thank people. There is no way any of us could manage this ridiculous time by ourselves. There are so many people to thank: The janitors who clean and sanitize spaces to keep us all healthy. The grocer who is there so you can buy food. The doctors and nurses who provide Covid-19 testing and counseling. The sanitation staff who continue to empty out the garbage and recycling bins. The plumbers who fix emergency sewage leaks. The person on the street who acknowledges you and makes an effort to stay at least six feet away. The bus drivers who continue to transport essential workers around the city. The first responders, including police, who are kind to the seemingly increasing number of people who are sleeping outside. God/the Universe/whatever Deity that I still have a job, a stable place to live, and, thus far, good health.

Do you have other suggestions?

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Consult-Liaison Medicine Nonfiction Reflection Systems

Mental Health Awareness Month During a Pandemic.

It’s been Mental Health Awareness Month during a pandemic.

When we look back at this time, people will have different memories of their experiences: Some will remember changes in job duties and extra time for leisure. Others will remember intense pressure and stress as essential workers. Still others will remember the despair due to unemployment and financial worries. We all will remember how the COVID-19 pandemic disrupted our routines and affected our mental well-being: It impeded our freedom to go outside, abilities to pursue the activities we want to do, and usual opportunities to express ourselves.

Wearing a face covering may mask the expressions of displeasure and anxiety on our faces, but it does not diminish the discomfort and worry we feel within. As many in our community try to avoid illness, some will fall ill and and others will succumb to death. There are reasons to grieve.

Because discomfort and anxiety are internal experiences, our culture often frames these reactions as a personal problem—a disorder of one individual mind. However, this pandemic has had adverse effects on everyone. Many of us are feeling the same emotions. These are unsurprising reactions to an unexpected and (hopefully) once-in-a-lifetime situation.

We must avoid medicalizing these reactions. Individuals receive psychiatric diagnoses within specific contexts. Our reactions as a result of the the pandemic are collective experiences within the same context. It is unfair to argue that all people experiencing distress during this pandemic have psychiatric disorders. This argument also undermines opportunities for communities to support their own members who are suffering.

Not all distress reaches the threshold for a clinical diagnosis, especially during extraordinary times. While mental health professionals can help people who feel anxiety and sadness, that doesn’t mean that increasing the number of mental health professionals and their services is the primary solution during this pandemic. Most people feeling worry and anguish now will not need specialized services. Support from people from the same culture or context can and will help people tolerate and then grow from these emotional experiences. Relationships, stemming from faith traditions, hobbies, cultural groups, and friendships, are invaluable during these times of stress, loss, and grief. Providing education and resources to the community at large, such as through programs like Mental Health First Aid,[1. You can learn more about Mental Health First Aid here. I have no affiliation with them.] can help ensure that those in our community receive attention and emotional support. Communities can also provide support through other concrete means, such as financial donations, food assistance, and employment opportunities. Though individuals should remain six feet apart, the distance does not dilute the healing power of relationships.

To be clear, some individuals do experience levels of distress due to the pandemic that warrant professional mental health intervention and support. This does not mean that they have meaningless relationships or are “weak”. We often do not know the struggles people endure. Complications from the pandemic can overwhelm already strained internal and external resources.

We are living through an extraordinary time in history. We are all experiencing psychological stress, though perhaps at different frequencies and intensities. There is nothing routine about our external circumstances, so there is nothing routine about our internal experiences, either. The pandemic has demonstrated how interconnected we are. Let us focus not on individual distress, but focus instead on how we can all help each other during this difficult time. This will not only bolster the mental well-being of others, but will help our mental health, too.

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COVID-19 Homelessness Medicine Nonfiction Observations Policy Seattle

The Space Between Us.

I am one of the few people walking through downtown Seattle these days. Most of the people outside are people who slept outside the night before. Sometimes they are still sleeping in sleeping bags or tattered boxes when I walk past. They’ve always been there, but now that there are much fewer people outside, they seem to be everywhere.

The other people walking through downtown in the morning fall into two groups: People going to work, like me, and people walking their dogs. The people out and about in the morning are much more likely to wear face masks. The evening crowd seems to be younger and they are much less likely to wear face masks.

I see the magnolia trees bloom. Their pastel petals are already falling off to make room for new leaves. The soft pink cherry blossoms are already gone; the tree limbs are already full of fresh green leaves.

The offices now have bottles of liquid hand sanitizer from local distilleries. The hand sanitizer coming out of the wall dispensers have floral and chemical notes.

Every staff person should have their own set of cloth face masks. There are two in a bag. Volunteers sewed and packaged them. One of mine is dark blue with intersecting white lines. The other is light blue with a large pattern that is reminiscent of paisley.

Several people staying in our shelters have tested positive for coronavirus. There haven’t been “clusters” of cases yet, just one here, another one there. Staff show up to work, don their cloth face masks, put on gloves, and wipe down surfaces with disinfectant when they can. Some people staying in shelters cough and sneeze. Most put on the surgical face masks that staff give to them and try to stay away from other people, but where are they to go? A few are unable or unwilling to wear face masks. Staff continue to don their cloth face masks, put on gloves, and wipe down surfaces.

People are moving from congregate shelter settings into motel and hotel rooms. What will happen when people have their own private spaces? Their own bathrooms, their own beds, their own doors that they can lock? This reduces the likelihood of disease transmission. What else does this reduce? Hypervigilance? Paranoia? Pain? Substance use? (Or maybe it increases all of those things?)

The nurses are amazing. They try to assess for respiratory symptoms from six feet away, a subtle dance that we’ve all had to learn how to do quickly. Maybe it’s a chronic cough. Maybe it’s flu-like symptoms. Maybe it’s coronavirus.

The internal coronavirus team is amazing. They organize the waterfall of data and quickly refer people to the county isolation and quarantine sites. The system has started to move faster, but it’s not fast enough. And what are we to do when the isolation and quarantine sites won’t accept our referrals? Who holds the balance between liability and public health? What will the emergency departments say when it is the fear of acute withdrawal, not the actual withdrawal itself, that results in a visit from someone with coronavirus?

When I start feeling angry, I pause and realize that my colleagues in hospitals have even more reasons to feel anger. I’m not misreading the guidance: Following a high risk exposure to someone with confirmed coronavirus, staff should continue to work even if asymptomatic. Of course, I know why: The system needs health care workers to work during this pandemic. But what is the message this sends to individual workers? You might get sick, you might contribute to asymptomatic spread at work. The people who live with you might get sick. Despite this worry for yourself and those around you, please continue to work. And because we don’t have enough tests right now, we won’t test you until you start to demonstrate symptoms.

(What about the grocery store workers and farm workers? Do their employers provide face masks? Are they part of unions? Do they have health insurance?)

You are essential, you are a critical worker, you are immune to worry and anxiety. Right? This is no time to worry about yourself because we also don’t have time to worry about you.

I see the pairs of police officers leaning against their cars on Pike and Pine, their arms crossed. The sun stretches its warm rays across the sound and the new leaves rustle in the spring breeze. My cloth mask is mildly damp from the humidified air moving in and out of my lungs. I make brief eye contact with the person approaching me. We make time to worry about each other and the physical space between us grows.

Categories
COVID-19 Nonfiction Observations Seattle

Spacious in Seattle.

Downtown Seattle isn’t completely empty, but there is suddenly more space. Buses zoom by, though they carry few passengers. Rush hour traffic is a faint memory as cars speed along the avenues. Instead of weaving my way through crowds of people, I now have meters of sidewalk all to myself.

I went on a cookie break this afternoon. The sole employee in the cookie shop saw me pause at the front door while I read the sign: “Express window is open”. From inside, she beckoned me to walk three meters to the right, and when I arrived at the window, she slid it open.

“Hi.”

“Hi. Do you have day-olds?”

“Yes, right here.” She waved a gloved hand over the small basket sitting just inside the window. Cookies, stacked three high, were wrapped tightly in saran wrap. I selected a standard chocolate chip stack and a double chocolate stack.

While we waited for the credit card reader, we talked about these extraordinary times.

“Thanks for providing cookies to those of us who are working.”

“Thank you for buying them!”

“Yes, I’m glad that this shop is open. At least we have jobs.”

She nodded vigorously, then added, “Yeah, we are lucky.”

About an hour earlier, I asked one of the younger nurses at the agency how she was doing. She said that she was doing okay, then shared that she was grateful that she still had a job. She grimaced while she shared this anecdote: “Have you heard of This Fancy Restaurant? They laid off all of their staff on the same day. They can’t even collect unemployment.”

After tucking the two stacks of cookies into my coat, I saw this:

handwash

The restaurant serves a type of Asian cuisine. The man behind the counter was helping a customer, so I didn’t go in to thank him. Had I done so, I think I would’ve started crying.

Categories
Homelessness Medicine Nonfiction Policy Seattle Systems

More Reflections about COVID-19 from Seattle.

This is another unpolished post. Several physicians and nurses in other states have reached out to ask for suggestions and perspectives related to behavioral health and homelessness during this COVID-19 epidemic in Seattle. Here are some reflections:

Coordination with partners is not only essential for services, but also to maintain morale. No single agency is able to address this alone. Government partners need feedback and information about what the community needs (and, I’m sorry to say, sometimes the community ends up providing government officials with updates that government should be telling us). The actions and energy of partners can buoy others when it seems things are stuck.

There aren’t enough supplies. Clinics, hospitals, and agencies can’t get face masks, hand sanitizer, and other sanitation supplies. Vendors are all sold out. Local governments are appealing to the federal government to provide supplies; I understand that the US military protects a national stockpile of such items? Which is something I had never considered in the past. And, perhaps most importantly, there aren’t enough COVID-19 tests! It seems that most of our local publicly funded primary care clinics have, at most, 30 test kits on site with no replenishment coming. Some private labs are only now agreeing to provide COVID-19 testing.

Many employees don’t have enough paid time off accrued to take time off of work for self-quarantine. Thankfully, our state and federal governments have passed or will pass legislation to address this and ensure that people can still get paid despite having to take time off of work. HR departments everywhere would do well to look out for their employees, particularly those who provide direct service to people who are higher risk of experiencing illness due to COVID-19.

People may (or may not) bristle at the infringement of civil liberties. The Washington State Governor has banned gatherings of more than 250 people. The CDC has provided “mitigation strategies” specific to Seattle-King County for the next 30 days, some of which are about workplace behaviors and COVID-19, which includes checking temperatures for fever and screening for illness when employees show up to work. The CDC has also recommended prohibiting visitors to certain sites. These are extraordinary times, hence these extraordinary measures… and some people may bristle at having to follow these rules. So far, people have been voluntarily complying with these changes.

The balance of individual patient health information and public health wobbles. For the past two weeks, a local clinic and our shelter have gone back and forth (in a collegial way) about protecting an individual’s privacy versus protecting the health of other people staying in the shelter. In short, the clinic argued that if Mr. Doe, a person who stays in the shelter, gets tested for COVID-19, the shelter isn’t entitled to know (a) that the test occurred and (b) the test results. We have countered that the shelter should know about Mr. Doe’s testing and the results during this extraordinary time because we want to do everything we can to prevent or minimize a localized outbreak within our shelter. Thankfully, the State Attorney General issued guidance that sided with our view (to be clear, the clinic was sympathetic to our view and did not balk with the change in practice… and I completely understood where the clinic was coming from). However, this is something that the clinic and our shelter had to pursue on our own; this was not proactive guidance we received from our government officials.

Government bureaucracy is in full effect. In this instance, I’m referring to practice of government officials who are unwilling to send out official communication until numerous gatekeepers have vetted it. Thus, guidance is slow to come out, so everything slows down. I understand the reason for vetting—confusion isn’t helpful, either—but we also feel frustrated when we feel like we’re losing a race against an invisible enemy.

People staying in shelters are resilient. Many staff feel anxious about how COVID-19 will impact the people who stay in shelters and receive clinical services from us. I find that I have to remind myself that many of the people who stay in shelters have experienced traumas and horrors that we will never know or understand. Many of them have already experienced illnesses and pain that we cannot fathom. I do not mean to minimize the very real possibility that some of them, should they contract COVID-19, will develop severe illness and die. I don’t want that to happen, which is why we are in constant communication with our partners to coordinate services and care. However, many of them will either not get sick, or they will recover despite our anxiety and efforts. It is a privilege that these individuals even let us into their lives.

Screening guidelines for COVID-19 are mushy. Some of our local infectious disease experts have taken to crafting their own screening guidelines because they are dissatisfied with the vague guidelines from the CDC. (This ties back to the lack of available tests—if we had more COVID-19 test kits, then we wouldn’t be wringing our collective hands about screening guidelines, particularly for vulnerable populations like people staying in shelters, which, no kidding, includes a significant proportion of people who are over the age of 60.)

The workforce shortage seems like it will only get worse. Social service and health care agencies often struggle with having a sufficient number of staff to address the clinical need. As people call out due to illness, whether COVID-19 or otherwise, this will turn into a vicious cycle: Fewer staff for a constant or growing need means that those staff will get tired and sick, which increases the likelihood that they will call out, and if the return to work rate doesn’t match the “attrition” rate, then soon there will be only minimum staffing at best. We also cannot expect individual people to successfully address systemic problems. It is not uncommon for people who go into social and health services to overwork (whether in quantity, quality, or both); this is unsustainable during usual times, let alone during an epidemic.

Social distancing seems like it will have the highest yield. The Institute for Disease Modeling published a paper specific to King and Snohomish Counties (the “epicenter” of the outbreak in the US) about the importance of social distancing. It is both compelling and disturbing. I don’t know how to successfully balance this with the clinical services that the medical team provides to the agency. Telehealth options are limited because of the population we serve (i.e., they generally don’t have telephones), though we plan to implement some creative ideas to at least try to keep people out of emergency departments.

It’s a weird time. We continue to do the best that we can, while recognizing that what comes next may knock us off our feet.