Category: Public health psychiatry

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Homelessness Policy Public health psychiatry Seattle

Housing as the Most Effective Treatment.

(I know it’s been a minute since my last post. The announcement from HHS about “HHS, ONDCP, and HUD Launch First-Ever ‘Treatment First’ Toolkit to Combat Homelessness and Addiction” reminded me that I submitted the op-ed below at the end of June. The newspaper chose not to publish it, so I’m sharing it here. I’ll review the toolkit above next, though I have a feeling that I may reiterate what I’ve already written below.)

The Trump administration believes that mental illnesses and substance use disorders are the root causes of homelessness. Thus, HHS Secretary Kennedy recently announced funding for the Safety Through Recovery, Engagement, and Evidence-based Treatment and Support (STREETS) program. Because of the “unprecedented burden and impact of addiction and mental illness among the homeless population”, he asserted that this funding “aligns with President Trump’s Executive Order on Ending Crime and Disorder on America’s Streets”.

STREETS may help people with mental illnesses and substance use disorders, but it will not end homelessness. People need safe places to call home to recover.

The vast majority of people with mental illnesses and substance use disorders are not homeless. In Washington State, over 2.2 million adults have had any mental illness and over 1.4 million people over the age of 12 have had a substance use disorder in the past year. Compare these numbers with the 163,000 Washingtonians who are homeless. If we (incorrectly) assume that every person became homeless because of a mental illness or substance use disorder, that means over three million Washingtonians will lose their housing. This is wrong. Someone in a Mercer Island mansion drinks bottles of wine between meetings, just as someone in an Auburn apartment takes medication for schizophrenia before going to work. 

I work as a psychiatrist in Seattle with people who are currently and formerly homeless. Psychiatric conditions that are common in the general population, like anxiety and depression, are also common among those who are homeless. For many of them, housing is the most effective treatment. Having reliable access to one’s own bathroom and bed reduces stress. A lock on the door assures safety and security. 

Practically everyone who is homeless now has had a place to call their own in the past. Because of rising rents, reduced incomes, and the onset of health problems, nearly half of people becoming homeless for the first time are over the age of 50. With older age often comes increased physical and cognitive vulnerability. Anxiety and depression often follow. The loss of health and housing can tip people into major mental illnesses and substance misuse. 

In a minority of people, severe mental illnesses and substance use disorders are the primary drivers of their homelessness.  Because of their symptoms, they sometimes are unwilling or unable to work with traditional health care systems. Finding these individuals is often the hardest part of my job. I cannot build relationships and then offer treatment if I cannot find my patients. When someone has a stable and safe place to live, it is far more likely we will connect. Only then can people participate in care.

For those who are unable or unwilling to engage in outpatient treatment, civil commitment is the last option. Laws for involuntary hospitalization already exist. Every day, someone is hospitalized against his will. In many instances, this is lifesaving. However, recovery quickly unravels if people have nowhere to go when they are discharged from the hospital. It is hard to attend appointments, take medication consistently, and build a life you want to live when you don’t know where you will sleep.

To be fair, STREETS funding will help the health and wellbeing of some people, including individuals who are homeless. Prevention and early intervention work. Some people at risk of becoming homeless because of mental illnesses and substance use disorders will remain housed. However, psychotherapy and medications are often no match for the stress and chaos that comes with homelessness. Housing is health care.

RFK Jr. has shared his own history with drug use and depression. As far as we know, he never experienced homelessness. Having a stable place to call home was foundational to his recovery. He knew where he could go after attending 12-step meetings; he had a safe place indoors to read books by Carl Jung. Housing alone does not treat mental illnesses and substance use disorders. But treatment alone also doesn’t solve homelessness. People need both. 

Categories
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
COVID-19 Public health psychiatry Seattle

StoryCorps Interview.

I wasn’t familiar with StoryCorps until I received an invitation to record with them. They were looking for people who were front-line workers during the Covid-19 pandemic. Once I learned that the recording would be archived in the Library of Congress, I signed up.

Here’s the recording of the interview. It’s about 48 minutes long.

I still believe that most people don’t want to hear anything about the pandemic. Prior to the recording, I have said little about it. (My conversation partner in the recording has been a close friend of mine for over 20 years. Almost everything I shared during our recording she had never heard before.)

There was a time when I literally could not say anything about it: my mind would go blank, my chest would tighten, and no speech would come out.

“I don’t know,” I’d finally say. The blankness—how expansive it was, how it encompassed everything—was overwhelming.

I myself have not listened to the recording and don’t expect that I will anytime soon. Even though the recording was nearly an hour, it still wasn’t enough time. (Enough time for what?) Working as the medical director during the pandemic was the hardest thing I’ve ever done in my professional career. I am thankful that I was given the chance to talk about it.

If one person, 100 years from now, before, during, or after another pandemic, benefits from hearing my experiences, then it will have been worth it. May they learn from my experiences and errors.

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
Public health psychiatry

Psychological First Aid.

My plan over the past week was to craft a post about psychiatrists becoming agents of social control in China. Then federal agents killed another person in Minneapolis.

During the Covid-19 pandemic, I posted few entries here. This was a natural consequence of me not writing in general. Fatigue and anxiety were constant companions. Why was a psychiatrist working as the medical director for one of the largest homelessness services agencies in the county during a public health crisis? The pressure felt relentless.

By December 2020, I also felt anger because I was disappointed:

As the federal government has not provided any coherent response to the actual disease pandemic, I do not expect that it will provide any response to the psychological suffering that has already occurred and will continue to occur due to Covid-19.

Nearly a year had passed since the first US death from Covid. There was no indication that this federal government had any interest in applying lessons learned from epidemics elsewhere. The Pan-American Health Organization published a free document—free!—entitled, Protecting Mental Health During Epidemics.

At that time, though, I still held hope in my heart. Government often does not move fast. This is desirable: If government moves too fast, smaller jurisdictions don’t have the chance to give feedback or adapt.

By 2025, we would all learn that this government would use speed against its people.

By January 2022, my anxiety, anger, and disappointment had disappeared. The chronic anxiety and fatigue had squashed everything else.

I recognized at the time that this was a problem.

Worry had become an ingrained habit, so it was easy to express this concern:

I worry about the psychological consequences of this pandemic in the years to come. We continue to focus on the viral pandemic; the psychological pandemic has already arrived. We have yet to see an organized response to that.

Months ago I had already reluctantly recognized that we could not rely on this government to help us. We crafted our own best practices; we cobbled together our own policies and procedures. Within the community we shared information and ideas. We pooled together what power we had to push local government authorities to meet our needs.

You, dear reader, are gracious to give me the gift of your attention. I know some of you work as psychiatrists, psychologists, and other health professionals. Because this federal government is moving fast and has shown that it is unreliable, let me share with you the manual for Psychological First Aid:

Gives guidance on responding to disaster or terrorism events using the Psychological First Aid intervention. This evidence-informed approach helps to assist children, adolescents, adults, and families in the aftermath of disaster and terrorism.

Here’s the two-page overview.

I wish it had a stronger evidence base, and I don’t like that the last update was in 2006. (WHO has a similar psychological first aid manual, though its last update was in 2011.)

People other than mental health professionals can administer psychological first aid. Much of it seems like common sense, but if you have made it this far in this post, you’re probably feeling generally calm. Common sense often disappears during times of stress. The time to learn how to manage yourself, to practice having equanimity in the face of calamity, is when you are calm.

May what is happening in Minneapolis not happen in your city. May you already be a member of PRKA (People Reluctant to Kill for an Abstraction):

resisting the urge to generalize, insisting upon valuing: the individual over the group; the actual over the conceptual; the small, decent act over the sudden violent lunge; the complicated reality of the present moment over the theoretically euphoric future supposedly to be obtained via murder or massacre.