Category: Public health psychiatry

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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?

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Homelessness Nonfiction Policy Public health psychiatry

Who is Actually Unsafe?

Before she and I reached the gate in the chain-link fence, a man approached us from the opposite direction. A hoodie shaded his face and his hands were in his pockets.

When she and I got closer, we waved first, all smiles. This was intentional. Hello! We are harmless, but we are paying attention!

He slowed down and pulled the hoodie off of his head, revealing the AirPods in his ears and a tentative smile on his face.

He and my colleague started greeting each other at the same time. She deferred to him.

“I’m just out for a walk,” he said. The accent in his voice revealed that English was not his first language.

“So are we,” my colleague said. This was a lie.

“Oh,” he said, his face now soft and kind. “A worker, a government worker, told me yesterday to be careful when walking here. He said that there are dangerous people back there”—he pointed to the area behind the chain-link fence—“people who are homeless.”

“Oh, okay, thanks,” we replied. His intentions were kind; he was looking out for us. He continued on to the parking lot. 

When we arrived at the gate in the chain-link fence, we ignored the sign posted on it: DO NOT CROSS.


Despite years of doing homeless outreach, I still feel my heart beat a little faster and my shoulders tense a bit whenever I approach an encampment. It doesn’t matter if it’s tucked in a wooded area, under a freeway, or behind a building.

Nothing dangerous has ever happened to me when I’ve outreached more remote locations. Sites where I have been at risk of injury were almost all public places with plenty of people milling about, or in spaces where people are literally locked in.

I don’t ignore my anxiety—our emotions are sources of information—but continue to wonder how much of my unease is due to stigma.

She and I followed the worn footpath through the overgrown grass and were soon under a canopy of leafy trees. On one branch hung a jacket that had been singed by fire. As we approached the underpass, the vegetation receded. A small river was on one side; on the other was a slope of rocks and loose dirt that led up to the concrete base of the road.

A small tent was closer to the river. A larger structure was tucked further away, just underneath the roadway. Old clothing, food wrappers, worn blankets, and other detritus were scattered about, evidence of people who were once there. Maybe they had moved on?

We saw no signs of life.

“Outreach!” my colleague called out. The rumbling of the cars overhead muffled her voice.

The small tent shifted back and forth; we heard rustling sounds.

“Outreach, hello?” my colleague called to the small tent.

“Yes, I’m coming out,” a tired voice responded. Within a few minutes, the person inside unzipped the door flap. A young woman wearing a soiled sweatshirt adorned with the name of a law school peered out. Her face was thin and her limbs were slender.

She didn’t need anything, but accepted some snacks and water. She wasn’t the one we were looking for. We wondered if she had seen The Person?

“Yeah, from time to time,” she replied. “She might be up there.”

After thanking her, we plodded through the soft dirt and climbed over wobbling rocks to the larger structure. A multi-gallon clear barrel in front of the tent was about half full of water. Nearby were piles of blankets and clothes.

The tent was wide open. There were no blankets, sleeping bags, or pillows inside. At the back of the tent was The Person. She was sleeping directly on a tarp.

The Person is not well, but aside from sleeping underneath a road, she breaks no laws. She mumbles and often says things that only she understands. In stores she quickly picks up what she wants and pays with cash and coins. 

As far as we know, she’s lived outdoors for years. And now she is over 60 years old.

These two women are homeless, but they do not contribute to crime and disorder on America’s streets. They are not safety threats.

Who is truly unsafe: Us, or them?

Categories
Homelessness Nonfiction Public health psychiatry

Opening Doors.

For our first appointment, she didn’t come downstairs. The building staff, who described her as a high-priority patient, had predicted this.

After I knocked on her door, a gruff voice shouted back, “What do you want?!”

She eventually opened her door. Inside, the room was furnished with only a bed and nightstand. The mattress still looked brand new; no linens or blankets were on it. The only item on her nightstand was a lamp, the shade still wrapped in plastic. The walls were bare; her closet was empty. Blinds kept the sunlight out.

The only personal item in her room was a flattened cardboard box. It was next to her bed. Though she had lived in that unit for almost a full year, she was still sleeping on the floor. She preferred the cardboard to the mattress.

“I don’t need anything, I’m fine, I’m fine,” she grumbled. She pointed an arthritic finger at the door before announcing, “I’m leaving now.” I stepped to the side. She hobbled past me towards the elevator, mumbling to herself. She didn’t close the door to her apartment. I did.

That first appointment was a success! Not only did she open her door, but she also spoke to me. Sure, it was a short and superficial conversation. Her primary goal, it seemed, was to get away from me. But she didn’t yell at me, despite my introduction: “Hi, my name is Dr. Yang. I work as a psychiatrist. I just wanted to introduce myself. How are you doing?”

There was a fair chance that she would talk to me again in the future. I had two goals now: Create conditions so that she would (1) talk with me again and (2) tolerate a longer conversation with me. Maybe two to three minutes next time?

Back downstairs, I tapped out a quick note:

This is a 79yo woman with a historical diagnosis of schizophrenia. She reportedly has a history of street homelessness of at least twenty years, though housing staff believe that she had been homeless for longer. She finally moved into housing about a year ago….

Categories
Homelessness Policy Public health psychiatry

Homelessness is Not a Crime.

Last week, the current Presidential administration released an executive order with a noble title, “Ending Crime and Disorder on America’s Streets.” Here is the opening paragraph of this problematic memo:

Endemic vagrancy, disorderly behavior, sudden confrontations, and violent attacks have made our cities unsafe. The number of individuals living on the streets in the United States on a single night during the last year of the previous administration — 274,224 — was the highest ever recorded. The overwhelming majority of these individuals are addicted to drugs, have a mental health condition, or both. Nearly two-thirds of homeless individuals report having regularly used hard drugs like methamphetamines, cocaine, or opioids in their lifetimes. An equally large share of homeless individuals reported suffering from mental health conditions. The Federal Government and the States have spent tens of billions of dollars on failed programs that address homelessness but not its root causes, leaving other citizens vulnerable to public safety threats.

There are misconceptions and factual errors throughout this order. (There are errors and twisting of facts in that single paragraph alone.) Dear reader, I’m just one finite person, so I will only address one problem today.

This order conflates homelessness with mental illness, substance misuse, and crime. This is wrong.

The Venn diagram below is an approximation of the reality of the intersections of homelessness, mental illness, substance misuse, and crime:

Green = Homeless; Yellow = Mental Illness, Substance Misuse; Red = Criminal Behavior; Blue = Civil Commitment

Most people are not homeless, which is why the green circle is small. Here in King County (the county Seattle is in), over 97% of people will sleep indoors tonight. Are there people who are homeless with mental illness and/or substance misuse? Of course. Did some of these people have such issues before losing their housing? Yes. Did some of them develop these problems after becoming homeless? Indeed.

Then there are all the people with a place to call home who also have mental illnesses and substance use disorders (yellow circle). In fact, many people with mental illnesses (including schizophrenia and bipolar disorder) and substance use disorders (like alcoholism, which kills more people each year than opioids) are not homeless. Furthermore, they will never be homeless.

Likewise, many people who do criminal things do not have mental illnesses or substance use disorders (red circle). If they are incarcerated, they go home when they are released from jail. Psychiatric “beds” make up only a small fraction of all jail beds. Most people who are incarcerated do not behave in ways that warrant psychiatric intervention while they are there.

The blue dot represents civil commitment, or forcing someone into an institution for psychiatric reasons. The vast majority of people with mental illnesses and/or substance misuse will never be hospitalized, let alone involuntarily committed. Some people end up in jail when they would be better served (i.e., get treatment) in a psychiatric institution.

This seems to be the worldview of the current Presidential administration:

Green = Homeless; Yellow = Mental Illness, Substance Misuse; Red = Criminal Behavior

The language of the executive order suggests that if someone is homeless, then they must have a major mental illness and/or substance use disorder. (Hence the green “homeless” circle is completely surrounded by the yellow “mental illness, substance misuse” circle.) This is wrong. It does not reflect reality.

However, as a result of this cognitive error of conflating homelessness with mental illness and substance misuse, they offer the solution of civil commitment:

Green = Homeless; Yellow = Mental Illness, Substance Misuse; Red = Criminal Behavior; Blue = Civil Commitment

Notice that the blue dot of civil commitment has transformed into a bigger blue circle that surrounds the green circle of homelessness. The memo also argues for “maximally flexible” civil commitment, which is a convenient way to keep people off the streets if homelessness equals mental illness and substance misuse (which, again, it does not).

To be clear, I am not cool with people being homeless. I ended up in public health psychiatry because there are people who are homeless because of debilitating mental illnesses and substance misuse. They get better with treatment. Then they escape homelessness — and all the challenges that come with it.

If you look at that first diagram, though, the overlap between homelessness and mental illness and substance misuse is limited. And a number of people — often people in their late teens and early 20s — don’t have any major mental health or substance use problems when they become homeless. (They are often fleeing unsafe and untenable situations in their homes.) Not knowing where you will sleep tonight is stressful. Trying to appear “normal” and “fine” makes you anxious and depressed. Worrying about unwanted attention and personal safety while outside, unsheltered, when it is dark is exhausting. No one, as a kid, thinks, “When I grow up, I want to be homeless, have a drug or alcohol problem, and need psychiatric services.” That is literally no one’s ambition.

This administration wants you to believe it’s humane — offering treatment to people with mental illness and substance use disorders. But that’s not what it’s about. It’s about hiding people who are so poor they have nowhere to live.

If this were really about providing mental health and substance use disorder support and treatment — you know, actually helping people — then the Presidential administration would not have cut $1 billion (yes, billion with a B) from the Substance Abuse and Mental Health Services Administration. The administration would not have gutted Medicaid, which is the primary funder of mental health and substance use disorder support and treatment to people who are poor, including those who are homeless.

Don’t be fooled. Pay attention.

Categories
Homelessness Policy Public health psychiatry Systems

Loud Music Is Disorder. What About Memecoins?

I read this provocative essay about “disorder” when it was first published in September 2024. I found myself alternating between nodding and frowning. It’s not a short essay, but I do encourage you to read it. (For those who lean left politically, the author is a thoughtful conservative commentator named Charles Fain Lehman, a fellow at the Manhattan Institute.) I considered writing up my reactions at the time, but I deferred. My reactions felt squishy. I didn’t have data to back up my reasons for frowning.

I still don’t have data, but the increasing disorder at the federal level frustrates me.

To summarize: Lehman opens by citing statistics that crime has indeed fallen in the US. Many Americans, though, feel that crime is rising both in their communities and across the nation. He then argues that “disorder” is increasing and offers these as examples of “disorder”:

  • A man blasting loud music from his phone in a subway car;
  • Teenagers spray-painting graffiti on a public park;
  • A large homeless encampment taking over a city block;
  • A man throwing his trash on the ground and walking away;
  • A group of women selling sex on a street corner.

From this, he proposes a definition for “disorder”: domination of public space for private purposes.

He goes on to argue that engaging in disorderly behavior is the rational choice, but most people do not contribute to disorder. Why? He attributes this to

“social control”—the regulation of individual behavior by social institutions through informal and formal means.

Lehman says that the Covid pandemic, in particular, weakened social control (e.g., fewer “eyes on the street” due to increasing remote work; reduction of law enforcement numbers due to the George Floyd murder and defund the police efforts). He adds that “the core to combating disorder is restoring public control of public space.”

To his credit, he doesn’t offer law enforcement as the sole solution. Lehman briefly describes changing the environment with intention (e.g., broadcasting deterrent music, putting pressure on landlords to clean up spaces). But, once informal efforts fail to restore order, then formal systems must intervene. In his view, law enforcement is the primary formal system.

Most of my professional work has been with people experiencing homelessness and mental illness. But I’m not actually cool with people living outside. I feel discouraged and unsettled when I see tents blocking lengths of sidewalks. When I see people slumped on the sidewalk due to fentanyl, my first thought is, “I wish you would stop using drugs.” I am not a fan of disorder.[1]

I like Lehman’s definition of disorder. While not comprehensive, “domination of public space for private purposes” is a reasonable starting point.

What I don’t like is how many of his examples are associated with poverty (homeless encampment; prostitution; loud music on public transit, a space rarely used by wealthy people). Yes, these are visible and common examples of disorder. But what about the disorder associated with people with wealth and power? Just because we don’t see it every day doesn’t mean people with money and influence are paragons of morality. Why no commentary on that?

Is it disorder when the President visits golf resorts that he owns? He profits from his Secret Service detail staying in his hotels. Isn’t that the domination of public funds (our tax dollars!) for his private, profit-building purposes?

Likewise, is it disorder when the President and his wife launch their own memecoins? Isn’t their use of public office to collect millions of dollars a form of disorder?

Is it disorder when the deputy chief of staff in the White House redirects ICE agents to enact his own anti-immigration agenda?

Is it disorder when the federal administration cuts millions of dollars from scientific research funding because language in the grants references race, gender, and sex? Isn’t this the domination of public resources for a private, anti-DEI ideology?

Is it disorder when the federal administration wants to cut billions in Medicaid funding so that people with extraordinary wealth will get tax breaks? How is that not domination of public resources for private purposes?

None of these actions had occurred by September 2024. Regardless, I wonder if Lehman had considered the intersection of power with his definition of disorder. Lehman says early on in his essay that

critics [contend] that disorder is just another word that the powerful use for whatever it is the non-white, poor, and otherwise marginalized do.

This criticism, combined with Lehman’s omission of power, illustrates who does and does not get to define “disorder”.

We are seeing nauseating abuses of power in this Presidential administration. If blasting music on a bus is disorder, but funneling public money into personal projects is not, then we’re not defining disorder. We’re excusing power.

[1] I am a fan in believing that people can change. And they do! People stop drinking and using drugs. They start taking medication, and they learn how to manage their symptoms sooner. Again, just because we don’t see that change every day doesn’t mean it isn’t happening.