Category: NYC

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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.
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Homelessness Lessons Medicine NYC Observations Reflection Seattle

The Kind of Energy We Send Out to the World.

I have been writing; I just haven’t posted anything here. These days, it seems that we cannot escape increasing types of noise and their loud volumes. It’s not all noise, but the signals are overwhelming.

It was a busy teaching week for me: I had the privilege to speak at two community clinics and a public hospital. In all three presentations I commented on the tension between “the system” and our efforts as individuals. When we’re trying to provide care and services to individuals, sometimes the constraints of “the system” interfere with our efforts: Sometimes fiscal concerns reign supreme; sometimes the bureaucracy is inflexible; sometimes the system does not have noble intentions. We grumble, we get angry, we feel helpless.

When we’re trying to design “the system” to provide care and services, sometimes the constraints of people interfere with our efforts: Sometimes there aren’t enough people; sometimes people make mistakes; sometimes people do not have noble intentions. We grumble, we get angry, we feel helpless.

The two, of course, are related: People design systems. People work within systems. People can change systems.

People also have values. Sometimes we find that our values clash with those of the systems we work and live in. That doesn’t mean that we must defer to the values of the system. It takes courage to resist. To show our values to the world without flinching is an act of bravery.

While speaking, I told a story about my first boss when I finally started working as an attending psychiatrist. Our jobs included working with people who were homeless in New York City.

“I want people who don’t have a place to live to get excellent care,” he said, perhaps talking more to himself than to me. “Good care shouldn’t be limited to people who can afford to pay a psychiatrist who works out of a plush office on Park Avenue. People who don’t have money should have access to and get good care, too.”

“These are choices under our control,” I said to the audience yesterday, perhaps talking more to myself than to them. “Even though system pressures are very real, you can choose to give good care to the people who come here for help. You can treat people with dignity and respect, particularly if they are people of color with very low incomes. They might not get dignity or respect elsewhere.”

Perhaps my exhortations sound naive. Perhaps cynicism will triumph over virtue. However, I refuse to embrace cynicism. Cynicism makes for terrible company. Life is already full of challenges; we do not need negative soundtracks to accompany us as we travel through life. What we do affects others. What we say can inspire others.

We have responsibility for the kind of energy we send out to the world.

Categories
Funding Homelessness Nonfiction NYC Policy Reflection Seattle Systems

God’s Work versus Meaningful Work versus Value.

Every now and then, when some people learn what kind of work I do, they say, “You’re doing God’s work. Thank you.”

They mean well, so I accept the compliment, though I also tack on, “I also like what I do. It’s meaningful work for me.”

So many of the people I see, whether in my current job or in my past jobs working in other underserved communities, have a lot going on that psychiatry and medicine cannot formally address. One example is housing. It is often an effective intervention for the distress of people who don’t have a place to live, though housing is not something physicians can prescribe. However, there are individuals who are eligible for housing, but do not want to move into housing for reasons that do not make sense to most people. For example, in New York I worked with a man who would spend his days sitting in front of the building where he once worked before he became ill. He talked to himself and burned through multiple packs of cigarettes. He did not recognize how soiled his clothes and skin became with time. At night he disappeared into the subway tunnels and rode the trains. He did not want to move into an apartment until he was able to get his job back, even though he hadn’t worked there in over ten years. With time (nearly two years!) and unrelenting attention, our team was able to persuade him to try living indoors. He eventually accepted the key and moved in.

There are other active conditions that I do not have the skills to treat: Sometimes it’s institutional racism; sometimes it’s multiple generations of poverty. Both prevent people from accessing education, housing, and other resources. Do some of these individuals end up taking psychotropic medications due to the consequences of these systemic conditions? Yes. Do I think they’re always indicated? No.

Most of my jobs have been unconventional: I worked on an Assertive Community Treatment team that often provided intensive psychiatric services in people’s homes. I worked with a homeless outreach team and did most of my clinical work in alleys, under bridges, and in public parks. I worked in a geriatric adult home and saw people either in my office, which was literally the storage room for the recreational therapist’s stuff, or in their apartments if they were uncomfortable seeing me in the storage room. I was recruited to create and lead the programming for a new crisis center whose goal was to divert people from jails and emergency departments.

And now I work in a jail.

As time progresses, it has become clear to me that I have not had the typical career for a psychiatrist. I like that. However, I often also feel out of touch with my colleagues. I believe that they are all trying their best, but they don’t have the time to see how systems end up failing the most vulnerable and ill in our communities. They work in the ivory towers of academia and don’t seem to realize the dearth of resources—financial, administrative, academic—in the community. They work in private practice and don’t seem to realize how ill some people are and how we need their expertise. They work in psychiatric hospitals and seem to believe that some of these individuals will never get better when, in fact, they do.

Because much of my work has been outside of the traditional system, I consider myself fortunate that I have been able to escape the box of simply prescribing medications. Many of the individuals under my care do not want to take medications. Their desire to not take medications, though, doesn’t stop us from working with them. We meet them where they are at and remember that they are, first, people. As we are in the profession of helping people shift their thoughts, emotions, and behaviors, we believe that there will come a time—maybe soon, but maybe not for weeks, months, or years—that something will change. Just getting someone to talk to us becomes the essential task. This is true whether someone is in a jail cell, living in a cardboard box under a bridge, or residing in a studio apartment.

Should systems pay psychiatrists to do this work? Maybe it’s not “cost effective” because of its “low return on investment”. After all, this task of “building rapport” means psychiatrists aren’t working “at the top of their licenses”. If a psychiatrist is able to get people to talk to her and help them shift their behaviors, whether or not that involves medications, does that have value?

Does the psychiatrist’s efforts have value if it helps the “system” save money?

Is there value if it reduces the suffering of these individuals who have had to deal with police officers, jails, and living on the streets due to a psychiatric condition?

Perhaps my idealism blinds me. One of my early mentors in New York City often said, “I want the guy who lives under the Manhattan Bridge to have a psychiatrist who is as good as, if not better than, the psychiatrist who has a private practice on Fifth Avenue.” I couldn’t agree more.

Categories
NYC Observations Reading Reflection

Three Comments about Race.

I’m currently reading Nelson Mandela’s autobiography Long Walk to Freedom. Learning about his experiences with apartheid in South Africa provide both hope and discouragement about current race relations[1. The juxtaposition of reading Mandela’s book with the protests about Ferguson and Eric Garner is… interesting.] in the United States. While there has been some progress in the past fifty years, it seems like it’s not happening fast enough. Why do Nelson Mandela’s experiences and words still apply to the world today?[2. Though I am just over halfway through it, I would recommend Mandela’s autobiography. He tells his story with clarity, humor, and dignity. Do note that it over 650 pages long.]

While in New York I visited the New York Historical Society, which had an exhibit entitled Chinese American: Exclusion/Inclusion. The banner fluttering in front of the museum for this exhibit features the “certificate of identity” of a Chinese actress. I, of course, have no idea what she was thinking when the authorities took her photo, though I see fierceness and indignation in her face.

There I learned that the Geary Act of 1892, which served as an extension of the Chinese Exclusion Act of 1882, introduced the first form of photo ID in the United States. (Which makes me wonder if the Chinese in America were the first to create fake IDs.)

Again, there has been progress in the past century, but that there exists a museum exhibit on the exclusion/inclusion of Chinese Americans tells me that, as a population, we continue to wobble across that slash. And I think it is meaningful that “exclusion” comes first.[3. Iris Chang wrote an engaging book about The Chinese in America that discusses these exclusion acts. I will note that Chang’s writing brims with anger and hostility at points throughout the book. I nonetheless still recommend it. A more modern perspective on Chinese exclusion/inclusion is Gene Yang’s lovely graphic novel American Born Chinese.]

One of my patients in the jail, a man who is not Caucasian, has significant psychiatric symptoms. Some days he tolerates our conversation better than others. He recently became overwhelmed with rage and, in the midst of some colorful epithets, shouted, “I’m gonna rape you! No! You know what? I’m gonna get a whole bunch of WHITE GUYS to rape you!”

I immediately ended the conversation (for what I hope are obvious reasons). His commentary, though, fascinated me:

The emphasis of his threat was focused on race, not on the number of men. When you look him or me, you can instantly discern that neither one of us is white. He judged that the threat of a white man raping me was more demeaning and insulting than a man of any other race raping me.

It is also noteworthy, though perhaps not surprising, that he has directed this specific threat only to me. He has told my male colleagues that he will either beat or kill them. Neither threat, of course, is desirable.

Categories
Lessons Nonfiction NYC Observations Reflection

Living in New York, or Assertiveness Training.

Over three years have passed since I moved out of New York—or returned to Seattle, however you want to look at it. I have had the good fortune to visit New York every year since my departure, though I was unable to last year due to my mother’s illness.

Whenever people ask me about my time in New York, I usually say something like, “I’m so thankful that I had the chance to live there, but I ultimately found it too overstimulating.” Sometimes I comment how I found myself laughing when I realized the number of people who seemed to take everything, including themselves, so seriously. I didn’t laugh because I found their behaviors funny; I often didn’t know how else to react.

When I was an intern in Seattle, one of the fellows told me about the year he spent in Boston earning an Master’s degree in public health. “Living on the East Coast is like going through assertiveness training,” he quipped.

Indeed, I found my three years in New York to be a course in assertiveness training. This training did not occur because “people are rude in New York”. To be clear, there are rude people in New York, but not more so than anywhere else.

People learn to assert themselves in New York City because of the constant crush of people and what seems like scarce resources. (“Resources” isn’t limited only to money; I refer also to time, attention, and space.) If you don’t assert yourself, people overlook you. And I’m not even talking about people overlooking you for promotions, relationships, or praise. I’m talking about crowds overlooking you while you try to get on a subway car[1. Here are photos of men taking up too much space on the train. Many of the photos feature the New York City subway.], taxi drivers overlooking you as they race down the avenues, or the guys at the pizza counter overlooking you when you’re trying to order a slice.

You learn to change the way you walk, the way you hold yourself, the way your form occupies space. You learn to arrange your body and face to announce, “I am here.” You don’t send that message because you want to be the center of attention; you just want to get stuff done.[2. Because you learn how to adjust your body and face to make your presence known and felt, you also learn how to turn all that off. Sometimes you want to disappear into the crowd; you just want to watch what is happening around you without having to take part.]

You learn to speak up. Speaking up doesn’t mean speaking more; you learn how to get enough attention for enough time to say what you need to say. You learn that if you don’t speak up, people

  1. may not realize you are there
  2. may not realize that you have something useful or helpful to offer
  3. may develop wrong opinions about you, what you think, or what you’re about

You learn to speak up and make your presence known because you witness someone else speak up and advocate for you. You pay that forward and notice that, for whatever reason, that karmic system works.

You also learn to assert yourself because sometimes you get attention you don’t want. There are all the irritating men who catcall you[3. I am an N of 1, but men in New York catcalled me way more than men in any other city I have lived in. That video resonated with me.], the taxis that trail you as you walk on the sidewalk, and the disgruntled people you happened to interact with at the wrong time. You learn to ignore the unwanted attention without showing discomfort or fear on your face. You arrange your body and face to announce, “I am here, but not for you.”

You learn that people respond to you—favorably!—when you assert yourself. You learn that when you speak up and deliver your message in an envelope of good manners, people often change their behavior. You learn who respects you. You also learn that one of the best ways to show respect to others is to tell them what you’re thinking and feeling. You learn that they can handle it. You also learn that you can handle it, too.

I remain grateful to New York for teaching me how to sharpen my assertiveness skills. I’ll be visiting the great city soon and trust that I will have no choice but to review the coursework.